Freemium World Blog Rip A2Z Blogging
Home / Surgery / Clinical audit of diagnosis and management of patients with dry eyes in the corneal service at St. Paul’s Eye Unit, Liverpool

Clinical audit of diagnosis and management of patients with dry eyes in the corneal service at St. Paul’s Eye Unit, Liverpool

Full article by Chean Chung Shen

SummaryFull ArticleReferences

Introduction- Dry eye disease (DED) is a common condition associated with autoimmune diseases and usually affects elderly and postmenopausal women. DED predisposes to corneal ulcers and perforation, thus should be diagnosed and managed appropriately.

Aim-The primary objective of this audit is to compare the various treatments of dry eyes provided in St. Paul’s eye unit, Liverpool, with the standard recommendations by DEWS report 2007, in order to implement change and improve quality of care offered.

Methods- Retrospective data were collected from case notes of 18 dry eye patients for 3 months. Patient demographics were analysed and the diagnostic methodologies used were reviewed. The severity of DED of every patient was graded and their respective treatment provided were then compared against the standard recommendations.

Results- All patients were female with the mean age of 70.5 (SD=12.63). Patients were divided into subgroups of primary, secondary, and non-Sjogren’s syndrome dry eye. Most patients (55.6%) suffer from non-Sjogren’s syndrome dry eyes and grade 3 severity dry eyes. One-third (33.3%) of patients have adequate treatment which correlates with their DED severity grading.

Discussion-There are various diagnostic methodologies that can be used to investigate dry eye disease according to the DEWS report 2007. St. Paul’s eye unit mainly uses a patient’s clinical history and slit lamp examination to look for signs of dry eyes (meibomian gland disease, corneal staining, keratinization, tear-film break up time (TFBUT)), Schirmer’s test, and the presence of autoantibodies as main diagnostic criteria. From this audit, it was found that diagnostic methodologies used in St. Paul’s were up-to-date according to the standard recommendation.

Dry eye is usually a chronic presentation, exacerbated by various types of systemic illnesses and its severity and presentation varies at different times. This makes grading of dry eyes disease severity more difficult.  The dry eye severity grading scheme recommended by the DEWS report 2007 should be used under experienced interpretations by qualified practitioners. More studies should also be performed to assess and compare the sensitivity and specificity of different diagnostic tools or criteria, to formulate an algorithm for a more objective measure of dry eyes severity

Conclusion and Recommendations- Clear and full documentation of patients’ DED control (dry eye symptoms, disabilities and signs), more detailed dry eyes investigation using slit lamp, Schirmer’s score and tear-film break up time (TFBUT), and accurate and full documentation of re-assessment/ re-grading of dry eyes severity should be encouraged among clinicians. Dry eye questionnaire (OSDI) can be used on patients’ arrival to clinic in addition to comprehensive dry eye history. DEWS report 2007 guidelines of DED diagnosis and management is of considerable clinical utility. It is advised to be used based on individual patient profile and clinicians’ experience for patients’ best interest

What is already known on this topic –There are two main classifications of dry eyes: aqueous deficient dry eyes (ADDE) and evaporative dry eyes (EDE).  Various dry eyes diagnostic methods are used, of which Schirmer’s test and corneal staining are the two main methods. Dry eye severity is graded using symptoms, signs and investigation results, which is then managed accordingly

What this audit adds- Recommend using questionnaires for dry eye screening, tear osmolality, tear functional index (TFI) and tear film break up time (TFBUT) in combination to give better diagnostic accuracy. Recommend grading dry eye severity into 4 different grades, using symptoms, signs, and investigation, and managing accordingly based on the recommendations of the DEWS report 2007 .The standard guideline recommendations from DEWS report 2007 is of considerable clinical utility and should be used as an aid for clinicians to provide the best treatment for dry eye patients. It can be modified on the basis of their clinical experience and individual patient profile.

