Dry eye decision tree – 10 years after DEWS

I am sometimes asked about medical decision-making by students, interns, fellows, or optometry colleagues. “How did you come up with that decision in managing that ocular surface disease case?” I give the answer appropriate to the particular case, but I also note that sometimes it comes down to experience. “That’s why they call it ‘practicing medicine,’” I say. “At first, it might seem that we are ‘practicing’ with patients. But, with experience, decision-making becomes more instinctual and less like practicing.”

The first step in developing the most appropriate treatment plan for a patient with dry eye disease (DED) is to correctly categorize the stage and type of DED the patient exhibits using the available technology. Then address the patient’s symptoms using the appropriate evidence-based therapies.

To make the right diagnosis, start with a complete DED examination. Think of this as analogous to diagnosing and managing glaucoma. Primary open-angle glaucoma is a diagnosis of exclusion: the patient’s intraocular pressure, nerve fiber layer, visual fields, cup-to-disc ratio, corneal hysteresis, anterior angles via gonioscopy, medical and family history, and other ancillary factors are all assessed. Treatment is based on whether aqueous production must be reduced or outflow must be improved. Then, over time, the patients is reassessed to determine if the patient is reaching target pressure or not and whether the visual field is stabilizing. If not, the treatment plan must be made more aggressive. A similar process goes on in the care of patients with DED.

In 2007, a committee of optometrists, ophthalmologists, and scientists convened the International Dry Eye WorkShop (DEWS). The aim of DEWS was to outline the information needed to fully diagnose and treat patients with DED. In the almost 10 years since that effort, there have been significant advances in the field of DED. This article presents an update on how we approach the management of this disease where I practice, Vance Thompson Vision.

GRADING DED

One of the products of the DEWS effort was a schema that helps practitioners to grade the level of severity of DED (Table 1). What is nice about this classification system is that it directly corresponds to both subjective and objective testing that eye care providers routinely utilize in clinical practice.

Two factors that this system does not include, however, are osmolarity (per the TearLab test) and inflammation (per the InflammaDry test), both of which are included in the DEWS definition of DED. In modern practices, osmolarity can be assessed using the TearLab Osmolarity Test (TearLab) and inflammation can be assessed with the InflammaDry test (Rapid Pathogen Screening). With the further understanding of the inflammatory element of DED, measurement of inflammation is crucial for the success of treatment and management. Because imaging devices that perform meibography, such as the LipiView II (TearScience) and Oculus Keratograph systems, are now available, this information can also be assessed and used to determine the proper course of action.

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