A lot of people ask me how to start a focus on dry eye in their practice—but the reality is, if you are practicing as a primary care optometrist, you may already have the beginnings of a thriving dry eye specialization.
In the latest installment of Dry Eye Coach, I interviewed noted dry eye content expert Paul Karpecki, OD, about how clinicians can expand their dry eye focus. He told me that about 30 to 50 million people in the United States have dry eye, but only about one million are actively receiving treatment. The staggering disconnect highlights a tremendous unmet need in this area. The good news for interested clinicians, though, is that many of these patients are already in your practice. For instance, if you simply ask your contact lens patients about discomfort or wear tolerance issues, or if you perform easy tests, such as expression of meibomian glands, you start uncovering all kinds of precursors to what will become contact lens dropout. Another area for finding potential dry eye, Dr. Karpecki said, is among patients being evaluated for surgical procedures and those being comanaged. These are just two of many potential patient types who might have unknown dry eye disease.
The truth is, it is very likely that a lot of dry eye is missed in the clinic because it is not actively looked for or because the symptoms are confounded by any number of variables. Epidemiologic evidence shows us that the age of onset for dry eye is getting younger, likely due to an increase in computer screen use. Also, more men are developing dry eye. However, a lot of optometrists are trained to initiate the dry eye interview among postmenopausal women, especially those over the age of 55. With knowledge of these evolving trends, we can change how we look for dry eye, thus recognizing more cases and starting treatment sooner.
Another key factor Dr. Karpecki pointed out in our interview is the growing understanding of the tear film in recent years. While it will remain relevant to ask about grittiness and burning in individuals who experience a change in refraction, such symptoms are typically indicative of later stage dry eye. Commonly, the first symptoms are blurring or fluctuating vision, which may be caused by an imbalance in the tear film. Because dry eye is chronic and progressive, if intervention is not initiated, the underlying condition worsens, and it becomes harder to treat the dry eye even as it becomes more recognizable.
The tricky part for clinicians is how to differentiate tear film imbalance from other causes of refractive error. Measuring tear break up time is an option in individuals with suspected imbalances, but the old standard diagnostics, such as fluorescein staining, are part art and science—in other words, there is still a high degree of subjectivity that can obfuscate more than elucidate. On the other hand, as Dr. Karpecki pointed out, performing minimally invasive objective tests, like tear osmolarity testing (TearLab), more often than not adds to the clinical picture, which may be critical for diagnosing early so treatment can be started before the dry eye progresses to later stages.
Having the results from tear osmolarity testing in your hands when you talk with the patient about initiating treatment also helps with compliance. Dr. Karpecki said he uses a three-prong approach to getting early compliance with patients and it all starts with having something to show the patient, whether that is the osmolarity score or a meibography image. The second step is to relay to the patient that the findings are a cause for concern, and the third is to explain the consequences of not treating.
I truly wonder if colleagues who want to expand their focus on dry eye might suffer from a bit of analysis paralysis. On the one hand, there are myriad diagnostics, point of care tests and questionnaires we can use in the clinic to identify patients either at risk for or in the early stages of dry eye disease. Taken together, the growing complexity of dry eye, from the sophisticated science to the changing epidemiology to the array of testing to the expanding treatment options, can seem daunting to get a handle on. But if we start to look within in our patient rosters, we are likely to find countless individuals who need our help and guidance to treat a disease that can be both visually disturbing and personally uncomfortable.
Dry eye patients are not that difficult to identify. The most difficult thing we might have to do as clinicians is think about how to find them.