Eyeworld

EW FEATURE 35 The DEWS grading scheme takes practitioners through dry eye disease W hen it comes to grad- ing and progression of ocular surface dis- ease, in recent years the standard has be- come the Delphi and the Interna- tional Dry Eye Workshop (DEWS) report, according to Deepinder K. Dhaliwal, M.D., associate professor of ophthalmology and director of cornea and refractive surgery service, University of Pittsburg School of Medicine. The panel updated the thinking on dry eye and instituted a progressive series of levels to stage and ultimately treat the disease. "The world's experts in dry eye and meibomian disease got to- gether," Dr. Dhaliwal said. The Del- phi panel members started from the ground up. "They renamed dry eye disease dysfunctional tear syndrome because people who have dry eyes sometimes have overflow tearing as a symptom," Dr. Dhaliwal said. "It's very confusing for patients who have an uncomfortable ocular sur- face with tearing to find out that their diagnosis is dry eye—they look at you like you have two heads." Now that is no longer a prob- lem. Dr. Dhaliwal tells them that they have dysfunctional tear syn- drome and finds that this encom- passes the whole category. DEWS classifications Among the other DEWS recommen- dations was a classification of dis- ease based on severity. The disease is currently categorized into four lev- els. "Level 1 is where patients have only symptoms and no signs, which is a lot of patients," Dr. Dhaliwal said. Symptoms may come and go with environmental stresses. How- ever, clinical signs such as conjuncti- val injection and staining or corneal staining and tearing are either miss- ing or mild. Meibomian gland dysfunction may be present in some cases but not in others. In ad- dition, tear film break-up time and Schirmer's scores tend to be variable. While many of these patients are in an early stage, this is not al- ways the case. "In patients who are complaining severely but don't have a lot of signs, there might be neuro- pathic pain involved," Dr. Dhaliwal said. "I think that in this category, all practitioners deal with patients who have severe symptoms but don't have a lot of signs." This can be frustrating because practitioners end up treating the patient's symp- toms without any signs to corrobo- rate the need for it. If after treatment the patients are not better, Dr. Dhali- wal said that perhaps another ap- proach is needed. "Practitioners should think about oral medications such as Neurontin (gabapentin, Pfizer, New York) or Lyrica (prega- balin, Pfizer)," she said. With level 2 disease, patients' discomfort becomes moderate and can be episodic or chronic, and pa- tients may complain of annoying vi- sual symptoms. There can also be variable corneal or conjunctival signs. "In category 2 there is mild staining," Dr. Dhaliwal said. There is also mild corneal debris and a de- creased tear meniscus. Meibomian gland disease remains variably pres- ent, tear break-up time is at the stage where it is less than or equal to 10 seconds, and Schirmer's scores are less than or equal to 10 mm in 5 minutes. By level 3 dry eye, discomfort has become severe for patients and is constant. Patients complain about annoying, chronic visual symptoms that can in some cases be constant and can limit activities. There's also moderate to marked conjunctival and corneal staining. "In category 3 there is more central staining and possible visual compromise," Dr. Dhaliwal said. This level is also marked by corneal and tear signs such as filamentary keratitis, mucus clumping, and increased tear debris. Level 3 patients frequently have lid and meibomian gland disease with a tear film break-up time of less than or equal to 5 seconds and a Schirmer's score of less than or equal to 5 mm in 5 minutes. For patients who have reached level 4, the disease has become se- vere, with constant and possibly dis- abling visual symptoms with marked conjunctival staining. "They could have filaments and even scarring," Dr. Dhaliwal said. These patients may also have increased tear debris and even corneal ulceration. Their Schirmer's score is less than or equal to 2 mm in 5 minutes and their tear film break-up time is immediate. Dr. Dhaliwal thinks that the good thing about the DEWS system is the stepwise approach. "The sys- tem breaks it down and gives us ta- bles," she said. "It's spelled out how to treat these patients and how to go along with the progression of the disease." John D. Sheppard, M.D., pro- fessor of ophthalmology, microbiol- ogy, and molecular biology, Eastern Virginia Medical School, Norfolk, thinks that the DEWS system has al- tered the way that practitioners view February 2011 April 2011 OCULAR SURFACE by Maxine Lipner Senior EyeWorld Contributing Editor Leveling the ocular surface disease playing field In recent years, the DEWS report has become the standard for understanding dry eye disease (pictured here) Source: Peter J. McDonnell, M.D., and the Delphi Task Force AT A GLANCE • The DEWS system categorizes dry eye disease into four levels • Level 1 patients are the least se- vere and have only symptoms and no signs • In level 2, patients have moderate discomfort and may complain of annoying visual symptoms and show mild staining and debris • By level 3, discomfort is severe and patients' visual complaints can be constant. There can also be marked central staining and visual compro- mise • When they reach level 4, the dis- ease is severe and can be visually disabling. Patients can have fila- ments, scarring, corneal ulceration, and more continued on page 36 032-047 Feature_EW April 2011-DL_Layout 1 4/10/11 8:00 AM Page 35

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