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HomemifeatureUniform Clinical Approach to Treating Dry Eye

Uniform Clinical Approach to Treating Dry Eye

The trauma suffered by people with dry eye, in particular extreme dry eye, is unbearable. These people require Australian optometrists to follow a uniform approach to diagnosing, testing for and treating dry eye. Instead, according to a recently published study, they receive a mix of ‘clinical intuition’ and ‘objective testing’. Dr. Laura Downie believes the key to improving professional practice and patient outcomes, involves the adoption of a more evidence-based approach to eye care.

“There is a significant variability in clinical care for dry eye provided by optometrists here including diagnostic testing and infrequent use of standardised grading scales,” according to study lead author Dr Laura Downie (PhD), from the Department of Optometry and Vision Sciences at the University of Melbourne.

“Our results highlight the potential to improve the translation of dry eye research evidence into the clinical practice of Australian optometrists.”

Dr. Downie says that for dry eye diagnosis there is scope for objective grading scales of clinical signs, for example corneal sodium fluorescein staining, to be used more frequently, and for practitioners to quantify patient symptoms more rigorously, through the adoption of standardised dry eye questionnaires (DEQ) such as McMonnies Dry Eye Questionnaire and the Ocular Surface Disease Index.

Less than one quarter of practitioners ranked peer-reviewed journal articles in their selection of the top two influences for their management practices…

The research, published in the journal Optometry and Vision Science, is the first to analyse how current Australian optometric practice behaviours compare with internationally recognised guidelines for dry eye diagnosis and management.

An online survey was completed by almost 150 registered optometrists from all over Australia of whom just over half nominated a specific interest in treating dry eye disease.

Overall, the surveyed practitioners demonstrated a strong knowledge in tear film evaluation with 75 per cent correctly listing appropriate diagnostic techniques for assessing tear volume and stability.

For tear film stability the appropriate clinical techniques were tear breakup time (TBUT – nominated by 93 per cent), the Tearscope (3 per cent), quality of Placido-disc topography mires (2 per cent) and interferometry (2 per cent).

Two thirds of respondents said patient symptoms were the most important and most valuable information for making a diagnosis, with fluorescein assisted TBUT chosen as an alternative to symptoms-based diagnosis by 17 per cent and in addition to symptoms by 35 per cent of respondents. Other less utilised tests included corneal fluorescein staining and meibomian gland evaluation.

Interestingly, despite patient symptoms ranking most highly, less than four per cent of practitioners said they used a standardised dry eye questionnaire (DEQ) to assist in a diagnosis.

Approximately half of practitioners indicated that they assess dry eye severity with their own ‘clinical intuition’, the study authors note.

Optometrists with an interest in dry eye more frequently used lissamine green, phenol red test, interference fringes and tear osmolality in making a diagnosis than non-specialist practitioners.

Heterogeneous Approaches

The mainstays of therapy were non-preserved lubricants and eyelid hygiene, and over half of respondents said they would recommend omega-3 fatty acid supplementation or that patients should up their dietary intake of fish.

Specialised practitioners were more likely to use preserved drops and gels and to prescribe topical corticosteroids.

According to the study authors, this subgroup was also more likely to be informed about recent research, advances and changes in treatments and diagnostic techniques for dry eye.

For example, they note that although the strong preference for more practitioners to use TBUT with fluorescein to make a diagnosis is in accordance with previous studies and is easily performed, fluorescein itself destabilises the tear film.

“Consequently, there has been a research-driven trend to adopt techniques that can evaluate the stability of the tear film in its natural state,” says Dr. Downie.

Moreover, the study found that optometrists who nominated an interest in dry eye disease tended to use non-invasive observation of interference fringes more frequently than non-specialist practitioners, reflecting an enhanced understanding of fluorescein’s limitations.

Asked why there is such heterogeneity in approaches to dealing with this condition, Dr. Downie told mivision that although dry eye is commonplace, “it is a complex ocular condition”.

