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Dry Eye

Sorting Through the TFOS’s New Report on Dry Eye

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What are the most important points to remember regarding the Tear Film & Ocular Surface Society Dry Eye Workshop’s definition and classification report on dry eye disease? A member of the workshop’s committee presented her thoughts during the American Academy of Ophthalmology’s 2018 annual meeting in Chicago.

Esen K Akpek MD, Bendann Family Professor of Ophthalmology at Johns Hopkins University School of Medicine’s Wilmer Eye Institute, reviewed the new definition, addressed who to screen and how best to do that, and presented changes in the dry eye management algorithm. 

The revised definition: “Dry eye is a multifactorial disease of the ocular surface characterized by a loss of hemostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.” 

“Loss of homeostasis and tear film instability are the two primary factors that define dry eye and perhaps differentiate it from other ocular surface diseases,” noted Dr. Akpek. “Ocular surface changes are secondary.” 

With regards to screening, the accompanying diagram “tells me is that all patients who have an eye evaluation should have an ocular surface and tear film evaluation regardless of whether they may or may not have dry eye. Obviously, risk factors should be considered, but dry eye has to be assessed [in all patients]. And patients who are symptomatic or have risk factors need more detailed evaluation.




The committee recommends these two screening questionnaires:

  • The DEQ 5.  “The important thing here concerns the answer to question 3,” she explained, which asks: During a typical day in the past month, how often did your eyes look or feel excessively watery? “If a patient answers ‘never’, immediately think about Sjogren’s syndrome and evaluate that patient accordingly.”
  • Ocular Surface Disease Index (OSDI).  “I like this screen because it evaluates and incorporates visual function of the patient into the questionnaire.”

As for testing, Dr. Akpek said her gold standard is ocular surface staining. “I use lissamine green for conjunctiva, and fluorescein for the cornea. It really doesn’t take much effort, and it is very inexpensive.”

The 4-step management algorithm includes certain recommendations that have been moved from step 3 to step 2, including the use of in-office treatments such as intense pulsed light, MiBoFlo, and LipiFlow. Additionally, the recommended use of topical corticosteroids and immunomodulatory drugs are now moved up to step 2.  

You can see the full revised management algorithm here.

Akpek E. DEWS II: How Might This Affect Your Approach to Dry Eye Patients in the Future? Talk presented at: AAO 2018 annual meeting; October, 26-30, 2018; Chicago.

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