Dry Eye Dx and Tx
BY KATHERINE M. MASTROTA, MS, OD, FAAO
In developing a specialized clinic dedicated to ocular surface care, we have spent hours discussing logistics. How patients will be initiated into the clinic, appointment template timing, technology and instrumentation needs, staffing, patient counseling, referring-practitioner communications, and marketing the service have all been considered.
One element of the program that received much attention was the examination/treatment scheme. What tests are essential? In what order will they be done? Who will administer and evaluate the tests? What treatments would we offer? As an evaluation and benchmarking tool, we concurred that a dry eye questionnaire would be a part of each patient profile. But, which one(s) would we use? Or should we devise our own?
A variety of International Dry Eye WorkShop (DEWS)-validated questionnaires are available to use in a clinical setting (DEWS, 2007). DEWS-validated, questionnaires have met 1 or 2 and 3 and 4 of the following criteria: 1) used in randomized clinical trials; 2) tested or used in epidemiologic studies; 3) had some psychometric testing; 4) are available and appropriate for generic, non-disease-specific dry eye populations.
DEWS identified 15 questionnaires that met the criteria. Common elements included queries of clinician-based or other diagnosis of dry eye; frequency and/or intensity of symptoms; effect of symptoms on activities of daily living; effect of environmental triggers on symptoms; presence of dry mouth; effect of visual tasks on symptoms (e.g., computer use); effect of treatment on symptoms; contact lens wear; medications; and allergies.
The number of questions in this battery of surveys ranged from six to 57 and, of course, required appropriate and thoughtful patient engagement. Perhaps most familiar is the Ocular Surface Disease Index (OSDI) that elicits the presence of dry eye symptoms and their severity (Schiffman et al, 2000). Other surveys serve as screening tools or assess quality of life issues.
Since the DEWS report, other questionnaires have been developed that target identifying and quantifying additional dry eye symptomatology. The results of the validated Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire are comparable to the OSDI in differentiating symptomatic from asymptomatic patients (Ngo et al, 2013). The brief, eight-question SPEED survey evaluates both the frequency and severity of symptoms within a 90-day time frame. DEWS 2.0 is also happening now, with more information and recommendations expected on questionnaires.
What We Chose
I’ve never been a proponent of questionnaires, although they are necessary in clinical trials and have some utility. I find that a verbal history with questions that emerge and build upon prior responses is most effective. In my experience, patients tend to rush through questionnaires. Additionally, I wonder about the thought put into their responses.
Thus, I am considering the validated, one-question University of North Carolina Dry Eye Management Scale (UNC DEMS) (Grubbs et al, 2014). It provides a snapshot of patients’ overall experience/symptoms and quality of life with dry eye within the past week of their life. The single question is easily understood and can be quickly answered. It can be administered at each follow up if warranted.
I look forward to reporting on how the UNC DEMS works for me and our practice. It is available for nonprofit clinical and research use at https://www.med.unc.edu/ophth/for-patients/clinical-specialties/unc-dry-eye-management-scale. CLS
For references, please visit www.clspectrum.com/references and click on document #247.
Dr. Mastrota is Program Chair-Elect of the Anterior Segment Section of the American Academy of Optometry. She is a consultant or advisor to Allergan, B+L, Bio-Tissue, OcuSoft, Paragon Bioteck, and Shire and is a stock shareholder of TearLab Corporation. Contact her at email@example.com.