Download a dry eye disease decision tree

CORNEA/EXTERNAL DISEASE
A DRY EYE DISEASE
DECISION TREE
With the DEWS guidelines almost 10 years old, new approaches are needed.
BY JASON SCHMIT, OD
I am sometimes asked about medical
decision-making by students, interns, fellows, or optometry colleagues. “How did
you come up with that decision in managing that ocular surface disease case?” I give
the answer appropriate to the particular
case, but I also note that sometimes it
comes down to experience. “That’s why
they call it ‘practicing medicine,’” I say. “At first, it might
seem that we are ‘practicing’ with patients. But, with experience, decision-making becomes more instinctual and less
like practicing.”
The first step in developing the most appropriate treatment plan for a patient with dry eye disease (DED) is to
correctly categorize the stage and type of DED the patient
exhibits using the available technology. Then address the
patient’s symptoms using the appropriate evidence-based
therapies.
To make the right diagnosis, start with a complete DED
examination. Think of this as analogous to diagnosing and
managing glaucoma. Primary open-angle glaucoma is a
diagnosis of exclusion: the patient’s intraocular pressure,
nerve fiber layer, visual fields, cup-to-disc ratio, corneal
hysteresis, anterior angles via gonioscopy, medical and
family history, and other ancillary factors are all assessed.
Treatment is based on whether aqueous production must
be reduced or outflow must be improved. Then, over
time, the patients is reassessed to determine if the patient
is reaching target pressure or not and whether the visual
field is stabilizing. If not, the treatment plan must be made
more aggressive. A similar process goes on in the care of
patients with DED.
In 2007, a committee of optometrists, ophthalmologists, and scientists convened the International Dry Eye
WorkShop (DEWS). The aim of DEWS was to outline the
information needed to fully diagnose and treat patients
with DED. In the almost 10 years since that effort, there
have been significant advances in the field of DED. This
article presents an update on how we approach the management of this disease where I practice, Vance Thompson
Vision.
12 ADVANCED OCULAR CARE | JULY/AUGUST 2016
Figure 1. The cyclic cascade of inflammation in DED.
MULTIFACTORIAL DISEASE
Reports of the prevalence of DED varies in the literature,
but is estimated to affect 30 to 40 million adults in the
United States, or about one out of every seven adults, and
it is twice as common in women as men.1,2
DED, as defined by the DEWS, is “a multifactorial disease
of the tears and ocular surface that results in symptoms
of discomfort, visual disturbance, and tear film instability,
with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.”3 As many as 50% of patients
with DED are asymptomatic, so it is important to screen
all patients for DED.4 This can easily be done using one of
the DED questionnaires that are readily available, such as
the Standard Patient Evaluation of Eye Dryness (SPEED)
questionnaire.5
It is also important to understand that there are two
types of DED: evaporative and aqueous-deficient.6 Purely
Dry eye severity level
1
2
3
4
Discomfort, severity,
frequency
Mild and/or episodic;
occurs under environmental stress
Moderate episodic or
chronic, stress or no
stress
Severe frequent or constant without stress
Severe and/or disabling
and constant
Visual symptoms
None to episodic mild
fatigue
Annoying and/or activity-limiting episodic
Annoying, chronic and/
or constant, limiting
activity
Constant and/or possibly
disabling
Conjunctival injection
None to mild
None to mild
+/-
+/++
Conjunctival staining
None to mild
Variable
Moderate to marked
Marked
Corneal staining
None to mild
Variable
Marked central
Severe punctate erosions
Corneal tear signs
None to mild
Mild debris
Filamentary keratitis,
mucus clumping, tear
debris
Filamentary keratitis,
mucus clumping, tear
debris, ulceration
Lid/meibomian glands
MGD variably present
MGD variably present
MGD frequent
Trichiasis, keratinization,
symblepharon
TBUT (sec)
Variable
< 10 sec
< 5 sec
Immediate
Schirmer score
Variable
< 10 sec
< 5 sec
< 2 sec
Abbreviations: DEWS, Dry Eye WorkShop; MGD, mebomian gland dysfunction; TBUT, tear breakup time.
aqueous deficient DED is relatively rare, occurring in
only about 10% of cases.7 Meibomian gland dysfunction
(MGD) has been shown to be evident in about 86% of all
DED cases, far outweighing purely aqueous deficient DED.
Many patients have a combination of both conditions.7
Three forms of MGD have been recognized: hypersecretory, hyposecretory, and obstructive, with obstructive the
most common.
