The diagnosis and management of dry eye disease (DED) has significantly benefited from an improved understanding of the pathophysiologic, immunologic and etiopathogenic mechanisms of ocular surface diseases. An evidence-based approach to dry eye management has also been facilitated by the proceedings of well-recognized Tear Film & Ocular Surface Society (TFOS) Dry Eye Workshop II (2017) and the International Workshop on Meibomian Gland Disease (2011).1,2
During this time, we have witnessed the emergence of many dry eye technology innovations that attempt to improve diagnostic accuracy and efficiency and enable targeted treatment strategies. We no longer must rely on patient complaints and biomicroscopy findings to recognize dry eye. We are no longer limited to a variety of artificial tears and punctal plugs to treat dry eyes.
The integration of newly acquired dry eye care technologies in a practice presents unique challenges. First, implementation has been hampered by eye-care provider inertia, disinterest in dry eye care and the financial challenges of high acquisition cost. Also, many dry eye services remain non-covered by insurance plans, despite FDA approval and the validation of robust clinical research. In addition, these technologies may disrupt existing work flow patterns.
Despite these hurdles, current dry eye technologies open opportunities to create a new practice profit center. Several essential elements of integration warrant further consideration. Eye-care providers must select appropriate diagnostic and therapeutic devices consistent with their practice emphasis, which may range from comprehensive, surgical specialty or dry eye center. They must define their priorities in dry eye care and decide to identify and refer, to comanage or to establish a comprehensive dry eye center. They must further embrace the use of dry eye metrics to guide the decision making in clinical management. They must effectively educate patients regarding DED and current treatment strategies to convey the clinical value of these new technologies. Also, they must educate staff on the clinical value and the role of the new technologies in patient care to ensure successful implementation.
Consistent with our understanding of disease
Eye-care providers must decide which clinical tests, devices and procedures to embrace for dry eye management. The cost of technology acquisition can be formidable and warrants judicious selection reflecting the proposed time and resources committed to dry eye care. The rationale for technology selection should be consistent with current etiopathogenic understanding of DED provided by TFOS DEWS II as well as the International Workshop on MGD (see “Global consensus statements,” below). The TFOS DEWS II characterized DED in terms of the loss of tear film homeostasis. The Workshop on MGD described the structural and functional alterations seen with progressive meibomian gland dysfunction. Current diagnostic technologies that illustrate or detect manifestations of the loss of tear film homeostasis and altered meibomian gland health are clinically the most useful. These diagnostic technologies enable rapid capture of useful biometric data and images to complement clinical DED recognition. They may further reinforce patient education efforts, which enhance patient compliance and receptiveness to treatment recommendations.
Tear film instability may be graphically represented with three technologies: the HD Analyzer (Visiometrics), the Keratograph 5M (Oculus) and the LipiView II (J&J Vision).
The HD Analyzer relies on double-pass retinal imaging to analyze point-spread function changes at 0.5-second intervals to illustrate the unstable tear film graphically over a 20-second period. The Keratograph 5M provides a graphic representation of the tear film breakup time along with an image of the corneal surface area of tear film disruption. The LipiView II provides imaging of lid closure dynamics and quantifies partial blink patterns that contribute to evaporative stress. All of these technologies are powerful tools for patient education. They are not covered by insurance.
Tear film hyperosmolarity may be identified by elevated sodium concentration in the tear film under evaporative stress. The TearLab assay of tear osmolarity has been validated as highly sensitive and specific for DED detection. It also provides a useful metric for longitudinal disease monitoring and treatment assessment. Insurance coverage is widely available.
Global consensus statements
- TFOS DEWS II: “Dry eye is a multifactorial disease of the ocular surface characterized by the loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities play etiologic roles.”
- International Workshop on MGD: “Meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of the eibomian glands, commonly characterized by the terminal duct obstruction and/or qualitative changes in glandular secretions.”
Ocular surface inflammation
Ocular surface inflammation may be detected with the InflammaDry test (Quidel). This test identifies MMP-9 levels above 40 ng/ml. Although useful to correlate with symptoms and signs, the InflammaDry test does not have specificity for DED. This test permits longitudinal monitoring of DED as well as treatment response assessment. Insurance coverage is widely available.
