Pearls detail targeted interventions for management of dry eye disease

(Image Credit: AdobeStock/Alessandro Grandini)

Reviewed by Alice Epitropoulos, MD

In an Ophthalmology Times Insight roundtable discussion, Alice Epitropoulos, MD, and Laura M. Periman, MD, shared insights into their comprehensive approach to treating patients with dry eye symptoms. Epitropoulos is director of the Dry Eye Center of Excellence at The Eye Center of Columbus and a clinical assistant professor at The Ohio State University in Columbus. Periman is in private practice at the Periman Eye Institute in Seattle, Washington.

Diagnostic tests to evaluate dry eye

Addressing dry eye disease is critical, particularly for patients undergoing cataract surgery, because the presence of dry eye can affect surgical outcomes and patient satisfaction, Epitropoulos explained. Periman enumerated the top 3 diagnostic tests she would most likely perform when a patient presents with classic dry eye symptoms. She advised that before attempting to diagnose dry eye, clinicians should listen to patients’ complaints, review their medical history and medications, and assess their risk factors for dry eye.

When diagnosing dry eye, she emphasized the importance of osmolarity, matrix metalloproteinase 9 (MMP-9), and vital dyes.

“It really is that simple,” Periman pointed out. “By assessing these 3 factors, a great deal can be learned about the patient’s ocular surface status.”

Epitropoulos strongly agreed. “These tests are the basis for a story,” she said. “The diagnostics of MMP-9 reveal the presence of inflammation in the tear film, and tear osmolarity reveals if the tear film is in homeostasis.”

Moreover, Epitropoulos pointed out that meibography provides an excellent tool to show patients the status of their meibomian glands.

“These tests make diagnosing dry eye disease much easier than before the tests were available,” she said.

Periman explained that the overlap in dry eye symptoms between patients with normal osmolarity and those without, for example, can tell the physician a great deal. Normal osmolarity in a patient with symptoms forces physicians to look for other etiologies, such as allergic conjunctivitis.

“All of these tools are helpful to identify the key drivers in dry eye disease,” Periman said.

Assessing tear film abnormalities: Watch for multiple culprits

When faced with a patient with normal osmolarity, a high MMP-9 value, and lissamine green staining on the lid margin, telangiectasias, and gunky meibum, Periman suggested that clinicians consider ocular rosacea or Demodex blepharitis. These observations help clinicians to complete the clinical picture and indicate that there may be more than 1 “mischief maker” in action, Periman pointed out. In most cases, she noted, more than 1 thing is happening.

Periman also discussed the importance of differentiating aqueous deficient from evaporative dry eye. Although the 2 types overlap, inflammation drives both, creating a common viscous cycle.

“This realization helps clarify different clinical scenarios and helps physicians get to the root of the patient’s symptoms,” she explained. “For example, a patient may have a low tear meniscus height and a high osmolarity value or a normal osmolarity that results from a compensatory mechanism in a patient with primarily rosacea or blepharitis.”

Epitropoulos pointed out that research shows 86% of patients with dry eye disease have a component of meibomian gland disease (evaporative dry eye disease), making it the most common form of dry eye disease. “It is important to distinguish purely aqueous deficient dry eye, such as in Sjögren syndrome, from evaporative dry eye because of the differences in treatment,” she said. “Proper diagnosis ensures that the underlying causes are adequately addressed and patients’ needs are met.”