Expert panel suggest new name, issues therapeutic guide for dry eye

Dorado, Puerto Rico-An international group of experts using a modified Delphi panel approach has developed recommendations for the management of dysfunctional tear syndrome (dry eye) to assist clinicians with their therapeutic decisions in the current era of expanding therapeutic choices, said Peter J. McDonnell, MD, at Current Concepts in Ophthalmology. He spoke at the conference, sponsored by Johns Hopkins University School of Medicine, Baltimore, and Ophthalmology Times.

"Dysfunctional tear syndrome, or dry eye, is a complex condition that has been somewhat unsatisfying to treat. In recent years there has been an increased understanding about its pathophysiology with recognition that it is not only a condition related to inadequate tears, and there also has been a proliferation of new therapies. These recommendations are designed to help clinicians know what modalities to use when, and they can be updated as we accumulate more experience with existing newer therapies and as other interventions become available," said Dr. McDonnell, William Holland Wilmer professor and director, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore.

Consensus process The panel's recommendations represent a consensus opinion established as a majority of at least two-thirds of the 17 participants. The process for reaching the recommendations began with development of a survey based on review of the literature and standard of care. The survey was completed by all panel members and the results analyzed and discussed to formulate recommendations.

"It is clear that not all dry eye patients actually have dry eyes-some have aqueous deficiency, but many others have normal or even high Schirmer test results and are suffering because of lid margin disease and/or tear composition abnormalities," he explained.

Consequently, dry eye may be the wrong name for this disease, and its use may misdirect clinicians into thinking erroneously about its underlying cause, techniques for diagnosis, and proper treatment. In addition, substituting the term DTS for dry eye may be valuable for enhancing communication with patients.

"There are patients whose eyes are tearing and watery and who insist emphatically they do not have dry eye. The term dysfunctional tear syndrome affords the clinician a diagnostic label that is acceptable to patients and allows them to validate their conviction that they suffer from a disease that significantly affects quality of life," Dr. McDonnell said.

Evaluation and treatment The panel members agreed there is no single sign or symptom that allows diagnosis of DTS or adequate monitoring of disease progression or treatment response. They also noted that there is no correlation between severity as experienced by the patient and the more objective disease signs.

A four-level severity rating scale was established to guide treatment decisions, in which each level is defined by symptom severity and/or the presence and severity of various disease-related signs, including conjunctival signs, visual signs, corneal and conjunctival staining, filamentary keratitis, erosions, and scarring. Symptom severity was considered highly important in determining disease severity and therefore guiding appropriate treatment for each patient.

"The bottom line is that symptoms are really important. A patient whose symptoms are significantly disabling and impairing quality of life is considered to have the most severe level of disease whereas a patient who might have mild corneal staining seen at the slit-lamp is categorized as having mild DTS," Dr. McDonnell noted.

The treatment algorithm also takes into account factors such as disturbances of tear distribution/clearance and the presence or absence of lid margin disease (e.g., meibomian gland dysfunction). With regard to the latter, patients are further stratified according to whether existing lid margin disease is anterior or posterior based on recognition that different treatment approaches are needed depending on the type of lid margin disease. Appropriate treatment for anterior lid margin disease consists of lid hygiene with a topical antibiotic, while local hyperthermia with massage, topical steroids, and tetracycline were recommended for posterior disease.

"The panel felt strongly that tetracycline was underutilized in clinical practice and should be prescribed more for patients with posterior lid margin disease," Dr. McDonnell said.

In patients with very mild DTS in the absence of lid margin disease, intervention begins conservatively with education and perhaps use of preserved artificial tears. For Level 2 disease, therapy advances to use of unpreserved artificial tears and lubricating gels or ointments.