Dry Eye Dx and Tx

Ocular Surface Disease Is Still Underdiagnosed

Dry Eye Dx and Tx

Ocular Surface Disease Is Still Underdiagnosed


There have been many advances in the field of ocular surface disease (OSD). We can now assess the tear film for osmolarity, inflammation, noninvasive tear breakup time, and more. We can image meibomian glands and evaluate their expressed oil quantity and quality. We have been re-educated regarding the significance of Demodex mites as a cause of blepharitis. We can treat dry eye disease with oral and topical anti-inflammatory medication, punctal occlusion, blink exercises, and expressing thickened oil from clogged meibomian glands.

Presented Statistics

A poster, presented recently at the 2015 American Academy of Optometry meeting in New Orleans, detailed the prevalence of ocular surface disease (Kwan et al, 2015). We’ve all seen the numbers; however, this poster was truly an epiphany for me as it presented the prevalence information in a very striking way.

Approximately 250 subjects were enrolled (average age of 40 years) and evaluated for three conditions: allergy, aqueous insufficiency, and meibomian gland disease (MGD). Investigators found that only 27% of the subjects were considered “normal.”

If this study had also evaluated for the presence of anterior blepharitis, a common anterior segment condition that is known to contribute to OSD, the number of “normal” subjects would likely be much less.

Standard of Care

Eyecare practitioners often lament the fact that they want to be busier and attract more patients, but we have to consider whether we are providing the highest level of care and maximizing every single interaction with the patients we’re seeing now. If we are truly honest, the answer is likely “no.”

Take a moment to think about the last 10 patients you examined who were 40 years or older. Did you diagnose OSD in at least seven to eight of them? That’s what the statistics suggest should be the case.

There is a tremendous opportunity here: If you want to provide a higher level of care for your patients and fill your schedule, looking for OSD more closely may be the answer. Not only will this be good for your patients, it will be good for your practice and will likely increase word-of-mouth referrals.

As we know all too well, signs and symptoms don’t often match in OSD, so it is important to screen our patients earlier and more routinely, even if they are asymptomatic. Yes, that requires more time and effort. However, if great vision begins at the tear film, why are we not paying more attention to the ocular surface?

Additionally, as our patients’ visual demands increase and they stare at devices all day, we are beginning to see MGD in younger individuals (Harthan et al, 2015). If we don’t intervene early, it’s possible that we might be seeing a profound increase in MGD in the coming years. Of course, like all OSD, early intervention allows for easier treatment protocols and more successful outcomes.

It is surprising that despite all of the advancements we’ve enjoyed in the field of OSD over the last decade (i.e., new screening tools, treatment options, and pipeline drugs), the biggest news seems to be that it is still very widely underdiagnosed and undertreated. Are we missing the diagnosis or ignoring it? Be an advocate for your patients. It’s why they come to see you. CLS

For references, please visit and click on document #243.

Dr. Schachter is in a practice in Pismo Beach, CA that focuses on Demodex blepharitis. He has been a Vision Source administrator since 2003. He is a consultant for Allergan and Bio-Tissue. Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.