Gaining Some Perspective on Dry Eye Treatment
BY LEO SEMES, OD, FAAO
The spectrum of dry eye problems seems endless. The current terminology is even confusing. This seemingly simple disorder has evolved to be designated by a number of terms — ocular surface disease and dysfunctional tear syndrome to name but two. The American Optometric Association's Clinical Practice Guideline on the topic uses the phrase Ocular Surface Disorders. Perhaps it is the most inclusive.
In this column, it would be impossible to outline all etiologies, anatomical correlates, diagnoses, and management strategies available for so-called "dry eye." Instead, I will outline some of the history to give a perspective on where we are in diagnosis and treatment options.
Dry Eye Factors
Since Schirmer introduced his eponymous test for dry eye more than 100 years ago, diagnosis has been enigmatic. Most of the outcomes of this original scheme centered around tear production and its deficiencies. Results of the tests are variable. Lids became the focus of Thygeson's now 60-year-old classification of anterior lid problems. This was largely focused on the lid skin and lash issues. Recently, both tear production and the posterior lid margin's role in contributing to the ocular surface have emerged as areas of study and remediation.
Significant recent milestones in dry eye diagnosis include the inclusion of a questionnaire to add patients' subjective impression of symptoms. These have been implemented by clinicians and validated as well.
We have also learned more about the role of tear osmolarity as a contributor to dry eye symptoms and signs. Gilbard (1994) initiated and contributed to the understanding of dry eye's early stages by demonstrating that concentrated tears play a vital role in patients who have ocular surface conditions and dry eye complaints.
Most recently, the role of inflammatory mediators has been proposed and elucidated. The question revolving around these items is whether they represent the result or the cause of ocular surface manifestations.
With the wealth of history, research, and information swirling, what guidance can we derive to relieve patient symptoms?
Perhaps the best advice comes from the results of the Delphi panel. This group evaluated severity based on clinical presentation. The panel's classification scheme took into account whether the patient has lid disease, whether it was anterior or posterior, and the integrity of the tear film. From this, they assigned four levels of severity of what they termed dysfunctional tear syndrome. In each level, treatment recommendations were developed. These included tear supplements, topical steroids and immunomodulators, nutritional support, and even surgery in the most severe instances.
That said, each clinician has a template for managing dry eye. When targeted to specific symptoms and clinical signs, that protocol may be effective. But we must also consider the burden of treatment. Does the patient need a prescription medication and can afford treatment? Can the patient benefit from over-the-counter products and be compliant? We face these issues daily. Managing dry eye is complex.
Difficult, But Rewarding
Finding the appropriate treatment, even after tedious diagnostic testing, can be daunting. Recommending a precise treatment modality and having the patient make progress with it can be most rewarding. CLS
For references, please visit www.clspectrum.com/references.asp and click on document #164.
Dr. Semes is an associate professor and director of continuing education at the University of Alabama at Birmingham School of Optometry.