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Dry eye common, but complicated


Making a diagnosis is only the first step in treating dry eye syndrome

Take home

Despite the fact that dry eye is a very common complaint and a very common symptom, ophthalmologists must be familiar with its various signs, be able to assess severity, and treat it effectively


By Liz Meszaros; Reviewed by Christina Rapp Prescott, MD, PhD

Baltimore-Dry eye is a common complaint in patients. Therefore, ophthalmologists must be familiar with its various signs, be able to assess severity, and treat it effectively.

“No matter what your specialty is or what your area of interest is, you will see patients who come in with a chief complaint of dry eye,” said Christina Rapp Prescott, MD, PhD, assistant professor of ophthalmology, cornea, external disease & refractive surgery, Wilmer Eye Institute, Johns Hopkins University School of Medicine. “It is therefore important for everyone to have a framework of how to approach these patients.”

Despite the fact that dry eye is a very common complaint and a very common symptom, the definition of dry eye is something that has been quite controversial, Dr. Prescott said. Not until 2007 was an official definition developed, as a result of the International Dry Eye Workshop Study Group (DEWS).

Dry eye is currently defined as “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.”

The prevalence of dry eye disease is quite high and on the rise, Dr. Prescott continued. In the United States, 7.5% of men aged ≥80 years, and 10% of women aged ≥75 years have dry eye complaints and symptoms that meet the official definition of dry eye.

“This prevalence is even higher in other countries, most notably in Asia, where over one-third of the population (33.7%) meets the definition for dry eye syndrome,” he said. “This is really quite epidemic in proportion throughout the world.”

The most common dry eye symptoms patients complain of include dryness, ocular fatigue, grittiness, redness, and soreness. To assess symptoms of dry eye, two questionnaires-the “Ocular Surface Disease Index” and the “Symptom Assessment in Dry Eye”-may be helpful, Dr. Prescott said.

“Unfortunately, no questionnaire has really proven itself to be the best option,” she said. “Symptoms are very subjective and often not correlated with the severity of disease that you will see on the exam, and this makes [a diagnosis] quite challenging.

Further complicating the diagnosis is the fact that symptoms can also vary depending on the time and the day, season to season.

Many different treatments exist for patient with dry eye and these include: artificial tears, lubricating ointment, oral omega-3 supplementation, punctal occlusion, warm compresses, topical cyclosporine, lid scrubs, humidifier use, eye wash, erythromycin, moisture goggles, cevimeline, and pilocarpine.

“When we see this many different treatments for one disease, it makes us wonder if these treatments are effective. Why are there so many different options? Why is there so much variability if we are treating only one disease?” Dr. Prescott said.

Is there a standard treatment for dry eye? In 2006 the Delphi Treatment algorithm was developed for patients with dry eye disease. It categorizes patients into four levels according to disease severity.

“But this only addresses dry eye according to severity, not according to the underlying cause,” Dr. Prescott said.

Addressing underlying causes

“What if dry eye is not just dry eye? What if there is an underlying cause?” Dr. Prescott asked.

In these patients, she said, first look for a systemic cause of disease, and look especially at the skin. Systemic causes can include Sjögren’s syndrome, Stevens-Johnson syndrome, and thyroid disease.

“Any kind of underlying autoimmune problem will be quite challenging to deal with,” Dr. Prescott said. “Work with the patient’s rheumatologist to treat the underlying cause. These patients need aggressive treatment of inflammation as well as lubrication.

Once systemic causes have been addressed, you can continue to look for specific ocular causes of dry eye symptoms. These can include:

  • Eyelid position, which can be affected by floppy eyelid syndrome, post-surgical effects, thyroid eye disease, and neurotrophic problems cause by past herpetic infection or a neurologic event. Treatments include ointment, taping worse eye at night, temporary or permanent tarsorhaphy, eyelid surgery, or PROSE lenses (Boston Foundation for Sight). “Bandage lenses are also an option, but these patients need to be treated with antibiotic prophylactically and followed closely for infection,” Dr. Prescott said.

  • Eyelid margin problems, such as blepharitis, conjunctivitis, or excessive conjunctiva.

  • Episcleritis and scleritis;

  • Limbal stem cell deficiency; or

  • Corneal dystrophy or recurrent erosion syndrome.

“If you cannot find an underlying cause, treat the dryness using the Delphi Treatment Algorithm,” Dr. Prescott concluded.


Reference for Figure 1: The International Dry Eye Workshop (DEWS) defined four categories of dry eye severity. Source: Behrens A, Doyle JJ, Stern L, et al. Dysfunctional tear syndrome: a Delphi approach to treatment recommendations. Cornea. 2006;25:900-907.



Christina Rapp Prescott, MD, PhD

P: 410/836-7010 or 410/893-0480

F: 410/877-9796

Dr. Prescott did not indicate any proprietary interest in the subject matter. This article is adapted from Dr. Prescott’s presentation at the 25th annual Current Concepts in Ophthalmology meeting, held in association with the Wilmer Eye Institute and Ophthalmology Times.

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