Advances in the Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease

Advances in the Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease

June 29, 2022
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In the development of DED, inflammation, tear hyperosmolarity and aberrant neurosensory functions are critical components which interact with one another to form a vicious cycle, leading to a chronic and progressive course of disease.

The continually rising prevalence rate of DED, which affects millions of people in the world, has become a major challenge for ophthalmologists.

Yang W. et al. evaluated data from three eye facilities in a study of the economic impact of DED in China, finding that a patient's annual DED expenses can exceed $422.6, or to $166.6 billion per year nationally.


The rising frequency of DED, as well as the immense economic burden it imposes, necessitates a greater understanding of its underlying pathophysiology and the development of effective diagnostic and therapeutic measures.

Dry eye disease (DED) is a common ocular condition with a prevalence ranging between 5% and 50% in the adult population. It is a disabling disorder affecting both visual function and quality of life, and has a significant socioeconomic impact.

The disease is characterised by the loss of homoeostasis of the ocular surface, which results in tear film instability, hyperosmolarity and inflammation of the ocular surface.

Dry eye is a multifactorial disease of the tears and the ocular surface, a system formed by several structures working together to protect the eye from excessive environmental and biological stress.

It is therefore critical to treat the main pathogenic mechanisms involved in DED and to address also the secondary mechanisms that, if not appropriately controlled, might contribute to perpetuate the vicious circle of DED.

A proper and adaptable treatment will improve the ocular surface inducing a relief from symptoms and an effective improvement of the quality of life.

Doctor and Patient Relationship

Empathy and willingness to explain the disease with patients, who often fell isolated without much understanding and comprehension from both medical professionals and relatives, is an important part of the treatment process.


Patients generally feel that their disease is impossible to treat, leading to non-compliance and discontinuation, which can perpetuate the vicious circle of ocular surface damage.

It is important that physicians explain that the disease is chronic, with the severity of signs and symptoms fluctuating depending on internal body circumstances and reactions to environmental conditions.


Consequently, therapies will need to be monitored and adjusted if necessary. Critically, it needs to be stated that there will frequently be a time lag before any kind of improvement will occur, but that therapies will substantially improve their quality of life.

It is possible that the eyes will remain slightly more reactive to changes in the environment. Therefore, it should be explained that patients might need to modify the frequency and/or type of eye drops according to the change of symptoms, following a preplanned rescue prescription.

As the demand for effective dry eye treatment grows, so does the need for specialized and efficient dry eye clinics. Here are few practical tips that promotes efficiency;

• Consider providing patient questionnaires prior to appointments. Obtaining a detailed chief complaint, in conjunction with the exam and testing, is invaluable in determining the cause of the patient’s symptoms.

Is it blepharitis, meibomian gland dysfunction, or an auto-immune or inflammatory response? Arriving at the chief complaint can be time-consuming. To increase efficiency, consider asking the patient to fill out a questionnaire, which can expedite and guide the process.

The questionnaire can be individualized, based on doctor preference, and given at check-in, mailed to the patient, or made available on a secure patient portal. Input the completed questionnaire in the patient’s chart.

A variety of DED questionnaires are available, such as the National Eye Institute Visual Function Questionnaire and Ocular Surface Disease Index (OSDI), created by Allergan.

• Conduct a thorough medical history. A thorough medical history is as important as the chief complaint.

The history should record: medical conditions for which the patient is being followed, previous eye surgeries, history of dry eye treatments at other clinics, brand names of over-the counter treatments used, etc.


Also obtain a list of allergies, including any to tea tree oil, as this is a common treatment for Demodex. Errors or gaps in the history can decrease efficiency, for example, when the doctor pauses to correct charting during a review of the medical history with the patient.

• Provide work-up technicians with a doctor’s preference list. Treatment plans for DED can vary depending on the doctor and diagnosis. Consider having common treatment plans available for technicians to reference to expedite the work-up process.

These treatment plans should include each doctor’s preference in artificial tears brands, nutritional supplements, warm compresses/heat mask, and Demodex treatment products. Document any brands the patient is using in the chart and, carefully review the doctor’s previous treatment plan with the patient.

• Establish a proper and consistent training program for the dry eye staff. A knowledgeable technician promotes patient confidence in care throughout the examination process; when follow-up instructions are not clear, it can cause inefficiencies and longer patient wait times.

Ensure each technician working in the dry eye clinic has proper and consistent training, specifically geared towards DED.

Each technician should be familiar with the EMR system, doctor’s preferences, work-up steps (which often excludes eyedrops instilled in clinic), dry eye equipment operation/maintenance, and common treatment plans.


• When establishing a dry eye clinic, choose experienced technicians. Consider staffing with experienced technicians, scribes, and trainers to increase efficiency in a newly-established clinic.

It is beneficial if they are familiar with cataract and refractive pre-surgical measuring devices. As efficiency increases and troubleshooting decreases, then train in new staff.

• Establish effective communication procedures with the doctor and all staff. The management team should be open to staff suggestions.

There is always room for improvement, and the technician may identify patient concerns, as some patients may be more willing to mention complaints to the technician versus completing a patient survey.

Occasional short meetings at the end of morning or end of day with dry eye clinic staff and doctors can ensure everyone is on the same page with new equipment, exam protocols, and treatment plans. Remember, teamwork is vital when it comes to increasing dry eye clinic efficiency.

• Regularly audit charts to ensure accuracy. As always, increasing efficiency is secondary to providing optimal patient care. Audit charts on a regular basis to ensure errors are not increasing and documentation is meeting doctor expectations.

DED and Cataract/Refractive Surgery

For cataract surgery, it is imperative to have valid and accurate measurements prior to the surgeon selecting an intraocular lens (IOL) implant.


Dryness can cause inaccuracies in keratometry measurements, making IOL power selection challenging. To ensure accuracy, keratometry is checked and rechecked. If measurements are flawed due to DED, the surgeon may refer to dry eye clinic.

The technician should review any referral notes in the chart prior to initial visit. Measurements for refractive surgery can also be deemed inaccurate due to DED. Again, multiple keratometry measurements are performed prior to any refractive surgery.

Dry eye clinic technicians should be familiar with measurements for both cataract and refractive surgery. If possible, a technician should take keratometry measurements at the initial visit and then again after appropriate treatment.

This firsthand experience will drive home the importance of dry eye treatment prior to surgery. As important as pre-surgical treatment of DED is post-surgical treatment. DED may need further management after LASIK/PRK, cataract surgery, etc.

Blurred vision or intermittent blurred vision is a common DED complaint that a patient might notice even after a great surgical outcome. In this case, referral to a dry eye clinic is helpful for specialized dry eye treatment.