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CET Continuing education

T Practical guide to dry


ype the term dry eye into
Google and the result is about
32,000,000 hits ranging

eye management
from comprehensive
overviews of symptoms,
diagnosis and management
to chat groups, support groups and
blogs. Companies manufacturing
pharmaceuticals, over-the-counter
artificial tear preparations and other Caroline Christie explains how best to assess and manage the dry
treatment devices have entire websites
dedicated to dry eye. eye. Module C17953, one specialist point for CLOs and one
It is, however, well within the clinical general CET point for optometrists and DOs
competencies of both optometrists and
contact lens practitioners to manage dry
eye and in most instances these patients Subjective Evaluation of Symptoms of Dryness (SESoD)
do not require to be referred to the GP/
Evaluate your ocular discomfort due to the symptoms of dryness on a scale of 0 (none) to 4 (severe).
ophthalmologist nor should the practice You may use the following descriptions to assist in your score
watch sales of products related to dry eye
management be lost to pharmacies and Dryness Grade Description
the internet.
None 0 I do not have this symptom
As a disease, dry eye is complex.
Modern research and understanding has Trace 1 I seldom notice this symptom, and it does not make me uncomfortable
shown that we simply cant view dry eye Mild 2 I sometimes notice this symptom. It does make me uncomfortable, but
as a failure of tear quantity or quality, but it does not interfere with my activities
recognise it as a complex ocular surface
disease. Moderate 3 I frequently notice this symptom, it does make me uncomfortable, but it
sometimes interferes with my activities
The Dry Eye Workshop (DEWS)1
forum is composed of an international Severe 4 I always notice this symptom. It does make me uncomfortable, and it
panel of dry eye experts tasked to usually interferes with my activities
update our understanding of dry
eye. The panel has released several Trefford Simpson and colleagues2 recently assessed four commonly used questionnaires McMonnies, DEQ, Ocular Surface
papers on definition and classification, Disease Index (OSDI) and Subjective Evaluation of Symptom of Dryness (SESoD) found overall scores highly correlated
diagnosis, epidemiology, treatment and concluded use of a quick three-question screening tool is ideal for routine clinical practice.
management, and research.
A fundamental change in our Key questions (1) Frequency of symptoms (2) Presence of discomfort (3) Interference with activity
understanding of dry eye is evident in
its current definition:
Figure 1 Dry and environments change. However, identify and categorise the presence and
Dry eye is a multifactorial disease of eye grading we rarely see our patients for more than more importantly the severity of dry eye
the tears and ocular surface that results scale 15-20 minutes when collecting their among patients. A good questionnaire
in symptoms of discomfort, visual contact lenses or 30 minutes over the will bring problems to your attention
disturbance, and tear instability with course of an entire year, in the case of and help you ask the right sort of probing
potential damage to the ocular surface. It annual eye examinations. questions. I then want to hear patients
is accompanied by increased osmolarity How then can we possibly expect to describe how their eyes feel in their
of the tear and inflammation of the correctly identify a patients problem and own words, which can then lead into a
ocular surface. confidently recommend a management more detailed informative conversation.
approach? Often our recommendations What time of the day does the problem
How does this definition apply are not followed through, leading to occur? Have you ever tried anything to
to us in a clinical setting today? similar or even increased symptoms by deal with this? If so, what? What, if any,
The new definition has done a great the time of the next appointment. activities does it affect, computer work,
deal to show that dry eye is not a simple Optimal management of dry reading, driving and so on?
problem with a simple solution. Indeed, eye requires careful listening to the The DEWS report does not specify
the clinical picture for a patient can patients history and symptoms, how we should routinely ask patients
change as a result of any and all of the gleaning information about their about symptoms but does indicate several
factors that go into producing dry eye work and recreational environment, important components to symptom
initially. A previously happy patient a detailed assessment of the tears and assessment:
living in a cool, humid environment ocular surface using a battery of tests Frequency how often a symptom
may increase the amount of computer and an appreciation of the numerous is expressed
based work in an air conditioned office management approaches that exist. Severity how bad or disabling the
while starting a course of medication for The first step is to properly identify symptom is
increased blood pressure. Should any of dry eye sufferers. Most dry eye patients Interference with activity how it
us then be surprised to find out that this have symptoms, but they are not always affects specific work/home based tasks.
patient had quickly become a dry eye reported with the chief complaint or It is now believed that in the early
victim and subsequently unhappy? reason for visiting the practice. Therefore, stages of dry eye disease symptoms are
The key point is that a patients it is valuable to conduct a symptom not present all of the time but are episodic
clinical picture can change as lifestyle survey (dry eye questionnaire) to help in nature and could be influenced by

