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Dry eye disease

What's new

Added 2024 AAO, 2024 BSR, 2023 CO, and 2020 EULAR guidelines for the diagnosis and management of dry eye disease.

Background

Overview

Definition
DED, also known as dry eye syndrome or keratoconjunctivitis sicca, is a chronic, multifactorial condition characterized by a deficiency in tear production or excessive evaporation, leading to ocular surface inflammation and discomfort.
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Pathophysiology
The pathophysiology of DED involves two main mechanisms: aqueous tear deficiency and evaporative dry eye. Aqueous tear deficiency is due to decreased tear production, often associated with age, autoimmune disorders such as Sjögren's syndrome, or certain medications. Evaporative dry eye is primarily due to meibomian gland dysfunction, which results in an unstable tear film and increased tear evaporation.
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Epidemiology
The prevalence of DED varies widely globally, depending on the geographic region and the diagnostic criteria used, ranging from 5% to 50%. In the US, the prevalence of DED in adults is estimated at 5-7%, with rates 2-3 times higher in females.
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Disease course
The clinical course of DED is characterized by symptoms of ocular discomfort, irritation, pain, foreign body sensation, burning, and visual disturbances. Signs of DED include conjunctival injection, corneal staining, and meibomian gland dysfunction. DED can also impact daily activities such as reading, driving, and using digital screens.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of dry eye disease are prepared by our editorial team based on guidelines from the American Academy of Ophthalmology (AAO 2024,2022,2019), the British Society for Rheumatology (BSR 2024), the College of Optometrists (CO 2023), the European League Against Rheumatism (EULAR 2020), the Sjögren's Syndrome Foundation (SSF 2017), and the American Academy ...
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Screening and diagnosis

Differential diagnosis: as per AAO 2019 guidelines, distinguish between blepharitis and meibomian gland dysfunction from aqueous deficient dry eye in the management of ocular surface disease. Recognize that symptom worsening in the morning is typical of blepharitis, while symptom worsening later in the day is typical of aqueous deficient dry eye.
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Diagnostic investigations

History and physical examination: as per AAO 2024 guidelines, obtain clinical assessment as the gold standard for diagnosing DED, recognizing that no single test is adequate for establishing the diagnosis of DED.
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  • Laboratory tests

Medical management

Topical agents, approved agents: as per AAO 2024 guidelines, recognize that US FDA-approved treatments for DED include topical loteprednol 0.25%, lifitegrast 0.5%, cyclosporine 0.05% and 0.09%, varenicline nasal spray, and perflurohexyloctane ophthalmic solution.

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  • Topical agents (corticosteroids)

  • Topical agents (cyclosporine)

Nonpharmacologic interventions

Artificial tears
As per CO 2023 guidelines:
Offer tear supplements (preferably unpreserved) for use during the day, with or without unmedicated ointment for use at bedtime.
B
Offer liposomal sprays in cases of evaporative dry eyes.
B

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  • Dietary supplements

Therapeutic procedures

Punctal plugs: as per AAO 2024 guidelines, consider offering silicone plugs for symptomatic relief in patients with severe DED. Use the largest plug that can be inserted to reduce the risk of extrusion.
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Specific circumstances

Patients with Sjögren's disease, topical agents: as per AAO 2024 guidelines, consider offering autologous serum or autologous plasma rich in growth factors drops to improve ocular irritation symptoms and conjunctival and corneal dye staining in patients with Sjögren's syndrome.
B

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  • Patients with Sjögren's disease (systemic agents)

  • Patients with Sjögren's disease (therapeutic procedures)

Patient education

General counseling: as per AAO 2024 guidelines, provide education on the condition, its management, treatment, including potential dietary modifications (oral essential fatty acid supplementation), and prognosis.
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  • Preoperative counseling