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Dry eye work-up is vital
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PHILADELPHIA – William Townsend, OD, has invented a mnemonic device to help practitioners get a complete dry-eye workup from patients.
HMMSST – Her Mother Must Sleep Soundly Tonight – should help optometrists remember to ask about a patient’s history and medications, evaluate the meibomian glands, conduct a Schirmer’s test to determine tear level, stain with lissamine green and determine tear break-up time.
“History is the single best means of diagnosis, both sensitive and specific,” Dr. Townsend told the audience here at the Primary Care Optometry News symposium.
“By the end of the history, you should have a pretty good idea of what it is you’re trying to deal with and where you’re trying to get,” said Christopher J. Quinn, OD, FAAO, Dr. Townsend’s co-lecturer.
Both doctors suggested doctors design a dry eye questionnaire, either by using McMonnie’s (Journal of AOA, April 1987) or making their own.
Systemic medications also exacerbate the symptoms of dry eye, the doctors said. Some drug categories associated with reduced tear production include antispasmodics, antiemetics, antihistamines, tricyclic antidepressants, selective serotonin reuptake inhibitors and antipsychotics.
When examining the meibomian gland, practitioners should determine if orifices are patent, if glands are capping or if there is telangectasia or notching. Dr. Townsend uses transillumination to look for widespread gland atrophy.
Despite some false negative results, Dr. Townsend said he still uses the 101-year-old Schirmer’s – or phenol red thread – test.
“What it does tell us is whether or not the person can produce tears,” Dr. Townsend said.
Staining also is an important test in a dry eye workup, the doctors said. Rose bengal staining indicates that cells have inadequate mucin production, as does lissamine green. Dr. Townsend has designed formulary-prepared syringes for the lissamine green test.
“We have lissamine green flourescein made up by a compounding pharmacy in syringes with a filter on the end,” he said. He then uses the syringe to put the drops in the eye. “We always get the same concentration,” he said.
Finally, both doctors said to examine a patient’s tear break-up time using a nonpreserved saline with a NaFl strip or Dr. Townsend’s syringes.