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HomemieyecareAvoiding Snowballs A Proactive Approach to Mild Dry Eye

Avoiding Snowballs A Proactive Approach to Mild Dry Eye

Dry eye disease causes ocular discomfort, fatigue and visual disturbances that have been shown to negatively impact quality of life.1-3 Like many chronic diseases, inflammation plays a role and there’s a spectrum of disease severity, beginning with mild dry eye. DEWS II provided us with clear, evidence based guidance on both the diagnosis and management of mild dry eye disease4… but have we paid attention?

Figure 1. The Vicious Circle of Dry Eye, DEWS II Pathophysiology Report

As optometrists we play a key role in the detection and management of a plethora of chronic diseases that include glaucoma, diabetes, macular degeneration, myopia, corneal dystrophies, and dry eye disease… chronic disease is a key part of our day to day practice. And while the impact of these diseases on vision, ocular and systemic health varies, one thing they have in common is that they impact a patient’s quality of life.

On a busy day in practice, it might be easy to overlook someone who only mentions dryness symptoms briefly in passing, has slightly pouted meibomian gland orifices or slightly reduced tear break up times. But it’s important to consider that whenever we see a patient, it’s a snap shot in time and really it’s only a piece of the clinical picture. If we send that patient away with no advice or management, except a routine recall in a few years, we leave them open for disease progression.

THE SNOWBALL EFFECT

“Snowball Effect – a process that starts from an initial state of small significance and builds upon itself, becoming larger (graver, more serious) and also perhaps potentially dangerous or disastrous (a vicious circle)”.5

Where in eye care do we hear about vicious cycles? Dry eye disease. The DEWS II Pathophysiology Report proposed the Vicious Circle of Dry Eye (Figure 1).6 While it can begin at any point in the cycle, it flows like this: tear hyperosmolarity causes damage to the corneal epithelium, which releases inflammatory mediators.6 Epithelial damage involves cell death by apoptosis, goblet cell loss and changes to mucin expression; which leads to further tear film instability, which exacerbates hyperosmolarity… and on and on.6

Because of this cycle, dry eye disease (DED) is a chronic, progressive condition and may advance if not managed.2 It’s reported prevalence is between 5–50% of the adult population.3 The DEWS II Epidemiology Subcommittee has suggested that mild or episodic disease is closer to the upper end of this prevalence, being the majority of DED.3

Meibomian gland dysfunction (MGD) accounts for the majority of DED.6 When looking at clinical signs of MGD, the prevalence of MGD in populations over 40 years is reported to be higher than DED, with a range from 38% to 68%.3 It’s also important to consider asymptomatic MGD, which has been reported to have a prevalence double that of symptomatic MGD in Caucasian populations.7 While there is limited data on the natural history of MGD, it does become more common with age, and patients report an increased severity of symptoms with time.

With so many patients out there with DED, and the majority of those in our practice living with mild DED, most likely from MGD, the question is, are we managing those patients well?

THE WISDOM OF MANAGING EARLY

In our practice, effective patient management begins with being proactive when taking down a patient’s history. Rather than waiting for patients to introduce the subject, we should ensure we’re asking every patient if they have any symptoms of irritation, tired eyes, redness or sore eyes. This will go a long way in identifying all dry eye patients.

The risk factors for DED are well known: female gender, older age, Asian ethnicity, diets low in omega 3, LASIK and other refractive excimer laser surgery, vitamin A deficiency, medications such as antihistamines, connective tissue disease, diabetes, and radiation therapy.3,6,9 We should be particularly proactive in both our assessment and management of patients with these risk factors.

A good assessment, and good recording of it, helps our management now and into the future. Like all chronic disease, having good data over time helps assess disease progression. While there are some incredible options for high tech dry eye diagnosis, DEWS II recommends using an OSDI or DEQ-5 questionnaire with one of the following diagnostic tests: tear break up times, ocular surface staining and/or osmolarity.10 In combination with a thorough slit lamp examination, this is a good assessment that all optometrists can do.

Table 1.

Management Options 

There are a wide variety of management options for DED comprising lubricating drops with or without lipid components, dietary modification, warm compresses and lid hygiene measures. Lifestyle advice also benefits these patients: the 20:20:20 rule when at the computer, general hydration, and care with both make up application and removal, can all help.

