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Choosing dry eye treatment: The role of the exam
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In an earlier post, I offer the SkyVision philosophy on when to treat a patient with dry eye.
For the most part, we treat patients when they have symptoms, although admittedly we have a rather broad definition of what constitutes symptoms resulting from dry eye.
Remember what the smart guy said: “You can’t make an asymptomatic patient feel better”? The logical extension of this philosophy is that it is the sum total of the data collected in the exam that then determines the variety of ocular surface disease present. That, in turn, should drive the treatment.
Through the good graces (or momentary bouts of insanity) of a number of groups, I have been invited to sit at the table with a bunch of really smart eye docs who take care of dry eye syndrome. There is a common thread that emerges at these meetings: all the docs who do a great job treating dry eye/ocular surface disease create an examination protocol to which they relentlessly adhere.
It’s not rocket science, and most of what the basic dry eye exam involves is the “blocking and tackling” of our everyday clinical existence. If there’s anything extraordinary about these protocols, it is simply the dogged devotion to following them every single time, especially for the initial evaluation.
Some examples: Visual acuity, near and far, with best correction of whatever type; a Schirmer test, with or without anesthesia, but consistently one or the other; tear osmolarity (sorry, this is just the way it’s going and you can’t escape it); a slit lamp exam that begins with a detailed examination and description of the lid margin and meibomian glands (including expression of Mebum) and includes tear film, tear break-up time and staining patterns (consistently using the same dye, whichever you choose).
It’s pretty basic stuff for sure, just like blocking and tackling in football. But without the basics done right and done every “play”, it’s tough to win the game.
At the end of the day, the exam is what lets us do the cool doctor thing we were put here to do: make an exact diagnosis and then get to work treating it.
Next up: using the exam to differentiate dry eye syndrome types. See ya then.