The incidence of MGD is thought to be rising because
of an increase in incomplete blinking among patients.8 As
use of computers and handheld mobile devices and smartphones increases, users tend not to blink as frequently
or as completely as previously. The squeeze action that
occurs with a blink is the force needed to release oil from
the meibomian glands. With incomplete blinking, the oils
in the glands become stagnant, hyperkeratinization of the
meibomian ducts occurs, and the glands start to atrophy,
a phenomenon termed disuse atrophy.9 As this cycle
occurs over long periods of time, further gland atrophy
occurs, and, with the reduction of the lipid content of
tears, evaporative DED develops.
This understanding is important to frame your
approach to treating patients with DED; everyone must be
assessed for DED. Much of the initial management will be
based on the results of testing for osmolarity and inflammation. Most cases of DED are evaporative in nature due
to deficiencies of the meibomian glands, and therefore
gland imaging is a crucial component of assessment.
INFLAMMATORY CASCADE
When we delve into what is happening in the inflammatory process at the cellular level, we find a cyclic cascade
of events occurring. Intercellular adhesion molecule 1
(ICAM-1) is a protein found in the epithelial and endothelial cells of ocular tissues. ICAM-1 is found in excess in
patients with DED. Adhesion molecules aid in recruiting
other mediators toward sites needing attention. In this
case, ICAM-1 is sending signals for other inflammatory T
cells to flock to its site to promote inflammation. A receptor on inflammatory T cells called lymphocyte functionassociated antigen 1, or LFA-1, adheres to ICAM-1, activating the T cells and releasing cytokines that further increase
ICAM-1 expression, leading to the continuation of the
cycle of inflammation (Figure 1).10
JULY/AUGUST 2016 | ADVANCED OCULAR CARE 13
CORNEA/EXTERNAL DISEASE
TABLE 1. DEWS CLASSIFICATION: DRY EYE SEVERITY GRADING SCHEME3
CORNEA/EXTERNAL DISEASE
Figure 2. Stages of DED, evidence-based testing.
Figure 3. DED treatment initiation.
14 ADVANCED OCULAR CARE | JULY/AUGUST 2016
A BETTER NOMOGRAM
The guidelines for managing DED based on the 2007
DEWS findings are now almost 10 years old.11 The DEWS
treatment recommendations are stratified according to
the severity of the disease (Table 2).
“
At Vance Thompson Vision, we
have been diligently working
on developing a nomogram to
better classify the diagnostic
levels of DED.
At Vance Thompson Vision, we have been diligently
working on developing a nomogram to better classify the
diagnostic levels of DED (based on severity and progression), as well as an algorithm tool for eye care providers.
This tool would guide treatment decisions taking into
consideration the diagnostic technologies now available
and the treatments that might not have been available
at the time of the DEWS report almost a decade ago.12
This nomogram includes a three-part process: clinical
indicators, treatment options, and engagement (Figures
2-4) The first part (clinical indicators) includes all of the
structured and standardized testing needed to diagnose
patients into the correct stage of DED. The second part
(treatment options) then allows the clinician to better
manage the patient, by instituting the proper treatment
regimen paired with the corresponding diagnostic tests.
Figure 4. Recommended clinic engagement for DED patients (annualized).
JULY/AUGUST 2016 | ADVANCED OCULAR CARE 15
CORNEA/EXTERNAL DISEASE
GRADING DED
One of the products of the DEWS effort was a schema
that helps practitioners to grade the level of severity of
DED (Table 1). What is nice about this classification system is that it directly corresponds to both subjective and
objective testing that eye care providers routinely utilize
in clinical practice.
Two factors that this system does not include, however, are osmolarity (per the TearLab test) and inflammation
(per the InflammaDry test), both of which are included
in the DEWS definition of DED. In modern practices,
osmolarity can be assessed using the TearLab Osmolarity
Test (TearLab) and inflammation can be assessed with
the InflammaDry test (Rapid Pathogen Screening). With
the further understanding of the inflammatory element
of DED, measurement of inflammation is crucial for the
success of treatment and management. Because imaging
devices that perform meibography, such as the LipiView II
(TearScience) and Oculus Keratograph systems, are now
available, this information can also be assessed and used
to determine the proper course of action.
CORNEA/EXTERNAL DISEASE
TABLE 2. TREATMENT OF DRY EYE
DISEASE ACCORDING TO SEVERITY3
Level 1 treatment consists of the following:
• education and environmental or dietary modifications
“
DED is multifactorial, but it is
defined by abnormal osmolarity
and inflammation.