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Continuing education CET

The type of blink required for optimum blink efficiency has the following characteristics:

An efficient blink is full and complete, meaning that the top lid lightly touches the bottom lid
A n efficient blink is relaxed and light, meaning that only the muscles of the eye are involved.
Specifically, the muscles of the eyebrows and cheeks are not involved
An efficient blink is quick and rapid, taking only one third of a second to complete
Finally, an efficient blink looks confident and natural

Figure 2 Extract from a blink exercise sheet3

environmental factors including the and increases the potential for increased
growing use of visual display devices tear layer loss by evaporation from the
and exposure to air conditioning/central areas of conjunctiva and cornea which
heating at work and in the home. are exposed by an incomplete blink.
How disabling a symptom may be Although deliberate, forceful blinks
is likely dependent on the individual. promote secretion from unobstructed
Some patients have a higher tolerance glands, they have a tendency to produce
for ocular irritation compared to others. debris in the tear film leading to transient revealed that MGD may actually
Other patients may stop or avoid certain blurring. Patients will prefer not to blink comprise the majority of dry eye
activities but may not consider this to be rather than depend on conscious forceful disease.
related to how their eyes feel. blinking episodes. It may be better to try DEWS:
Asking patients specific questions to achieve longer lasting benefits from Meibomian gland dysfunction (MGD)
about how eye irritation or discomfort improved unconscious blink efficiency. is a chronic, diffuse abnormality of
may prevent them or reduce their ability Figure 2 shows a blink instruction the meibomian glands commonly
to perform certain activities, such as sheet. characterised by terminal duct obstruction
reading or using a computer, can help Failure to address blink efficiency and/or qualitative/quantitative changes
in determining the impact of symptoms. where a need is indicated may have in glandular secretion.4
The impact of the symptoms may be greater significance with computer use
recorded by reference to a grading scale and/or with other forms of reading and In MGD, the meibomian glands are
(Figure 1). close vision demands. Such activities are frequently obstructed, affecting the
Specific questions about length of associated with reduced blink efficiency volume and quality of the oily secretions.
comfortable computer use in hours can and this may be exacerbated with The result is tear film instability, which
help track changes over time with or concurrent exposure to central heating can lead to ocular surface damage
without treatment. or air conditioning. and inflammation, and, commonly, to
At present, there is no single gold symptoms.
Blink rate standard test for developing a clinical However, despite the frequency of
Given that evaporative dry eye is the diagnosis of dry eye; therefore, a battery presentation, MGD remains relatively
most common form of tear deficiency of tests is generally employed in clinical poorly managed in clinical practice. The
seen in routine optometric practice, practice (as well as for research purposes) chronic nature of the condition requires
failure to consider the need to improve to define dry eye. that therapy be applied regularly, and with
blink efficiency may significantly Remember, however, to always carry long-term commitment. Management
undermine efforts to improve tear out the least invasive tests first as you of MGD typically includes warm
function in general. want to minimise the disruption to the compresses, massage and lid scrubs
The normal apposition of the lids tear film if you are attempting to measure known to improve lipid layer thickness
during a complete blink promotes lipid and monitor changes to factors such as and, in turn, reduce tear evaporation.
secretion from the meibomian glands. the tear quantity, quality and stability The goal of MGD management is
The lipid layer is spread across the (Table 1). Ideally carry out the tests in the two-fold:
cornea by the upper lids and inefficient same order, under the same conditions To assist the remaining meibomian
blinking may be associated with poor and where possible the same time of day glands in producing more and better
maintenance of lipid layer integrity. For at each visit to aid comparison of results quality lipids
example, during prolonged reading, to make better informed decisions on To reduce inflammation of the glands,
when blink rate and blink completeness ongoing management plans. this is nearly always present.
are significantly reduced, the lipid layer Dry eye evaluation must also be
can thin and virtually disappear before multifaceted. In addition to assessing Warm compresses and eyelid
reappearing with conscious blinking. tear volume, quality, and stability, it is massage. The warmth helps to
It is possible that reduced lipid flow necessary to interpret staining patterns overcome the elevated melting point of
associated with inefficient blinking and complete a full lid evaluation to lipids inspissated within the glands. It is
contributes to stasis and gland blockage. rule out the presence or co-existence important to note that although many
In addition, lipid flow from glands of blepharitis. There is overlap of text books suggest the use of warm
that have been unblocked with warm many symptoms of dry eye disease and flannels, they rarely reach or indeed
compresses, lid massage and cleansing blepharitis, so careful clinical evaluation maintain the temperature required to
may not maintain their patency and is important. melt these inspissated lipids and repeated
so elapse to a blocked state if blink removal and reheating of the flannel is
inefficiency is not remediated. Meibomian gland dysfunction required. There are, however, a number
Apart from the potential to contribute (MGD) of commercially available devices from
to reduced lipid flow, incomplete blinking The International Workshop on the simple and inexpensive MGDRx
effectively doubles the inter-blink interval Meibomian Gland Dysfunction report EyeBag and iHeat devices through to

