Catch the Buzz on Dry Eye

HOT TOPIC

Parts of the TFOS DEWS III Report Are Now Out!

The Tear Film & Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) III Management and Therapy Report is beginning to circulate among the medical community. Recently, the TFOS DEWS III Diagnostic Methodology Report was published in the American Journal of Ophthalmology. In it, the authors stress that clinicians can perform a practical dry eye examination by first administering a simplified version of the Ocular Surface Disease Index questionnaire. They also recommend measuring noninvasive tear breakup time, although osmolarity testing is noted as an appropriate alternative. Finally, doctors should scrutinize the ocular surface and note any staining patterns. This is what is recommended at the very least.

James S. Wolffsohn, PhD, lead author of the Diagnostic Methodology Report, states “The subtyping of dry eye disease is the biggest change … Previously we just recommended stratifying aqueous deficiency from evaporative-driven disease, but virtually all dry eye disease has an evaporative component. This limits the differentiation of treatment strategies for an individual patient.” He goes on to comment that “drivers from the tear film layers, eyelid, and ocular surface can each be identified and then mapped to the evidence presented in the TFOS DEWS III Management and Therapy Report as to identify effective approaches.”

My Two Cents

There’s a lot to take away from this report, as it shares quite a bit of interesting information, quite notably a minimal and subtle change in the TFOS DEWS definition of dry eye. Here’s the new wording: “Dry eye is a multifactorial, symptomatic disease characterized by a loss of homeostasis of the tear film and/or ocular surface, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities are etiological factors.” (The emphasis on “symptomatic” is mine, as that appears to be the only change from the TFOS DEWS II definition.) Quite interesting!

It also seems TFOS DEWS III has subclassified dry eye into a few new divisions, which include tear film (lipid, aqueous, and mucin/glycocalyx), ocular surface, and adnexa (anatomical misalignment, blink/lid closure, lid margin, neural dysfunction, ocular surface cell damage/disruption and primary inflammation/oxidate stress) components. I have additional thoughts on this report, which I share further down below.

OUTSIDE THE LANE

When Patients Turn to Their Own Devices …

An 84-year-old retired British nurse removed a cyst from her own eye after waiting years for treatment. Her experience was profiled in a citizen experiences report presented during a meeting of the Betsi Cadwaladr University Health Board, which aimed to analyze the reportedly long delays that some citizens in north Wales have experienced regarding receiving medical treatment. These long waits have frustrated some citizens enough that they have taken matters into their own hands; one report details a National Health Service patient performing their own tooth filling with a kit from a pharmacy.

Not shockingly, the National Health Service health board has fully acknowledged that it has “significant work” to do to address these lengthy waits in a “sustainable, long-term way.”

Back to the nurse with the cyst. She waited 3 years just to be seen by the ophthalmology unit after being placed on the waiting list in 2019. According to the report, “She is waiting for an eye operation, which was requested in October 2023, and her eyesight is deteriorating rapidly… . As a former nurse and nurse manager, she has dedicated her working life to caring for others. Now she needs some care of her own.”

The same report that profiled this patient also found that patients in ERs at three local hospitals waited up to 36 hours amid “overcrowding, uncertainty, and discomfort.” A theme of the report was these long lines, with some patients having “catastrophic impacts” because of the delays, including one patient who was waiting for surgery for bladder stones. The report especially highlights extremely long referral delays for specialty services, including dentistry, audiology, cataract surgery, and respiratory care.

My Two Cents

This at least makes the American health care system look a little better! I don’t know many of our patients who are waiting a long time for cataract surgery or access to our care, and I could not imagine a 36-hour wait in the ER. It is unimaginable. For all the flaws in the American health care system, of which there are many, at least these seem to be issues that are relatively few and far between!

CAN YOU RELATE

What a week in eye care—most notably in dry eye! Unless you’ve been living under a rock, you’ve undoubtedly heard about Alcon’s big victory in getting FDA approval of the newest dry eye medication, acoltremon ophthalmic solution 0.003% (Tryptyr, pronounced trip-tear, I think). For those unaware, Tryptyr is believed to work by activating the trigeminal nerve pathways to stimulate natural tear production. Similar in some ways to varenicline solution nasal spray 0.03 mg (Tyrvaya, Viatris), which is also approved to treat the signs and symptoms of dry eye disease, pivotal phase 3 trials of Tryptyr demonstrated an increase in natural tear production as early as day 1 by targeting the TRPM8 receptor agonist. TRPM8 stimulates corneal sensory nerves to enhance tear production rapidly. Notably, a significant number of patients in the study reported experiencing a burning or stinging sensation with the medication. I’ll be especially curious to see how that plays out in my patient base.

Not only have we been given a new drop for dry eye, but as mentioned earlier, a new segment of the TFOS DEWS III study dropped as well, as the kids say. This is huge news for our profession! Whether you love or loathe dry eye treatment, the DEWS studies are eye care’s guiding light when it comes to both defining and treating the disease process. Essentially, the most recent DEWS information is considered gospel until proven otherwise. I’ll be curling up with a good glass of wine this weekend and tearing through all this information before leaving for Chicago to deliver a day-long dry eye lecture with the renowned Paul Karpecki, OD, FAAO, and Jaclyn Garlich, OD, FAAO. Check us out at the Ocular Surface Symposium if you’re in the area. I’m sure all this information will be discussed ad nauseum, so we can learn together!

QUOTE OF THE WEEK

“We now accept the fact that learning is a lifelong process of keeping abreast of change. And the most pressing task is to teach people how to learn.”

— Peter Drucker, Austrian-American consultant and educator