• elimination of offending systemic medications
• preserved artificial tear substitutes, gels, and ointments
• eyelid therapy
If level 1 treatment is inadequate, level 2 measures are
added, including the following:
• nonpreserved artificial tear substitutes
• antiinflammatory agents (topical cyclosporine, topical steroids)
• tetracycline (for meibomitis or rosacea)
• punctal plugs (after inflammation has been controlled)
• secretagogues
• moisture chamber spectacles
If level 2 treatment is inadequate, level 3 measures are
added, including the following:
• autologous serum or umbilical cord serum
• contact lenses
• permanent punctal occlusion
If level 3 treatment is inadequate, level 4 treatment,
consisting of the administration of systemic
antiinflammatory agents, is added.
Finally, the third part (engagement) helps to set the
standard for having patients return for follow-up care.
(There can be nearly $400 in additional revenue annually
when patients return for their scheduled DED follow-up
appointments. In addition, incorporating a DED retail
center into the practice can be another significant source
of revenue.)
patients on the root causes of their DED problems
is critical to increase patient compliance with your
selected treatment plan. Specifically targeting the causes
of each patient’s DED with products and treatments
designed to improve function will make a difference in
your patient’s well-being and quality of life.
DED is multifactorial, but it is defined by abnormal
osmolarity and inflammation. If you incorporate new
testing modalities into your practice and follow a systematic protocol for management of the disease, hopefully your decision-making will be less like “practicing
medicine” on your patients. You can potentially make
your patients, and yourself, much happier. n
1. 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.
2. Howden LM, Meyer JA. Age and Sex Composition: 2010. United States Census Bureau. May 2011. http://www.
census.gov/prod/cen2010/briefs/c2010br-03.pdf. Accessed May 4, 2016.
3. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of
the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):75-92.
4. Sullivan BD, Crews LA, Messmer EM, et al. Correlations between commonly used objective signs and symptoms
for the diagnosis of dry eye disease: clinical implications. Acta Ophthalmol. 2014;92(2):161-166.
5. Ngo W, Situ P, Keir N, et al. Psychometric properties and validation of the Standard Patient Evaluation of Eye
Dryness questionnaire. Cornea. 2013;32(9):1204-1210.
6. American Academy of Ophthalmology. Dry Eye Syndrome PPP - 2013. http://www.aao.org/preferred-practicepattern/dry-eye-syndrome-ppp--2013. Accessed May 4, 2016.
7. Lemp MA, Crews LA, Bron AJ, et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based
patient cohort: a retrospective study. Cornea. 2012;31(5):472-478.
8. Blackie CA, Korb DR. Non-obvious meibomian gland disease. Optometric Management. June 2010.
9. Jester JV, Parfitt GJ, Brown DJ. Meibomian gland dysfunction: hyperkeratinization or atrophy? BMC Ophthalmol.
2015;15 Suppl 1:156.
10. Cunningham KN. Overexpression of ICAM-1 in dry eye disease. Shire ClinTopics. S11568, 4-5.
11. Management and therapy of dry eye disease: report of the Management and Therapy Subcommittee of the
International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):163-178.
12. Schmit J, Jensen M. Internal research at Vance Thompson Vision. 2016.
13. American Optometric Association. Glaucoma FAQs. www.aoa.org/patients-and-public/eye-and-visionproblems/glossary-of-eye-and-vision-conditions/glaucoma/glaucom-faq?sso+y.
14. Cunningham D, Epstein A, Nichols K, Whitley W. Advancing the treatment of dry eye disease. Advanced Ocular
Care. March 1, 2016.
Jason Schmit, OD
CONCLUSION
DED is a long-term, chronic disease that affects tens
of millions of people in the United States, compared
to about 2 million suspected glaucoma patients in this
country.13 DED can disrupt the quality of life for many,
and it is estimated that people spend up to $2 billion
dollars annually on DED products and treatments.14
Recognizing signs and symptoms early and educating
16 ADVANCED OCULAR CARE | JULY/AUGUST 2016
In private practice specializing in oculoplastics, aesthetics, cataract, and refractive clinical care at Vance Thompson Vision in
Sioux Falls, South Dakota
n President of ConceptualEyes, an ophthalmic consulting company
specializing in improving operational excellence and overall practice growth
n [email protected]
n Financial interest: none acknowledged
n