Article

CLINICAL: DRY EYE

DEWS NEWS: PART ONE

DEWS II PROVIDES CLARITY AND SIMPLIFIES DIAGNOSIS

THIS YEAR some O.D.s will add to their New Year’s resolution list, “establish a dry eye disease (DED) clinic.” But, how do you get started? Arguably, the first step is to acquaint yourself with the latest information on the chronic disease, via the Tear Film and Ocular Surface Society (TFOS) Dry Eye Workshop II report (DEWS II), published May 2017.

DEWS II offers countless clinical pearls, and this column is the first in a two-part series that will offer highlights.

AQUEOUS DEFICIENT OR EVAPORATIVE?

Erroneously, many doctors and researchers believed patients fell in to either aqueous-deficient DED or evaporative DED, and that neither of the two met.

This perception changed, however, in 2012, when Lemp, et al. published in Cornea that of 224 subjects, 57 showed evidence of MGD (evaporative) and aqueous-deficient DED.

DEWS II further illustrates that DED is often on a continuum, meaning that many DED patients can fall within both categories and, therefore, must be treated for both types.

DIAGNOSTIC MISMATCH?

DEWS II suggests the reason a patient’s level of complaint doesn’t match clinical signs is likely because of neuropathy. Neuropathy is a malfunction of the nerves affected by injury or disease.

Often when assessing for DED, doctors look for signs that trigger nociceptive pain (a response to actual tissue damage) vs. neuropathic pain (where tissue may appear essentially normal). The neuropathic pain experienced by DED patients is no less real than the pain noted by those who have frank signs of disease.

Regarding course of action, DEWS II recommends referral to a pain management doctor. That said, be certain that diagnostics, such as point-of-care testing, support the referral to a doctor who specializes in pain management.

SIMPLIFYING DED MANAGEMENT?

Whenever deciding to add a new service to one’s practice, time is top of mind, as we know all too well that it is particularly precious in healthcare. DEWS II offers a straightforward, easy-to-navigate flow chart (see http://bit.ly/2AhVjbH ) for the diagnosis of DED, hopefully facilitating the addition of a clinic to one’s practice.

Echoing back to the popular “Choose Your Own Story” books, the illustration provides a pathway most eye care providers can engage in immediately, no matter what equipment they have in their office. The “if this, then this” approach allows for an elegantly simple process for proper diagnosis of an often complicated, multifactorial disease.

In addition to the diagnostic decision tree, DEWS II offers broad management considerations that are more fully developed deeper in the body of the report. OM