The historical classification of dry eye disease (DED) has typically considered two distinct disease entities:
• Aqueous deficient
• Evaporative
The latest thinking from the TFOS DEWS II report suggests moving away from this separation and more towards a blurring of the lines between the two classically considered sub-types. In other words, we should consider the disease as more of a continuum of these two sub-types rather than separate entities. In this final case study, the patient was found to lie towards the aqueous deficient end of the continuum.
Case 3
Background: AD, female, age 82, retired. She was a driver, keen reader and tablet user.
AD first attended my dry eye clinic after initially having seen me for removal of multiple filaments during an acute filamentary keratitis flare up.
Visit 1
1st December 2017 – dry eye clinic appointment
AD presented with a history of dry, gritty, sore, irritated and ‘uncomfortable’ eyes, especially in the evening. She was diagnosed with Sjögren’s syndrome in 2008, and has had increasing difficulties with her dry eye symptoms since then. She had punctual plugs fitted at the hospital years ago, but no improvement had resulted with them so they were removed.
She has reached a level of discomfort now where she has completely given up reading, despite it being her favourite pastime, as she finds it so uncomfortable.
At this visit, she was using in both eyes the following:
• Viscotears nocte (overnight)
• Systane prn (as necessary, from the Latin pro re nata)
This management gave her some degree of relief, but it did not last any decent length of time. She previously had tried a heat pack but gave up as it didn’t seem to help.
Clinical findings
(Author throughout uses grading based on a modified Efron grading principle; 0 = normal 4 = severe):
• DEQ-5 score 19
• Acuity; R 6/7.5, L 6/9+, variable on blinking
• Osmolarity (TearLab); R 335 L 351mOsm/L
• Eyelid aspects:
• Lid closure analysis; normal, no incomplete blinks observed
• General observation showed minimal inflammatory signs on outer lids (figure 1, looks healthy from afar)
• Lid wiper epitheliopathy (LWE); grade 2 showing irregular (but very pale) band stain on lower lid wiper (figure 2)
Figure 2
• No signs of blepharitis at all (figure 3)
Figure 3
• No gland notching visible
• Minimal to no telangiectasic vessels noted on all inner lid margins (figure 4)
Figure 4
• Low tear prism height (figure 4), indicative of possible aqueous deficiency
• Non-obvious MGD, only made visible by gland expression (figure 5):
Figure 5
• Expressability grade 1 (most glands expressed with force applied)
• Secretion viscosity grade 3 to 4 lower lids, 2 upper lids R and L
• Meibography; grade 2, with some significant gland shortening but no complete atrophy R and L (figure 6)
Figure 6
• Conjunctival hyperaemia; grade 2 with visible roughness to conjunctival surface (figure 7)
Figure 7
• Ocular surface aspects:
• Meniscometry: tear prism height 0.1mm indicating low level (figure 4) and likely aqueous deficient component
• Fluorescein TBUT; 2 seconds R and L
• Ocular surface staining: extensive confluent patches of corneal SPEE, most dense inferiorly and superiorly, grade 4+ R and L. Figure 8 shows the confluent patches of staining on the left cornea
Figure 8
• A single mucous filament adherent to the left inferior cornea (figure 9, stained with lissamine green) was also visible today.
Figure 9
Diagnosis
My conclusion drawn from the diagnostic work-up was a provisional diagnosis of longstanding primarily aqueous deficient dry eye disease secondary to Sjögren’s syndrome, with some additional evaporative component and meibomian gland dysfunction.
Management plan
My proposed management plan was divided into the in-practice component and the at home plan.
In-practice procedure:
• Removal of adherent filament strand from cornea with fine forceps (available from www.specialisedophthalmicservices.com ) and to be repeated on a prn basis
• All four lid margins expressed using meibomian gland forceps
• Educated and explained full diagnosis and management plan to patient
• Consider reinserting punctual plugs again, but patient not keen as had tried before
Management plan at home:
• Ilube (three times a day for one month) to reduce likelihood of mucous filaments forming
• Thealoz Duo Gel (every hour)
• Xailin ointment (nocte)
• Warm compress with mask 10 minutes once a day
• Omega-3 supplement provided
• Book follow up appointment in three months
• Emergency appointment available if required
Visit 2
24th March 2018; follow up appointment
The patient returned having been mostly compliant with the regime, admitting to ‘just missing the odd day’ and ‘not always putting in drops as regularly.’ She was now applying drops around maybe six times a day. She reported feeling she had already gained some significant control over the symptoms as compared to the first visit. She still struggled towards the end of the day with discomfort (‘gritty and burning feeling’) but felt noticeably better. Also, she had found that putting in ointment during the day for added relief helped too.
Clinical findings
• DEQ-5 score; 13
• Acuity; R 6/6 L 6/6
• Osmolarity (TearLab); R 325 L 331mOsm/L
• TBUT; 4 seconds R and L
• Meibomian gland dysfunction; on expression, grade 1 (some 2) and secretion grade 1 (see figure 10)
Figure 10
• Conjunctival hyperaemia; grade 1
• Blepharitis; grade 0
• Tear prism height; 0.1mm (unchanged)
• Corneal surface review; corneal superficial punctate epithelial staining still significant (grade 2), especially inferiorly and superiorly, though none confluent at all (figure 11)
Figure 11
Management decision
The corneal surface appeared vastly improved with the current strategy, with much less, non-confluent staining. Meibum viscosity in glands was responding well to the current regime and patient compliance was good. I decided to continue with the same regime and review again in further six months for further assessment.
Conclusion
This case review gives us an example of a primarily aqueous deficient dry eye disease related to Sjögren’s. It also indicates the significant improvement that can be realised with a regimented strategy if it is implemented well at home. This often comes down to good patient education, involving the patient directly in your approach to their at-home regime and ensuring regular in-practice reviews to keep them on track.
The DEWS II report is a fantastic free resource for giving practitioners evidence based best guidance on work up, diagnosis and logical management strategies for dry eye disease. Go to www.tfosdewsreport.org or download the app.
Sarah Farrant is a therapeutic optometrist with a special interest in dry eye disease who works in independent practice in Somerset.
For an interactive CET exercise related to DEWS II dry eye disease, go to page 20.