Ocular surface injury may be documented by imaging of vital staining patterns with fluorescein and lissamine green. Slit-lamp photography may also facilitate patient education. The Keratograph 5M enables grading of conjunctival hyperemia. Corneal topography that utilizes Placido imaging or LED technology (iOptics) may also illustrate corneal surface alterations resulting from DED and other corneal disorders.
Meibomian gland obstruction, gland functionality and meibum alteration may be characterized and measured with the Korb Meibomian Gland Evaluator (MGE) and a Q-tip. The Korb MGE allows for a defined gland function score (MG score) based on the number of functional glands and the meibum appearance grade.3 Lid margin compression with a Q-tip may distinguish partial from total gland obstruction (MG count).
The LipiView II uses interferometry to measure the lipid layer thickness in nanometers. It further provides high-resolution meibography to define the state of structural gland dropout resulting from meibomian gland constipation and/or obstruction.
The Keratograph 5M also provides a colorful qualitative lipid layer assessment by interferometry as well as infrared meibography. Lipid layer thickness, MG score and meibography grading provide important biometrics for longitudinal monitoring for MGD. They also permit assessment of therapeutic interventions.
These diagnostic tests are not covered by insurance.
The mainstay of therapeutic intervention in DED involves stabilization of the tear film, control of ocular surface inflammation and relief of meibomian gland obstruction. In addition, management of exacerbating ocular surface disorders is important.
Several therapeutic technologies have emerged that address these priorities.
The TrueTear device (Allergan) is an innovative technology that relies on intranasal neurostimulation to modulate autonomic innervation of the lacrimal functional unit, resulting in increased tear volume of normal composition. This device may reduce the burden of frequently used artificial tears and decrease the need of punctal plugs.
Moisture chamber eyewear (Eye Eco) has provided relief to many dry eye sufferers by reducing ocular exposure resulting from incomplete blink or unprotected air currents. This protective eyewear design reduces evaporative stress to the eyes by providing frame contact with periorbital skin and side panels with a concealed moist sponge insert.
Control of ocular surface inflammation has been facilitated by photofacial therapy with Intense Pulsed Light (IPL) therapy (Lumenis). The application of filtered visible light to the midfacial skin in dry eye patients with rosacea and fair complexion has been an effective adjunctive therapy to reduce lid margin and ocular surface inflammation. It may also reduce the burden of Demodex infestation in the periorbital skin. It is of note that IPL is an off-label treatment for DED.
Microblepharoexfoliation with Ry-Surg’s BlephEx is an effective treatment to remove the biofilm, bacteria and debris from the lid margin and lashes that contribute to ocular surface inflammation. BlephEx represents a complementary office technology to address the usual poor patient compliance with lid hygiene therapy at home.
Relief of meibomian gland obstruction with improved meibum release is now available with two FDA-approved technologies. In the presence of partial gland obstruction with thick meibum, an automated vectored thermal pulsation therapy with LipiFlow (J&J Vision) has proven long-term efficacy. A significant body of literature has validated the benefits of LipiFlow over the past seven years to restore gland function. Also, a new manual vectored thermal lid compression therapy with iLux (Tear Film Innovations) demonstrates similar short-term clinical efficacy at a lower acquisition cost. When extensive total gland obstruction is demonstrated, meibomian gland probing has value in mechanical disruption of the terminal ductal obstruction prior to LipiFlow or iLux therapy.
None of the above therapeutic technologies have insurance coverage.
The use of biometrics to guide diagnostic and therapeutic decision making in dry eye care is critical to effective technology integration. These measurements may be correlated with dry eye symptoms and signs. They are compared with baseline values over time, permitting the monitoring of disease progression.
These measurements may also permit evaluation of response to therapeutic intervention.
Just like glaucoma management?
We understand DED and MGD to be chronic, progressive and destructive with often poor correlation with clinical symptoms. This same disease description can also be applied to another familiar disorder: glaucoma. Dry eye care must rely on objective methods to define structural and functional alterations of the lacrimal functional unit. We have the same approach in glaucoma with assessment of optic nerve structure and function. A consistent, disciplined use of metrics in dry eye care enables improved diagnostic accuracy and effective targeted therapy (See “Dry eye metrics,”). In addition, patient trust and cooperation with treatment recommendations are enhanced.
