This is a phrase I always keep in the back of my mind when a dry eye evaluation is starring me in the face. I am sure by now all of us have read the DEWS II study from front to back. We can all treat our patient’s loss of homeostasis of the tear film, tear film instability, ocular surface inflammation and damage, and neurosensory abnormalities better than ever before with procedures and medications that are top notch. But if a patient doesn’t have adequate lid architecture, no one is going to be successful treating dry eye disease.
Pulling on patients lids prior to putting them in a slit lamp can go a long way at the start of a dry eye exam. If the patient has floppy eyelid syndrome, lid laxity, ectropion, entropion, poor apposition of the lid to the globe, or a chalazion (just to name a few) there should be a referral to an oculoplastic specialist to restore the lid architecture with whatever procedures are necessary.
Correct lid architecture will ensure each blink will be able to spread every component of the tear film you have worked so hard on to restore and give you and the patient the solid foundation for further dry eye disease treatment if needed.
I always tell my patients that I don’t care what kind of car they drive, how good their windshield wiper fluid is, or how full their wiper fluid reservoir is…if they don’t have good windshield wipers, all that doesn’t matter.
So make your life and your patient’s life easier and set everyone up for success, don’t forget about the windshield wipers.