Suggestions of future re-audits of dry eyes- Recommend using questionnaires for dry eye screening, tear osmolality, tear functional index (TFI) and tear film break up time (TFBUT) in combination to give better diagnostic accuracy  Recommend grading dry eye severity into 4 different grades, using symptoms, signs, and investigation, and managing accordingly based on the recommendations of the DEWS report 2007  The standard guideline recommendations from DEWS report 2007 is of considerable clinical utility and should be used as an aid for clinicians to provide the best treatment for dry eye patients. It can be modified on the basis of their clinical experience and individual patient profile.

Abstract
Background: Dry eye disease (DED) is a common condition associated with autoimmune diseases and usually affects elderly and postmenopausal women. DED predisposes to corneal ulcers and perforation, thus should be diagnosed and managed appropriately.
Objective: Clinical audit of diagnostic methodologies and management of DED in St. Paul’s Eye Unit, compared to Dry Eyes Workshop (DEWS) report 2007 as standard.
Methods: Retrospective data were collected from case notes of 18 dry eye patients for 3 months. Patient demographics were analysed and the diagnostic methodologies used were reviewed. The severity of DED of every patient was graded and their respective treatment provided were then compared against the standard recommendations.
Results: All patients were female with the mean age of 70.5 (SD=12.63). Patients were divided into subgroups of primary, secondary, and non-Sjogren’s syndrome dry eye. Most patients (55.6%) suffer from non-Sjogren’s syndrome dry eyes and grade 3 severity dry eyes. One-third (33.3%) of patients have adequate treatment which correlates with their DED severity grading.
Conclusion: Clear and full documentation of patients’ DED control (dry eye symptoms, disabilities and signs), more detailed dry eyes investigation using slit lamp, Schirmer’s score and tear-film break up time (TFBUT), and accurate and full documentation of re-assessment/ re-grading of dry eyes severity should be encouraged among clinicians. Dry eye questionnaire (OSDI) can be used on patients’ arrival to clinic in addition to comprehensive dry eye history. DEWS report 2007 guidelines of DED diagnosis and management is of considerable clinical utility. It is advised to be used based on individual patient profile and clinicians’ experience for patients’ best interest.
Introduction
Dry eye is a common, usually bilateral condition, seen more frequently in the elderly, post-menopausal women, and patients with autoimmune disease.1 According to the Dry Eyes Workshop (DEWS) report, dry eye is defined as ‘multifactorial disease of the tears and ocular surface, causing symptoms of discomfort, visual disturbances, and instability of tear film, with potential damage to the ocular surface’.1,2,3 It is accompanied by increased osmolality of the tear film and ocular surface inflammation.1, 2 Dry eye is generally innocuous, however, in susceptible group of patients, for instance, among patients with autoimmune diseases, it predisposes to the formation of corneal ulcers and perforations.1,4 Thus, dry eye symptoms may be a manifestation of a more severe concomitant systemic and ocular disease.1 Its aetiology and causative factors should be investigated, as it can be sight-threatening or even life-threatening if the symptom is not managed appropriately.2
