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What should we call this problem?
One practitioner makes the case for using the all-encompassing term "dry eye."
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It is summer, and my thoughts once again turn to the basics.
On my professional journey, I come in contact with all kinds of impressive, intelligent folks from all walks of our shared eye care world. We are truly blessed to practice in a specialty that attracts this kind of person on both the professional side as well as the industry side. One only needs to look at how hard our friends at pharma and medical device companies work to stay in our field after all of the various and sundry mergers and acquisitions to know that eye care is somehow different, in a good way, from much of the rest of medicine.
That is not to say that we always agree on things, even basic things such as what we should call a clinical entity described as “a multifactorial [problem] of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface.” Heck, my editors here are wondering if we should call it a disease (a specific disorder of structure or function that results in a recognized group of signs and/or symptoms) or a syndrome (a collection of symptoms and/or signs that is not necessarily tied to a single underlying cause). One young MD consultant I met at an advisory meeting was adamant that our present nomenclature was woefully outdated and painfully inaccurate; he felt we should have multiple names for every such entity for both professional discussions and patient interactions.
What do you think? What should we call it when a patient sits before us complaining of burning, tearing and scratchiness? What term should we use when we hear blurred or unstable vision despite a stable refraction and 20/20 vision? How about redness and discharge? “Eye fatigue” after hours on a computer or reading? Is there a new, all-inclusive term we should adopt, or rather is my young colleague more correct, and we should have multiple, ever-more precise names for a number of different entities tied to very specific pathology?
Let’s apply the KISS protocol and just call it “dry eye.”
Keep it simple for the patient
There are a number of reasons to seek simplicity in discussing dry eye, both in the exam room and among colleagues. Everything about my approach to dry eye is centered on the patient, so let’s begin with why using the most simple and inclusive term in the clinical setting makes the most sense. For starters, pretty much every patient in North America has heard the term “dry eye.” No matter what particular type of dry eye may be present, it is a straightforward proposition that you present to your patients when you tell them what they have and how you will help them feel better. Your eyes are dry, and they need more or better lubrication. Simple.
Patients typically do not need a detailed explanation of the pathogenesis of their dry eye. They are either suffering because they are not producing enough tear volume, or their symptoms are caused by tears that do not work well enough. Aqueous-deficient dry eye and its treatment are particularly easy to grasp: Make more tears, make your existing tears hang around longer, and/or supplement your own tears with artificial tears. The more arid the clime, the greater the need there is for water. Patients get this.
Evaporative dry eye is equally easy to explain if we continue with our KISS strategy. Patients with meibomian gland dysfunction (MGD) and ineffective tears will typically have plenty of tear volume, but their tears simply do not work well enough. In this setting, we invariably are confronted with the question, “How can I have dry eye if I have lots of tears?” Because burning is a common symptom, I find it useful to run with the metaphor of fire. Kerosene is certainly wet, but if we use it to put out a campfire, we are more likely to run afoul of Smokey the Bear than we are to quench the flames. The treatment of this type of dry eye is to make the tears more effectively wet — water rather than kerosene. Either way, we have provided our patient with a simple, familiar diagnosis that is understandable and actionable.
Keep it simple among colleagues
When physicians are discussing the aforementioned constellation of symptoms and signs associated with a tear problem, there is no reason to make things any more complex or fancy. Even when we are talking doctor to doctor, it is still dry eye. Ocular surface disease is a perfectly reasonable omnibus title for a basket of problems that includes dry eye along with infectious and allergic conjunctivitis, among other entities. If we are being honest, we are actually having a conversation about only one of these problems at any given time. You are not really discussing dry eye when you are batting around the relative merits of various topical antihistamines. MGD is its own “big tent” problem with an attendant suite of solutions, but discussions and meetings about those solutions are typically driven by the location of the symptoms — lid or eye. MGD in the context of burning, scratchy, teary eyes is a discussion about — wait for it — dry eye.
Dry eye is a perfectly adequate, fully functional label, regardless of its age and checkered history.
A final thought on the merits of keeping it simple, if I may. Just over the horizon looms the specter of ICD-10, the monolithic climax to all that is wrong with the business of medicine in the U.S. Eye doctors will doubtless be presented with dozens of coding options for “a multifactorial [problem] of the tears and ocular surface.” Just think of how much easier your life would be if all of it were coded “dry eye.” That’s it. Just “dry eye” for every single tear problem visit. Not only would it be accurate, but it could be our tiny little protest “march” against regulatory burdens.
KISS. Dry eye. It will drive them nuts.
- For more information:
- Darrell E. White, MD, can be reached at SkyVision Centers, 2237 Crocker Road, Suite 100, Westlake, OH 44145; email: dwhite@healio.com.
Disclosure: White reports he is a consultant for Bausch + Lomb, Allergan, Shire and Eyemaginations and on the speakers board for Bausch + Lomb and Allergan.