Patients with mild signs and symptoms of DED but minimal risk factors, can be well managed with education and some lubricating drops. The lubricants will play a role in improving symptoms, ocular surface staining, lid wiper epitheliopathy and tear break up times.11,12 

However, for patients with mild signs and symptoms but multiple risk factors, we should not only recommend a more frequent review but also a more comprehensive management plan with lubricating drops, dietary advice or modification, and if needed, eyelid hygiene or in practice therapies. Warm compresses, when done well, and eyelid hygiene can be safe, effective therapies for MGD and blepharitis.13

We are lucky that we have moved beyond baby shampoo, which can negatively impact conjunctival goblet cells,10 and have a range of good eyelid hygiene products available. Lid hygiene removes debris, lipid byproducts, bacterial load, biofilm and toxins to help reduce inflammation and return the lid margin and tear film to homeostasis. OptiMel drops, twice a day, may also be beneficial for mild dry eye patients as they improve hyperaemia, osmolarity, TBUT, staining and meibum quality.14 

We also should consider the pre-clinical dry eye state and those with episodic or environmental dry eye. DEWS suggests ongoing follow up to evaluate the development of signs and symptoms, as well as education for these patients.10 

PROTECT QUALITY OF LIFE

Practicing in a proactive way can help prevent more of your patients from developing more moderate or severe dry eye. It can also position you as the eye health expert, which means if their symptoms do change, they are more likely to return to you for care.

Dry eye patients report progression of their symptoms over time,8 so don’t wait for your patients with mild dry eye to experience the snowball effect – find them, intervene early and prevent their disease from progressing. In doing so you will also help protect their quality of life.

Adele Jefferies BOptom(Hons) CertOcPharm (Therapeutics) is an optometrist working in independent practice in Auckland with special interests in contact lenses, ocular surface disease and therapeutics. She is the National Clinical Manager for the Matthews Eyewear Eyecare Ltd Group of independent practices throughout New Zealand. She holds positions on the CPD Accreditation Committee and Competence Review Committee for the New Zealand Optometrists and Dispensing Opticians Board, is a councillor for Cornea & Contact Lens Society (NZ) and a Clinical Masters Student at the University of Auckland. She graduated from the University of Auckland with Honours in 2003 and completed her Postgraduate Therapeutics Studies in 2005. Adele’s career has predominantly been in full scope independent practice, including practice ownership. She has also been a Professional Teaching Fellow at the University of Auckland School of Optometry and Vision Science. She has been a conference speaker for optometrists and dispensing opticians in Australia and New Zealand, and a pre-market evaluator of contact lens, contact lens care solutions and dry eye care products for various companies. 

References 

  1. Uchino M, Schaumberg DA. Dry eye disease: impact on quality of life and vision. Curr Ophthalmol Rep 2013; 1: 51-57.
  2. Figueiredo FC, Steeds C, Figueiredo MS et al. The treatment and disease progression of patients with moderate to severe dry eye disease over time in routine clinical practice in the UK. Invest Ophthalmol Vis Sci 2007; 48.
  3. Stapleton F, Alves M, Bunya VY et al. TFOS DEWS II epidemiology report. Ocul Surf 2017; 15: 334-365.
  4. Wolffsohn JS, Arita R, Chalmers R et al. TFOS DEWS II diagnostic methodology report. Ocul Surf 2017; 15: 539-574.
  5. Wikipedia. Snowball effect. In, 2020.
  6. Bron AJ, de Paiva CS, Chauhan SK et al. TFOS DEWS II pathophysiology report. Ocul Surf 2017; 15: 438-510.
  7. Viso E, Rodriguez-Ares MT, Abelenda D et al. Prevalence of asymptomatic and symptomatic meibomian gland dysfunction in the general population of Spain. Invest Ophthalmol Vis Sci 2012; 53: 2601-2606.
  8. Lienert JP, Tarko L, Uchino M et al. Long-term natural history of dry eye disease from the patient’s perspective. Ophthalmology 2016; 123: 425-433.
  9. Sullivan DA, Rocha EM, Aragona P et al. TFOS DEWS II sex, gender, and hormones report. Ocul Surf 2017; 15: 284-333.
  10. Jones L, Downie LE, Korb D et al. TFOS DEWS II management and therapy report. Ocul Surf 2017; 15: 575-628.
  11. Kislan T. Cross-over evaluation of blink tears versus Systane Ultra in mild dry eye patients. Optometry – Journal of the American Optometric Association 2010; 81.
  12. Lee JH, Ahn HS, Kim EK et al. Efficacy of sodium hyaluronate and carboxymethylcellulose in treating mild to moderate dry eye disease. Cornea 2011; 30: 175-179.
  13. Arita R, Fukuoka S. Non-pharmaceutical treatment options for meibomian gland dysfunction. Clin Exp Optom 2020.
  14. Albietz JM, Schmid KL. Randomised controlled trial of topical antibacterial Manuka (Leptospermum species) honey for evaporative dry eye due to meibomian gland dysfunction. Clin Exp Optom 2017; 100: 603-615.