A DRY EYE DISEASE DECISION TREE
With the DEWS guidelines almost 10 years old, new approaches are needed.
BY JASON SCHMIT, OD.
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.