CET Continuing education
T Practical guide to dry
ype the term dry eye into
Google and the result is about
32,000,000 hits ranging
from comprehensive
overviews of symptoms,
diagnosis and management
to chat groups, support groups and
blogs. Companies manufacturing
pharmaceuticals, over-the-counter
artificial tear preparations and other
treatment devices have entire websites
dedicated to dry eye.
It is, however, well within the clinical
competencies of both optometrists and
contact lens practitioners to manage dry
eye and in most instances these patients
do not require to be referred to the GP/
ophthalmologist nor should the practice
watch sales of products related to dry eye
management be lost to pharmacies and
the internet.
As a disease, dry eye is complex.
Modern research and understanding has
shown that we simply cant view dry eye
as a failure of tear quantity or quality, but
recognise it as a complex ocular surface
disease.
The Dry Eye Workshop (DEWS)1
forum is composed of an international
panel of dry eye experts tasked to
update our understanding of dry
eye. The panel has released several
papers on definition and classification,
diagnosis, epidemiology, treatment and
management, and research.
A fundamental change in our
understanding of dry eye is evident in
its current definition:
Dry eye is a multifactorial disease of
the tears and ocular surface that results
in symptoms of discomfort, visual
disturbance, and tear instability with
potential damage to the ocular surface. It
is accompanied by increased osmolarity
of the tear and inflammation of the
ocular surface.
How does this definition apply
to us in a clinical setting today?
The new definition has done a great
deal to show that dry eye is not a simple
problem with a simple solution. Indeed,
the clinical picture for a patient can
change as a result of any and all of the
factors that go into producing dry eye
initially. A previously happy patient
living in a cool, humid environment
may increase the amount of computer
based work in an air conditioned office
while starting a course of medication for
increased blood pressure. Should any of
us then be surprised to find out that this
patient had quickly become a dry eye
victim and subsequently unhappy?
The key point is that a patients
clinical picture can change as lifestyle
30 | Optician | 25.11.11
eye management
Caroline Christie explains how best to assess and manage the dry
eye. Module C17953, one specialist point for CLOs and one
general CET point for optometrists and DOs
Subjective Evaluation of Symptoms of Dryness (SESoD)
Evaluate your ocular discomfort due to the symptoms of dryness on a scale of 0 (none) to 4 (severe).
You may use the following descriptions to assist in your score
Dryness Grade Description
None 0 I do not have this symptom
Trace 1 I seldom notice this symptom, and it does not make me uncomfortable
Mild 2 I sometimes notice this symptom. It does make me uncomfortable, but
it does not interfere with my activities
Moderate 3 I frequently notice this symptom, it does make me uncomfortable, but it
sometimes interferes with my activities
Severe 4 I always notice this symptom. It does make me uncomfortable, and it
usually interferes with my activities
Trefford Simpson and colleagues2 recently assessed four commonly used questionnaires McMonnies, DEQ, Ocular Surface
Disease Index (OSDI) and Subjective Evaluation of Symptom of Dryness (SESoD) found overall scores highly correlated
concluded use of a quick three-question screening tool is ideal for routine clinical practice.
Key questions (1) Frequency of symptoms (2) Presence of discomfort (3) Interference with activity
Figure 1 Dry and environments change. However, identify and categorise the presence and
eye grading we rarely see our patients for more than more importantly the severity of dry eye
scale 15-20 minutes when collecting their among patients. A good questionnaire
contact lenses or 30 minutes over the will bring problems to your attention
course of an entire year, in the case of and help you ask the right sort of probing
annual eye examinations. questions. I then want to hear patients
How then can we possibly expect to describe how their eyes feel in their
correctly identify a patients problem and own words, which can then lead into a
confidently recommend a management more detailed informative conversation.
approach? Often our recommendations What time of the day does the problem
are not followed through, leading to occur? Have you ever tried anything to
similar or even increased symptoms by deal with this? If so, what? What, if any,
the time of the next appointment. activities does it affect, computer work,
Optimal management of dry reading, driving and so on?
eye requires careful listening to the The DEWS report does not specify
patients history and symptoms, how we should routinely ask patients
gleaning information about their about symptoms but does indicate several
work and recreational environment, important components to symptom
a detailed assessment of the tears and assessment:
ocular surface using a battery of tests Frequency how often a symptom
and an appreciation of the numerous is expressed
management approaches that exist. Severity how bad or disabling the
The first step is to properly identify symptom is
dry eye sufferers. Most dry eye patients Interference with activity how it
have symptoms, but they are not always affects specific work/home based tasks.
reported with the chief complaint or It is now believed that in the early
reason for visiting the practice. Therefore, stages of dry eye disease symptoms are
it is valuable to conduct a symptom not present all of the time but are episodic
survey (dry eye questionnaire) to help in nature and could be influenced by
opticianonline.net

The type of blink required for optimum blink efficiency has the following characteristics:
An efficient blink is full and complete, meaning that the top lid lightly touches the bottom lid
A n efficient blink is relaxed and light, meaning that only the muscles of the eye are involved.
