Dry eye disease (DED) can significantly impact a patient’s quality of life (QoL), which can manifest as decreased visual quality, physical discomfort, decreased productivity, and even psychological distress. This is something that Sydney optometrist Hanna Kim knows all too well, from both professional and personal experience.
According to the Tear Film and Ocular Surface Society (TFOS), the prevalence of DED ranges from 5% to 50%. However, the prevalence of signs of DED is higher and more variable, reaching up to 75% in some populations.1
There are many studies that confirm the significant negative impact of DED on QoL. One study compared DED to other ocular conditions such as glaucoma, age-related macular degeneration (AMD), and retinal detachment. DED showed the highest risk of low health-related (HR) QoL. The authors stated that their results underline the importance of recognising dry eyes as a serious disorder.2
Dry Eye: It’s Personal
I have struggled with bothersome dry eye symptoms for decades. Reading and computer use caused burning and irritation; lubricants offered minimal relief. I dreaded air-conditioning and suffered from intermittent hordeolum.
Despite trying every new treatment as they became available (lubricants, hot compresses, lid hygiene, omega 3, ciclosporin etc.), I experienced limited improvement. Admittedly, I had inconsistent compliance with treatment – a struggle for practitioners and patients alike! Hence, I can empathise with my patients in both their suffering and with the difficulty of treatment compliance.
So, the pursuit of effective dry eye relief is personal and has become a professional endeavour, especially as I witness its increasing prevalence in younger patients.
As practitioners, we are in a fortunate position to be able to help preserve or improve patients’ QoL.
Meibography: A Picture Tells 1,000 Words
The first time I had meibography on myself, I was alarmed to discover rapid meibomian gland (MG) atrophy, further driving me to educate patients about the progressive nature of meibomian gland dysfunction (MGD) and the importance of early intervention.
In my practice, routine meibography has significantly improved patient understanding and treatment compliance. The Oculus K5M, with its dry eye related assessment suite, including meibography, has revolutionised patient communication and allows for monitoring of disease and treatment impact.
I now include meibography in every comprehensive eye exam, including for children. The high prevalence of advanced, often asymptomatic MGD I see – even in young patients – is alarming. This highlights the well-known disconnect between symptoms and disease severity.
I emphasise the ‘iceberg’ analogy to patients, explaining that mild symptoms may mask significant underlying disease that can worsen over time.
Early Detection and Treatment
Figure 1. Non-invasive keratograph tear break up time (NIKBUT) pre-Envision treatment.
Figure 2. NIKBUT post-Envision treatment.
As optometrists, we are involved in the early detection and management of a wide range of eye diseases. Most ocular pathologies like glaucoma and AMD are asymptomatic in early disease, requiring timely diagnosis and intervention.
We all know that myopia management is now a standard of care for optometrists. I believe, as do my fellow dry eye enthusiast colleagues, that dry eye disease ought to receive the same prominence. In my mind, the old saying ‘prevention is better than cure’ couldn’t be more applicable to atrophying meibomian glands. Optometrists are uniquely positioned to help prevent patients suffering from significant dry eye symptoms through early detection and management. Enhancing patient awareness through education and promoting lifestyle modifications can significantly improve long-term QoL.
Treatment Modalities
The increasing number of DED treatment options for optometrists is exciting. I’m always eager to explore new therapies and admittedly struggle to resist the temptation of trying every new device that comes along. Here’s a summary of my experience with DED treatment devices so far.
Blephasteam: Around 17 years ago, I was excited to get my first Blephasteam unit, which I have used in conjunction with meibomian gland expression (MGX). I still perform blephasteam with expression treatments for patients who want MGX but are contraindicated to have (or can’t afford) other in-office treatments. It is highly satisfying to see positive changes in meibum quality, expressibility, and improved patient symptoms over time.
Intense pulsed light (IPL): In pursuit of improved dry eye treatment efficacy, I purchased the E-Eye IPL unit in 2019. I observed physiological improvement post treatment in almost all patients. However, the degree of symptomatic relief with E-Eye IPL, perhaps due to my patient demographic, was sometimes unpredictable. Some had only mild symptom relief and others had significant improvement.
Rexon-Eye: To add to my toolbox of DED treatments (and because IPL is not suitable for all skin tones), I acquired the Rexon-Eye unit (Eyetek) in mid-2022. I have observed that almost every patient I have treated with Rexon-Eye has noticed moderate to significant improvement in symptoms. When Rexon-Eye treatment is used along with MGX, I noticed that symptomatic improvement is heightened and even MG morphology with meibography can improve slightly in many patients.
Envision: At the end of 2023, I decided to invest in Envision (InMode) to replace my E-Eye IPL unit, as it had both IPL and radio frequency (RF) treatment heads. There is an adaptor that effectively allows the unit to act like spot IPL (for IPL use very close to the lid margin) as well as the original larger head for IPL application on the cheeks (tragus to tragus IPL). In my opinion however, if I had to choose one modality of treatment that is most efficacious for MGD, the RF treatment with MGX is more effective than IPL alone or any other treatment for MGD I have tried to date.
