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Ophthalmic Professional

Article

Classification of dry eye disease

Set up your practice for success by using a proper diagnostics and screening approach.

By: Patti Barkey, COE
Ophthalmic Professional November 1, 2021 Vol 10, Issue November/December 2021 Page(s): 20, 21, 43

Imagine an eye disease so complex that no single algorithm has been able to encompass all the factors associated with the disease. This is the life of dry eye practices. The medications, products, treatments, and therapies continue to rapidly evolve. This is an ever-changing space, and the winners continue to be the millions of patients, the practices that have embraced caring for these patients, and the eyecare industry. It’s a win for everyone involved.

Per Bionity.com , a medical algorithm is defined as: “any computation, formula, statistical survey, nomogram, or look-up table, useful in healthcare. Medical algorithms include decision tree approaches to healthcare treatment ... and also less clear-cut tools aimed at reducing or defining uncertainty.”

Treating dry eye disease (DED) starts with understanding the multiple factors that affect the ocular surface. DED algorithms are helpful when combined and applied to the whole patient and whole surface. All signs and symptoms must be explored. Not every patient is symptomatic and may not place value on early intervention. This should not stop the provider from educating the patient on the potential of future concerns. Much like glaucoma suspects, these patients should be handled early on with care and attention.

I asked a few providers at Bowden Eye & Associates in Jacksonville, FL, for their perspective regarding dry eye algorithms. Here are their responses:

Dr. Frank W. Bowden: “I have found the algorithms to be helpful in providing an evidence-based approach to dry eye management as we similarly approach other chronic, progressive medical disorders. The algorithms are not followed as a recipe per se. Patients have varied clinical presentations of DED, which don’t permit a rigid approach for successful management. An evidence-based approach guided by the algorithms foster patient trust and understanding as well as clinical efficiency. In addition, I feel more confident in my approach with challenging patients.”

Dr. Sarah Darbandi: “I think the algorithms emphasize the need for multiple treatments, which highlights the importance of education to the patient. Their understanding of disease through diagnostics and explanations by the staff and physicians are the key to being successful in applying all steps of current or future treatments.”

Dr. Jerry Robben: “The dry eye algorithms can provide a starting point and framework for practices to use to develop a more standardized dry eye treatment plan based on the presentation of an individual patient. This can provide a more stepwise approach to treatment and reduce occurrences of under or over treatment, at least initially.”

Dry Eye University just held its 21st program, and the mindset of all attendees is clear. Everyone is searching for the simplest, most efficient approach to diagnose and treat this large segment of the patient population. Using diagnostics and screening approaches often yield patients that need intervention. Having a clear plan of approach that your providers have agreed to and that your staff is trained on is very important to your success. Creating a consistent approach to implementing your plan is important.

Here are the algorithms we have utilized to help us create our practice approach as well as what we teach at Dry Eye University.

The Tear Film and Ocular Surface Society International Dry Eye Workshop

Published in The Ocular Surface in 2017, the TFOS DEWS II algorithm (Figure 1) is a helpful guide for practitioners. TFOS has worked to define DED as a whole. The TFOS DEWS II report defined dry eye as "a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiologic roles." This helps define that DED is multifactorial and that homeostasis is a huge factor in diagnosing.

Figure 1. TFOS DEWS II algorithmReprinted from The Ocular Surface, 2017 Jul;15(3):276-283, Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. doi: 10.1016/j.jtos.2017.05.008, with permission from Elsevier.
Figure 1. TFOS DEWS II algorithmReprinted from The Ocular Surface, 2017 Jul;15(3):276-283, Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. doi: 10.1016/j.jtos.2017.05.008, with permission from Elsevier.

 

The TFOS DEWS II Patient Summary (Figure 2) is also a great diagnostic approach necessary for these patients.

 

Fig 2. TFOS DEWS II Patient SummaryThis figure originates from the TFOS DEWS II Patient Summary (https://www.tearfilm.org/dettnews-tfos_dews_ii_patient_summary/6814_5519/eng/ ), and is reprinted with permission from TFOS. The figure is a modification of Figure 3 in the Definition and Classification report of TFOS DEWS II (Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017 Jul;15(3):276-283. doi: 10.1016/j.jtos.2017.05.008. Epub 2017Jul20 PMID: 28736335)
Figure 2. TFOS DEWS II Patient SummaryThis figure originates from the TFOS DEWS II Patient Summary (https://www.tearfilm.org/dettnews-tfos_dews_ii_patient_summary/6814_5519/eng/ ), and is reprinted with permission from TFOS. The figure is a modification of Figure 3 in the Definition and Classification report of TFOS DEWS II (Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017 Jul;15(3):276-283. doi: 10.1016/j.jtos.2017.05.008. Epub 2017 Jul 20. PMID: 28736335)

 

ASCRS Preoperative OSD algorithm

This algorithm was developed by the ASCRS Cornea Clinical Committee. It was the first presurgical-specific algorithm for diagnosing all ocular surface diseases prior to surgery (Figure 3). The ASCRS website has a PDF version available for download for your team.

 

Figure 3. ASCRS Preoperative OSD algorithm
Figure 3. ASCRS Preoperative OSD algorithm

 

 

Custom algorithms

I am proud to be the CEO of Bowden Eye & Associates. We have used the wisdom of TFOS and experience with the treatment of thousands of dry eye patients to round out a standard of care for our practice (Figure 4).

Figure 4
Figure 4

We keep this updated regularly. At our monthly provider meeting, we discuss the plan and move things out based on the availability of newer and better products for our patients.

Conclusion

Every practice should review the algorithms available and create an internal standard of care for application of diagnosis and treatment of DED. Hopefully, these algorithms can be a guide for you and your patients. OP

 

Ms. Barkey is CEO at Bowden Eye & Associates in Jacksonville, Fla., and is the director of Dry Eye University and Dry Eye Access. She is also the vice president for the American Society of Ophthalmic Administrators and the administrative program chair of Hawaiian Eye.
Ms. Barkey is CEO at Bowden Eye & Associates in Jacksonville, Fla., and is the director of Dry Eye University and Dry Eye Access. She is also the vice president for the American Society of Ophthalmic Administrators and the administrative program chair of Hawaiian Eye.

 

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