It’s been a pretty cool decade in the field of external disease. As ODs, we are confident and sophisticated in treating patients with new knowledge and therapies. The area of dry eye has been particularly explosive, with thought leaders in ODs like Kelly Nichols, Tom Kislan, and Scott Schachter leading the charge for better dry eye disease care. We simply don’t need to refer these patients in order to get state-of-the-art diagnosis and treatment.
If you’ve followed any of my previous columns, you’re thinking, “OK, what’s he leading up to NOW?”
It’s hard to explain. Dry eye can be as mysterious as it gets, due to complex physiology balanced against the symptoms generated by the sensitive corneal and conjunctival innervation. “Homeostasis” is the current buzzword.
Talk to your colleagues at the grassroots level, and ask them “What testing do you perform for dry eye disease, and what do you do for treatment?”
You’ll get a broad response on the testing side. Some are doing tear assays and meibomography. Some are doing traditional testing only, like tear BUT and Schirmer. Some are treating based on symptoms only.
Who is right and who is wrong here? Are the advanced tests leading to more precise treatment? You could argue that testing distinguishes aqueous deficiency versus Meibomian dysfunction/evaporative forms. You could argue that dry eyes are more osmolar, and show more MMP-9 concentration. You could argue that Meibomian gland dropout is a harbinger of trouble. I would, too.
I’d also argue that there is an INCREDIBLE disconnect between testing results and therapeutic choices. There, I said it.
Tear and Meibomian testing come to mind as potentially problematic. I have yet to see a dry eye case presentation with multiple testings, where the treatment differs from what I, or most of us, would do.
We’ve come so far in the treatment of dry eye, with Xiidra (lifitegrast, Shire) and Restasis (cyclosporine, Allergan) emerging as treatment game-changers. We are getting sustained results with both of these agents. The coming neuro-stimulative device by Allergan is especially interesting and holds promise.
The testing is another story. It’s an area of great potential, but the scenario goes something like this. A tear assay test result of X leads to an Rx of Y. Retest after treatment shows a 5% improvement, and the Doc leans forward and says, “See? SEE?” Forgetting for a moment that the reliability of some assay testing has been challenged (footnotes 1-4), one has to ask, “What is the margin of error for the test?” Is there a statistical norm that suggests that patient well-being has been improved, too? Can’t tear findings vary from hour to hour or day to day, like fasting blood sugar and refractive errors seem to do?
Is it a shock to ANYONE that we find an increased tear level chronic inflammatory mediator (MMP-9) in a chronic inflammatory condition?
One of my bottom lines here is that the advanced testing does not seem to match up with our more limited ability to select treatment options. Let me say that a little more crudely. I’ve seen a ton of patients with advanced testing done elsewhere, and they have almost never had a treatment sequence that differs from my own or suggests doing something that we didn’t consider.
The problem is that proper dry eye treatment is a form of step therapy, similar to what a rheumatologist would do for an arthritic patient. Pick the right level of intervention for the presenting level of signs and symptoms. Compare this to treatment of infection, where initial “scorch the earth” treatment is usually appropriate. Am I going to start a mild dry eye patient on top quality artificial tears, regardless of findings? Yes, I am. (I was fairly stunned when a fellow FB poster suggested that this was inappropriate and old school.) Am I going to review environment and diet, and make suggestions? Yes, I am. Am I going to send for Lipiflow, at entry level? I am not.
Point being, initial treatments may not vary enormously based on whether or not we’ve done assays, gland studies, etc.
Noncompliance with dry eye is enormously high, and I can’t help but think that some of our “programs” are especially onerous when compared to the level of symptoms given. Is it possible that we’ve become TONE DEAF to patient needs, in the face of enormous dry eye disease information and pushy journalism? It says here that the advanced testing may not be resulting in incrementally better treatment for these patients. The tests themselves could drive a culture of overkill that I am seeing in some of our literature. My only plea here is that we let dry eye symptomatology remain as the primary driver of our great treatments, and prescribe in steps to make the patient well.
1 http://jamanetwork.com/journals/jamaophthalmology/article-abstract/2451642
2 https://eandv.biomedcentral.com/articles/10.1186/s40662-014-0006-y
3 https://jamanetwork.com/journals/jamaophthalmology/fullarticle/2210535
