Diagnose dry eye in a few simple steps
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Even if your practice is pressed for time, you have time to diagnose dry eye disease, treat it and track your results. Diagnosis doesn’t take a lot of extra equipment — just simple steps you can fit into a basic exam.
Dry eye disease (DED) is chronic, progressive and highly prevalent, which makes screening extremely important. Early detection and management of DED can prevent downstream effects, from chronic discomfort and contact lens dropout to meibomian gland atrophy and corneal scarring. You can follow up with periodic medical visits, just as you do with any other chronic condition you’re treating. And because DED causes fluctuating vision, patients both see and feel better when DED is well-managed.
Start with a screening questionnaire
In my practice, patients fill out a simple, effective symptom questionnaire with the rest of their paperwork. The Ocular Surface Disease Index (OSDI) or Standard Patient Evaluation of Eye Dryness questionnaires are both excellent.
For efficiency and ease of use, I choose to use the Symptom Assessment In Dry Eye questionnaire, which is very quick (just two intuitive questions) and has accuracy equivalent to OSDI (Amparo F, et al). My patients’ questionnaire scores help inform my exam.
Perform a basic dry eye evaluation
Just as a screening questionnaire tells us whether the patient is experiencing symptoms of DED, our exam can reveal the signs. We always evaluate patients for redness or inflammation during a routine slit lamp examination, but paired with results from the questionnaire, these signs may support a diagnosis of DED. I also look for telangiectasia, which can accompany ocular rosacea, a common cause of DED.
Next, I look for evidence of damage on the conjunctiva or cornea with fluorescein dye or lissamine green staining. With dye on the eye, I also measure the tear meniscus height (the lacrimal lake) to understand the patient’s tear volume (< 0.2 mm is below normal). As an alternative, you might choose to use a Schirmer’s test or technology to quantify the tear volume. Finally, I apply gentle pressure (about 1.25 g/mm2) to the meibomian glands in the lower eyelid and count how many meibomian glands are yielding liquid secretions (MGYLS). Six or fewer MGYLS indicate meibomian gland dysfunction (MGD).
At this point, if the questionnaire shows that a patient has symptoms of DED and/or my slit lamp exam shows signs, such as corneal or conjunctival staining or low tear volume, we can confidently diagnose DED, initiate the first steps of management, and schedule a medical visit to dig in more and develop a treatment plan.
Initial steps of DED management
Although patients with DED need medical visits for in-depth management, we can get patients started with early care before they return for that visit. I have all patients start using a “dry eye bundle” that includes daily warm compresses, omega supplements and lid scrubs. I also want patients to proactively use preservative-free artificial tears in the morning and every few waking hours to help hydrate, nourish and calm the ocular surface without risk of ocular surface toxicity.
With so many confusing artificial tear options available, I’m very clear about the tear I want patients to use. I’ve been starting patients on iVizia (Théa), a drop with povidone — a lubricating, viscosity-enhancing ingredient — as well as hyaluronic acid and trehalose, which protect and rehydrate the eye (Liu Z, et al). The drops come in a safe, convenient multidose bottle that my patients find easy to use.
Some patients’ conditions benefit from other early treatments. For example, if there is staining or a patient has red, inflamed eyes, I immediately order a short-term steroid such as Eysuvis (loteprednol etabonate ophthalmic suspension 0.25%, Kala Pharmaceuticals), rather than waiting for the medical visit.
Recheck in 2 to 4 weeks
When patients return for a medical visit, I track their progress using the same tests (questionnaire, slit lamp exam, staining and tear meniscus measurement). I compare the results against baseline while I talk to patients about their experience in the last few weeks. If there are positive results, then the dry eye bundle, including proactive artificial tears, may be enough.
If there’s no improvement or too little, patients continue first-line therapy while adding second-line treatments. At this point, you can choose to perform second-line treatments yourself, such as prescribing immunomodulator drops like Restasis (cyclosporine ophthalmic emulsion 0.05%, AbbVie) or Xiidra (lifitegrast ophthalmic solution 5%, Novartis), or refer the patient to a specialist.
In my DED specialty practice, I perform additional tests for inflammation, tear quality, tear meniscus height and tear breakup time, MGD and other factors as needed. I also perform thermal pulsation (iLux, Alcon; LipiFlow, Johnson & Johnson Vision) for inspissated meibum, light-based therapy (OptiLight, Lumenis) for both MGD and lacrimal functional unit dysfunction, and severe DED treatments such as amniotic membrane, amniotic or autologous serum, or platelet-rich plasma eye drops.
Keep following up
To manage DED effectively, we need to see patients regularly and track their results. A good rule of thumb is to see patients once a month to track their progress with at-home care and prescriptions, and then stretch that to 6 months once their condition is stable.
Because I perform in-office procedures, I see patients several times in the first few months before switching to a 6-month interval. By tracking how well current therapies are working at regular follow-up visits, we can adjust the management plan to ensure DED patients maintain a stable tear film and clear vision.
Editor's note: This article was updated June 1, 2023, to change the name of iVizia's manufacturer to Théa.
References:
- Amparo F, et al. Ophthalmology. 2015;doi:10.1016/j.ophtha.2015.02.037.
- Astolfi G, et al. J Clin Med. 2022;doi:10.3390/jcm11061518.
- Casey-Power S, et al. Pharmaceutics. 2022;doi:10.3390/pharmaceutics14071479.
- Fariselli C, et al. Clin Ophthalmol. 2018;doi:10.2147/OPTH.S174290.
- Liu Z, et al. Invest Ophthalmol Vis Sci. 2020;doi:10.1167/iovs.61.10.26.
David Kading, OD, is CEO at Specialty Eye in Kirkland and Bellevue, Washington.
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