Dry eye clinical practice patterns of UK optometrists

If you are a busy clinician in a high street practice, surely you see lots of patients with dry eye symptoms every week, if not everyday. In recent years, patients presenting with symptoms of dry eye appear to be an everyday occurrence for most eye care professionals (ECPs).

Increasing prevalence of dry eye disease (DED) is known to pose a significant economic burden, both in time and resources.¹ Due to its multifactorial nature and the poor correlation between signs and symptoms, accurate diagnosis and management can prove challenging,² particularly in a busy high street practice.

ECPs have been reported to express thoughts of ‘frustration’ and ‘dread’ in the context of a disease with a perceived ‘time-consuming’ nature with ‘limited therapeutic options’.³

Dry eye practice in the UK is evolving

However, the roles of UK optometrists have also increased, with many now pursuing further qualifications to develop their interest in specialist areas of practice. Independent Prescriber (IP) registration has permitted qualified optometrists to clinically assess a patient, establish a diagnosis, determine the clinical management needed and prescribe where necessary.

Many UK optometrists are now also involved in provision of an extended service, such as a minor eye condition service (Mecs). They are often the first port of call for primary, supplementary, or unplanned eye care provision, with DED managed either during a routine eye examination, an enhanced commissioned service, or a specialist dry eye appointment.

To understand practitioners’ current views and practices, we conducted a survey of 131 UK optometrists involved in diagnosis and management of DED in a primary care setting. The survey specifically aimed to focus on current high street practice, and therefore optometrists who worked in a hospital or secondary care setting only, were excluded.

Survey design and participant demographics

The survey consisted of 16 questions (including several sub-questions) that collected information primarily on the following areas:

• Practice patterns and demographics of the practitioner’s experience, current knowledge, practice location and understanding of DED
• Preferred diagnostic techniques used for DED
• Preferred treatment and patterns of intervention based on severity of DED
• Therapeutic qualification and Mecs involvement

Practitioner demographics

The practitioner demographics of the survey are illustrated in figure 1 (a to d). Responses were gathered from all four constituent countries of the UK, the majority from England (63.6%). Eighty-eight percent of responses were obtained from practitioners working in either a multiple or independent practice primary care setting.

Although the highest number of responses came from optometrists with 15-25 years of experience, a good range of experience was represented. Of the optometrists who had been qualified for less than five years, 71.4% of them reported working for a multiple practice. Twenty-three respondents (18.7% of the responses) were IP-qualified and just under a half-reported involvement in Mecs provision.

Practitioners’ estimation of the percentage of their adult patients who they believed to have DED varied widely, with a mean of 47.1 ± 21.2%. They reported seeing an average of 33.3 ± 31.0 patients with DED per month.

Practitioner’s opinions about DED

Overall, optometrists were aware of the importance of DED and felt to have adequate knowledge and equipment to diagnose it. They regularly included questions related to DED in their work up and thought that signs and symptoms in DED may not always correlate.

Optometrists generally agreed with the statement that ocular surface inflammation causes DED, however there was a stronger perception that DED is likely to induce ocular surface disease. It was likely that UK optometrists would treat a patient with signs, but no symptoms of dryness, however, they may not have adequate time for appropriate management. See figure 2 for the responses to some of the questions asked.

Most optometrists believe they are confident and have adequate knowledge in managing DED; IP qualified optometrists were significantly more confident and felt more knowledgeable about available treatment options. Mixed responses were received regarding confidence in patient specific targeted treatment, although IP optometrists were again more confident.

Diagnostic clinical procedures recorded or performed

Respondents were asked only to complete the survey for the type of appointments that they provide for patients: (1) a routine eye examination with no dry eye symptoms, (2) a routine eye examination with dryness symptoms reported, (3) a specific appointment for a dry eye assessment (including a Mecs-type appointment).

Fewer responses were obtained from practitioners seeing patients for a specific dry eye appointment, with less than half of the total respondents (59) involved in Mecs-type provision.

Assessment of screen use (81%), history of occupation (89%), contact lens wear (89%) and blepharitis (77%) were popular questions during routine eye examination; 66% of optometrists reported also evaluating the meibomian glands. Interestingly, none of the tear film assessments such as NIBUT, FBUT or TMH were performed during routine eye examination by many practitioners.

Responses changed substantially when patients report dry eye symptoms. Approximately 90% of the practitioners would ask about self-treatments and perform fluorescein corneal staining and BUT, and meibomian gland evaluation, in addition to the tests performed for routine non-dry eye examination.

Additional attention would also be given to tear film parameters, lid margin, and meibomian gland expressibility. When patients were booked specifically for dry eye management (including a Mecs-type appointment), all optometrists would perform assessment for blepharitis, TMH, corneal fluorescein staining and meibomian gland expression.

Tear film osmolarity, lipid layer qualitative assessment and MMP-9 measurements were performed relatively rarely; approximately one in five at specific dry eye appointments only.

The five most commonly used clinical methods for DED diagnosis

Fluorescein breakup time (FBUT) was the most commonly used clinical procedure, favoured by more than 72% of the respondents (figure 3). This was followed by corneal fluorescein staining (>70%), assessment of blepharitis (65%), and meibomian gland evaluation (64%), which were the other three popular choices. None of the participants preferred Schirmer’s or Phenol red test for this purpose.

