Make the dry eye disease evaluation part of the comprehensive annual exam

Imagine this: A patient presents for their annual comprehensive eye exam during which it is revealed their spectacle prescription has changed. The patient receives their new prescription and either purchases new ophthalmic lenses for their current frames or a completely new pair of glasses.

A day or two after picking up said spectacles, the patient calls the practice, “My new prescription just doesn’t seem right.”

While the reason for this could be a mistake made by the optician or lab, it could also be that the optometrist didn’t make assessing the patient for dry eye disease (DED) part of the annual comprehensive exam.

THE DED AND SIGHT CONNECTION

The front surface of the eye provides 80% of the refractive power, and the tear film is part of this complex optical system. Tear film optics are an important factor in quality of vision. Specifically, between each blink, the tear film starts to evaporate and can cause transient aberrations and reduction in the optical quality.¹ Thus, if either the front surface of the eye or the tear film is damaged, distorted, or unstable due to DED, the patient’s vision will fluctuate, affecting their ability to correctly answer “which is better” and receive the correct prescription.

PUBLISHED PROOF

Visual quality can be measured by instruments that assess both the ocular scatter and the effect of higher- order aberrations.² This testing system demonstrates an unstable tear film between blinks in those who have DED.² This results in decreased vision quality and fluctuation, confirming what we experience clinically when trying to refract a DED patient.²

A study looking at patients across different refractive errors shows that those requiring glasses and contact lenses had a higher rate of self-reported DED. Specifically, approximately 53% of contact lens wearers and 17% of spectacle wearers report suffering from DED, while only 7% of emmetropes report suffering from DED.³

Additionally, it’s no secret that undetected DED can lead to contact lens intolerance and dropout.

FOR OUR CONSIDERATION

Given what is discussed above, should ODs change how they approach the annual comprehensive eye exam? Should they, perhaps, perform the slit lamp exam first to avoid chasing their tails on a DED patient’s refraction? This optometrist says “absolutely!”

Further, upon suspicion of DED, I believe ODs should perform testing to make a definitive diagnosis, prescribe treatments for any DED signs and symptoms, and then check ocular surface health prior to finalizing the refraction.

ONE LAST SCENARIO

Imagine this: A patient presents for their annual comprehensive eye exam during which it is re-vealed they may have DED. The patient is educated that additional testing will be needed to confirm a diagnosis and that related treatments may be needed before they can undergo a refraction, as DED can alter their true refraction.

After undergoing additional testing and complying with the prescribed treatment for their DED, the patient confidently chooses “which is better,” picks up their new spectacles and calls the practice:

“My new prescription is amazing! Everything is so clear! Thank you!”

The bottom line: DED is a chronic, common ocular condition, so its evaluation should be a part of all eye exams. OM

References:

1. Montés-Micó R, Alió JL, Muñoz G, Pérez-Santonja JJ, Charman WN. Postblink changes in total and corneal ocular aberrations. Ophthalmology. 2004;111(4):758-67. doi: 10.1016/j.ophtha.2003.06.027. 
2. Nichols JJ, Ziegler C, Mitchell GL, Nichols KK. Self-reported dry eye disease across refractive modalities. Invest. Ophthalmol. Vis. Sci. Invest Ophthalmol Vis Sci. 2005;46(6):1911-4. doi: 10.1167/iovs.04-1294.

DR. KOETTING practices at Hines-Sight in Denver, Colo. She is a fellow of the American Academy of Optometry, diplomate of the American Board of Optometry, an active member of AOA, and a speaker and consultant for multiple companies. Follow her on Instagram at Dr_Jazz_Hands, or email her at Dr.CeceliaKoetting@gmail.com.