DRY EYE DISEASE
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DRY EYE DISEASE - 1

I-MEDPHARMA 1601 St-Regis Blvd. Dollard-des-Ormeaux (QC) Canada H9B3H7 Phone: (514) 685-8118 Fax: (514) 685-8998 DRY EYE DISEASE DIAGNOSIS AND MANAGEMENT By Richard Maharaj, od, faaoPublished November 2017 t Richard Maharaj, OD, FAAO completed his Doctor of Optometry degree at the University of Waterloo School of Optometry in 2003, and Fellowship of the American Academy of Optometry in 2012. Dr. Maharaj is lead optometrist at Humber River Regional Hospital - York/Finch Eye Associates - an integrated medical eye clinic. Dr. Richard Maharaj has a special interest in dry eye disease, glaucoma and disease of the retina. He is a clinical adjunct associate for the University of Waterloo College of Optometry. He is a published respected national speaker in eye education on diseases and diagnostics of cornea, retina, and meibomian gland dysfunction. His primary research is in non-surgical treatments of the eyelid and periocular glands. He is an active member of the Ontario Association of Optometrists, Canadian Association of Optometrists, American Academy of Optometrists and the College of Optometrists of Ontario.

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DRY EYE DISEASE - 2

Dry eye disease (DED) is a distinct clinical entity with a grouping of clinical signs and symptoms. According to TFOS DEWS II the following definition encapsulates our current understanding of DED: Dry eye is 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 etiological roles (DEWS II). A central mechanism that has become cemented with the pathophysiology of DED is that...

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DRY EYE DISEASE - 3

Presenting Patient #TFOSDEWSII Pathophysiology/Tear Film/Diagnosis No Signs ^ Signs of Ocular Surface Disease j Signs of Ocular Surface Disease Triaging Questions #TFOS DEWS II Latrogenic DED #TFOS DEWS II Management Other Ocular Surface Disease Different Diagnoses Symptoms Without Signs Pre-dinical State Neuropathic Pain Non-OSD Refer/Manage According to Differential Diagnosis #TFOS DEWS II Diagnosis Observe / Offer Education / Preventive Therapy #TFOS DEWS II Management Refer for Pain Management #TFOS DEWS II Pain & Sensation Figure3. DEWS II classification flowchart (2) DED, as noted on...

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Exclusion of masqueraders of DED is part of the intake process and can be analyzed through the questions listed in Figure 4. Severe symptoms in the absence of signs may suggest a neuropathic component. Figure 4. Triaging questions to identify DED masquerading factors (2) Personal and iatrogenic factors may include but are not limited to the following (2) (3): Pharmaceutical use (antidepressants, anticholinergics, antipsychotics, antispasmotics and antihistamines, chemotherapeutics, antihypertensive, anti-arrhythmics, antithyroid agents, opioid analgesics, accutane) Smoking Chronic...

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The two most widely accepted and validated questionnaires for DED severity are Ocular Surface Disease Index (OSDI) and Dry Eye Questionnaire 5 (DEQ-5) (Appendix 1 and 2) (2) (4). When triaging questions and risk factors have been addressed, OSDI > 13 or DEQ-5 > 6 signals the need for homeostasis marker testing which is detailed below. A positive symptom questionnaire plus at least one of the following homeostatic markers will yield a diagnosis of DED. Tear Break-up Time 210s (NIBUT vs. FBUT) Non-invasive BUT is the preferred method where available which can be measured subjectively with any...

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(e.g. allergy, Sjogren's syndrome, contact lens complications, etc.) Validated Symptom Questionnaire Possible flow, outcome depending Defined pathway Homeostasis Markers (at least one) <10s (NIBUT vs FBUT) Tear Osmolarity i 310 mOsm/L in either eye or inter-eye difference > 8 mOsml/L Corneal staining > 9 or more spots Lid Wiper Epitheliopathy > 2mm in length and a 25% width (Without homeostasis markers) Neuropathic Conditions Sub-category Specific Testing (Without symptoms) Neurotrophic Conditions Figure 6. Adapted Dry Eye Workflow for Clinical Assessment Based on the Figure 6, a clinical...

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Meniscometry SMTube® The latest quantitative tear function test: rapid, reliable and non-invasive. Ocular Surface Testing Biomarker testing (MMP-9) Osmolarity Testing (l-PEN®) LIPCOF (Lid Parallel Conjunctival Folds) Eyelash evaluation (Demodex) In vivo Conf oca I Microscopy Corneal esthesiometry Conjunctival Redness Aqueous Testing Schirmer Phenol red thread Meniscometry (SMTube®) OCT meniscometry Management According to the DEWS II management and therapy report, the aim of clinical management of DED is to restore homeostasis to the ocular surface. Given the multifactorial etiology of this...

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Stepl Education regarding the condition, its management, treatment and prognosis Modification of local environment Education regarding potential dietary modifications (including oral essential fatty acid supplementation -l-VU® OMEGA-3 PLUS) Identification and potential modification/elimination of offending systemic and topical medications Ocular lubricants of various types (l-DROP® PUR and l-DROP® PUR GEL) (if MGD is present, then consider lipid-containing supplements) Lid hygiene (l-LID’N LASH®) and warm compresses/ heat therapy masks of various types (l-RELIEF®) Dietary Modifications...

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Other Therapeutic Options Within the steps of management, clinicians invariably need to customize the treatment plan to cater to the particular case. Knowledge of all options available will enhance patient outcomes. Below are some therapeutic options to consider within the stages. Tear Replacement Approaches After lifestyle changes, the least invasive approach to restoring homeostasis is artificial tear substitutes. Within this category, viscosity enhancing agents can enhance the stability of the tear film by increasing residence time on the eye: Carbomer 940 (polyacrylic acid)...

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TFOS DEWS II Definition and Classification Report. Craig JP, Nichols KK, Akpek EK, Caffery B, Dua HS, Joo CK, Liu Z, Nelson JD, Nichols JJ, Tsubota K, Stapleton F. 3, Jul 2017, Ocul Surf, Vol. 15, pp. 276-283. TFOS DEWS II Diagnostic Methodology report. Wolffsohn JS, Arita R, Chalmers R, Djalilian A, Dogru M, Dumbleton K, Gupta P, Karpecki P, Lazreg S, Pult H, Sullivan BD, Tomlinson A, Tong L, Villani E, Yoon KC, Jones L, Craig J. 3, July 2017, Ocul Surf, Vol. 15, pp. 539-574. Clinical, immunologic and molecular factors predicting lymphoma development in Sjogren's syndrome patients....

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