Essentially, dry eyes can be classified into evaporative and tear-deficient. For evaporative dry eyes (EDE), it is due to excessive evaporation of tears, whereas in tear-deficient dry eyes, also known as aqueous deficient dry eyes (ADDE), it is due to insufficient secretion of tears. However, there is often an overlap between the two groups. For instance, meibomian gland dysfunction (MGD), which usually causes EDE, can also affect patients with ADDE.1
DEWS report also mentions that ADDE can be further subdivided into two groups, which are Sjogren’s syndrome dry eyes (SSDE) and non-Sjogren’s syndrome dry eyes (NSSDE).1 Sjogren’s syndrome is an autoimmune disease which affects many organs, including lungs, kidneys, skin and the nervous system, causing main symptoms like dry eyes and dry mouth.2 There are two types of Sjogren’s syndrome: primary (occurs by itself) and secondary (occurs in association with autoimmune connective-tissue diseases).1 Diseases affecting lacrimal ducts or causing lacrimal obstruction can also cause ADDE. This subgroup is usually age-related.1
Dry eyes can also be caused by excessive evaporation of tears. The tear film consists of 3 layers: the inner mucin layer), central aqueous layer, and outer lipid layer.1 The tear film plays a very important role in maintaining an optically smooth surface and along with the cornea provides 80% of the refractive power of the eye.2 The outer lipid layer is produced by meibomian glands and the gland of Zeis. The lipid layer prevents excessive evaporation of tears, allows smooth movement of eyelids over the globe and lowers the surface tension of tear film, which then promotes the integrity of the aqueous tear film.5
EDE can be subdivided into intrinsic and extrinsic causes. Intrinsic causes are meibomian oil deficiency, lid aperture disorders, low blink rate and drug side-effects.2 Extrinsic causes include ocular surface diseases, vitamin A deficiency, topical drugs, and contact lens use1.
Aim
The primary objective of this audit is to compare the various treatments of dry eyes provided in St. Paul’s eye unit, Liverpool, with the standard recommendations by DEWS report 2007, in order to implement change and improve quality of care offered.
Methods
After getting departmental audit approval, we performed the audit from the first week of January to the end of March 2014. Corneal clinics were attended every Friday afternoon and patient consultation notes were used as the main source to collect data for the purpose of this audit. The data was collected for 3 months in total and it was then analysed.
In this clinical audit, patients with known causes of SSDE and NSSDE were included.
Primary Sjogren’s syndrome consists of occurrence of ADDE (ocular symptoms and signs) in combination with dry mouth, presence of autoantibodies, evidence of reduced salivary secretion and with a positive focus score on minor salivary gland biopsy.1
The standard used for grading severity is shown in table 1. According to the DEWS report, there is considerable clinical utility in using a classification system of dry eyes disease based on severity. The basic scheme of the Delhi Panel Report was modified to produce the third component of the recommendation. Table 2 shows the recommended treatment for each severity level (from the DEWS report) which was used as the standard.1,4

