Although it’s hard for me to believe how time passes, I started my first dedicated dry eye disease (DED) clinic in 1998. Things were limited back then—we had crude diagnostics, a poor understanding of the disease, a large unserved patient population and no on-label therapeutic agents. There were times when more than half the patients I saw were dissatisfied with their treatment. What a terrible scenario. 

Fast forward 23 years and we have four approved dry eye disease therapies, numerous effective in-office treatment options, advanced DED diagnostics, easy-to-follow protocols and a greater understanding of the disease. Today, over 95% of the patients that come into my dry eye clinic are satisfied with their treatment. 

 I’ll share what I feel are the keys to that transformation. 

Where to Start? 

Many doctors serve their dry eye patients well even without advanced technology, but for those looking for more control over the experience, the first piece of equipment I’d recommend would be a slit lamp imaging system (e.g., Haag-Streit, TelScreen, Firefly). This helps with patient education and lets you reference the baseline pathology from a previous visit. Another consideration for education is providing dedicated video assets from Rendia (formerly Eyemaginations) that explain the complexities of DED in a straightforward way without tying up staff time. If you want to offer in-office procedures, you’ll need a tool for expressing meibomian glands (e.g., Mastrota Paddle or Meibomian Gland Evaluator) and an eyelid debrider. For evaluation, NaFl dye and a yellow filter are standard. If you want to have a dedicated dry eye center, you’ll also need osmolarity, meibography or a tear diagnostic system. 

Next, you need to identify patients who may have DED. My favorite triaging questions came from the Optometric Dry Eye Summit in 2014 and I still use them today (see table above). These quick and easy questions could even be asked by your front office staff with each patient. 

Find a good diagnostic protocol such as the Tear Film and Ocular Surface Society’s DEWS II diagnostic methodology algorithm. Be sure to differentiate the types of dry eye (lipid/evaporative, mucin or aqueous-deficient), as each has slightly different treatment approaches, although inflammation may be the one consistent component across all forms.  

Management Methods

In-office procedures to mitigate dry eye symptoms have become increasingly relevant during this pandemic as patients have spent far more time on digital devices, which exacerbates pre-existing dry eye. Consider the merits of procedures that may include BlephEx, thermal pulsation, intense pulsed light and/or low-level light therapy. Products such as omega fatty acids, hydrating compresses, nighttime lid seals and lid cleansers also provide patients with much-needed convenience when offered and explained in the practice, rather than expecting them to fend for themselves with nothing but Google to guide them. 

The eyelids are the most important component of DED and you have to be a keen observer to differentiate Demodex from staphylococcal and seborrheic blepharitis. You must then treat each condition appropriately. Meibomian gland dysfunction (MGD) is a greater opportunity than DED. This requires early identification and treatment, but patients will remain in contact lenses longer. Look for reasons why MGD is present, such as non-sealing lids, with the Korb-Blackie light test. 

In addition to immunomodulatory drugs, steroids are a necessity when managing DED, but keep them to short-term therapy and flare-ups. Consider extended-duration punctal plugs for appropriate patients and be open to the role of biologics (e.g., amniotic membrane, autologous serum, cytokine extract) and ultimately scleral lenses.  

Managing dry eye disease is an enormous opportunity that, with a sound protocol, is exciting to treat and extremely rewarding for both you and your patients.

Dr. Karpecki is medical director for Keplr Vision and the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chairman of the affiliated New Technologies & Treatments conferences. A fixture in optometric clinical education, he provides consulting services to a wide array of ophthalmic clients. Dr. Karpecki’s full disclosure list can be found here.