“It is well known that there is often a limited correlation between patient symptomatology and its clinical manifestations. The categorisation of dry

eye is also complicated by the fact that the condition typically involves multiple components, such as the tear film, the eyelids, the lacrimal gland, accessory tear glands, the corneal surface and the conjunctival surface.

“As yet, there is also not one single clinical diagnostic test that can be used to definitively diagnose dry eye disease and assess or monitor its severity with treatment. In this respect, clinicians often utilise a range of different diagnostic techniques in order to try and obtain a ‘complete clinical picture.’ It is not surprising that different clinicians will have varying preferences for the techniques they adopt as part of a clinical work-up,” she says.

“However,” Dr Downie adds “it is important that clinicians are aware of and evaluate the evidence, as it becomes available, relating to the diagnostic efficacy of these different tests; in doing so, we would expect to observe over time relatively less heterogeneity in these clinical approaches.”

Further Education and Guidelines

The survey showed that optometrists’ knowledge about dry eye and management practices is more often garnered from secondary sources, such as conferences, than primary information sources, such as peer-reviewed journals.

“Less than one quarter of practitioners ranked peer-reviewed journal articles in their selection of the top two influences for their management practices,” said Dr. Downie.

By definition, a peer-reviewed or refereed journal subjects the articles that are submitted for publication for review by experts in the field, who provide a critique and assess its overall suitability for publication. This ‘peer’ scrutiny sets peer-reviewed journals apart from other forms of press. Common examples in the optometric and ophthalmologic professions include Clinical and Experimental Optometry and Optometry
and Vision Science

According to Dr. Downie, an evidence-based approach to clinical care requires an understanding of the nature of research ‘evidence’ and, in particular, how ‘hierarchies of evidence’ are relevant to clinical decision making.

“There are established hierarchies or levels of evidence, such as those provided by the National Health and Medical Research Council in Australia, that describe the degree to which bias has been eliminated from a clinical study. It is important for optometrists to base their clinical practices upon a rigorous and critical interpretation of the best available evidence.

One of the best approaches is the consideration of a systematic review of the literature, such as those provided by the Cochrane Collaboration database. These reviews systematically locate, appraise and synthesise all relevant evidence relating to a particular clinical question; using this approach, bias is minimised and apparently contradictory findings from different studies are often resolved.”

Speaking with mivision about her approach in treating dry eye, Sydney-based optometrist Chantelle Sayegh, said that having assessed the patient using TBUT and meibomian gland function she advises them to go on non-preserved tear supplements (usually Systane ultra) and to use a gel at night.

“If their dry eye is due to meibomian gland dysfunction then I will usually recommend lid scrubs, warm compressors and, more recently, Systane balance or unpreserved ocular lubricants.”

Ms. Sayegh believes when it comes to diagnosing and managing the condition “there isn’t a one-size fits all model.

“However, I do believe we need further training and a guideline for treatment as dry eye is a growing problem among patients,” she adds.

Workshops Planned

Dr. Downie believes that there is the potential to upskill clinicians in evidence-based practice, as it applies both to dry eye disease and more broadly to clinical practice, through the development of didactic and workshop-based sessions that review both fundamental skills and techniques that are essential to the delivery of evidence-based care; such programs have been shown to have a beneficial impact on professional practice and patient outcomes.

“At a more fundamental level, our research highlights that there is the potential to improve the adoption of evidence-based practice in optometric clinical settings.”

Laura Macfarlane is a trained ophthalmic nurse, professional journalist and member of the Australasian Medical Writers’ Association.

Evidence Based Workshops

Dr. Laura Downie and Associate Professor Peter Keller will conduct workshops on evidence-based practice for Victorian optometrists on Tuesday 20 May (with a repeat on Wednesday 21 May). The workshops will cover ‘Hot Topics in Optometry’ and the management of clinical case scenarios, including the management of dry eye disease. For information contact Laura Downie on [email protected].