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HomemieyecareMild Dry Eye Disease: Why it Deserves our Attention

Mild Dry Eye Disease: Why it Deserves our Attention

When your patients have a good tear film, their spectacle, contact lens and other treatments are more effective. Discussing this with them, and explaining the importance of diagnosing and treating mild dry eye, is vital to maintaining satisfied patients with a greater quality of life.

On a typical day, how many of your patients have signs or symptoms of mild dry eyes?

As you greet your patient, they might say, “I feel like it’s getting harder to read,” and later add, “I can read okay for about 20 minutes, but then I get a film that drifts in front of my eyes. I have to stop and blink several times to refocus.”

The more that patients understand their eyes and dry eye disease, the more informed they are to make better choices

Dry eye disease (DED) is increasingly common. According to the Tear Film and Ocular Surface (TFOS) DEWS II report, it affects between 5-50% of the population. Dry eye symptoms are one of the most common presentations that prompt patients to book an appointment with an optometrist.

Yet patients often put mild dry eye down to tiredness, stress or refractive error. They might say that they notice occasional dryness or wateriness, but it doesn’t get in the way of their lifestyle or work.

Such patients clearly have signs of DED. The questions remain – should you be doing a dry eye treatment for this patient? Would they be compliant with your treatment? Would they notice a difference?

Should you fail to address these early signs, mental health issues – such as anxiety and depression – can begin to take a toll, as worsening symptoms can affect a patient’s work, lifestyle and quality of life.



The easiest way to improve dry eye disease diagnosis is to continue your clinical history throughout the eye examination. As they have time to reflect during the examination, patients tend to share more.

Some of the common questions I like to ask are:

  • Do your eyes ever feel itchy or watery?
  • How do your eyes feel at the end of the day?
  • How do they feel after concentrating for a long period of time?
  • How do your eyes feel when you first open them in the morning?


Tear film instability can significantly affect refraction and acuity. When you refract, listen as patients describe the appearance of the visual acuity chart. Look for variations in acuity between eyes, or small script changes that make a big change to vision. Dry eye disease tends to cause more variable refraction for phoropter compared to trial frame refraction. Ask your patient to blink a couple of times and try reading again.

Quick Dry Eye Questionnaires 

If you suspect dry eyes, consider giving your patient a symptom questionnaire, like the DRY Eye Questionnaire (DEQ5) or Ocular Surface Disease Index (OSDI).

These symptom score tests are recommended by TFOS DEWS II. I like to give the DEQ5 test, which only takes 30 seconds for my patients to complete while I’m typing in my notes for slit lamp.

When you’re scoring DEQ5, a score of six or above is considered significant. Depending on the day, your patient may be above or below this threshold.

Smartphone Photography 

Seeing pictures of their own eyes helps a patient to better understand them. Sometimes, it helps them to remember the instances where they do have significant dry eye symptoms.

My favourite tool is my smartphone as it allows me to show details by zooming in and panning across high resolution photos, all within a few seconds.

You might point out things like:

  • Scurf or collarettes,
  • Lash base tenting,
  • Lid margin telangiectasia,
  • Lid margin biofilm or makeup debris,
  • Meibomian gland capping,
  • Punctal stenosis,
  • Papillae,
  • Conjunctivochalasis,
  • Lissamine or fluorescein staining (corneal or conjunctival), and / or
  • Incomplete blinking.

Showing photos to patients can also enhance compliance. Patients often ask me, “how do my eyelid bugs look today?”. They enjoy seeing that their treatment is working.


Let’s take an example of a patient who scores low on a symptom score test. For example, five or below on the DEQ5.

The patient likely reported that they ‘rarely’ notice discomfort, dry or watery eyes. So, what should you do for this patient?

If you treat this patient, will they value your treatment? Will they comply with it?

Optometrists and ophthalmologists routinely screen patients for pathological myopia, macular degeneration or glaucoma. Screening for dry eye disease should be part of our routine battery of tests.