Specifically, the muscles of the eyebrows and cheeks are not involved
An efficient blink is quick and rapid, taking only one third of a second to complete
Finally, an efficient blink looks confident and natural
Figure 2 Extract from a blink exercise sheet3
environmental factors including the
growing use of visual display devices
and exposure to air conditioning/central
heating at work and in the home.
How disabling a symptom may be
is likely dependent on the individual.
Some patients have a higher tolerance
for ocular irritation compared to others.
Other patients may stop or avoid certain
activities but may not consider this to be
related to how their eyes feel.
Asking patients specific questions
about how eye irritation or discomfort
may prevent them or reduce their ability
to perform certain activities, such as
reading or using a computer, can help
in determining the impact of symptoms.
The impact of the symptoms may be
recorded by reference to a grading scale
(Figure 1).
Specific questions about length of
comfortable computer use in hours can
help track changes over time with or
without treatment.
Blink rate
Given that evaporative dry eye is the
most common form of tear deficiency
seen in routine optometric practice,
failure to consider the need to improve
blink efficiency may significantly
undermine efforts to improve tear
function in general.
The normal apposition of the lids
during a complete blink promotes lipid
secretion from the meibomian glands.
The lipid layer is spread across the
cornea by the upper lids and inefficient
blinking may be associated with poor
maintenance of lipid layer integrity. For
example, during prolonged reading,
when blink rate and blink completeness
are significantly reduced, the lipid layer
can thin and virtually disappear before
reappearing with conscious blinking.
It is possible that reduced lipid flow
associated with inefficient blinking
contributes to stasis and gland blockage.
In addition, lipid flow from glands
that have been unblocked with warm
compresses, lid massage and cleansing
may not maintain their patency and
so elapse to a blocked state if blink
inefficiency is not remediated.
Apart from the potential to contribute
to reduced lipid flow, incomplete blinking
effectively doubles the inter-blink interval
opticianonline.net
Continuing education CET
and increases the potential for increased
tear layer loss by evaporation from the
areas of conjunctiva and cornea which
are exposed by an incomplete blink.
Although deliberate, forceful blinks
promote secretion from unobstructed
glands, they have a tendency to produce
debris in the tear film leading to transient
blurring. Patients will prefer not to blink
rather than depend on conscious forceful
blinking episodes. It may be better to try
to achieve longer lasting benefits from
improved unconscious blink efficiency.
Figure 2 shows a blink instruction
sheet.
Failure to address blink efficiency
where a need is indicated may have
greater significance with computer use
and/or with other forms of reading and
close vision demands. Such activities are
associated with reduced blink efficiency
and this may be exacerbated with
concurrent exposure to central heating
or air conditioning.
At present, there is no single gold
standard test for developing a clinical
diagnosis of dry eye; therefore, a battery
of tests is generally employed in clinical
practice (as well as for research purposes)
to define dry eye.
Remember, however, to always carry
out the least invasive tests first as you
want to minimise the disruption to the
tear film if you are attempting to measure
and monitor changes to factors such as
the tear quantity, quality and stability
(Table 1). Ideally carry out the tests in the
same order, under the same conditions
and where possible the same time of day
at each visit to aid comparison of results
to make better informed decisions on
ongoing management plans.
Dry eye evaluation must also be
multifaceted. In addition to assessing
tear volume, quality, and stability, it is
necessary to interpret staining patterns
and complete a full lid evaluation to
rule out the presence or co-existence
of blepharitis. There is overlap of
many symptoms of dry eye disease and
blepharitis, so careful clinical evaluation
is important.
Meibomian gland dysfunction
(MGD)
The International Workshop on
Meibomian Gland Dysfunction report
revealed that MGD may actually
comprise the majority of dry eye
disease.
DEWS:
Meibomian gland dysfunction (MGD)
is a chronic, diffuse abnormality of
the meibomian glands commonly
characterised by terminal duct obstruction
and/or qualitative/quantitative changes
in glandular secretion.4
In MGD, the meibomian glands are
frequently obstructed, affecting the
volume and quality of the oily secretions.
The result is tear film instability, which
can lead to ocular surface damage
and inflammation, and, commonly, to
symptoms.
