Find Dry Eye by Looking For It … But Should You Ever Stop Looking For It?
There is an adage that is tossed around at eye care meetings these days that if you want to find dry eye in your clinic population, just look for it.
By all accounts, this is a true statement. If anywhere from 5% to 30% of the general population has dry eye, then it stands to reason that the prevalence is the same in any given patient population of the average eye care clinic. The problem we have is that if we look too hard for various conditions affecting the ocular surface, we risk getting mired by a single focus. Because OSD is that prevalent, and when its various precursors and manifestations are considered, including MGD, blepharitis and dry eye, the number of eyes we could reasonably evaluate and potentially initiate treatment in grows exponentially.
Even specialists who focus a large part of their clinic on ocular surface issues can get bogged down in the numbers, especially with the spate of technology available for clinical use. The ever-growing list of testing modalities is staggering: keratography, osmolarity, meibography, vital stains, slit lamp evaluation, Schirmer test, tear break up time, tear meniscus, MMP-9 testing, etc., and etc.
So where do we stop? And more important, how does one build clinical infrastructure sufficient to attend to the needs of patients with various forms of ocular surface issues? Is it necessary to spend tens of thousands of dollars in diagnostic equipment, disrupt clinical efficiency and convert to a full-time dry eye specialist?
In truth, diagnostic equipment of any ilk is really intended to complement the clinical evaluation, and such testing is most effective when used in a directed and intentional manner. There could be an entire textbook on how to fit the dizzying array of testing modalities into practice; yet, without a meaningful evaluation of the eye, the output of all the testing in the world is virtually meaningless.
The eye care practitioner is the most crucial element in evaluating the ocular surface. The trick is to figure out a way to direct the examination towards clinically relevant findings. Fortunate for all of us (and for our patients), validated questionnaires are the perfect low-cost, high-reward starting point. I have spoken with several of my colleagues who distribute questionnaires to all patients, regardless of risk profile or age, and then set a barrier for conducting follow up (for example, a 7 or higher on the SPEED questionnaire). Only when a patient passes the set threshold will more resources be directed to discovering relevant signs and symptoms.
Perhaps it is time to update that mantra we hear so often about looking for dry eye. Perhaps the “just look for it” mentality is a bit limited, a bit ominous. Perhaps we should encourage each other to look smarter, not harder. I don’t think we should ever stop looking for OSD in our patients; but I do think we should change how we should look for it so that our efforts do not interrupt all the other important clinical work we do.
In fact, using questionnaires is just one small part of efficiently monitoring for dry eye and other ocular surface issues. We have all been told that looking for dry eye in our patients is incredibly important—and it is. But as the dry eye space gets more and more complicated and sophisticated, what is lacking is practical insight on how to get started in dry eye, how to maintain an efficient practice while still attending to the ocular surface needs of patients and how to grow this aspect of one’s practice.
These are the kinds of questions I look forward to tackling in the ongoing series, Dry Eye Coach. This website and the accompanying blog space will seek to address these questions and more. While it will be impossible to be completely comprehensive, I do hope that at least some practical insight can be gleaned.
I am most fortunate to start this effort with a 1-on-1 interview I recently conducted with Scott Schachter, OD, of Advanced Eyecare and Eyewear Gallery, in Pismo, Calif. Dr. Schachter is extremely knowledgeable about dry eye, but more so, he has seamlessly integrated comprehensive OSD evaluation into his thriving practice. I would encourage anyone interested in demystifying the approach to MGD to listen to our interview.
We can and should find dry eye among our existing patient populations. This can and should be an important part of one’s clinical operations, and it most definitely can be an important revenue center. Yet, like all aspects of what we do on a regular basis, providing dry eye work-ups are only one service we can provide our patients. Above all else, we should keep in mind the practical benefit and not get intimidated by the details.