Results
The total sample size was 18 patients. The mean age was 70.5 with a standard deviation of 12.63. All 18 (100%) patients were female. Among the 18 patients, 14 (77.8%) were referred from their GP, 2(11.1%) from an optician, 1 (5.55%) from a specialist rheumatologist and 1 (5.55%) had no specified referral letter.
Associated diseases of patients which are risk factors for dry eyes were also recorded during this audit. Risk factors for dry eyes such as contact lens use, history of atopy and other associated systemic diseases, were documented as they can affect the severity and dry eyes management. Among 18 patients, 14 (77.8%) did not wear contact lenses and 4 (22.2%) did not have the information in the notes. There was only 1 (5.55%) patient with a history of atopy. 3 out of the 18 patients (16.7%) had primary Sjogren’s syndrome, 5 (27.8%) had secondary Sjogren’s syndrome, whereas the others (55.6%) had non-Sjogren’s syndrome dry eye. Table 4 shows the demographics of different subgroups of dry eye patients included in this audit.15

The dry eye patients of varying severity grading were then provided treatment in St. Paul’s eye unit. Table 5 shows the 18 patients involved in this audit, their dry eye severity grading and their treatments respectively.
As compared to the standard recommendation of DEWS report 2007 (Table 3), among the 18 patients, 6 patients (33.3%) had suitable treatment according to their dry eye severity grades. 10 patients (55.6%) had treatment deemed ‘inadequate’. 2 patient (11.1%) were considered to be over-treated.
Discussion
Diagnostic tools used to assess dry eyes
There are various diagnostic methodologies that can be used to investigate dry eye disease according to the DEWS report 2007. St. Paul’s eye unit mainly uses a patient’s clinical history and slit lamp examination to look for signs of dry eyes (meibomian gland disease, corneal staining, keratinization, tear-film break up time (TFBUT)), Schirmer’s test, and the presence of autoantibodies as main diagnostic criteria. From this audit, it was found that diagnostic methodologies used in St. Paul’s were up-to-date according to the standard recommendation. However, to more accurately assess dry eye severity, the standard diagnostic protocol recommended by DEWS report should be followed (Table 2). For instance, to screen dry eye patients, one of the validated dry eye screening questionnaires should be used in combination with other objective clinical measures.1 Recommendation: for trained auxiliary staff to administer the questionnaire to optimize clinic time.1,16
St. Paul’s eye unit has been following the standard recommendation of DEWS report in which every dry eye patient in the corneal clinic has been offered Schirmer’s test. The Schirmer’s test without anaesthesia is a well-standardised test. There is wide intrasubject, day-to-day and visit-to-visit variation, but the variation and the absolute value decreases in ADDE, due to the decreased reflex response in lacrimal failure.1 Recommendation: that Schirmer’s test is carried out using a cut off of
Severity grading of dry eye and treatment recommendation
Based on the aforementioned results, most clinicians in St. Paul Eye Unit appear to be more conservative in the treatment of dry eye disease of varying severity. This audit however has its limitations, including the small sample size. Besides, due to the nature of this audit and the incomplete documentation on patient case notes, it is unable to comment as to whether the treatment provided by St. Paul’s has achieved the desired effect. If the treatment provided by the practitioners in St. Paul’s Eye Unit, based on their clinical experience and judgment, is thought to achieve best disease control, then reasonable treatment adjustments of escalating and stepping down of treatment should be allowed. Likewise, DEWS report 2007 noted that the treatment recommendations may be modified by practitioners accordingly, depending on individual patient profiles and clinical experience.1
There might also be a possibility of discrepancies of clinical judgment between different practitioners of varying experiences. In clinical settings, patients usually present with various spectrum of diseases or presenting symptoms. Additionally, dry eye is usually a chronic presentation, exacerbated by various types of systemic illnesses and its severity and presentation varies at different times. This makes grading of dry eyes disease severity more difficult.
In addition, there might be a possibility of overlap between different components required to grade dry eyes severity. In most cases, not all diagnostic tools (i.e TFBUT) were used, and not all clinical examination findings (corneal staining, conjunctival staining, conjunctival injection, lid/meibomian gland disease) were documented. Therefore, in complex dry eyes cases with subjective dry eyes presentations, it would be difficult to objectively and practically grade its severity. The dry eye severity grading scheme recommended by the DEWS report 2007 should be used under experienced interpretations by qualified practitioners. More studies should also be performed to assess and compare the sensitivity and specificity of different diagnostic tools or criteria, to formulate an algorithm for a more objective measure of dry eyes severity
Conclusion and Recommendations
The standard recommendations from the DEWS report 2007 is of considerable clinical utility and it is advised to be used as guidance together with the individual patient profile. Due to the subjectivity of the dry eyes severity grading scheme, in the event of complex dry eye cases there might be ambiguity as to which severity grade a case belongs.
To minimise ambiguity, full documentation of patients’ dry eyes visual symptoms (perceived severity, frequency, effects of environmental factors), disabilities, signs (conjunctival injection, conjunctival staining, corneal staining, corneal/ tear signs), and investigation results (TFBUT and Schirmer’s test) are essential. Ocular surface disease index (OSDI) questionnaires can also be given to all patients on arrival to dry eyes clinic to address symptomatology and to help quantify dry eye severity. Dry eye severity can then be graded according to the DEWS report 2007 and documented in case notes.Treatment is then given according to their respective severity grading.
Patients with dry eyes should be followed up and monitored regularly. In follow-up appointments, dry eye disease control should be documented, and the appropriate treatment based on severity and current control should be determined. Dry eyes severity should be re-assessed and re-graded if necessary. In complex dry eyes cases, second opinion regarding dry eyes management from another ophthalmologist should be encouraged. A leaflet on dry eyes management could be produced and to be used by clinicians in corneal/dry eyes clinics as an aide memoire.
What is already known on this topic:

