How necessary is point-of-care testing in dry eye disease management?
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
Dry eye disease is a highly prevalent condition encountered by ophthalmologists across subspecialties. Point-of-care testing with the use of high-tech devices has gained an increasing role in the diagnosis and management of dry eye. However, some physicians still feel more comfortable relying on traditional slit lamp and physical examinations. Our monthly discussion focuses on this topic, with Frank W. Bowden III, MD, and Richard S. Davidson, MD, expressing their points of view.
Image: Adobe Stock
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Diagnostic testing supports evidence-based approach to dry eye
Point-of-service diagnostic testing in dry eye disease has been an integral component of my comprehensive anterior segment surgical practice for many years.
These tests support an evidence-based approach to comprehensive dry eye management. It also drives consistency and continuity, particularly in an integrated MD/OD eye care practice. Office protocol-driven point-of-service testing further enhances clinical efficiency as technicians are empowered to perform tests driven by the SPEED questionnaire. The test results are presented to the doctors at the time of surgical consults, dry eye consults and interval general care visits.
Variability in dry eye disease presentation along with sign and symptom discordance create a significant challenge with efforts to engage patient trust and compliance with daily dry eye measures. Effective management of dry eye disease with meibomian gland dysfunction (MGD) requires a commitment to patient education, consistent messaging to patients regarding treatment strategy, and objective metrics for assessment of therapeutic interventions. Diagnostic testing may be helpful to enable coordination of care among multiple providers with a shared general dry eye care protocol. The diagnostic tests may also support efforts to persuade patients to embrace unanticipated medication expenses and self-pay office procedures. In many cases, these tests may not be required for dry eye disease diagnosis; however, they may guide the selection of office procedures and timing for interval visits. It is important to reinforce to patients if their home measures are effective or not with objective metrics regardless of symptoms. This helps to identify those patients with few symptoms yet clinical disease progression. Trend analysis with a testing data flowsheet may also facilitate clinical management with timing of interval MGD procedures, as well.
It may not be practical to embrace all the diagnostic testing platforms and devices available from a cost, space and workflow perspective in most practices. The eye care provider must define their level of dry eye focus accordingly. My selection of diagnostic tests and imaging has been guided by the need to detect loss of tear film homeostasis as well as to recognize changes in meibomian gland structure and function. The consensus statements of the MGD workshop in 2011 and the second dry eye workshop in 2017 have been particularly helpful in this regard. These tests are further selected with patient education in mind. Patients are generally receptive to a comparison of their testing results and images with reference values and images explained by the doctor and dry eye counselor. This approach improves home care compliance, patient satisfaction and continued engagement. Point-of-service diagnostics and imaging have also translated to improved refractive outcomes and reduced chair time dealing with unanticipated postoperative discomfort and visual disturbances in my practice.
- For more information:
- Frank W. Bowden III, MD, of Bowden Eye & Associates in Jacksonville, Florida, can be reached at fbowden3@hotmail.com.
Nothing is as good as a physical exam
In my opinion, nothing is as good as a physical exam. We have relied on this for more than 100 years, and it is sufficient to have a good assessment of what is going on and make a nice plan for the patient.
Whenever I see a patient with dry eye, I need to establish the type and cause — in other words, whether the eye is suffering from insufficient tear production or from lack of oil on the ocular surface and excessive tear evaporation. We can figure that out by closely observing the eye and lids.
First, I want to rule out any type of anatomic lid abnormality. I assess lid apposition and tightness because poor lid apposition of the upper eyelid to the globe may lead to ectropion, which in turn causes poor lubrication of the ocular surface. If there is excessive tearing, I look at the punctum to see if it is in its proper position. Then, I look at the lashes and meibomian glands. I gently press near the glands to see if they are functioning properly and producing sufficient and healthy oil to lubricate the ocular surface. I look at the lid margins to detect potential signs of inflammation, such as small blood vessels growing along the edges.
The next step is the ocular surface, starting from the conjunctiva. A lot of conjunctivochalasis can lead to tearing and foreign body sensation. The eyes may be producing enough healthy tears with good oil in them, but if the conjunctiva is loose, every blink may cause irritation, foreign body sensation and redness. So, we want to look at that as a potential cause. Then I move to the cornea, and here I use some simple testing, such as lissamine green or fluorescein staining. Tear breakup time is a classic test to assess tear film stability, and I look at the tear meniscus to see how high the tears are sitting at the lower lid. All these things together can help determine whether you are dealing with an aqueous deficient or an evaporative type of dry eye or a combination of the two.
Once we have established an etiology, we can make our treatment decisions. Basically, we will adjust therapy based on what we think is going on. So, if there is meibomian gland dysfunction and meibomian gland dropout, then thermal therapy and expression of the lids can be helpful. If it is aqueous deficient dry eye, there are several drops that we can use. A lot of times I have to go through trial and error because dry eye disease is a complex condition, and there is no magic bullet to treat it. We often need multiple attempts and multiple modalities to properly manage the various aspects of dry eye.
- For more information:
- Richard S. Davidson, MD, professor of ophthalmology at UCHealth Sue Anschutz-Rodgers Eye Center, University of Colorado School of Medicine, can be reached at richard.davidson@cuanschutz.edu.
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