Ocular surface disease: One physician’s approach to testing, examining and making a diagnosis

Issue: January 10, 2016

ByRichard L. Lindstrom, MD

One or another form of ocular surface disease, usually dry eye syndrome, blepharitis, meibomian gland dysfunction, ocular allergy or conjunctivitis, accounts for nearly 40% of patient visits to a comprehensive ophthalmologist. DES and blepharitis/MGD with associated evaporative DES are the leading diagnoses made, and in various studies, as much as 15% of the population suffers from at least mild DES.

The accompanying cover story is quite interesting and highlights opinions from prominent actively practicing clinicians from around the world. I have found that the definition of dry eye, the diagnostics employed, and the treatments available and utilized vary significantly as I travel the world interacting with my colleagues. In this commentary, I will give a few thoughts as to how my approach to the diagnosis and treatment of DES and blepharitis/MGD has evolved and is evolving in a high-tech/high-touch integrated MD/OD care delivery model in Minneapolis. Of note, I consult widely in this field with industry and, as a fellowship-trained corneal specialist, see a diverse group of patients. Over the last 10 years, the way I manage patients with DES has changed dramatically. I am sure some of my approaches will be controversial, but they will represent an accurate portrayal of what currently works for me.

At Minnesota Eye Consultants, we have 13 ophthalmologists, 11 optometrists, 26 ophthalmic technologists, technicians or assistants, and two physician assistants who work collaboratively and collegially in the care of a large volume of patients. Our patients, whether new to the office or returning for follow-up, are usually seen first by a non-MD for a preliminary history, vision, refraction and appropriate diagnostic testing as indicated and ordered. If possible, I like to have the non-MD who works up my patients perform appropriate diagnostic tests before I see the patient. This presents the first challenge: Who deserves to be tested for DES, and with what test or tests?

Our non-MD technical team is quite sophisticated, and I am comfortable delegating to them the responsibility to initially screen for symptoms of DES during their work-up. The easiest and most efficient way to do this is to simply ask the patient a question such as, “Are your eyes comfortable? Do you have any ocular irritation, burning or itching symptoms?” If the answer is yes, these are quantified as to severity and recorded in the electronic medical record.

I have looked at the various questionnaires but found most of them to be too time-consuming. For a clinical trial, the Ocular Surface Disease Index, Standard Patient Evaluation of Eye Dryness questionnaire, McMonnies dry eye questionnaire, Subjective Evaluation of Symptoms of Dryness, and DEQ-5 dry eye questionnaire work well, but in everyday clinical practice, they are, for me, just too much. I mention them for completeness, as many doctors suggest that such a questionnaire be utilized for every new patient and every return patient with DES as a diagnosis. For those interested, the questionnaires can all be found on the Internet. I have tried some of these longer questionnaires in my practice, and it is just too much for our technicians. There is a simpler validated questionnaire, the UNC Dry Eye Management Scale, that is very quick and easy to use, and for those who like a screening form, I recommend a look at this one. But the honest truth is that while I see value in all these surveys, my technicians prefer to simply ask the question mentioned above.

So, now we have a patient with symptoms of ocular surface disease. What tests do I want before I see the patient? In our practice, I could ask for many, including a Schirmer’s test with or without anesthesia, tear film osmolarity, RPS MMP-9, Lipiview 1 or Lipiview 2 (both TearScience), AcuTarget HD (AcuFocus), tear lactoferrin and many others. The only one I ask for in all patients before I see them is a tear film osmolarity in both eyes, and I find it useful when it is normal and when it is abnormal. It is quick and easy for a technician to measure tear film osmolarity with the TearLab device, and it is in most cases reimbursed. Others would choose differently, selecting no tests before seeing the patient or perhaps more tests, but this is my current practice.

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Now the patient is in my examination room. My EMR tells me he has DES symptoms, and I will expand on the HPI as appropriate and look for comorbidities, medication issues and the like. I will have a tear film osmolarity to review from both eyes, and if it is below 290 and symmetrical in both eyes, that to me is an important finding and means about the same as a symmetrical IOP of less than 15 mm Hg in a patient referred to rule out glaucoma. Just as a low normal symmetrical IOP does not rule out glaucoma, a low normal symmetrical tear film osmolarity does not rule out DES, but untreated significant DES is rare with bilateral symmetrical tear film osmolarities under 290. If the patient is symptomatic and has elevated or asymmetric tear film osmolarity, pretty much he has DES, and now I need to classify it in terms of severity and etiology and develop a treatment plan.

