It probably doesn’t come as a surprise that our profession writes more prescriptions for dry eye disease (DED) than any other condition and that the vast majority of dedicated dry eye clinics are run by optometrists. Having worked in this field for more than 25 years, during most of which I ran a dry eye clinic, I want to share insights to help save you a few years in developing a successful and rewarding dry eye practice.
Where to Start?
It’s important to have the base to apply your skills. The first piece of equipment I’d recommend purchasing is a slit lamp imaging system. This technology helps you recall the specific staining from an exam that happened three months prior, is a great educational tool and can increase efficiency, as patients are able to quickly understand what you are diagnosing and managing.
Next, you’ll need an instrument for expressing the meibomian glands, such as a Mastrota Meibomian Gland Paddle (Ocusoft), Collins Meibomian Expressor Forceps (Collins) or the Meibomian Gland Evaluator (Johnson & Johnson). In addition, NaFl dye strips and a yellow Wratten #15 filter are essential tools that allow you to see staining of the cornea and the conjunctiva without the need for lissamine green.
Expression is Essential
Imagine deciding to manage glaucoma but refusing to look at the optic nerve. It doesn’t make much sense, but that’s essentially what’s happening if a doctor managing DED doesn’t express the meibomian glands. About 86% of all DED has a meibomian gland dysfunction (MGD) component. It takes seconds to do; you simply look at the lower eyelid central to nasal meibomian glands and assess the quality of meibum you express.
Eyelids are Important
Besides MGD, blepharitis is a significant contributor to DED. Examination of the eyelids will uncover Demodex collarettes, bacterial biofilm, telangiectatic blood vessels indicative of ocular rosacea and thickened eyelids pointing to chronicity—all which help determine how to best treat this form of DED. Morning symptoms are critical and the usual culprit is inadequate overnight eyelid closure.
Make Diagnosis Easy
The TFOS DEWS II algorithm is actually an easy and effective way to diagnose DED. Begin by looking at risk factors, ensure you have symptoms documented through a questionnaire or the patient’s history and confirm with signs such as ocular surface staining or tear break-up time. Once you’ve made the diagnosis, you need to determine the subtype. Abnormal meibomian gland expression will confirm an evaporative form. Normal expression with a very thin tear meniscus indicates an aqueous- deficient DED.
Treat Each Subtype Differently
Although it’s likely that inflammation is present in all forms of dry eye, evaporative DED requires managing obstructed meibomian glands using hydrating compresses and in-office treatments. Aqueous-deficient DED requires managing mucin deficiency (vitamin A ung) and aqueous deficiency requires increasing the tear volume (punctal occlusion). For inadequate overnight lid closure, consider lid seals (SleepTite/SleepRite is one example).
Having the knowledge to effectively manage DED is important, but without properly educating the patient, success is unlikely. I’ve seen patients confuse medication dosage, use ointments instead of prescription drops twice a day and complain about blurred vision. I’ve also seen patients discontinue treatment; many times they were lost because they couldn’t get oriented as to which structure on the eye we were managing. An education tool worth considering is a platform called Rendia, which features patient-friendly animations, an image library and patient point-of-view options.
DED could be optometry’s greatest opportunity, and it starts with your knowledge to simplify the disease and diagnosis. It requires easy but specific treatments for each subtype, meibomian gland expression and a thorough eyelid examination. That’s when things get fun and exciting—when you start seeing patients who failed many times experiencing relief and satisfaction in the care of your hands.
Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.