Caroline_Christie_-_CET_dry_eye

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CET Continuing education

T

ype the term ‘dry eye’ into Google and the result is about 32,000,000 hits ranging from comprehensive overviews of symptoms, diagnosis and management to chat groups, support groups and blogs. Companies manufacturing pharmaceuticals, over-the-counter artificial tear preparations and other treatment devices have entire websites dedicated to dry eye. It is, however, well within the clinical competencies of both optometrists and contact lens practitioners to manage ‘dry eye’ and in most instances these patients do not require to be referred to the GP/ ophthalmologist nor should the practice watch sales of products related to dry eye management be lost to pharmacies and the internet. As a disease, dry eye is complex. Modern research and understanding has shown that we simply can’t view dry eye as a failure of tear quantity or quality, but recognise it as a complex ocular surface disease. The Dry Eye Workshop (DEWS)1 forum is composed of an international panel of dry eye experts tasked to update our understanding of dry eye. The panel has released several papers on definition and classification, diagnosis, epidemiology, treatment and management, and research. A fundamental change in our understanding of dry eye is evident in its current definition: ‘Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear and inflammation of the ocular surface.’ How does this definition apply to us in a clinical setting today? The new definition has done a great deal to show that dry eye is not a simple problem with a simple solution. Indeed, the clinical picture for a patient can change as a result of any and all of the factors that go into producing dry eye initially. A previously happy patient living in a cool, humid environment may increase the amount of computer based work in an air conditioned office while starting a course of medication for increased blood pressure. Should any of us then be surprised to find out that this patient had quickly become a dry eye ‘victim’ and subsequently unhappy? The key point is that a patient’s clinical picture can change as lifestyle 30 | Optician | 25.11.11

Practical guide to dry eye management Caroline Christie explains how best to assess and manage the dry eye. Module C17953, one specialist point for CLOs and one general CET point for optometrists and DOs Subjective Evaluation of Symptoms of Dryness (SESoD) Evaluate your ocular discomfort due to the symptoms of dryness on a scale of 0 (none) to 4 (severe). You may use the following descriptions to assist in your score Dryness

Grade

Description

None

0

I do not have this symptom

Trace

1

I seldom notice this symptom, and it does not make me uncomfortable

Mild

2

I sometimes notice this symptom. It does make me uncomfortable, but it does not interfere with my activities

Moderate

3

I frequently notice this symptom, it does make me uncomfortable, but it sometimes interferes with my activities

Severe

4

I always notice this symptom. It does make me uncomfortable, and it usually interferes with my activities

Trefford Simpson and colleagues2 recently assessed four commonly used questionnaires McMonnies, DEQ, Ocular Surface Disease Index (OSDI) and Subjective Evaluation of Symptom of Dryness (SESoD) – found overall scores highly correlated – concluded use of a quick three-question screening tool is ideal for routine clinical practice.

Key questions (1) Frequency of symptoms (2) Presence of discomfort (3) Interference with activity

Figure 1 Dry eye grading scale

and environments change. However, we rarely see our patients for more than 15-20 minutes when collecting their contact lenses or 30 minutes over the course of an entire year, in the case of annual eye examinations. How then can we possibly expect to correctly identify a patient’s problem and confidently recommend a management approach? Often our recommendations are not followed through, leading to similar or even increased symptoms by the time of the next appointment. Optimal management of dry eye requires careful listening to the patient’s history and symptoms, gleaning information about their work and recreational environment, a detailed assessment of the tears and ocular surface using a battery of tests and an appreciation of the numerous management approaches that exist. The first step is to properly identify dry eye sufferers. Most dry eye patients have symptoms, but they are not always reported with the chief complaint or reason for visiting the practice. Therefore, it is valuable to conduct a symptom survey (dry eye questionnaire) to help

identify and categorise the presence and more importantly the severity of dry eye among patients. A good questionnaire will bring problems to your attention and help you ask the right sort of probing questions. I then want to hear patients describe how their eyes feel in their own words, which can then lead into a more detailed informative conversation. What time of the day does the problem occur? Have you ever tried anything to deal with this? If so, what? What, if any, activities does it affect, computer work, reading, driving and so on? The DEWS report does not specify how we should routinely ask patients about symptoms but does indicate several important components to symptom assessment: ● Frequency – how often a symptom is expressed ● Severity – how bad or disabling the symptom is ● Interference with activity – how it affects specific work/home based tasks. It is now believed that in the early stages of dry eye disease symptoms are not present all of the time but are episodic in nature and could be influenced by

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