Thorough dry eye evaluation can help personalize treatment
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Dry eye disease has no specific diagnostic approach despite its high prevalence. Understanding an individual patient’s visual challenges and test results is the optimal path to personalizing treatment options.
“Incorporating dry eye diagnostic testing is vital for a successful contact lens practice,” Stacy Zubkousky, OD, FSLS, from the Weston Contact Lens Institute in Weston, Fla., said in an article on Healio.com. “Evaluating the type and severity of dry eye is crucial in determining the ideal contact lens choice and dry eye treatment that will facilitate ultimate success for that lens.”
Working in a specialty contact lens practice, Zubkousky often sees patients struggle to continue to wear contact lenses along with those who have altogether stopped due to dry eye symptoms.
Source: Stacy Zubkousky, OD, FSLS
“Often these patients will remark that contact lenses are not for them, but they do not really understand why and are typically unaware of the many treatment options that could result in successful contact lens wear,” she said. “While some modifications in contact lens modality, material and solution can help with tolerability, treating the patient’s underlying dry eye disease is essential for a positive contact lens experience.”
Zubkousky highlighted meibomian gland imaging or meibography as a diagnostic tool that provides insight into the prevalence of dry eye disease. About 85% of dry eye is evaporative in nature and stems from meibomian gland dysfunction (Findlay, et al.), she said.
“When presented with this overwhelming statistic, it makes sense for an eye care practitioner to start here, at the root of the problem,” Zubkousky said.
Meibomian gland imaging devices currently available include LipiScan (Johnson & Johnson), LipiView II Ocular Surface Interferometer (Johnson & Johnson), Oculus Keratograph 5M and Meibox and MX2 (Box Medical Solutions). These devices provide imaging of the patient’s oil glands and quantify the amount of atrophy, which allow the practitioner to determine the best course of treatment and contact lens choice.
In contrast to traditional belief that dry eye syndrome was a condition exacerbated by inflammation and advancing age, a recent study showed that most asymptomatic children age 4 years to 17 years old had at least mild meibomian gland atrophy (Blackie, et al.). As atrophy is a lifelong process and can be expedited by the growing regularity of digital device use, early intervention becomes essential to extend contact lens tolerability.
“Having a profile of the robustness and posture of an individual patient’s meibomian glands helps twofold: the image provides the patient with a direct visualization of their individual glands, motivating them to pursue intervention prior to onset of symptoms; and it enables practitioners to better treat patients by suggesting personalized therapies, contact lens materials and modalities that best serve them,” Zubkousky said.
Another diagnostic tool is InflammaDry (Quidel), which is useful for a complete dry eye work-up or in determining a topical treatment of steroids or immunomodulatory agents such as Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan), Xiidra (lifitegrast ophthalmic solution 5%, Novartis) or Cequa (topical cyclosporine ophthalmic solution 0.09%, Sun Pharmaceutical).
This in-office test detects elevated levels of matrix metalloproteinase-9 (MMP-9), an enzyme implicated in the propagation of inflammatory dry eye disease. Zubkousky said that the tool is particularly useful for patients who wear contact lenses and show little to no clinical signs of dry eye but are symptomatic for dry eye while wearing contacts.
“Not all diagnostic testing requires significant monetary investment on the part of the practitioner,” she said. “Schirmer test is an inexpensive method of assessing tear production involving the placement of a filter paper strip into the lower fornix of the eye for several minutes. If the tear production is under 10 mm, it is considered abnormal and suggests aqueous deficient dry eye. Schirmer testing is performed on my patients during a complete dry eye evaluation. This test is particularly useful when I suspect Sjögren’s syndrome.”
Another option that does not require additional equipment is tear break-up time (TBUT). When a patient wears contact lenses, the tears are separated into pre- and post-tear film (Markoulli, et al.). Evaluating the overall tear film quality and stability can further help the clinician understand why a patient may be experiencing dryness with their contact lenses.
“This is measured by instilling sodium fluorescein dye into the patient’s eye and observing the tear film evaporation under cobalt blue light,” Zubkousky said. “The patient is asked not to blink, and the tear stability is documented by the number of seconds that the tear film coats the cornea before the onset of desiccation. A result under 10 seconds suggests evaporative dry eye.”
Zubkousky recommends the Lipi-View II, which can can measure lipid layer, and the Oculus Keratograph 5M, which takes a noninvasive TBUT measurement without the need for dye.
“A toolbox of diagnostic dry eye tools is important for any contact lens practice,” she concluded.