  •  There are two main classifications of dry eyes: aqueous deficient dry eyes (ADDE) and evaporative dry eyes (EDE).
  • Various dry eyes diagnostic methods are used, of which Schirmer’s test and corneal staining are the two main methods.
  • Dry eye severity is graded using symptoms, signs and investigation results, which is then managed accordingly
    What this audit adds:
  • Recommend using questionnaires for dry eye screening, tear osmolality, tear functional index (TFI) and tear film break up time (TFBUT) in combination to give better diagnostic accuracy
  •  Recommend grading dry eye severity into 4 different grades, using symptoms, signs, and investigation, and managing accordingly based on the recommendations of the DEWS report 2007
  •  The standard guideline recommendations from DEWS report 2007 is of considerable clinical utility and should be used as an aid for clinicians to provide the best treatment for dry eye patients. It can be modified on the basis of their clinical experience and individual patient profile.
    Suggestions for future re-audits of dry eyes:
  •  Dry eye severity criteria, such as visual symptoms (frequency, duration, level of discomfort, and associated dry eye symptoms), examination signs, and investigation results should be recorded in more detail in patient notes for easier data collection and grading of severity of dry eyes. A leaflet can be produced as guidance for ophthalmologists in St. Paul’s eye unit to manage patients with dry eyes.
  •  Data collection should be performed over a longer period to recruit more patient data.
1. Methodologies to diagnose and monitor dry eye disease: report of the Diagnostic Methodology Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5(2):108-152.
2. The tears and lacrimal gland. Diagnosing sight and life-threatening eye disease. OT CET March 10, 2006.
3. Bron AJ, Tomlinson A, Foulks GN, Pepose JS, Baudouin C, Geerling G, Nichols KK, Lemp MA. Rethinking dry eye disease: a perspective on clinical implications. Ocul Surf. 2014;12(2 Suppl):S1-31.
4. Basak SK. Dry Eye disease. Programme notes for the 72nd Annual Conference of the All India Ophthalmological Society. All India Ophthalmology Society July 2013.
5. Bhavsar AS, Bhavsar SG, Jain SM. A review on recent advances in dry eye: Pathogenesis and management. Oman J Ophthalmol. 2011;4(2):50-56.
6. Lemp MA. Report of the National Eye Institute/Industry workshop on Clinical Trials in Dry Eyes. CLAO J. 1995;21(4):221-232.
7. Adatia FA, Michaeli-Cohen A, Naor J, Caffery B, Bookman A, Slomovic A. Correlation between corneal sensitivity, subjective dry eye symptoms and corneal staining in Sjogren’s syndrome. Can J Ophthalmol. 2004;39(7):767-771.
8. Pflugfelder SC, Solomon A, Stern ME. The diagnosis and management of dry eye: a twenty-five-year review. Cornea. 2000;19(5):644-649.
9. Lopez Bernal D, Ubels JL. Artificial tear composition and promotion of recovery of the damaged corneal epithelium. Cornea. 1993;12(2):115-120.
10. Baxter SA, Laibson PR. Punctal plugs in the management of dry eyes. Ocul Surf. 2004;2(4):255-265.
11. Avunduk AM, Avunduk MC, Varnell ED, Kaufman HE. The comparison of efficacies of topical corticosteroids and nonsteroidal anti-inflammatory drops on dry eye patients: a clinical and immunocytochemical study. Am J Ophthalmol. 2003;136(4):593-602. 12. Foster CS, Ekong AS, Anzaar F, Yuksel, E. Dry eyes syndrome treatment & management. Medscape Feb 20, 2014. http://emedicine.medscape.com/article/1210417-treatment (accessed 28 March 2015).
13. Henderson R, Madden L. Dry-eye management. Optometry in Practice 2013;14(4):137-146.
14. Patel A, Shah S. Investigations and management of dry eyes. OT CET. http://www.optometry.co.uk/uploads/exams/articles/cet_27_july_2012_patelsh ah.pdf (accessed 1/4/2015)
15. Vitali C. Classification criteria for Sjogren’s syndrome. Ann Rheum Dis. 2003;62(1):94-95; author reply 95.
16. Ousler GW, Gomes PJ, Welch D, Abelson MB. Methodologies for the study of ocular surface disease. Ocul Surf. 2005;3(3):143-154.
17. Xu KP, Yagi Y, Toda I, Tsubota K. Tear function index. A new measure of dry eye. Arch Ophthalmol. 1995;113(1):84-88.

 

Get Amazing Stories

Get great contents delivered straight to your inbox everyday, just a click away, Sign Up Now.
Email address
%d bloggers like this: