Eyeworld Supplements

therapeutic solutions: Ocular surface disease and episodic flares of dry eye disease 4 | SUPPLEMENT TO EYEWORLD | MAY 2019 Diagnostic considerations in dry eye flare evaluation T he signs and symptoms of dry eye often are not correlated. Patients who have the worst signs may have the least symptoms and vice versa. This contradiction is important to consider when diagnosing dry eye flares. Patient questionnaires, point of care (POC) testing, and osmolarity testing are use- ful methods of diagnosing dry eye flares, but not at the expense of a thorough eye exam and discussion where the eyecare provider takes the time to listen and engage in a dialogue about symptoms and associated concerns. Screening suggestions Screening for dry eye disease (DED) using a patient ques- tionnaire is an effective and almost universal method of catching DED that otherwise might fall through the cracks. Preeya Gupta, MD, does this, and she describes it as an efficient way to assess the pa- tient's symptoms. Alternative- ly, she suggests that eyecare providers can direct their practice technician to ask pa- tients key questions about vi- sion fluctuation, redness, and irritation. Point of care (POC) testing, too, is particularly helpful, she said, in terms of identifying patients who might have DED and not realize it. "Typical tests that we perform include osmolarity testing and matrix metalloproteinase-9 (MMP-9) testing, but meibog- raphy is also quite useful to identify potentially advanced gland disease," she said. Listen and learn Edward Holland, MD, agreed that those methods are sound, but he added that initiating a dialogue with patients and listening to their description of their symptoms is critical. "Eyecare profession- als have been taught to put fluorescein in the eye and look for corneal staining. If we don't see corneal staining, we tend to discount the patient's symptoms," Dr. Holland said. "However, early onset dry eye patients or patients with dry eye flare can be highly symptomatic with discomfort and fluctuating vision without corneal staining." He added that the concept that punctate staining on the cornea only accompanies mild to moder- ate dry eye is incorrect. "If dry eye is bad enough and the patient has punctate staining, that's moderate to severe dry eye, and we should diagnose and treat patients earlier. If a young patient comes to me and says, 'My eyes are irritated' or 'I have fatigue syndrome,' but I don't see sig- nificant conjunctival injection or corneal staining, it does not mean that the patient does not have a dry eye flare. That's why it is so important to listen to the patient," he said. Tear film testing Similarly, Elizabeth Yeu, MD, said there are cases where the InflammaDry (Quidel) will turn positive in patients who have had some chronicity to their disease process. "I've noticed that tear osmolarity can indicate acute or chron- ic changes, while a positive InflammaDry often denotes more chronic disease. It is interesting to see someone who has been demonstrating stable tear osmolarity values who comes in with a flare. Conjunctival chalasis can often mimic dry eye disease. "Early onset dry eye patients or patients with dry eye flare can be highly symptomatic with discomfort and fluctuation of vision without corneal staining." —Edward Holland, MD

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