As an ophthalmologist at Bowden Eye & Associates, I see many patients who present with symptoms of dry eye disease (DED), and equally as many who are asymptomatic. Just about all of our patients have some variation of DED, though some are not as obvious as others. And while it may be simple enough as the physician to make this diagnosis, we also work to empower our staff to help identify these patients in order to facilitate a thorough exam with the appropriate metrics.

Why dry eye metrics matter

The staff play an important role with the dry eye patient as they can be the first ones to introduce the concept of DED to a patient. It’s important that staff understand that DED is a condition that represents an “imbalance of the tear film.” I like to advise patients that the tear film is made up of water, oil, and a little bit of mucus, and the eye becomes dehydrated and vision can be affected when these components get out of balance. This reinforces the importance of obtaining dry-eye metrics, even when patients are asymptomatic. We can advise patients that these tests are like getting routine blood work done at their primary care physician even without symptoms; these metrics are used to ensure the tear film remains in balance so that the patient does not experience symptoms such as irritation, tearing, fluctuations in vision, or redness.

Dry eye tests

One way staff can facilitate the dry eye workup is by understanding the role of questionnaires, including Standard Patient Evaluation of Eye Dryness (SPEED). When done properly, the questionnaire will start the discussion regarding the patient’s dry eye symptoms. Our SPEED score also includes questions that ask about allergy symptoms as well as symptoms of auto-immune conditions to reveal if the patient has risks for Sjögren's.

If the patient has a SPEED score of 1, the staff member knows to proceed with a tear osmolarity test (Trukera Medical). This test is important to perform approximately 20 minutes after the last eye drops, so staff must recognize that they cannot check IOP or use any numbing drops prior to this test.

We also encourage staff to obtain testing for InflammaDry (Quidel), which measures levels of MMP-9 in tear fluid samples taken from the inside lining of the lower eyelid. InflammaDry is an extremely important metric for determining the inflammatory state of the pre-op patient. In addition, this is a useful metric for the surgeon to help their patient understand the need to use anti-inflammatory drops such as cyclosporine or mild steroids prior to a procedure. Without these tests and the corresponding discussions, patients may present postoperatively with complaints of DED, which they did not have prior to surgery, or even for future contact lens wearers.

Staff members also perform lipid layer thickness and meibography for patients who have symptoms of DED or as part of the preoperative workup. These metrics are great visuals that patients appreciate seeing, as they can demonstrate that their tear film is out of balance and how the oil component is contributing to their evaporative DED. When staff members obtain these metrics effectively, they are helping to aid in the discussion of recommending treatments that can help these patients. In contrast, without these metrics, the discussion is very lengthy, as the patient does not fully understand the significance of meibomian gland function as a cause of their dry eye.

Another less obvious metric can be the refraction. If the patient is repeatedly blinking during this test or the technician has to instill lubricating drops, a savvy technician will recognize this fluctuation in vision as a sign that the tear film is out of balance and understands to redirect testing to dry eye metrics.

Our standard of care

At our practice, staff issue a SPEED questionnaire to every patient (except emergency patients) at every visit. When allergy symptoms are present, the staff discusses the benefits and ease of having allergy testing done, making them more receptive to this when the physician orders it. When Sjögren's symptoms or family history is present, the staff know to put a Sjögren's lab order form in the chart, saving time later.

When the SPEED score is greater than 1 and the patient hasn’t had dry eye testing done previously, staff know to perform tear osmolarity, meibography, and MMP-9 testing, and the physician reviews the results. For our preoperative cataract patients, aberrometry is obtained to assess higher-order aberrations coming from the dysfunctional ocular surface to allow for recommendations to be made prior to surgery.

Because staff members are often the first to bring up DED with patients, it is crucial they understand the need for this testing and know how to perform it quickly. Many patients are proactive in their eye care, but they are less receptive to having dry eye testing after the workup and after the encounter with the doctor. So, when a staff member does not get the testing appropriately and it has to be ordered later, the patient may feel like they are having too many visits, especially if they are trying to have surgery performed.

In summary

One of the most significant ways staff helps in the dry-eye workup is being thoughtful and proactive, and understanding that DED can be present in any patient. DED is not just the patient in the waiting room with red irritated eyes; it is likely in the asymptomatic patient who presents for a surgical consult as well.

Patients typically have to see it to believe it, and the savviest technicians who understand this are the most helpful. They understand the role of the testing that allows the physician to make appropriate recommendations for treatment that encourage compliance. OP

SARAH DARBANDI, MD joined the Bowden Eye & Associates in 2012 and became a partner and vice president of Bowden Eye in 2015. She provides general ophthalmic care, custom cataract surgery, corneal transplantation, ocular surface reconstruction, refractive surgery, and aesthetic care. Disclosure: Dr. Darbandi is a consultant for E-Swin.