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CET Continuing education

Figure 3 Lissamine staining of the conjunctiva Figure 4 Fluorescein tear break-up Figure 5 Tear break-up with superficial staining

more sophisticated moist heat devices Omega-3 FA supplements should glands can secrete more and better
such as Blephasteam goggles which not be considered if the patient is quality lipids. Therapy may need to be
achieve the 39-40C required to melt using a blood thinner and/or serum continued for 3-6 months in cases in
the meibum while maintaining a lipid-lowering drugs. Consult with which inflammation is not subsiding
constant heat over the treatment period the patients GP prior to starting any and/or symptoms are not improving.
of 10-15 minutes. supplements. It may take 1-2 months
Following the heat phase, firm of regular use before any effect is Artificial tears
digital massage of the lid margin helps noticed. Artificial tears are the first line therapy
to express the oils, so that the glands in patients with dry eye. However, a
become unblocked. Eyelid massage also Refer to GP for systemic tetracycline significant number of practitioners
encourages blood flow to the eyelid area derivatives. The tetracycline derivatives offer artificial tears as the only solution
containing the glands, which can help are anti-inflammatory in action and (treatment plan) to patients complaining
remove inflammatory mediators. when inflammation is reduced the of dry eye symptoms.
Finally, cleaning of the lid margin to Two particular statements published
remove excess oils and dead cells is best Table 1 in the DEWS report1 worth considering
done not with dilute baby shampoo but are:
with specifically designed commercial Dry eye work-up For patients with moderate to
solutions and wipes that are free from Dry eye questionnaire (record score) severe dry eye disease, the absence
preservative, fragrance and alcohol. Measure tear film osmolarity (if equipment of preservatives is of more critical
Baby shampoo contains surfactants and available) importance than the particular polymeric
when in contact with the tear film will Keratometer/topographer agent used in ocular lubricants
contribute to destabilising the lipid layer, NIBUT For patients with dry eyes even
detracting from the initial aim of the Tearscope (currently out of production) vanishing preservatives may not totally
entire lid hygiene exercise in providing Slit lamp degrade due to the decrease in tear
a thicker and more stable lid layer to Tear quality and meniscus height volume and may be irritating.
prevent/reduce evaporation of the tear Phenol red threads (if available)
film and improve symptoms of dry eye. Tear quantity This has changed my approach
Slit lamp somewhat and I now more than ever
Lipid replacement artificial tears. Grade conjunctival hyperaemia recommend non-preserved artificial
These products replace/supplement Insert lissamine green tears to my dry eye patients, irrespective
the missing lipids that should normally Record/grade conjunctival stain (Figure 3) of the number of times they insert the
be secreted by the meibomian glands. Insert FL drops or whether they are a contact lens
Observe tear mixing
While direct evidence is limited, lipid patient or not. Optician will be publishing
TBUT (Figures 4 and 5)
replacement drops should reduce the a comprehensive table of currently
Record/grade corneal staining (Figures 6 and 7)
evaporation rate and should provide Evert lid
available ocular lubricants in the UK
symptomatic relief and help to protect Record/grade - Lid wiper epitheliopathy
next week. Once the disease process is
and possibly heal the ocular surface. They Examine lid margin actively managed, artificial tears still play
also wash out inflammatory cytokines Check meibomian gland patency (Figure 8) a role as supportive therapy to alleviate
to provide a thicker, more stable tear Discuss thoroughly your findings symptoms.
film, which reduces the inflammatory If they understand why they are doing things
stimulus. they are more likely to do them! Patient education
Create a personalised management plan So, how do we educate our patients?
Dietary supplements/omega-3 fatty Write it down in clear simple steps What is the best way to ensure that they
acids. The metabolites of both omega-6 Demonstrate procedures and products are going to remember what was said in
and omega-3 essential fatty acids (EFAs) Prescribe and sell products the practice?
are anti-inflammatory when the dietary Dont try too much too soon It all starts with appropriate verbal
ratio is 4:1. The typical North American Compliance will be poor and you wont know communication. Make sure that your
diet (nowadays often similar in the UK) the effect of each therapy descriptive language is easy to understand.
is closer to 15:1 causing the derivatives Arrange suitable follow up appointment in 2-4 If the message is too scientific it may not
of the omega-6 EFAs to contribute to the weeks register and all your hard work would
inflammatory process. have been in vain. Supplement verbal