Combining treatment modalities: In practice, combining RF treatment with MGX and either IPL or Rexon-Eye therapy is proving more effective, both physiologically and symptomatically, than single modalities. These combinations appear to have a synergistic effect. I have also found a combination of treatments that has finally given me significant relief from my own dry eye symptoms.
The various ‘before and after’ images in this article are of patients who have undergone either Envision or combination treatment.
Each treatment modality has its advantages, disadvantages, contraindications, and considerations
Figure 3. Corneal staining of left eye pre-Envision treatment (left) and post-Envision treatment (right).
Figure 4. Improvement in meibography. The patient’s upper lid (top left) and lower lid (bottom left) before treatment. Images on the right show the same patient after Envision treatment.
Importance of a Holistic Approach
In 2023, the TFOS workshop published its extensive Lifestyle report, which highlighted direct and indirect impacts of everyday lifestyle choices and challenges on ocular surface health.3
Our knowledge of the impact of everyday lifestyle choices is improving and it is vital that we have discussions with patients on the importance of good lifestyle habits as part of a full dry eye consultation. During consultations, I discuss factors such as sleep, device use/blink habits, air-conditioning/artificial heating, nutrition, contact lens wear, and make-up use.
After treating patients with the Envision platform in the past year, the importance of a holistic approach to dry eye management has become more evident to me. I have found that after patients have finished their course of treatment (particularly with the Envision platform or a combination of Envision and Rexon-Eye therapy), their meibum quality and expressibility improves significantly.
Most patients have a decent flow of liquid meibum. However, some patients, despite a course of treatments along with ongoing at-home treatments – including omega 3 supplementation, hot compresses, and even therapeutic treatment (such as topical steroids and ciclosporine) – seem to hit a roadblock in further symptomatic and meibum quality improvement. The commonality with these patients is that they seem to have one or more major negative lifestyle factors such as poor sleep, cigarette smoking or very poor diet.
How Does it all Fit in Practice?
Armed with several treatment modalities and improved methods for tracking DED factors, we tailor treatment protocols to each patient’s needs. Each treatment modality has its advantages, disadvantages, contraindications, and considerations. These factors, along with patients’ individual needs, concerns, and budget, help to shape a tailored solution that can evolve over time.
Over the years, the strengths and weaknesses of different treatment modalities clinically, for practice flow and return on investment, are becoming more evident. It has been a particularly tricky handful of years for practice owners to navigate the COVID-19 pandemic and the so-called ‘new normal’.
While the journey hasn’t been without its challenges, I can confidently say that investing in my passion for helping patients with dry eye disease has ultimately given my practice a unique advantage. It has been a gradual process, but it is professionally very rewarding and I’m starting to see a return on investment.
Fortunately, I have a very capable and passionate optometrist, Irene Jin, working with me. Together we have refined our dry eye treatment skills over the past year and this, along with more powerful treatment modalities, has given us the confidence to tackle all types of DED and be able to make a significant positive impact for patients.
Expanding Scope, Sharing Care
Optometry has evolved greatly in the past several decades. The scope of practice is broader than ever and as an optometrist’s career develops, many find potential niche areas of interests and talents. To this point, as I have found myself dedicating more time and resources to myopia management and dry eye management, I have started to reach out to optometry colleagues, GPs, and ophthalmologists to let them know that I am happy to co-manage patients suffering from DED. This is especially if at-home treatments like hot compresses, lid hygiene, lifestyle advice, and therapeutic management do not result in sufficient relief of symptoms for patients.
Similarly, I have been referring patients that require behavioural optometry/vision training and specialty contact lens fittings to trusted colleagues with special interests in those areas.
Co-management is becoming increasingly common, and I believe it results in the best outcomes for patients – it is the way of the future.
Hanna Kim BOptom (Hons Class 1) CertOcTher (ACO) is the principal optometrist at Strathfield Eyecare, an independent, full-scope optometry practice located in Sydney’s inner west. She established the practice in 2004 and has keen interests in dry eye management, myopia control (including orthokeratology), and early detection and management of ocular diseases. Ms Kim is committed to collaborative care with optometry colleagues, ophthalmologists, and other health professionals to strive for optimal patient outcomes.
References
- Stapleton F, Alves M, Jones L, et al. TFOS DEWS II epidemiology report. Ocul Surf. 2017 Jul;15(3):334-365. doi: 10.1016/j.jtos.2017.05.003.
- Morthen MK, Magno MS, Vehof J, et al. The physical and mental burden of dry eye disease: A large population-based study investigating the relationship with health-related quality of life and its determinants. Ocul Surf. 2021 Jul;21:107-117. doi: 10.1016/j.jtos.2021.05.006.
- Craig JP, Alves M, Sullivan DA et al. TFOS Lifestyle report executive summary: A lifestyle epidemic – ocular surface disease. Ocul Surf. 2023 Oct;30:240-253. doi: 10.1016/j.jtos.2023.08.009.
