The ratings of importance to the care process (A, B, C) and the ratings of strength of evidence (I, II, III) are defined at the end of the "Major Recommendations" field.
Diagnosis
The initial evaluation of a patient who presents with symptoms suggestive of dry eye should include those features of the comprehensive adult medical eye evaluation relevant to dry eye. [A:III]
Patient History
- Symptoms and signs [A:III]
- Exacerbating conditions [B:III]
- Duration of symptoms [A:III]
- Topical medications used and their effect on symptoms [A:III]
The ocular history may include details about the following:
- Contact lens wear, schedule, and care [A:III]
- Allergic conjunctivitis [B:III]
- Corneal history [A:III]
- Punctal surgery [A:III]
- Eyelid surgery [A:III]
- Bell's palsy [A:III]
- Chronic ocular surface inflammation [A:III]
The medical history takes into account the following elements:
- Smoking [A:III]
- Dermatological diseases [A:III]
- Atopy [A:III]
- Menopause [A:III]
- Systemic inflammatory diseases [A:III]
- Systemic medications [A:III]
- Trauma [B:III]
- Chronic viral infections [B:III]
- Surgery [B:III]
- Radiation of orbit [B:III]
- Neurological conditions [B:III]
- Dry mouth, dental cavities, oral ulcers [B:III]
Examination
The physical examination includes a visual acuity measurement, [A:III] an external examination, [A:III] and slit-lamp biomicroscopy. [A:III]
The external examination should pay particular attention to the following:
- Skin [A:III]
- Eyelids [A:III]
- Adnexa [A:III]
- Proptosis [B:III]
- Cranial nerve function [A:III]
- Hands [B:III]
The slit-lamp biomicroscopy should focus on the following parts of the eye:
- Tear film [A:III]
- Eyelashes [A:III]
- Anterior and posterior eyelid margins [A:III]
- Puncta [A:III]
- Inferior fornix and tarsal conjunctiva [A:III]
- Cornea [A:III]
Diagnostic Tests
For patients with moderate to severe aqueous tear deficiency, the diagnosis can be made by using one or more of the following tests: tear break-up time test, ocular surface dye staining pattern (rose bengal, fluorescein, or lissamine green), and the Schirmer test. Corneal sensation should be assessed when trigeminal nerve dysfunction is suspected. [A:III] A laboratory and clinical evaluation for autoimmune disorders should be considered for patients with significant dry eyes, other signs and symptoms of an autoimmune disorder (e.g., dry mouth), or a family history of an autoimmune disorder. [A:III]
Treatment
For patients with aqueous tear deficiency, the following measures are appropriate: [A:III]
- Elimination of exacerbating medications where feasible
- Ocular environmental interventions
- Computer work site interventions
- Aqueous tear enhancement with topical agents or external means
- Medications
- Correction of the lid abnormality
- Punctal occlusion or tarsorrhaphy for severe cases
Follow-up
The frequency and extent of the follow-up evaluation will depend on the severity of disease, the therapeutic approach, and response to the therapy. Patients with sterile corneal ulceration associated with dry eye require careful monitoring, sometimes on a daily basis. [A:III]
Provider and Setting
Because dry eye can be associated with systemic immunological disorders and use of systemic medications, broad medical skills and training are important for appropriate diagnosis and management. Patients with dry eye who are evaluated by non-ophthalmologist health care providers should be referred promptly to the ophthalmologist if any of the following occurs: [A:III]
- Visual loss
- Moderate or severe pain
- Lack of response to the therapy
- Corneal ulceration
Counseling/Referral
The most important aspects of caring for patients with dry eye are to educate them about the chronic nature of the disease process and to provide specific instructions for therapeutic regimens. It is helpful to reassess periodically the patient's compliance and understanding of the disease, the risks for associated structural changes, and to re-inform the patient as necessary.
For patients with irreversible tear deficiency or evaporative increase associated with chronic conditions such as blepharitis, the ophthalmologist should educate the patient about the natural history and chronic nature of dry eye. [A:III] Patients with pre-existing dry eye should be cautioned that laser in situ keratomileusis or photorefractive keratectomy may worsen their dry eye condition. [A:III]
In moderate to severe cases that are unresponsive to treatment or when systemic disease is suspected, timely referral to an ophthalmologist who is knowledgeable and experienced in the management of these entities is recommended. [A:III] Patients with systemic disease such as primary Sjögren syndrome, secondary Sjögren (associated with a connective tissue disease), or connective tissue disease such as rheumatoid arthritis should be managed by an appropriate medical specialist. [A:III]
Definitions:
Ratings of importance to care process
Level A, most important
Level B, moderately important
Level C, relevant but not critical
Ratings of strength of evidence
- Level I includes evidence obtained from at least one properly conducted, well-designed randomized, controlled trial. It could include meta-analyses of randomized controlled trials.
- Level II includes evidence obtained from the following:
- Well-designed controlled trials without randomization
- Well-designed cohort or case-control analytic studies, preferably from more than one center
- Multiple-time series with or without the intervention
- Level III includes evidence obtained from one of the following:
- Descriptive studies
- Case reports
- Reports of expert committees/organization
- Expert opinion (e.g., Preferred Practice Pattern panel consensus)
