Five Rules of Thumb for Managing the Ocular Surface

With new options in dry eye diagnostics and treatment modalities continually coming out, practicality is king in the hectic world of today’s optometrist. Fine-tuning your approach to managing dry eye is essential for the streamlined care of this onerous eye disease. Following the simple rules of thumb outlined below can help you improve the way you handle the many presentations of dry eye disease.

RULE NO. 1: FOCUS ON PATIENT HISTORY

It has been said that with only a well-collected patient history and initial workup, a correct diagnosis of dry eye can be reached 80% of the time.¹ Dry eye questionnaires such as the Standard Patient Evaluation of Eye Dryness Questionnaire (SPEED) or Ocular Surface Disease Index (OSDI) should be common practice at this point. They take no time away from your schedule and provide a volume of information before you ever turn on a slit lamp.^2,3 If you are comfortable letting a questionnaire guide your technicians, develop a cutoff range that allows them to suggest point-of-care testing such as tear osmolarity, matrix metalloproteinase-9, or tear quantity based on the survey outcome (Figure 1). Again, before you have even set foot in the examination lane, the patient’s history should have guided analysis to give you pertinent information on tear quantity or quality.

Patients rely on their doctors to be effective communicators,⁴ and they occasionally relay to us things they won’t divulge to technical help. By briefly reviewing your patient’s symptoms at your initial point of contact, you will many times uncover hidden gems of information.

The types of symptoms associated with dry eye are well known, but the surrounding details can paint a different picture. Acute onset versus chronicity of symptoms is a good area to probe, as this will often guide treatment. If a patient has never had dry eyes until 2 weeks ago, it may steer your approach to initial therapy or lead to a different diagnosis. Medications and daily environment should not be missed when reviewing history. Antihistamines, antianxiety, antidepressants, and diuretics are all examples of medications that are known to negatively affect the ocular surface.⁵ Air quality and other attributes, such as humidity, are known to affect the eyes and can be amenable so don’t forget to ask patients about the environments in which they live and work.⁶ Now that you’ve clarified your patients’ symptoms and reviewed their complaints and history, it’s time to focus on the examination.

RULE NO. 2: USE REPEATABLE METRICS

You may not have every type of point-of-care testing or instrumentation that provides tear film analysis, but even without these decisive tools, the clinical exam will guide your diagnosis and help you arrive at the correct therapy.

Vital dyes can be placed first. Whichever dye you choose, be sure to allow enough time for it to equilibrate prior to your slit-lamp examination. You won’t see tear film breaking up if you look immediately following instillation, and it takes time for the stain to incorporate into devitalized or damaged epithelium. Form a habit of letting the dye do its job for approximately 2 minutes so you don’t miss these signs.⁷ Because there are many surface grading scales with no universally accepted metric, pick a numeric severity scale (ie, 1-4) and specify a location of the findings.⁸ The location of your staining is also important, as it could indicate various mechanisms behind the surface findings, such as lagophthalmos, neurotrophic changes, or superior limbic keratoconjunctivitis (Figure 2).⁹

Wait to anesthetize the eye when you use your vital dye. If you see significant surface staining, consider corneal sensitivity testing next to rule out neurotrophic changes (Figure 3). This can be performed with a cotton wisp or strip of floss. If sensitivity is diminished, you may see why significant findings are not matching your patient’s chief complaint. On the other hand, the surface could be pristine if the patient is hypersensitive to pain.¹⁰

Evaluating the meibomian glands should include visualizing structure by transillumination or meibography and determining function by expression. It is important to use uniform force to document expressibility.¹¹ The Meibomian Gland Evaluator (Johnson & Johnson Vision Care) is one way to apply uniform pressure to the meibomian glands and allows a grading of the expressions in three areas along the lower lid. Whatever your approach, remember to be systematic in your examination and to have a grading scale in place for each finding.

RULE NO. 3: TAKE A PICTURE (1,000 WORDS TAKES TOO LONG)

Now that you have performed your exam, how will you convey your findings and treatment goals to your patient? If they are largely asymptomatic, will they change their habits just to please their eye doctor? With ocular surface disease care, anterior segment imaging is critical for patient education and early intervention (Figure 4).¹²

Whether your camera is incorporated into your slit lamp, such as the Topcon DC-4 Digital Camera (Topcon Healthcare) and the IM 600 (Haag Streit), or you have a slit lamp attached to a device such as the Mx2 External Ocular Camera (Box Medical Solutions) or an iPhone adapter system, this key component to patient education should not be missed.

Meibomian gland function has been a growing area of concern in dry eye management. A study out of Duke Eye Center found meibomian gland atrophy in the pediatric population in up to 42% of asymptomatic children,¹³ and further studies have connected this atrophy to screen time.¹⁴ This research begs the question: Are we doing enough as eye care professionals to intervene earlier and take a proactive approach to help our patients with dry eye in the long run? Meibography can guide early intervention such as home-based heat therapy, quality omega 3 supplementation, and in-office treatments (Figure 5).

RULE NO. 4: TREAT AND FOLLOW

There are few dry eye diagnoses that do not require follow up. Selecting a treatment based on your examination and the suspected mechanism of action should always be followed by a set appointment to ensure progress and improvement in clinical findings and symptoms.¹⁵ In-office treatments are a growing part of optometric practice and are a first-line therapy for good reason. Patients with every level disease, especially the evaporative variety, can benefit from light-based therapies such as intense pulsed light therapy; thermal-based treatments, including theTearScience LipiFlow Thermal Pulsation System (Johnson & Johnson Vision Care), Systane iLux (Alcon), and TearCare (Sight Sciences); or biofilm removal, such as BlephEx (Alcon). Pharmaceutical intervention may be held off initially.^16,17

Aqueous deficiency symptoms can be improved with treatments that augment tear volume, such as punctal plugs¹⁸ or the new varenicline 0.03 mg solution nasal spray (Tyrvaya, Oyster Point Pharma), and such treatments should come to mind in cases of Sjögren syndrome or ocular graft-vs-host disease.

Most topical treatments target inflammation, which is almost always a component of underlying evaporative or aqueous-deficient mechanisms.¹⁸ Cyclosporine formulas and lifitegrast ophthalmic solution 5% (Xiidra, Novartis) are now tried and tested primary weapons in our arsenal of therapy. If a patient presents acutely with significant surface findings and symptoms, topical steroids that work on the surface are a great option to quell these flares.¹⁹ Although loteprednol–based topical steroids have become commonplace in managing surface inflammation, attention should still be given to length of use and refills authorized, along with IOP monitoring.²⁰ Make sure the patient received the drug you prescribed and not a ketone-based generic substitute.

For moderate to severe cases, biologic drops such as Regener-Eyes Ophthalmic Solution (Regener-Eyes), amniotic membranes, and autologous serum such as Vital Tears (Vital Tears) are also excellent options. Whatever treatment you choose, set a reasonable follow-up visit to assess effectiveness and make a plan to improve the progress you have or haven’t made.

RULE NO. 5: PROVIDE A WRITTEN PLAN

Before you send your patient out the door with a bag full of tears, prescriptions, supplements, and heating masks, you should write instructions down for them. Sometimes a pre-printed grid or checklist of your typical choices makes things orderly. It doesn’t get much easier than that!

CONCLUSION

As dry eye becomes increasingly common in our patient population, keeping some ground rules in mind at the beginning of your evaluation can lead to better outcomes. Additionally, establishing some sort of systematic approach to patient care will help prevent misdiagnosis, allow for proper treatment earlier, and improve your patient’s satisfaction with you and your care.