Stepwise strategy to dry eye targets vigilance, education, follow-up visits

Take-home message: A more comprehensive, meticulous approach to the assessment and treatment of chronic dry eye may improve its management and prevent ocular injury and damage resulting from delays in care.

By Nancy Groves; Reviewed by Jonathan Solomon, MD

Bowie, MD-With new diagnostic tools and treatment options available, management of chronic dry eye can be more effective. This also requires a commitment on the clinician’s part to do more than a cursory examination of the ocular surface, said Jonathan Solomon, MD.

“It’s important that we increase our level of vigilance to improve the level of care we provide to our community,” said Dr. Solomon, who is in private practice, Bowie, MD. “My approach really is global and fluid or dynamic in that we’re going to take a much more comprehensive review of the ocular surface from a diagnostic standpoint.

What to look for

“As part of our examination we’re going to spend a little bit more time looking at the ocular surface, making sure that for every patient who comes in we are evaluating not just the corneal surface, but the palpebral and bulbar conjunctiva,” Dr. Solomon added.

Though ophthalmologists are taught these things in training, these are often overlooked in a busy clinic, Dr. Solomon explained.

“Sometimes we need to take a step back and start fresh and really look at the lid surface, the lid margin, and the lashes-to evaluate the extent of potential comorbidities, such as blepharitis, meibomian gland disease, and aqueous deficiency,” Dr. Solomon said. “We also need to look for other comorbidities like allergic conjunctivitis, which contributes to a global decline in the ocular surface homeostasis.

“It certainly can make a relatively straightforward exam seem arduous, but once you get used to it, it can be rather efficient,” he added. “It reinforces the relationship with your patient . . . that you’re working toward a goal of finding a solution.”

Prevention is key

A second key point is to approach chronic dry eye from the standpoint of prevention or prophylaxis. This means educating patients at a much younger age instead of waiting until middle age or later, by which time significant damage or injury may have occurred.

“You can educate patients in much the same way a dentist would address tooth decay,” Dr. Solomon said. “Prevention is the key and this conversation is part of my normal consultation.”

Even if a patient’s ocular surface appears normal, Dr. Solomon evaluates tear osmolarity and the concentration of MMP-9 (a marker of ocular surface inflammation), performs a comprehensive allergy clinic, reviews the medical history to see if a patient uses medication that may compromise tear production, and suggests that patients of any age get in the habit of using artificial tears every day, particularly those who spend a significant amount of time on the computer or smartphone.

It is also helpful during the examination to listen closely and follow up. If a patient who has good vision nonetheless mentions a subtle change, such as occasional irritation, probe for more detail instead of brushing it aside.

The stepwise approach is advisable for treatment as well as diagnosis. When artificial tears do not provide effective symptom relief, be willing to recommend options, such as preservative-free tears, topical cyclosporine, or topical steroids, as well as more advanced treatments that may require collaboration with specialists, such as rheumatologists when a diagnosis or Sjögren’s syndrome is in the differential.

Looking beyond the corneal surface, a range of options is available for lids and lashes, such as a cleanser (Avenova [formerly named i-Lid Cleanser], NovaBay) that contains hypochlorous acid 0.01%, or products containing tea tree oil.

Follow-up visits depend on many factors. Dr. Solomon typically sees patients 3 to 4 weeks after instituting a mild steroid and cyclosporine.

“This is not because I necessarily expect the cyclosporine treatment to have been particularly beneficial, but I like to reinforce what we’re doing while emphasizing compliance,” he said.

Though vision may be only slightly better after a few weeks, knowing that there has been some progress builds confidence that things are moving in the right direction, Dr. Solomon explained.

A follow-up visit at this point is also a good opportunity to determine if the steroid has led to an increase in IOP, he added.

However, if the patient has a measure of blepharitis, Dr. Solomon recommends a follow-up visit after 2 weeks. Because the cleansing routine for lids and lashes is more arduous than using drops, an early follow-up helps monitor compliance.

Timing of treatments

Once patients with any form of dry eye reach a steady state, Dr. Solomon likes to see them every 4 to 6 months, since changes in weather and indoor environments can affect the ocular surface even in patients with purely aqueous-deficient dry eye. Those who also experience seasonal triggers may need to be seen three or four times a year.

Disease severity, confidence in patients’ ability to titrate their therapy, and the strength of the physician-patient relationship should guide the timing of treatments more than a static, calendar-based rule.

These days, educating patients about dry eye should include an explanation of computer-associated dry eye, since studies show that most people spend at least 2 hours a day looking at information in a digital format.

“I can only imagine we’re going to see more of this,” Dr. Solomon said, adding that ophthalmologists can offer suggestions on ergonomic issues, as well as urge regular use of lubricating eye drops.

Jonathan Solomon, MD

E: jdsolomon@hotmail.com

Dr. Solomon is a speaker for Allergan and an investor in RPS.