The biometrics of tear film homeostasis and meibomian gland health enable an objective approach to dry eye care that patients value.
Limitations and pitfalls
Clinicians must become familiar with the limitations and pitfalls of the selected dry eye care technologies. Use of multiple metrics may present confusing discrepancies, but they may usually be reconciled with a thoughtful review of the clinical presentation and exam findings.
Getting past preconceived notions
Effective patient education regarding current clinical understanding of DED is important. A primary reason is that many patients have preconceived notions that DED is managed with lubricant tears only, so they expect their eye doctor will simply prescribe the right eyedrop for them. Patients must be advised that DED/MGD is chronic, progressive and destructive with symptoms and signs that may not correlate — much like they have been advised by their dentists regarding periodontal disease. Also, patients must further understand that modifiable risk factors for DED should be addressed proactively. Work and lifestyle habits that involve prolonged use of computer screens and electronic devices must be identified. Patients must be advised of current treatment options for DED, their availability and the rationale for intervention.
Dry eye metrics
Useful dry eye metrics utilized at Bowden Eye & Associates include:
- SPEED score
- Tear film osmolarity
- Meibomian gland count
- Meibomian gland score
- Dynamic objective scatter index
- Tear film lipid layer thickness
- Partial blink ratio
- Meibography grading
- Meibum grading and corneal staining pattern
A customized treatment approach based on objective analysis of relevant risk factors, clinical findings and metrics is generally well received, even by the most frustrated and skeptical patients.
Staff’s role in educating patients
The front desk staff, technicians and dry eye counselors must effectively reinforce the value and importance of DED diagnostic tests and procedures. As many of these services are not covered by insurance plans, patients should receive information regarding non-covered treatment expenses prior to the office evaluation. Patients may then become more receptive and cooperative with the recommendations of the eye-care provider.
The cost factor
It is helpful to keep the cost of diagnostic tests reasonably low to overcome patient resistance to repeat testing required with longitudinal monitoring of DED. Selected tests may be packaged with premium services associated with refractive cataract surgery and laser vision correction. Procedural costs must reflect technology acquisition cost, time commitment and anticipated utilization.
When patients defer the tests and procedures, the medical record must document recommendations nonetheless. Patients are reminded that treatment recommendations have been made based on objective metrics, images and test results in addition to clinical findings in the same fashion that we document for other medical disorders.
Staff education is a critical component of technology integration for dry eye diagnostics and procedures. The staff must understand the priorities and needs of the eye-care provider in the management of DED to ensure the consistent documentation and data acquisition in dry eye patients. Dry eye practice protocols must be established that empower technicians and counselors to initiate point-of-service testing based on dry eye symptom questionnaires and presenting complaints. The eye-care provider must be unrelenting in insisting on adherence to the office protocol for clinical efficiency.
With each dry eye patient encounter, the use of metrics and review of dry eye flow sheets presented by the staff permits consistent messaging to the patient as well as the detection of compliance failure. The dry eye flow sheet completed by staff also helps to manage scheduled maintenance therapy, such as BlephEx, as well as surveillance osmolarity or lipid layer thickness.
Dry eye counselors, technicians and scribes in our practice are required to attend a session of Dry Eye University (dryeyeuniversity.com ) to boost their confidence with patient education. Web-based educational resources are also available (dryeyeaccess.com ).
The integration of new technologies in dry eye care has facilitated an evidence-based approach to disease management that is more effective and efficient. Dry eye patients are better served when eye-care providers rely on clinical findings and objective metrics to detect disease.
In addition, clinically validated therapeutic technologies provide improved patient satisfaction because they allow for more targeted treatment strategies. OM
- Craig JP, Nichols KK, AKpek EK, et al. TFOS DEWS II Definition and Classification Report. The Ocular Surface 2017;15:276-283.
- Nichols KK, Foulks GN, Bron AJ, et al. The International Workshop on Meibomian Gland Dysfunction: Executive Summary. Invest Ophthalmol Vis Sci. 2011;52:1922-1929.
- Korb DR, Blackie CA. Meibomian gland diagnostic expressible: correlation with dry eye symptoms and gland location. Cornea. 2008;10:1142-1147.