In a year of online disruptors, powerhouse mergers, and legislative battles, the story that most affects the day to day practice of optometrists in 2017 had several major contenders. But with an estimated 30+million Americans suffering from dry eye, a condition that we’ve been struggling to treat for decades, the DEWS II report stands out as a groundbreaking new mindset in what bread and butter patient care should look like. Aren’t so sure? If you’ve just skimmed a few summary articles and are thinking “it’s not really changed much for me” we’re highlighting the biggest takeaways that will make you rethink what you think you know about dry eye treatment in our podcast with Dr. Jennifer Craig, Dr. Lyndon Jones, and Dr. James Wolffsohn
1. Stop focusing on Aqueous Deficient versus Evaporative Dry Eye Disease.
If you’ve been putting energy in thinking that differentiating between these two different types of dry eye is essential to management, it’s time to rethink everything. The DEWS II report presents a much more modern understanding of dry eye, where aqueous deficiency and meibomian gland dysfunction are seen together in almost all patients. In fact, most studies show around 80% of people with dry eye have “mixed mechanism” where meibomian gland dysfunction is also a component. Instead of separating dry eye into two artificial categories, the DEWS II report defines dry eye syndrome as a loss of homeostasis within the entire lacrimal system: from lids to glands, to goblet cells. Treating patients means bringing all tear components into proper balance.
2. Pain and discomfort aren’t always treatable, and shouldn’t be the goal when treating dry eye.
We’ve all had patients that have symptoms significantly worse than their ocular surface signs, so this finding of the DEWS II report is not a surprise. But in the day to day patient care it’s great to have a clear knowledge of what we are treating and how we can do that as optometrists. Our focus is getting the ocular surface elements in balance and achieving that critical homeostasis. If we can get our patients to normal tear film osmolarity and resolve inflammation, heal all corneal and conjunctival staining, and restore meibomian gland function, then we have treated dry eye. If pain still persists, then a referral for pain management is needed because we have done all we can do with the ocular surface. We now have a defined goal for what treating dry eye can achieve, and if neuropathic pain persists, we’ll need to comanage with neuropathic pain management specialists. The DEWS II report shows us what success looks like, and gives us a clear path on what our treatments aim to accomplish, and what aspects of the patient’s presentation we can’t treat alone.
3. Dry Eye doesn’t look like a middle-aged woman.
A section of the report is how age and gender affects the prevalence of dry eye, but the key take home is to look for dry eye everywhere. While there are demographics where the condition is more prevalent, dry eye can appear in anyone at any age. Because of the predominance of device use in today’s world, blink rates are being significantly downregulated which can trigger dry eye syndrome in even the very young. The first place to look for dry eye in your patients? Start with the lid! Blink rate, meibomian gland function, and the lid wiper area are all early places where the cycle of dry eye inflammation can first rear its head.