Several studies estimate dry eye disease (DED) prevalence at more than 30 million—and yet only about 16 million cases are diagnosed and less than 1.5 million are being treated therapeutically.1,2 This is a huge problem for patients in need—and a significant area of growth for our practices. DED diagnosis and treatment can become an integral part of your practice, and this month’s issue covers many aspects that can help boost your dry eye care, including osmolarity testing, systemic confounders and long-term therapy options, to name a few. 

Put a Number on It

I couldn’t run a successful DED clinic without osmolarity testing. It has helped me avoid missteps in more cases than I can count. If a patient measures between 280mOsmol/L and 295mOsmol/L and both eyes are within 5mOsmol/L, chances are slim they have DED. 

Such a quick indicator can be hugely helpful. Just think of the myriad conditions that present with a normal tear film but dry, gritty, burning, irritated eyes: eye misalignment, Salzmann’s, basement membrane dystrophy, conjunctivochalasis, concretions, allergic conjunctivitis, mucin fishing syndrome, Demodex, GPC, limbal stem cell deficiency and many more.

However, osmolarity above 300mOsmol/L, or an inter-eye difference of than 8mOsmol/L, indices a lack of tear film homeostasis and instability indicative of DED.  

A Whole Body Issue

Sjogren’s syndrome (SS), as an important systemic diagnosis, warrants an aggressive treatment regimen combined with systemic immunosuppression. Diagnostic tests such as the Sjö test (Bausch + Lomb) are helping to positively diagnose more patients and get them the treatment they need. SS can affect practically every organ in the body, not just the eyes and mouth—ODs can be crucial care partners to help improve patients’ lives with early diagnosis.

The Long Haul

DED is akin to rheumatoid arthritis: chronic, progressive and with occasional flare-ups. For evaporative DED, long-term treatment might include hydrating compresses, lid hygiene, artificial tears and topical anti-inflammatory meds plus oral omega fatty acids. These patients will occasionally require in-office treatments such as thermal pulsation, blepharoexfoliation and amniotic membrane for persistent corneal superficial punctate keratitis and filamentary keratitis. They may also require topical corticosteroids for flare-ups. Aqueous-deficient dry eye patients often need more aggressive therapy such as autologous serum, punctal occlusion and scleral lenses. 

Ask the Right Questions

One key to reaching undiagnosed patients is better screening. The 2014 Optometric Dry Eye Summit provided four key questions we should ask every patient prior to examination:

  1. Do your eyes tear, burn, feel dry, gritty or irritated?
  2. Are your eyes red or do your eyes occasionally get red?
  3. Do you experience blurred or fluctuating vision?
  4. Are you using or do you feel the urge to use artificial tears?

Asking these questions is a crucial step toward increasing our treatment rates and preventing disease progression. If these screening questions are positive, validated questionnaires are valuable to follow patient symptoms, as are other tests such as osmolarity, vital dyes, meibomian gland expression and meibography. 

An Ounce of Prevention

The recent history of health care generally, and eye care as well, emphasizes preventive medicine. We need to direct more attention to dry eye. This might include the use of an ocular hygenist (perhaps: eye-genist?) who, under the supervision of an OD, would perform blepharoexfoliation, meibomian gland expression and help suggest proper nutrition, hydrating compresses, lid hygiene and lifestyle changes. 

We must get in front of this condition and prevent its progressive, chronic nature from interrupting our patients’ lives.

Dr. Karpecki is a consultant to several companies in the dry eye field.

1.  Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. Am J Ophthalmol. 2003;136(2):318-26.
2. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014;157(4):799-806.