However, despite the frequency of
presentation, MGD remains relatively
poorly managed in clinical practice. The
chronic nature of the condition requires
that therapy be applied regularly, and with
long-term commitment. Management
of MGD typically includes warm
compresses, massage and lid scrubs
known to improve lipid layer thickness
and, in turn, reduce tear evaporation.
The goal of MGD management is
two-fold:
To assist the remaining meibomian
glands in producing more and better
quality lipids
To reduce inflammation of the glands,
this is nearly always present.
Warm compresses and eyelid
massage. The warmth helps to
overcome the elevated melting point of
lipids inspissated within the glands. It is
important to note that although many
text books suggest the use of warm
flannels, they rarely reach or indeed
maintain the temperature required to
melt these inspissated lipids and repeated
removal and reheating of the flannel is
required. There are, however, a number
of commercially available devices from
the simple and inexpensive MGDRx
EyeBag and iHeat devices through to
25.11.11 | Optician | 31
 CET Continuing education
Figure 3 Lissamine staining of the conjunctiva
more sophisticated moist heat devices
such as Blephasteam goggles which
achieve the 39-40C required to melt
the meibum while maintaining a
constant heat over the treatment period
of 10-15 minutes.
Following the heat phase, firm
digital massage of the lid margin helps
to express the oils, so that the glands
become unblocked. Eyelid massage also
encourages blood flow to the eyelid area
containing the glands, which can help
remove inflammatory mediators.
Finally, cleaning of the lid margin to
remove excess oils and dead cells is best
done not with dilute baby shampoo but
with specifically designed commercial
solutions and wipes that are free from
preservative, fragrance and alcohol.
Baby shampoo contains surfactants and
when in contact with the tear film will
contribute to destabilising the lipid layer,
detracting from the initial aim of the
entire lid hygiene exercise in providing
a thicker and more stable lid layer to
prevent/reduce evaporation of the tear
film and improve symptoms of dry eye.
Lipid replacement artificial tears.
These products replace/supplement
the missing lipids that should normally
be secreted by the meibomian glands.
While direct evidence is limited, lipid
replacement drops should reduce the
evaporation rate and should provide
symptomatic relief and help to protect
and possibly heal the ocular surface. They
also wash out inflammatory cytokines
to provide a thicker, more stable tear
film, which reduces the inflammatory
stimulus.
Dietary supplements/omega-3 fatty
acids. The metabolites of both omega-6
and omega-3 essential fatty acids (EFAs)
are anti-inflammatory when the dietary
ratio is 4:1. The typical North American
diet (nowadays often similar in the UK)
is closer to 15:1 causing the derivatives
of the omega-6 EFAs to contribute to the
inflammatory process.
32 | Optician | 25.11.11
Figure 4 Fluorescein tear break-up
Omega-3 FA supplements should
not be considered if the patient is
using a blood thinner and/or serum
lipid-lowering drugs. Consult with
the patients GP prior to starting any
supplements. It may take 1-2 months
of regular use before any effect is
noticed.
Refer to GP for systemic tetracycline
derivatives. The tetracycline derivatives
are anti-inflammatory in action and
when inflammation is reduced the
Table 1
Dry eye work-up
Dry eye questionnaire (record score)
Measure tear film osmolarity (if equipment
available)
Keratometer/topographer
NIBUT
Tearscope (currently out of production)
Slit lamp
Tear quality and meniscus height
Phenol red threads (if available)
Tear quantity
Slit lamp
Grade conjunctival hyperaemia
Insert lissamine green
Record/grade conjunctival stain (Figure 3)
Insert FL
Observe tear mixing
TBUT (Figures 4 and 5)
Record/grade corneal staining (Figures 6 and 7)
Evert lid
Record/grade - Lid wiper epitheliopathy
Examine lid margin
Check meibomian gland patency (Figure 8)
Discuss thoroughly your findings
If they understand why they are doing things
they are more likely to do them!
Create a personalised management plan
Write it down in clear simple steps
Demonstrate procedures and products
Prescribe and sell products
Dont try too much too soon
Compliance will be poor and you wont know communication. Make sure that your
the effect of each therapy
Arrange suitable follow up appointment in 2-4
weeks
Figure 5 Tear break-up with superficial staining
glands can secrete more and better
quality lipids. Therapy may need to be
continued for 3-6 months in cases in
which inflammation is not subsiding
and/or symptoms are not improving.
Artificial tears
Artificial tears are the first line therapy
in patients with dry eye. However, a
significant number of practitioners
offer artificial tears as the only solution
(treatment plan) to patients complaining
of dry eye symptoms.
