“Without diagnosing dry eye, we cannot treat it properly”

You presented a lecture on Advances in objective dry eye assessment at 100% Optical 2020. What was your key message?

I wanted to give people a better understanding of how to diagnose dry eye. I also wanted to share awareness of the tools and software available to help practitioners and their patients. We need to understand the dry eye cycle to acknowledge what is happening.

You spoke about a ‘vicious circle’ in dry eye. What do you mean and what do we do?

There is a cascade of different events that lead to dry eye for patients. Each patient can join this cycle at different points – for example because of an allergy, blepharitis, glands that are not working, or a specific disease. It is our job to tackle this. When we treat patients, we need to make sure we address the vicious circle and break it.

Without diagnosing dry eye, we cannot treat it properly. The guidelines to do this can appear complex, but as clinicians if we do not diagnose in a uniform way, it means that we are not able to generalise and properly treat the problem. To address dry eye, we need to understand the symptoms and signs – if only one is present, the patient cannot be said to have dry eye.

When we treat patients, we need to make sure we address the vicious circle and break it

Having a questionnaire for patients is an important part of understanding the symptoms. We have to make sure patients answer the questionnaire in order to find out if they score a positive value.

Templates for the TFOS DEWS II recommended questionnaires are available for free online. These are the Ocular Surface Disease Index (OSDI) and the Dry Eye Questionnaire (DEQ-5). They are the ones I use.

Using a questionnaire is important because it is the only way that we can grade and understand patient symptoms. We start with the results as a baseline and when we offer treatment, we want to make sure that score is decreasing.

It is important to have this baseline. It means patients know where they stand and what to expect in future visits.

As a clinician, when we give the test for the signs, we are looking at three areas: non-invasive break-up time, osmolarity, and ocular surface staining. If one of these tests is positive, and the patients has symptoms, the clinician can diagnose dry eye.

In the lecture, you were asked about the loss of meibomian glands. What can practitioners do?

Once there is meibomian gland loss or dropout, the glands retract within themselves. Research has not proven yet an amelioration of those, but the contents can be improved.

To use an analogy, in myopia, we cannot stop what has happened, but we can decrease the progression of it.

The same is true with meibomian glands. Our job is to prevent the loss of more glands. They are complicated structures and there is a lot of research going on at the moment.

What we do inside the clinic is up to us, but my advice is to start by using whatever tools we have already to hand in the practice

The dry eye conversation is becoming broader and more engaged. Do you agree?

I think there is a lot of research that is already out there, but on a daily basis I believe clinicians are not exploring it enough. There are a lot of courses and dry eye seminars that we can do, and there is a lot of information and useful research available.

What tips would you offer practitioners who are keen to progress with dry eye management?

Start by having questionnaires printed out; ask the patient to fill it in while they are waiting to be seen. When they hand it in it means the first step in the process is complete already.

What we do inside the clinic is up to us, but my advice is to start by using whatever tools the practitioner has already to hand in the practice. If they have fluorescein, and a slit lamp, start with that. Remember, only one of the three signs need to be positive, be it break-up time, staining or osmolarity. I advise that it is better to not use fluorescein for break-up time so that we do not change the volume of the tear film.