Is This the New Norm?

Is Disregarding Patients’ Symptoms the New Norm?

BY MILE BRUJIC, OD, FAAO, & DAVID L. KADING, OD, FAAO

Traditionally, dry eye was coined as the disease that caused the eyes to “burn.” Although this is a major contributory symptom, we realize that this doesn’t represent its only symptom.

A number of conditions can cause symptoms of burning eyes: Thygeson’s superficial punctate keratitis, infiltrative keratitis secondary to contact lens abuse, and epidemic keratoconjunctivitis, just to name a few.

There also are several other symptoms that patients may use to describe their dry eyes: dry, gritty, scratchy, itchy, uncomfortable, sore, irritated, fatigued, and watery. Realizing that a stable tear film is a necessity for the best quality vision, it’s not surprising that patients will also experience symptoms of blurred vision.

But patients will describe the symptom of blurred vision very differently. Although visual stability will often be the problem, many will simply describe their symptom as fuzzy vision or as difficulty focusing as the day goes on. Certainly, if corneal staining is present, there is the potential to affect vision even more.

Objective Tests Are King

We are fortunate when identifying and managing individuals who have dry eye that we now have an amazing armamentarium of objective tests to help us with this endeavor. One test detects ocular surface levels of matrix metalloproteinase-9 (MMP-9) that are greater than 40ng/mL. Another measures tear osmolarity, which is the concentration of salts in the tear film; higher concentrations of salt mean insufficient tear volume and are related to ocular surface inflammation. Lipid layer thickness can be measured by yet another test. And, meibomian gland structure can be viewed with several technologies.

With the objective tests available and the variability in patient symptoms, should we rely on the objective tests and ignore the patients’ subjective symptoms?

The Verdict

The reality is that the signs and symptoms that we see and hear are nothing more than the manifested characteristics of an underlying condition producing an inadequately sufficient tear film to provide clear and comfortable vision. And, although we discuss variability in the signs and symptoms that we see in dry eye disease, it is not much different than what we see for a number of other clinical conditions.

For example, for a –1.00D uncorrected myopic patient, you would expect him to complain about blurred distance vision. However, I can guarantee that everyone reading this article has seen several patients with this uncorrected refractive error who really don’t feel like anything is wrong with their vision. Saying that, we’ve also all probably refracted some patients to 20/15 or even 20/10, and they feel like they still cannot see clearly. The reality is that clinical care of patients is filled with variability in presenting symptoms.

Clinical practice requires combining the art of listening with the science of the patient presentation, along with the objective metrics collected by highly advanced technologies. Either one without the other would be an incomplete picture and, ultimately, not in the patients’ best interest. If disregarding symptoms is the new norm, we don’t want to be normal. CLS

Dr. Brujic is a partner of Premier Vision Group, a three-location optometric practice in northwest Ohio. He has received honoraria in the past two years for speaking, writing, participating in an advisory capacity, or research from Alcon Laboratories, Allergan, B+L, Optovue, Nicox, Paragon, SpecialEyes, TelScreen, Transitions, Valeant Pharmaceuticals, Valley Contax, VMax Vision, VSP, and ZeaVision. Dr. Kading owns the Specialty Dry Eye and Contact Lens Center in Seattle. He is the co-owner of Optometric Insights with Dr. Brujic. He has received honoraria for consulting, performing research, speaking, and/or writing from Alcon, Allergan, Bausch + Lomb, CooperVision, Oculus, Ocularis Pharma, RPS, Shire, TearScience, Valeant Pharmaceuticals, Valley Contax, Zeiss, and ZeaVision. Follow him on Twitter @davekading.