As you explain your findings to the patient, they will feel more invested in their eye care, so that, if / when they become significantly more symptomatic, they understand the need to see you and take the first steps.

TFOS DEWS II gives helpful advice on other treatments for mild dry eye disease:

Change the Local Environment 

During lockdown, a friend of mine was working from home in a small office. There was room for a desk with a split system air conditioner above him. He spent long hours in this room staring at a screen. We discussed redirecting airflow in the office and taking screen breaks every half an hour. We also discussed incomplete blinking and being more conscious of blinking when reading or using a device. Following these changes, he noticed a significant improvement in his dry eye symptoms.

Dietary Modifications 

The western diet is often low in omega-3 fatty acids, especially EPA and DHA. Additionally, dry eye symptoms can occur with low vitamin D levels, especially during winter months. If a patient’s blood test reveals low levels of omega-3 and vitamin D, taking good quality fish oil and vitamin D supplements can significantly improve dry eye symptoms.

A dry eye patient shared how she was an undiagnosed coeliac. She had significant dry eyes and inflammation. Modifying her diet helped her to feel more energy during the day and provided significant dry eye relief.

Systemic and Topical Medications 

A glaucoma patient noticed itchy, red eyes when using Xalatan. We discussed an alternative with her specialist. She successfully changed to Timoptol drops and she now rarely experiences irritation.

Medications like anti-depressants can be associated with dry eyes. However, these are often delicately balanced by the patient’s GP. It is often easier to modify topical medications like anti-histamines (oral or nasal spray) or over-the-counter medications.

Lipid-Based Ocular Lubricants 

Lipid based drops are becoming more popular, especially for patients with meibomian gland dysfunction. Hylo- Forte and Novatears are good drops, however, patients need to carry two bottles around. Cationorm is a new drop that contains cationic emulsions to improve retention time. One clinical study found that Cationorm has mild antiinflammatory effects. That is, it reduces interleukin-6 and -8, presumably due to the nanoemulsion and vehicle.

Lid Hygiene 

One of the easiest things to show patients is an image of their blepharitis. You can point to early signs like lash base tenting (like a tree with heaped dirt at the base). You can also show scurf, collarettes and saponification (bubbles that often sit on the temporal canthus). Hypochlorous acid sprays, such as Avenova and Hypochlor, help reduce bacterial colonies such as staphylococcus aureus and epidermidis, and give patients a refreshing sensation.

Skincare and Makeup 

Any product that is applied to the skin can cause mild dry eyes. Similar to an acid burn to the cornea, the level of toxicity depends on three factors: the toxic product ingredient, the concentration and the exposure time. The two products that tend to have the most contact time are facial moisturisers/creams and mascara/eyeliner. These products sit on the skin for many hours a day. One of my dry eye patients swapped her facial moisturiser for a less irritating brand (such as Inika or Eyes Are The Story). She noticed a 25% reduction in her Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire without changing other products.


Mild dry eye disease is significantly increasing. Diagnosing and managing it can significantly improve patients’ quality of life in the long term, while ensuring they benefit from less tired eyes or blurred vision in the meantime.

From a practice perspective, treating mild dry eye improves optical devices, reduces glasses remakes and contact lens chair time, and boosts vision therapy outcomes.

Whether your patient is compliant or not, education is critical. The more that patients understand their eyes and dry eye disease, the more informed they are to make better choices. If they know that their eyes can get worse, they tend to be more likely to take your recommendations.

Consider the recommended treatments above as a starting point. Based on your examination, choose one of these that you believe is most likely to improve your patient’s eyes.

Whether you are a true generalist optometrist or have keen specialty interests, treating mild dry eye disease boosts your comprehensive eye care and creates more satisfied patients.

Leigh Plowman graduated with a Bachelor of Optometry (Therapeutic Endorsement) from the University of Melbourne in 2006. He practises at Otway Optical in Colac, Victoria. Mr Plowman is the founder of Dry Eye Directory as well as Optomly, a marketing consultancy for optometry.

Visit: dryeyedirectory.com/dry-eyes.