Dry eye: no longer a treatment conundrum

Issue: November 2005

ByMichael D. DePaolis, OD, FAAO

Michael D. DePaolis, OD, FAAO [photo]
Michael D. DePaolis

Merriam-Webster defines conundrum as “a question or problem having only a conjectural answer.” For sure, life is full of conundrums, and our professional existence is no different. When I think of the many conundrums we face on a daily basis, perhaps none is more evident than that of dry eye.

At first blush it really shouldn’t be that complex. A patient complains of dryness, an examination reveals dryness, and lubricating drops are prescribed. Unfortunately, we learned long ago that it isn’t that simple. The eye – with a very limited repertoire of symptoms – often sends mixed signals to both patient and doctor. It’s rarely just a complaint of dryness or grittiness, but rather stinging, burning, itching, variable vision and even tearing.

The examination can be equally confounding, with no single definitively diagnostic test. While we rely on questionnaires and a variety of tests, it’s not unusual to find conflicting results. With such a clinical conundrum, it’s easy to see why selecting the proper treatment strategy can be so daunting.

Conjecture leads to finding solutions

While a conundrum might have only a “conjectural” answer, this isn’t always such a bad thing. Conjecture is all about thinking, debating and finding solutions. Certainly there’s been a great deal of conjecture about dry eye – its etiology, diagnosis and treatments. This intellectual exercise is proving to be rather fruitful as we are now beginning to understand the role that neurotrophic states, hormonal imbalance and ocular surface inflammation play in propagating dry eye. We also better appreciate the significance of certain tear film inflammatory mediators as a harbinger of tissue change. In short, we have a much better sense of the pathophysiology underlying dry eye.

From a clinical perspective, these concepts are proving to be much more than theoretical constructs. They have been the basis for more targeted diagnostic questionnaires. They have also helped us better understand the significance of certain slit lamp findings and the benefit of a variety of ancillary tests. Most importantly, they have been the foundation for a more rationale approach to treatment.

Better management for today’s patient

Today’s dry eye patients are much more effectively managed than those of just a few short years ago. We more effectively counsel patients on environmental and lifestyle issues as well as provide dietary guidelines such as omega-3 intake. Where appropriate, we also prescribe lid hygiene and tear conservation techniques such as punctual occlusion. We no longer simply “splash” the ocular surface with any available eye drop. Rather, we select from a wide array of highly specialized eye drops designed to integrate with and fortify the tear film.

We also employ a variety of immunomodulators – both oral and topical – to quell inflammation and enhance tear production. Finally, for our patients who are interested in contact lenses, we prescribe from a wide array of materials, designs and care products specifically engineered for the dry eye patient.

The message is a simple one. No longer should dry eye be considered insurmountable. We now have the knowledge and tools to sort out the subtleties of each case and treat in a more targeted fashion. Adopting this philosophy means that there is one less conundrum that you – and your patients – deal with today.