Article Date: 6/1/2004

the dry eye file
Discovering Hidden Dryness
Don't rely solely on a patient's symptoms to make a diagnosis.
Milton M. Hom, O.D., F.A.A.O.

Are dry eyes prevalent? Massachusetts researchers last year found that nearly 7% of U.S. women aged 50 years and older either experienced significant problems with dry eye disease or have been diagnosed with dry eye. This means that about three million women in this age group have the disease. We can add at least one million men to the same age group, plus additional patients who fall within younger age groups.

Seek and ye shall find

I like to regularly screen my patients for dry eyes as part of their routine examinations. Many times, I'm surprised at the numbers of people who have dry eyes that would otherwise go undetected if I hadn't screened them. Patients who have dry eyes are at greater risk for infection, so most of them have a definite need for treatment. Rather than reaching for an artificial tear, keep in mind that prescribed pharmaceutical treatments can prove more beneficial to the patient.


My Cues to Prescribe a Drug for Dry Eye


Dryness: frequently or always.

Corneal/conjunctival staining: Grades 3 or 4

Redness: Grades 3 or 4

Artificial tear use: four or more times a day

How will I know?

When is the best time to turn to these pharmaceuticals? Here are some examples of the guidelines I use to prescribe a drug such as cyclosporine (Restasis):

Question dryness. We ask all of our patients the simple question, "How often do you experience dryness?" The answer choices are: seldom, sometimes, frequently and always. If they answer "frequently" or "always," then it usually means that they have a moderate or severe case of dryness and therefore require treatment.

Corneal/conjunctival staining. I prefer to stain with fluorescein. If Grades 3 or 4 are present, that indicates moderate to severe ocular surface damage and that I need to take action regarding treatment. I have seen too many cases where moderate or severe ocular surface damage results in subsequent infection.

Redness. Injection is the hallmark of inflammation. If Grades 3 or 4 are present, then cyclosporine is definitely indicated. Punctal plugs are counterproductive because they would serve to trap the inflammatory factors.

Artificial tear use. Use of tear supplements four or more times a day is a warning sign of a dry eye condition and is screaming for treatment.

Symptoms aren't everything

One important thing to note is the role of symptoms. As you can see, symptoms only play a role in the dryness question and artificial tear use. With dryness, many times there's little connection between signs and symptoms. Patients can have moderate corneal staining with absolutely no symptoms present. If patients have redness or staining of grades 3 or 4 and we know this is a dry eye, then I'll treat with cyclosporine regardless of symptoms.

References available on request.


Optometric Management, Issue: June 2004