In case you missed it, read part one of Insight Media’s Decoding Dry Eye Practice Success series, which is focused on effectively uncovering and diagnosing DED.
In 25 years of practice, I have learned that we need to evaluate for dry eye disease in every patient that we see.
The good news is that building a dry eye practice does not have to start with purchasing high-end technology. It can begin today with some simple tools already in the practice and by making a few intentional changes when evaluating, listening to, and examining patients.
Patient History, Observation, and Lifestyle Questions
Eyelid disease, systemic conditions, ocular history, and lifestyle behaviors can all influence the tear film and ocular surface. When diagnosing dry eye, I start by reviewing ocular and systemic conditions as well as ocular and systemic medications and over-the-counter supplements. Asking a few additional questions about lifestyle, digital device use, sleep, diet, contact lens wear, and systemic symptoms can uncover factors that contribute to ocular surface disease.
During the examination, I often have patients gently close their eyes so I can evaluate for meibomian gland dysfunction, blepharitis, and collarettes, the characteristic finding of Demodex blepharitis. I also evaluate for lagophthalmos, incomplete eyelid closure, and floppy eyelid syndrome, which is associated with sleep apnea.
I observe my patient from across the room, looking at eyelid position and facial features. Are there signs of rosacea? What do their hands tell me about possible systemic disease, such as rheumatoid arthritis? Are they wearing eyelash extensions? Is eyeliner applied along the lower lid (waterline)?
Another simple step that can be incredibly valuable is checking corneal sensitivity before instilling topical anesthetic. Reduced sensation may be an important clue to neurotrophic keratitis, especially when the signs and symptoms do not seem to match.
Utilize Simple Tools
My next step in diagnosing dry eye is to use the tools already available in the exam room. I utilize vital dyes such as sodium fluorescein to evaluate corneal staining and tear breakup time and lissamine green for conjunctival staining. Eventually, you can upgrade to more advanced tools to test tear meniscus height, tear osmolarity, MMP-9, meibography, and other non-invasive testing to further characterize ocular surface disease.
Specialty Patients
Contact lens wearers deserve special attention. Evaluate the ocular surface before fitting contact lenses and remove the lenses at follow-up visits to reevaluate the ocular surface.
The same is true for individuals preparing for refractive or cataract surgery. Identifying and managing ocular surface disease before surgery can help improve presurgical measurements to provide better visual outcomes.
Look Beyond the Eye
Ask about dry mouth and arthritis as potential indicators of autoimmune disease. Sleep quality and quantity, exercise, mental health, medications, chronic pain conditions, migraine, and other lifestyle factors have all been associated with dry eye disease. The TFOS Lifestyle Report emphasizes the importance of considering these factors as part of the overall clinical picture.
Fancy technology isn’t a requirement when building a dry eye practice. The tools already in the practice can help to improve patient care and support practice growth today.
Coming Next Month: Part three of Insight Media’s Decoding Dry Eye Practice Success series will provide takeaways on dry eye treatment.
Melissa Barnett, OD, FAAO, FSLS, FBLCA, ACC, is a doctor of optometry, podcast host, and founding board member of the Intrepid Eye Society. She is also an ICF Associate Certified Coach and the founder of Alpine Blue Coaching.