Now for my examination. There is, again, a very large number of things to look at and look for, but I start by looking at the hands and the face so as not to miss rheumatoid arthritis and acne rosacea, as well as lid abnormalities such as entropion, ectropion, trichiasis, conjunctivochalasis, floppy lids and the like. I start doing this while I take the history and complete my review of medications and potential associated diseases and symptoms. Then to the slit lamp examination.

Now for another potentially controversial statement. It is critical to carefully examine the health of the lids and meibomian glands at the slit lamp, not just the ocular surface. The lids and meibomian glands are critical to ocular surface health. There are 20 to 25 meibomian glands in the lower lids and 40 to 50 in the upper lids, and almost no one over the age of 50 years has 100% normal meibomian glands. So, I can put MGD in nearly all charts over the age of 50, and I usually do with a grading for severity. Of course, most are mild and asymptomatic, but a very careful look for MGD or other eyelid pathology is a critical part of my slit lamp examination.

There are a lot of other potential slit lamp signs, from tear meniscus height to conjunctivochalasis to tear breakup time, but the critical one for me is lid margin, conjunctival and corneal staining. My favorite vital dye for staining the ocular surface is a combination of fluorescein and lissamine green. I describe the findings as superficial punctate keratitis if it is Thygeson’s, punctate epithelial keratopathy if i can see the dry spot lesions without staining, and punctate epithelial erosions if they are only visible when stained. I am therefore in most patients down to only four findings in my initial evaluation, and these are what I also primarily follow for treatment response and effectiveness. The critical four are symptoms, tear film osmolarity, blepharitis/MGD/eyelid pathology, and lid margin, conjunctival or corneal staining. Each is always graded for severity. With only mild symptoms, especially if they are only occasional, I might not put DES on the EMR as a diagnosis, but any level of symptoms associated with a sign leads me to list DES and formulate a treatment plan. All too often, mild DES is a neglected disease to the detriment of many patients. I will of course order or perform other tests as indicated, but these are my key four, and they are easily and quickly attained.

Now, a new challenge in the U.S.: What diagnosis is available and appropriate for coding using the newly mandated ICD-10? Fortunately, we have dry eye syndrome of the lacrimal gland as a code and can code for right eye, left eye or bilateral. I also like to grade DES as mild, moderate or severe, using clinical judgment and leaning on the DEWS classification. I reserve keratoconjunctivitis sicca (actually in official ICD-10 nomenclature, sicca syndrome with keratoconjunctivitis) for confirmed significant aqueous deficiency (diagnosed with a Schirmer’s test), often associated with Sjögren’s syndrome or other systemic diseases. In regard to the lids, there is unfortunately no MGD code in ICD-10. I have the choice of unspecified blepharitis, squamous blepharitis and ulcerative blepharitis. None of these are diagnoses I utilized prior to ICD-10, but I have decided to use squamous blepharitis for the typical MGD patient. Of course, we now need to code whether the upper lid, lower lid or both are involved and whether it is unilateral or bilateral. I again grade lid margin disease as mild, moderate or severe using clinical judgment. My typical patient with signs and symptoms of bilateral evaporative dry eye with associated MGD will now have as ICD-10 codes: dry eye syndrome of bilateral lacrimal glands (even though the disease has nothing to do with the lacrimal glands) and squamous blepharitis of the right upper, right lower, left upper and left lower eyelid. I am no coding expert, but this seems to be a description that exists in ICD-10, generates a billable code and allows appropriate treatment. It is a lot to write, so I am glad I have EMR and a scribe.

In the next commentary, accompanying more round table discussion, I will discuss my thoughts on the amazing advancements we have for the treatment of DES and blepharitis/MGD/lid margin pathology and the increasing role of our doctors of optometry in the management of ocular surface disease in our practice.

Disclosure: Lindstrom reports he is a consultant for and investor in AcuFocus and TearLab.