Two particular statements published
in the DEWS report1 worth considering
are:
For patients with moderate to
severe dry eye disease, the absence
of preservatives is of more critical
importance than the particular polymeric
agent used in ocular lubricants
For patients with dry eyes even
vanishing preservatives may not totally
degrade due to the decrease in tear
volume and may be irritating.
This has changed my approach
somewhat and I now more than ever
recommend non-preserved artificial
tears to my dry eye patients, irrespective
of the number of times they insert the
drops or whether they are a contact lens
patient or not. Optician will be publishing
a comprehensive table of currently
available ocular lubricants in the UK
next week. Once the disease process is
actively managed, artificial tears still play
a role as supportive therapy to alleviate
symptoms.
Patient education
So, how do we educate our patients?
What is the best way to ensure that they
are going to remember what was said in
the practice?
It all starts with appropriate verbal
descriptive language is easy to understand.
If the message is too scientific it may not
register and all your hard work would
have been in vain. Supplement verbal
opticianonline.net

Figure 6 Inferior dessication staining
instructions with brochures or links to
websites where patients can get accurate
information.
Design a treatment plan, emphasise
the importance of adhering to this
plan and schedule a follow-up visit in
3-4 weeks. This gives the patient time
to form the habit of using the drops or
performing the lid hygiene routine but
does not give them time hopefully to fall
off the wagon or run out of the product
you advised.
Nowadays, patients can find out
anything they want on the web, so it is
Multiple-choice questions take part at opticianonline.net
1 4
According to the Dry Eye Workshop
Report (DEWS), which of the following is
NOT TRUE of dry eye?
A There is a decreased osmolarity of the tear
film
B There is potential for damage to the ocular
surface
C Symptoms include discomfort and visual
disturbance
D Dry eye is a multifactorial disease
2 What are the three key question areas
required to ascertain the grade for the
level of dryness?
A Frequency, presence of discomfort and
blurred vision
B Frequency, presence of discomfort and
interference with activity
C Frequency, presence of discomfort and
discharge
D Presence of discomfort, blurred vision and
discharge
3 Which of the following is NOT TRUE of an
ideal blink pattern?
A Full and complete
B Relaxed and light
C Slow and precise
D Confident and natural
Successful participation in this module counts as one credit towards the GOC CET scheme
administered by Vantage and one towards the Association of Optometrists Irelands scheme.
Deadline for responses is December 22 2011
opticianonline.net
Continuing education CET
Figure 7 Staining pattern related to poor blink
even more critical that their practitioner
leads them in the proper direction to
informative sites rather than leave them
to Google poorly referenced or, worse
still, pure selling sites.
A dedicated member of staff, the
optical hygienist trained in dealing with
dry eye management the insertion
of drops, lid hygiene techniques and
associated products is a major asset to
the practice both in time management
and patient improved compliance and
satisfaction.
Figure 8 Checking the meibomian gland patency Ensure that the patient understands
that this is a dynamic process and that
the required management may change
as mentioned at the beginning of this
article. They need to understand what
Which of the following is not a symptom to do if circumstances worsen and
of MGD? symptoms return.
A Burning sensation In summary, dry eye disease is
B Blurred vision commonly encountered in everyday
C Discomfort practice. We must use a thorough case
D Itching history of symptoms in conjunction
with a variety of clinical and diagnostic
5 For patients with moderate to severe
dry eyes, what should be avoided when
selecting a dry eye product?
tests to diagnose the condition and its
severity. Approach management and
treatment options in a systematic way
A High viscosity polymers based on symptoms and clinical signs of
B Hypotonic agents
C Preservatives
D Electrolytes
severity
Dry eye is a chronic disease and one
that can be frustrating for both patient
and practitioner. In our quick fix
6 What is the optimal temperature for a lid
warming device to reach and maintain to
melt inspissated meibum from the lid margin?
society, this is one disease process that
does not play by those rules.
A 25C
B 37C References
C 40C 1 The Dry Eye Workshop (DEWS). The Ocular
D 50C Surface; April 2007, Vol 5, No 2.
2 Simpson et al. Dry Eye Symptoms Assessed
by Four Questionnaires. OVS, 2008; 85:8
692-698.
3 McMonnies CW, Incomplete Blinking,
Contact Lens & Anterior Eye, 30 (2007)
37-51.
4 Nicholls K et al. International Workshop on
MGD. Invest Ophthalmol Vis Sci; March 30,
2011 vol 52 no 4 1917-1921.
Caroline Christie is associate director
for contact lens teaching, City University
25.11.11 | Optician | 33