Definitions and terms in dry eye: Do the words matter?
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Writer’s block is not really a common thing for me, but I do have to admit that there are times when I just sit, stare at my laptop, and hope that some sort of inspiration will drive my fingers across the keyboard.
Not often, mind you, but I will say that there was a whole lotta “sometimes I just sits” going on for this column. Occasionally I have a series of columns, ideas that stack up nicely and fall into place as naturally as the tumblers in a lock when you turn the key. Other times, mostly over on the blog but here in the column, too, the fruit is all low-hanging and just waiting to be picked. Pretty much every time I write about AzaSite (azithromycin ophthalmic solution, Théa), for example. This month? Not so much.
And then the mail arrived, and with it came inspiration wrapped in the deep blue of the March issue of Ophthalmology.
I am a words guy. The son and grandson of English teachers, I grew up in an environment that prized the proper use of the language. Finding the perfect word to convey a concept was handsomely rewarded. This has extended to all of my writings, be they personal or professional. Indeed, in order to have a conversation, whether in person or through the medium of the written word, I take great pains to begin each “conversation” by establishing the boundaries that will contain the interaction and to provide precise definitions of the terms to be used therein.
It will come as little surprise, then, that the editorial “Which dry eye? The case for precise diagnostic terminology in ophthalmology” by Anat Galor, MD, and colleagues was such an interesting and surprising “find” given the intersection between one of my major clinical interests — dry eye disease — and my love for precise language. I read it through, slowly and carefully, three times. While I do not know co-authors Ninel Gregori, MD, and Todd Margolis, MD, I am a card-carrying member of the Anat Galor fan club. The authors set for themselves the task of explaining the subtle effects that the words chosen to describe a clinical entity can, in and of themselves, exert an influence on treating that entity. Their primary foil, nay, their muse, it seems, is dry eye.
In their hearts of hearts, it seems to me that they really want us all to stop using “dry eye” and “dry eye disease.”
This is not the first time dry eye disease (DED) as a name has come under fire. Who remembers the gallant effort made some 10 or 15 years ago in which we were all encouraged to abandon “dry eye disease” in favor of “ocular surface disease”? Right around the time of the first DEWS report, if I recall correctly. I would really like to say that this effort went down in flames, but in reality, it just kind of faded away into the mist. Why? I think because the term “ocular surface disease” simultaneously means everything under the umbrella of DED and, well, everything that is wrong on the eye. While encompassing everything, it ends up meaning nothing.
Galor and colleagues find it troubling that patients, non-ophthalmologists and even ophthalmologists who do not specialize in ocular surface disorders will assume that the eye is dry in the most simple and straightforward way: like a desert bereft of water, one who suffers from DED just does not have enough tears. My son Randy, one of our techs, leans a bit toward this point of view when he receives pushback from patients who complain that their eyes do not feel quite right but that what they feel is not “dry.”
On the surface (see what I did there?), this is fair enough, both from our patients and from the authors of the editorial. But we have retina specialists who discuss macular degeneration as “wet” or “dry” with patients, physicians who are not ophthalmologists and non-retinal trained ophthalmologists. We know that the details that lie just below either “wet” or “dry” are almost countless and that they are relevant when it comes to treatment and prognosis, and yet I do not recall such constant dismay over these words. I believe this is because “wet” and “dry” are descriptors of a state. By themselves, they are neither diagnostic nor do they point to a specific treatment. In a directly similar way, we should see “dry eye disease” as a descriptor of a state: The surface of the eye is functionally dry, whether that state has been reached through a lack of tear quantity or tear quality.
Here I find myself nodding along with Dr. Galor and her colleagues as they bemoan the fact that the most commonly referenced definition of DED suffers from a similar “everything under the sun” syndrome. DEWS II “incorporates dozens of different conditions that have different pathologic causes and correspondingly different optimal therapies.” This aligns with everything I do as a writer. Defining a pivotal term should be a process of precision. A truly useful definition should be as concise and should pronounce its meaning in a manner similar to a single stanza in a poem. DEWMD fits the bill: “Reduced quantity or quality of the tear film resulting in ocular discomfort, visual disturbance or both.”
The eye is functionally dry. To quell the burning of a fire in a desert, one must use a functional lubricant. Although it is wet, kerosene, like tears that function poorly for whatever reason, will not quench the flames.
I could quibble with other details, of course. Knowing that increased exposure to air increases the evaporation of a water-based fluid resting on a surface and that air moving across a moist surface increases it yet again, is it truly necessary to measure the rate of evaporation of the aqueous portion of the tear film in order to name this type of DED “evaporative”? Much of the rest of the editorial is extremely sound, both in its reasoning and in what the authors suggest going forward. For instance, they suggest that each “dry eye” case be further subclassified along lines of specific pathology that would lend itself more readily to precise interventions. They implore us to use “accurate words” to identify local, periocular and systemic contributors to the symptoms of an individual patient. Drs. Galor, Gregori and Margolis have made an eloquent and impassioned case for increased precision in our terms and definitions. On these points, I think we can all agree.
However, I believe that we are all still going to be calling this “dry eye.”
- References:
- Galor A, et al. Ophthalmology. 2023;doi:10.1016/j.ophtha.2022.12.001.
- White DE. DEWMD: A lean definition of dry eye. https://www.healio.com/news/ophthalmology/20211015/dewmd-a-lean-definition-of-dry-eye. Published Oct. 20, 2021. Accessed March 24, 2023.
- White DE. Sometimes I sits and thinks. https://www.healio.com/news/ophthalmology/20210810/sometimes-i-sits-and-thinks. Published Aug. 18, 2021. Accessed March 24, 2023.
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
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