Q&A: Uncovering Dry Eye Disease in Clinical Practice: How Would You Diagnose and Treat?
Introduction:
Uncovering dry eye disease in clinical practice, how would you diagnose and treat? Q&A featuring Dr. Elise Kramer.
Elise Kramer, OD:
What treatments are you most commonly recommending to patients to do at home? So it really depends on the underlying etiology of their dry eye, right? So is it aqueous deficient? Is it neurotrophic keratitis? Is it evaporative? What exactly is going on? And obviously all those tests that we do in the office help us determine what the main cause is. Is it mixed? And so based on that, that’s when we can tell patients to do things at home, different things. I would say the most homework comes with the evaporative dry eyes. This is when they’re doing the hot compresses, they’re doing a lot more lid hygiene, perhaps focusing more on that. Of course, preservative-free artificial tears or serum tears. And then of course, if we’re prescribing medications. So yes, there’s quite a bit of homework that patients are going to have to do. But again, if we compare this to the dental model, it’s not kind of foreign to them. Everyone brushes and flosses at home and then goes in for regular follow-ups or treatments into the office. So I think this is just explaining to them and setting expectations.
How often do you follow up with patients who have dry eye? And basically that depends on the degree of severity of the dry eye that they have. Obviously the more severe, the more closely I want to follow up. So if it’s very severe, basically one to three months. If it’s more moderate, then maybe four to six months. And then if it is more severe, I would say 8 to 12 months, around there. If they’re having a flare, might need to see them quite often for the first two weeks, and then you can spread out their follow-ups as they stabilize and as things improve.
What are some practical ways to integrate meibomian gland expression into routine practice? So this is something that is important to do in order to see which meibomian glands are still functioning, and also what the consistency is of the meibom that is coming out. And so I think that we’re doing slit lamp exams on most patients who come in, not just those that complain of dry eye. And so when you’re examining the lid margins, just expressing them takes less than five seconds per eye. And so I don’t think it takes up too much chair time. And then if you were talking about meibomian gland expression as a treatment for meibomian gland evacuation, obviously that comes with educating our patients about treatments that we do in the office and then showing them educational material, perhaps videos, and then allowing them to understand that and then just integrating it and scheduling them for a treatment. Or doing it the same day if you have that capability in your practice.
What are some good dry eye tests that we can ask technicians to perform to make our own chair time more effective? The technicians are really key in kind of filtering out or screening for patients who may have dry eye and then just performing tests based on questions that they ask. And so this can actually save a lot of time. If I know that a patient comes into the room and they’ve already done meibography, they already know what treatments we have available, they already know what their meibomian glands look like, they’ve already had other scans depending on what equipment you have available, so this can save a lot of time. A lot of technicians have access to educational material as well, and they can show them prior to them coming into the room. And so this really helps because then it is more of a question and answer versus just explaining everything that the technicians can already do. Another thing I like to do is I actually like to give a lot of my technicians a lot of the products that I recommend so that they can try it and they can understand how they feel and also what works for them perhaps and give some anecdotal kind of support to a lot of the products that we have. And so that was really helpful as well.
How do you test for corneal sensitivity if the patient has already had Proparacaine instilled? So this happens a lot. So for example, if you see the patient once they have already been evaluated, so yeah. So this happens a lot if you are working with technicians, if you have a high volume practice, especially if you’re working in primary care or if you’re working in a more specialty like glaucoma or a retinal practice, then a lot of the time you’re seeing patients when they’re already dilated. They’re already dilated, likely they’ve already had their pressure measured as well, in which case Proparacaine has already been instilled. If that’s the case and you’re trying to test for corneal sensitivity, it’d probably be best to bring the patient back. If you’re the doctor that sees the patients prior to them being dilated and you’re suspecting NK, then definitely perhaps do corneal sensitivity testing before you measure the pressure, before you put in Proparacaine. But again, if you are seeing the patient after they’ve had Proparacaine instilled, then you’ll definitely want to bring them back, explaining to the patient basically that you’re suspecting that they may not have normal corneal sensitivity and that that might be the reason why they’re having certain issues. And then they’ll understand why they need to come back. And it’s not a very long exam to measure corneal sensitivity, so it should be pretty smooth.
When do you initiate anti-inflammatory therapies for your patients with dry eye disease? And what are your thoughts on the use of topical cyclosporine in combination with corticosteroids? I really do like to start an anti-inflammatory therapy when I have patients that are very symptomatic with a lot of inflammation due to dryness or other ocular surface issues. And that will kind of just jumpstart whatever treatment you initiate. So whether you’re doing treatments in the office for evaporative dry eye, or you’re starting them on cyclosporine or another type of treatment, corticosteroids gets rid of that initial flare and will get them to a more stable baseline position where they can only really go up from in terms of improvement of symptoms. So I think it’s really key and obviously the more symptomatic the patient, the more likely I am to put them on a topical steroid, corticosteroid.
Which diagnostic tests do you find most useful in making a diagnosis of meibomian gland associated dry eye disease? I personally love meibography. Meibography is so good because you can really visualize the meibomian glands. You can see if they’re open, you can see if they’re dropping out, you can see so many different things. And I think one of my favorite things about it is that you can actually also show the patient, and that really helps them understand what’s going on. And it’s good to have a scale as well, an image in your office of normal meibomian glands versus meibomian gland drop out, like a moderate or a mild and then severe, so they can see how their meibomian glands compare to those examples. And then it’s really easy for a patient to kind of be on board and compliant with a treatment when they see how much their meibomian glands are being affected. And so meibography has really been, I guess, revolutionary for me in my practice in terms of diagnosis of meibomian gland dry eye disease.