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Continuing education CET

Figure 6 Inferior dessication staining Figure 7 Staining pattern related to poor blink

instructions with brochures or links to even more critical that their practitioner
websites where patients can get accurate leads them in the proper direction to
information. informative sites rather than leave them
Design a treatment plan, emphasise to Google poorly referenced or, worse
the importance of adhering to this still, pure selling sites.
plan and schedule a follow-up visit in A dedicated member of staff, the
3-4 weeks. This gives the patient time optical hygienist trained in dealing with
to form the habit of using the drops or dry eye management the insertion
performing the lid hygiene routine but of drops, lid hygiene techniques and
does not give them time hopefully to fall associated products is a major asset to
off the wagon or run out of the product the practice both in time management
you advised. and patient improved compliance and
Nowadays, patients can find out satisfaction.
anything they want on the web, so it is Figure 8 Checking the meibomian gland patency Ensure that the patient understands
that this is a dynamic process and that
the required management may change
Multiple-choice questions take part at opticianonline.net as mentioned at the beginning of this
article. They need to understand what

1 4
According to the Dry Eye Workshop Which of the following is not a symptom to do if circumstances worsen and
Report (DEWS), which of the following is of MGD? symptoms return.
NOT TRUE of dry eye? A Burning sensation In summary, dry eye disease is
A There is a decreased osmolarity of the tear B Blurred vision commonly encountered in everyday
film C Discomfort practice. We must use a thorough case
B There is potential for damage to the ocular D Itching history of symptoms in conjunction
surface with a variety of clinical and diagnostic
C Symptoms include discomfort and visual
disturbance
D Dry eye is a multifactorial disease
5 For patients with moderate to severe
dry eyes, what should be avoided when
selecting a dry eye product?
tests to diagnose the condition and its
severity. Approach management and
treatment options in a systematic way
A High viscosity polymers based on symptoms and clinical signs of
2 What are the three key question areas
required to ascertain the grade for the
level of dryness?
B Hypotonic agents
C Preservatives
D Electrolytes
severity
Dry eye is a chronic disease and one
that can be frustrating for both patient
A Frequency, presence of discomfort and
and practitioner. In our quick fix
blurred vision
B Frequency, presence of discomfort and
interference with activity
6 What is the optimal temperature for a lid
warming device to reach and maintain to
melt inspissated meibum from the lid margin?
society, this is one disease process that
does not play by those rules.
C Frequency, presence of discomfort and A 25C
discharge B 37C References
D Presence of discomfort, blurred vision and C 40C 1 The Dry Eye Workshop (DEWS). The Ocular
discharge D 50C Surface; April 2007, Vol 5, No 2.
2 Simpson et al. Dry Eye Symptoms Assessed

3 Which of the following is NOT TRUE of an


ideal blink pattern?
A Full and complete
by Four Questionnaires. OVS, 2008; 85:8
692-698.
3 McMonnies CW, Incomplete Blinking,
B Relaxed and light Contact Lens & Anterior Eye, 30 (2007)
C Slow and precise 37-51.
D Confident and natural 4 Nicholls K et al. International Workshop on
MGD. Invest Ophthalmol Vis Sci; March 30,
2011 vol 52 no 4 1917-1921.
Successful participation in this module counts as one credit towards the GOC CET scheme
administered by Vantage and one towards the Association of Optometrists Irelands scheme.
Deadline for responses is December 22 2011 Caroline Christie is associate director
for contact lens teaching, City University

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