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Dry eye not just a biological condition
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LAS VEGAS – Patients with dry eye symptoms but no signs may fit the criteria for a chronic pain disorder, Richard Adler, MD, said here at Vision Expo West.
Adler was part of the Ocular Surface Disease and Wellness Symposium panel, which was co-sponsored by Primary Care Optometry News.
“To reduce these to a merely biological construct misses chronic pain disorders,” he said. “Dry eye is not simply cause and effect. It is a non-linear experience of multiple dimensions of ideas influencing our patients simultaneously and impacting the experience of dry eye disease. The way a patient perceives their disease affects how they will experience it.”
Adler said two significant changes in the definition of dry eye syndrome implemented by the Tear Film and Ocular Surface Society Dry Eye Workshop II involved the addition of the terms “homeostasis” and “neurosensory.”
“Homeostasis is an idealized molecular state on the cornea,” he said, “with an intent to preserve a physiological norm even in the absence of disease.”
Regarding the term neurosensory, he said: “We’re faced with a new etiological explanation. With neurosensory in the definition we have a potential explanation for why you can see a patient who’s miserable but can appear to have a normal slit lamp exam.”
Adler calls this condition “pain without stain.”
“They have every sign and symptom,” he said. “They’re sensitive to cold, wind and light. But the cornea is perfect. One of the challenges we have in dry eye is that the signs and symptoms correlate poorly. Other patients have all sorts of signs but are as happy as can be.”
Adler said that the biopsychosocial model, with the premise that diseases are not simply about biology, was introduced in 1980. He explained that multiple dimensions, including psychology and social factors, impact disease.
Adler used irritable bowel syndrome as an example of having “symptoms and behaviors and biological aberrations, but also social factors such as diet and fiber intake and psychological impact like stress.”
He suggested applying this model to dry eye.
“Start with biology, including neuropathic and chronic pain,” he said. “You see nothing on the slit lamp in a patient with chronic pain disorder.”
He said to consider the role of anxiety in this condition.
“Do you think if a patient is more anxious they’re more likely to experience their symptoms more intensely?” Adler said. “You could make this case about any disease. There’s no tidy package for dry eye. There’s no clear beginning or end like a cataract being removed or glaucoma pressure being up or down. It’s not as clearly defined.”
Studies have shown a correlation between anxiety, depression and dry eye, he added.
onsider the social dimension, he continued.
“Imagine the patient has been from doctor to doctor and is told nothing is wrong,” Adler said. “if the doctor has a bad attitude, how will that affect the patient’s experience?”
With dry eye, the patient has decreased tear production, which leads to increased pain, then decreased job performance, then anxiety, then the use of anticholinergic medications, he said.
“There’s the biology, psychology and social aspects,” he said.
“Assume excessive computer use leads to dry eye, apathy or lack of interest regarding dry eye and exacerbation by disease, and job performance is affected,” he continued. “This is the influence of biological and psychosocial factors.”
Diagnostic tests and devices also treat the patient, Adler said.
“You have a test you can use to talk to your patient – a test to use to educate and improve compliance,” he said.
Performing tests improves the doctor-patient relationship, decreases anxiety and potentially reduces chronic pain symptoms – social, biological and psychological influences, Adler said. – by Nancy Hemphill, ELS, FAAO
Reference:
Adler R, et al. The dry eye institute: The “why” and the integrated health care model. Presented at: Vision Expo West; Las Vegas; Sept. 13-16.
Disclosure: Adler is a consultant to Allergan, Lumenis and Topcon.