Eyeworld

57 EW FEATURE November 2017 • Dry eye disease update Dr. Starr said he considers TFOS DEWS II "mandatory reading" for cornea and anterior segment spe- cialists and any eyecare professional who sees a lot of dry eye or ocular surface disease patients. Dr. Nelson said he thinks cor- nea/external disease specialists will find the Diagnostic Methodology Report particularly helpful in deter- mining the appropriate screening questionnaire and clinical tests that should be performed. The Manage- ment and Therapy Report would be useful as well, he said. While clinicians who are dry eye experts would benefit from all of the reports, Dr. Nelson said the Patho- physiology Report in particular is an important read. Those interested in clinical trials should read this report as well, while ocular specialists and comprehensive ophthalmologists should read the Definition and Classification Report, the Diagnos- tic Methodology Report, and the Management and Therapy Report, Dr. Nelson said. Those in other subspecialties, such as glaucoma or retina, would benefit from reading the abstracts of the reports, Dr. Akpek said. "Eval- uating tear film and ocular surface should be routinely included in any slit lamp examination in order to diagnose and address dry eye," she said. The abstracts could also provide those in non-ocular specialties or tion cannot be measured from the ocular surface in a clinical setting. The definition also includes neuro- sensory abnormalities to expand to a group of patients experiencing pain without diagnostic dry eye conditions. The report includes a new classification system, which Dr. Sullivan, associate professor of ophthalmology, Harvard Medical School, Boston, explained begins with a clinical decision algorithm. It starts with an assessment of symp- toms followed by a review for signs of ocular surface disease and a series of triaging questions and ancillary testing. The classification system ends with etiological classification of the two predominant, but not mutu- ally exclusive, categories of aqueous deficient and evaporative DED. "The preponderance of DED is evapora- tive in nature," Dr. Sullivan added. "The new classification scheme depends on the information present- ed in the Diagnostic Methodology Report to determine what specific signs (tear breakup time, tear film osmolarity, and ocular surface staining) are necessary to diagnose DED and leads to recommending the appropriate therapies presented in the Management and Therapy Report, which goes into great detail on currently available therapies," Dr. Nelson said. Dr. Starr, associate professor of ophthalmology, Weill Cornell Medicine, New York, said the report updates understanding of the tear film as being composed of two lay- ers, not three. "TFOS DEWS II changes our thinking on this, stating that the tear film is likely more of a two-layer system with lipid on the surface and a mixed mucoaqueous gel-like layer underneath," Dr. Starr said. "The mucoaqueous layer is important in maintaining hydration and moisture and wettability, reducing frictional forces, and creating a barrier on the ocular surface. The lipid layer, which is spread over the ocular surface with each blink, may be less critical in preventing tear evaporation as we previously thought (only 10% contribution in one study)." Dr. Starr also noted the contin- ued validity of the concept of the vicious circle of DED, which was proposed in the 2007 TFOS DEWS. "Tear hyperosmolarity resulting from decreased lacrimal flow or tear film breakup contribute to ocular surface damage directly and indi- rectly through a cascade of inflam- matory events. This hyperosmolar inflammatory environment favors corneal and conjunctival epithelial and goblet cell apoptosis, which further contributes to tear film instability. Inflammation induced by tear film instability and hyperosmo- larity also contributes to neurogenic chronic inflammation and increased disease severity," Dr. Starr cited from the Pathophysiology Report. Many factors, be it low tear production, evaporation, surgery, medications, or contact lenses, can all lead to this vicious circle, Dr. Starr said. Dr. Sullivan said TFOS DEWS II provides a listing of consistent risk factors for DED, which include age, sex, race, meibomian gland dys- function, connective tissue disease, Sjögren's syndrome, androgen deficiency, computer use, and much more. TFOS DEWS II also addresses how sex, gender, and hormones play a role in the regulation of the ocular surface and adnexal tissues, and includes "an updated guide to improve the quality of clinical trials, to optimize resources, and increase the opportunity for novel therapeu- tics to reach patients with DED," Dr. Sullivan said. Who should read it and which parts Dr. Galor said the report is designed to provide pertinent information to everyone including cornea/external disease specialists, comprehensive ophthalmologists, optometrists, clinical scientists, and pharmaceu- tical manufacturers. She added that while some will read the whole report, she thinks it will function for many as an encyclopedia for dry eye where they can reference different reports quickly and receive an expert overview in an area that's specific to their needs. continued on page 58 Christopher Starr, MD, discusses findings of TFOS DEWS II Poll size: 122 In a patient with corneal fluorescein staining and complaints of dry eye symptoms, as my first line option, I use: Which statement best describes your understanding of the 2017 reports from the Tear Film & Ocular Surface Society International Dry Eye Workshop (TFOS DEWS II)? Cyclosporine 0.05% I have no idea what this is I plan to review the 11 reports in detail to see how it pertains to my practice I would like someone to summarize for me the key take-home points and changes included in the newest document compared to the first document from 2007 Lifitegrast Topical steroid pulse Combination of the above

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