Eyeworld

C ORNEA 12 | EYEWORLD BONUS ISSUE | OCTOBER 2025 which can be confusing to patients. Patients want to hear "dry eye," and we want them to hear "dry eye disease," he said, adding that this is not something to be taken lightly. DED is not just a condition. It's a complex, multifac- torial disease that requires astute analysis and data collection, then strategic intervention, Dr. Sheppard said. In general, Dr. de Luise said that patients with predominantly or purely aqueous deficient dry eye disease present with blurred or fluctuat- ing vision, sometimes with increasing blurriness as the day progresses (due to evaporation), burning, stinging, tired eyes, and foreign body sensation. They may present with lissamine green (or fluorescein) corneal and conjunctival staining, a thin to absent tear meniscus, low Schirmer testing, and an elevated and/or asym- metric tear film osmolarity. Meanwhile, patients with predominantly or purely evaporative dry eye, which Dr. de Luise said is most commonly meibomian gland dysfunction and less commonly a goblet cell deficiency with mucin quality issues or from exposure changes, often present with blurred or fluctuating vision. Their vision is usually worse in the morning than later in the day due to the overnight action of bacterial lipases, which create a buildup of soapy oils. "There is often a marked decrease in tear film breakup time (nor- mal is >10 seconds), corneal staining, a tear meniscus that even if not thin is often admixed with debris, cheesy to inspissated to caked meibum on lid margin compression, and/or keratinization of the meibomian gland orifices," he said. How do you approach these patients? All types of dry eye require a similar starting point, Dr. de Luise said. He and Dr. Sheppard agreed that a thorough history is crucial. Once you've figured out your global clas- sification, you need to collect a lot of data, Dr. Sheppard said. The entire history is important, he said, emphasizing that patients should share past surgical interventions, like lid or corneal surgery and surgery that involves vital organs. These are all important so you can target your therapy, he said. Other factors like occupation, environmental exposure, heating/AC preferenc- es, allergies, fan use, etc., are also important. Having a great staff can be an asset when it comes to doing this patient workup, Dr. Shep- pard said. In addition to a thorough history, the exam is a crucial piece. This should include evaluat- ing blink rate, knowing if the patient is neuro- trophic, if they have rheumatoid arthritis, and looking at the tear film, lids, meibomian gland orifices, and the lacrimal apparatus are all key. Dr. Sheppard said he also wants to assess the sensation of the corneal nerves, but this test is rarely done on the first visit because the pa- tient has usually had a pressure check and has been given an anesthetic. Dr. de Luise added that it's important to ask about topical and systemic medications and any associated systemic diseases, such as Sjögren's disease. He finds that ocular surface disease ques- tionnaires can be useful. It's also important to examine the lids and lashes for the presence of lash base collarettes diagnostic for Demo- dex mites. "Look at meibomian gland health and meibum quality; assess the meibum on lid compression to see if it is liquid or if there is inspissation and/or orifice plugging/caps and keratinization," Dr. de Luise said. All types of dry eye have underlying inflam- mation as part of their etiology. It might seem intuitive to start an immunomodulator (cyclo- sporine, lifitegrast) on all dry eye patients, but Dr. de Luise cautioned that while immunomod- ulators work well for aqueous deficient dry eye patients, they have had mixed results in patients with evaporative dry eye, which is by far the most common type. "With today's expanded ar- mamentarium of medications and technologies, continued from page 11 Meibomian gland dysfunction in a patient with evaporative dry eye Source: Vincent de Luise, MD

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