Literature review assesses diagnostic options
Kevin Wu, MD, and colleagues conducted a literature review that was published in the Journal of Clinical Medicine and focused on the assessment of tear volume and tear osmolarity.
“Dry eye disease [DED] affects tens of millions of people and poses a clinical challenge due to differences in patient-reported symptoms and physician-observed findings,” co-author Wu, a resident at Icahn School of Medicine at Mount Sinai, told Primary Care Optometry News.
“Patients often respond differently to intervention, signifying a growing need for advances in diagnosis and treatment techniques that allow for patient-specific management,” he said. “Our review seeks to not only highlight recent advances in dry eye disease diagnosis and treatment, but also note opportunities for future research and endeavors to benefit patients.”
The review evaluated the following outcomes:
- Raj and colleagues found no significant correlation between the tear meniscus (TM) area as measured by TBUT with the Keratograph 4, Fourier domain OCT and the Schirmer test.
- Fukuda and colleagues found a significant correlation between upper TM volume, lower TM volume and lower TM height (TMH) with the Schirmer test, but not with TBUT.
- Baek and colleagues found a significant correlation between TMH measured with keratography and FD-OCT, but keratography reported lower results in TMH elevation.
- Rocha and colleagues deemed the Wescor Vapro 5520 Pressure Osmometer accurate and precise for measuring tear osmolarity, and Yoon and colleagues came to the same conclusions for the TearLab Osmolarity System.
- Badugua and colleagues developed a novel technique for determining individual ion concentrations in tears using silicone hydrogel.
- Inomata and colleagues reported that maximum blinking interval (MBI) was significantly shorter in a DED group compared to the non-DED group. There was also a positive correlation between MBI and TBUT, with a negative correlation between MBI and corneal fluorescein staining.
- Palmar and colleagues reported using OCT to visualize significant meibomian gland loss in the lower eyelids of individuals with ocular rosacea.
- Finis and colleagues reported that the degree of meibomian gland atrophy in the lower and upper eyelids significantly correlated with TBUT and age.
- Sambursky and colleagues reported an 85% sensitivity and 94% specificity for InflammaDry DED diagnosis.
“Impression cytology combined with mass spectrometric analysis of metabolites (including those related to signaling lipids and oxidative stress) is another method that has potential to guide diagnosis and patient-specific treatment of dry eye disease,” Wu said. “[Co-author] Dr. Mashaghi’s group has just finished a study of metabolomics analysis on a small number of cells collected from ocular pemphigoid patients; a similar analysis can be done on dry eye disease patient cells.”
Dry eye treatment paradigm shifts
“Dry eye syndrome affects a significant portion of the population and often goes undiagnosed or ignored,” Margie Recalde, OD, owner of Lifetime Optometric, a private practice in the Central Valley of California, wrote in her Healio blog. “Besides being uncomfortable, dry eye contributes to visual disturbance and, left unchecked, can potentially damage the ocular surface. Dry eye symptoms may be triggered by a number of environmental or physiological factors, and it is our responsibility to identify and treat the root cause.”
Recalde discussed the Dry Eye Workshop II report, which updated the definition of dry eye to a loss of homeostasis in the lacrimal functional unit (the tear glands, nerves, conjunctiva and other systems that work together to keep the eyes moist and comfortable), rather than focusing on a single factor like a lack of tears or a problem with meibum.
“This idea of homeostasis emphasized restoring balance to a complex system, rather than treating symptoms,” she said. “We have a variety of diagnostic tools to identify patients at risk for dry eye disease and multiple treatment options to intervene early, potentially delaying later, more debilitating disease stages.”
Just as a comprehensive eye exam includes glaucoma screening for each patient, Recalde also checks for dry eye disease. She has her patients complete a survey, such as the Standardized Patient Evaluation of Eye Dryness questionnaire. This can help quickly point to or rule out the likelihood of dry eye.
Additionally, she advised that ruling out meibomian gland disease, another common cause of dry eye, is essential.
“We can safely diagnose dry eye with equipment that every optometry practice has: slit lamp, fluorescein strips and lissamine green strips. Including a dry eye questionnaire in your evaluation can help provide an objective measure of their symptoms at baseline and moving forward,” Recalde concluded. “We can level up our diagnostics with noninvasive technology for measuring tear breakup and tear osmolarity tests.” – by Talitha Bennett and Erin T. Welsh
Disclosures: Recalde reports she is a speaker/consultant for Allergan, Bausch + Lomb and Sun Pharma. Wu and Zubkousky report no relevant financial disclosures.
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