Preferred management options for mild, moderate and severe DED

Practitioners were also asked to indicate their preferred treatment options for mild, moderate and severe DED. These were presented in a list according to the stepwise recommendations of the TFOS DEWS II Management and Methodology report.⁴

Modification of the local environment such as drying conditions and digital device use, lid hygiene and hot compresses, and prescribing non-preserved tear supplements (step 1 interventions) were the preferred treatments for managing mild DED.

In addition, dietary advice, topical ointment at bedtime and advanced therapies such as IPL or Lipiview were preferred for moderate DED management. Preserved tear supplements were largely avoided for moderate and severe DED cases.

For severe DED, practitioners preferred to add almost all remaining additional measures ranging from punctal plugs, systemic and topical medications, to therapeutic and scleral lenses. All respondents would like to manage mild DED cases by themselves, whereas the majority would consider referring severe cases. See figure 4 which shows the treatment interventions, including step 2 and 3 interventions.

Around a third of all respondents reported recommending a topical steroid, while 19% and 41% reported recommending cyclosporine or systemic tetracycline, respectively, for severe DED. Statistically significant differences were observed in the recommendation of several treatment options between dry eye severity categories.

The management preferences in DED treatment modalities between ECPs who performed Mecs type appointments and those who did not showed no significant differences. However, significant differences were observed between ECPs with and without IP. A higher percentage of IP-qualified optometrists preferred to modify the local environment when treating mild DED.

When considering moderate DED, a significantly higher percentage of IP optometrists preferred to use punctal plugs, topical corticosteroids, systemic tetracycline, topical and systemic macrolides, cyclosporin and other advanced therapies. A similar trend was observed when treating patients with severe DED. Practice location, practice type and years of experience did not have any bearing on the recommendations made.

The three most commonly used procedures for determining treatment success Corneal fluorescein staining (figure 5) and FBUT were the most commonly used tests to determine success of ongoing treatment. This was followed by assessment of blepharitis, meibomian gland evaluation and use of DED questionnaires.

^{Figure 5: Corneal fluorescein staining seen in patient with dry eye disease}

Schirmer’s test, MMP-9 measurement, tear lipid layer quantification and blink rates were the least popular tests to characterise treatment outcome. Lid wiper epitheliopathy and lissamine green staining assessment were not commonly used procedures to aid with diagnosis or to judge success of treatment (figure 6).

^{Figure 6: Lower lid wiper epitheliopathy shown by instillation of lissamine green}

Decision on artificial tears

Sixty percent of respondents believed their patients are satisfied/managed with artificial tears alone, with the majority preferring to prescribe preservative free artificial tears. Almost half of their prescriptions would depend on work-place availability and/or drop ingredients. Other considerations included type of dry eye, cost, personal experience of the product, viscosity, lipid content, ease of use/manipulation and regional formulary prescribing guidelines.

Key findings from the survey

• The survey demonstrated a wide range of attitudes towards DED among UK optometrists; most expressed positive views regarding the importance of DED, and their knowledge and confidence in managing it.
• Practitioners estimated 47% of their adult patients have DED. This is in agreement with the estimated global prevalence, reported to range from 5-50%.5 Prevalence in the UK adult population has been reported to be 32%.6
• The survey findings for management of different severities of DED has provided evidence that practitioners are incorporating a stepwise treatment approach, consistent with the TFOS DEWS II management recommendations.4
• Low usage of dry eye questionnaires and Lissamine green were identified. DED is defined by TFOS DEWS II as the presence of both clinical signs and patient reported symptoms, using either the Dry Eye Questionnaire 5 or the Ocular Surface Disease Index questionnaire, both validated questionnaires.7 Therefore, the relatively low use of a questionnaire could imply an unfounded confidence in DED diagnosis.
• Unpreserved rather than preserved drops were more than twice as likely to be prescribed particularly with increasing disease severity.
• IP practitioners were significantly more likely to manage a patient with a pharmaceutical agent. Eighty-seven percent agreed that the qualification had widened their ability to diagnose and treat DED, reflected in the higher likelihood of prescribing for moderate and severe DED.
• IP optometrists were more than twice as likely to recommend a topical steroid to treat the inflammation associated with moderate and severe DED, compared to non-IP optometrists. Previously, a low rate of steroid prescribing for moderate and severe DED (1% and 8%, respectively) by UK optometrists was attributed to the low number of prescribing optometrists at the time (2015-2016).8 Therefore, this study has provided evidence of an increase in steroid prescribing for moderate and severe DED in the UK. No regional differences in prescribing were found.
• Very few practitioners reported use of tear film biomarkers, such as osmolarity or MMP-9 measurement to assist in diagnosis, even though there is a good evidence base for their use. While less than eight percent of respondents reported using InflammaDry (Positive Impact, East Sussex, UK) to measure inflammation, at a specific dry eye appointment, practitioners appeared willing to incorporate a similar device at a very similar cost.

Conclusion

The survey has provided a more current view of UK optometrists opinions and clinical practice patterns with regard to DED diagnosis and management. It has identified an increase in therapeutic management and shown that a stepwise approach to management is being employed.

Although an increase in evidence-based practice has been shown, the limited adoption of tear film biomarkers for diagnosis and management highlights the potential to further improve the translation of dry eye research evidence into clinical practice. 

Acknowledgements

Original paper:
Casemore, R. K., Wolffsohn, J. S., Dutta, D. Dry eye clinical practice patterns of UK optometrists. Contact Lens and Anterior Eye. 2023 Oct;46(5):101889. doi: 10.1016/j.clae.2023.101889. Epub 2023 Jul 15.

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