Today’s eye doctors are faced with a great deal of uncertainty. The more we learn about dry eye syndrome, the more we need to understand. In addition, corporate mergers, acquisitions and new companies all have altered the clinical and research landscape in ocular surface disease (OSD). Options for treatment are actually getting more restricted due to domination by prescription drugs which increased the cost of dry eye treatment in recent years by many folds.
What do we know about tear film and mucin?
Some of the new research in dry eye has a paradigm-shifting in our understanding of dry eye disorder. Take, for example, the tear film. Once thought to be 7µm in thickness and three layers thick (mucin, aqueous and lipid), it is now generally accepted the tear film is 3µm-to-4µm thick, and there are two layers: a mucin-aqueous gradient “gel” and a lipid layer. Taken at face value, the comparative differences do not seem that dramatic. However, what changed is our ability to accurately measure tear film thickness with interferometric techniques, which have been confirmed with anterior segment OCT. In addition, we now have a better understanding of mucins—MUC 16 is not a membrane-bound mucin and thus, is mobile and capable of forming a gradient in the aqueous layer. This allows the formation of “crusty” build up on eye lids.
The role of mucin in the health and disease of the ocular surface is still do not fully understood, but incremental yet logical steps forward in our knowledge of mucin biology will ultimately provide that answer.
Today’s Patients Are More Informed, and Demand Better Answers!
Today, both science and marketing plays important roles in clinical care. Very different than 15 years ago before the internet boom. Direct-to-consumer marketing, the Internet and education all result in increased awareness of disease states by both patients and clinicians. Patients today are more knowledgeable, and demand more information to make their own decisions. Doctors are influenced by supportive science for therapeutics, clinician practice patterns, education and peers. Doctors are trained a certain way in medical schools, and tend to stay with the way they were taught- slow to change. However, today’s patients demand more. Patients in this case, can be a great asset and advocate to their doctors -provide them with more options!
What is Ocular Surface Disease?
Ocular Surface Disease is composed a family of conditions impacting the front of the eye and associated adnexa. Terms such as blepharitis, meibomian gland disease or dysfunction (MGD), keratoconjunctivitis sicca, meibomitis, and meibomian keratoconjunctivitis, among others, led to the concept of dry eye disease and no less than 10 different classification schemes for some component of dry eye or blepharitis through the years.
How to Diagnose Dry Eye?
The problem is there is no single accepted diagnostic test for dry eye and the tests we do use often correlate poorly with symptoms. It is suggested that doctors ask a series of questions in addition to some of the more accepted conventional tests for dry eyes:
- Schirmer’s Test –to measure tear volume
- Tear Breakup Test- to determine tear viscosity
1. Ask about symptoms. Have the patient describe in his/her own words how his/her eyes feel, when they feel the worst and how it is impacting his/her life. Record this information, and refer to it at follow-up visits. Note current treatments, including frequency of application.
2. Look at the lids. Twenty years ago, we looked at the lids, but at some point, we stopped. Start to express the meibomian glands- squeeze fluid out. If you see a blocked gland on slit-lamp evaluation in symptomatic patients with quiet lids, you will be surprised by what you find. Be patient—press, move laterally, press, move back, re-press. Look at the quality of the secretions, and record your description.
3. Stain. Most practitioners use fluorescein to assess tear break-up and staining of the cornea. Wait at least one minute before fully evaluating corneal staining. Believe me, you will see more. Then, use lissamine green, and again, wait a minute or two before you observe the ocular surface. This dye takes time to color mucin and devitalized cells. A band-like pattern across the inferior third of the cornea usually means either incomplete blink or possible MGD. A new product, Fluramene (Noble Vision Group), can do the job of both staining agents with one drop.
4. Follow up. This takes valuable chair time, but is worth it in the long run. Recently, there has been a lot of discussion among clinicians with dry eye clinics about the best time to follow-up on a dry eye or MGD patient.
Data suggest that dry eye patients are not overly compliant with therapy—the drop-off from prescribed or non-prescribed treatments is usually four-to-six weeks. Therefore, a six-week follow-up may be the best way to keep your patient on track, and at this appointment, discuss improvements as well as changes to the treatment regimen. Get Your Doctor to Take Time for You Your doctor should take time to do the proper medical exam and provide sufficient information for you why certain decisions are made.
We hear all too often that the doctors are doing the minimal, do not take time to explain to the patients what is going on with their debilitating dry eye conditions – leading to much frustrations on both patients and doctors.
Source: Some of this information is extracted from an article Dr. Kelly Nichols wrote for Optometric Management, July 2011.
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