The American Optometric Association published “Care of the Patient with Ocular Surface Disorders” in 2010. Since then, the volume of information concerning the topic of dry eye, ocular surface diseases, ocular surface disorders, or dysfunctional tear syndrome (Craig et al, 2017) has grown exponentially (Albietz, 2000; Berehns et al, 2006; Lemp et al, 2007; Stapleton et al, 2017).

It is now reported that more than 30 million persons in the United States are afflicted with “dry eye,” but it is estimated that only half are diagnosed; further, fewer than 16% of those estimated to exhibit signs or symptoms are actually treated (Shire, 2016). The prevalence of those afflicted translates to about 10% of the U.S. population (Shire, 2016). This figure is borne out across several studies and among a range of age groups (Stapleton et al, 2017).

The prevalence of dry eye has increased with increasing age among both women and men, averaging just greater than 11% for age groups greater than 50 years. Most significantly, age groups between 18 and 49 years showed a dry eye prevalence rate of 3.4% (Farrand et al, 2017). But why, among studies reported by the Tear Film and Ocular Surface Society’s (TFOS) Dry Eye Workshop II (DEWS II), is this news?

It has been reported that, due to increased screen time/cellphone use, those under the age of 16 years may suffer dry eye signs or symptoms, most likely due to decreased blinking (Moon et al, 2016) (Figure 1). The same has been reported among office workers, representing another perhaps unsuspected at-risk group (Courtin et al, 2016).

Next Steps

The TFOS/DEWS II series offers a template for diagnostic screening strategies (Wolffsohn et al, 2017). One of the reasons for underdiagnosis may be attributed to the incongruity between presentation of symptoms and observation of signs. Other possible contributions include perceived inadequate treatment measures and the uphill battle that clinicians face with adherence to those poor management strategies.

Interestingly, the TFOS DEWS II report finds that the literature emphasizes eliciting symptoms and results of questionnaires for uncovering those undiagnosed (Stapleton et al, 2017). Implementation of such clinical protocols would go a long way to providing better patient care.

The TFOS DEWS II report proposed an updated treatment algorithm (Jones et al, 2017). This four-tier template begins with traditional pillars of patient education, topical lubricants, lid hygiene, and, potentially, dietary modifications.

Significantly, the second stage includes topical antibiotics, steroids, and newer molecules such as cyclosporine and lifitegrast (both now available in preservative-free formulations). Practitioners can now offer patients more options for treatment. Therapeutic contact lenses appear in stage three, and punctal occlusion is now relegated to stage four.

Learning from the Past

There is a striking similarity between the underdiagnosis of glaucoma and of dry eye. Among a high-risk population, a comprehensive diagnostic effort reported a glaucoma prevalence roughly 10 times the colloquial prevalence rate (Waisbord et al, 2016). Given this, primary eyecare providers seized the opportunity under scope-expansion legislation to fight the war against glaucoma.

We are now positioned to make a huge dent in the undiagnosed dry-eye population and to offer meaningful treatment protocols. This is an exciting time to grasp the opportunity for improving quality of life among our dry eye patients. CLS

For references, please visit www.clspectrum.com/references and click on document #272.