Article

CLINICAL: DRY EYE

Rock the Boat

Inform asymptomatic patients of their dry eye disease diagnosis

What doctor doesn’t love a happy patient? They make days replete with unhappy patients bearable.

But, when it comes to asymptomatic dry eye disease (DED) patients, in particular, we risk having these patients become unhappy and, thus, eventually seek care elsewhere, when we fail to rock the boat.

Don’t be the doctor who diagnoses “dry eye disease” in the chart and never utters a word to the uncomplaining patient, thinking it’s rarely vision threatening, anyway. Instead, inform him of the diagnosis, letting him know that immediate intervention is often in his best interest.

THE MILD PATIENT

This patient, when asked at his annual comprehensive eye and health examination how he’s feeling, often replies, “My eyes feel great, doc! Can I get my (spectacle or contact lens) prescription updated?”

Exam findings, however, reveal superficial epithelial keratitis (SPK), decreased TBUT, inspissated meibomian glands and more. And so “great” isn’t truly “great.”

Also, consider this: Research shows DED is linked with refractive errors, so this patient’s need for a new prescription may, in fact, be due to his DED clinical signs. How do you think he’s going to feel if he purchases new spectacles or contact lenses and, soon thereafter, hears from a friend or family member that he may not have needed to? Yup! There goes that happy patient!

KEY DED SIGNS

DECREASED TEAR LAKE: Identify at the slit lamp subjectively or objectively by diagnostic equipment.

SPK: Identify at the slit lamp, but allow fluorescein dye to sit for about one to two minutes to get the best image.

DECREASED TBUT: Identify at the slit lamp or more objectively through diagnostic equipment, such as a TBUT device.

THE MODERATE PATIENT

This patient is symptomatic, but doesn’t know it because, unbeknownst to her, she’s implemented habits that have masked her symptoms.

For example, recently, a patient presented for her annual comprehensive eye and health examination having a decreased tear prism height and below average phenol red thread testing. Additional testing led me to suspect Sj√∂gren’s syndrome risk. As I asked whether she suffered from dry mouth, the patient took a big gulp from a water bottle she incidentally presented with at her initial visit, and said, “No, I don’t have any problems with dry mouth.” Boom!

THE SEVERE PATIENT

This patient is the quintessential clinical train wreck (i.e. diffuse, dense SPK, lid margin telangiectasias and negligible meibum with expression) and, therefore, would be expected to complain at length about discomfort, right?

Doctors may be surprised to find that this patient does not always present complaining of traditional symptoms, such as grittiness and irritation, because he has lost much of his corneal sensitivity due to years of DED progression. Rather, this patient may report blur as the chief complaint, due to diffuse epithelial disruption.

Optometrists may argue that if the patient doesn’t feel it, why should it be communicated to him? The answer: Diffuse epithelial disruption affects clarity of vision and may increase exposure to bacteria through the compromised ocular surface. A loss of cellular integrity can impact both vision and ocular health.

SHARE AND ACT

Optometrists have an obligation to inform their patients of their diagnosis, regardless of whether they present asymptomatic.

Patients may choose to be aggressive about their DED diagnosis or put it on the back burner, but we must be vigilant in alerting them to any and all findings.

Don’t we expect the same of our doctors? OM