An extensive, multipart report on dry eye disease, published July 20 in the Ocular Surface, updates current understanding of the disease after the International Dry Eye Workshop II (DEWS II) conducted by the Tear Film and Ocular Surface Society (TFOS).
An overview of the DEWS II findings was presented in May during the Association for Research in Vision and Ophthalmology Annual Meeting. Their publication brings together every aspect of the research on this disease published since the DEWS I workshop in 2007 — more than 350 pages divided into 11 papers.
“My suggestion, if readers have limited time, is to first read the Definition and Classification Report, followed by the Diagnostic Methodology and Management and Therapy reports,” J. Daniel Nelson MD, chair of the TFOS DEWS II steering committee, told Medscape Medical News.
The definition of the disease has changed as research has provided a better understanding of it, said Dr Nelson, senior medical director of HealthPartners Medical Group and Clinics in St. Paul, Minnesota, and a professor of ophthalmology at University of Minnesota in Minneapolis.
“We’ve learned that osmolarity and inflammation are part of the etiology of the disease, so treatment has to [be] aimed at treating inflammation to reduce osmolarity to return to a normal tear film,” he explained.
He also emphasized the importance of understanding the broad heterogeneity of the disease.
“I believe we do a great disservice by labeling patients who come in with dry eye complaints as having a dry eye,” he said, noting that dry eye is often “the wastebasket term clinicians use when they do not know how else to explain a patient’s complaints of eye irritation, tearing, dryness, burning, and foreign body sensation.”
Hence the importance of starting with the Definition and Classification Report, which includes a flow chart of signs and symptoms for diagnosis and classification of the disease. Similarly, the Diagnostic Methodology Report covers clinical examinations, tests, and screening tools related to dry eye disease, along with a diagram of appropriate steps in screening and testing for dry eye disease.
“For the practitioner to think that through might help them arrive at what might be the possible cause of the dry eye symptoms,” Dr Nelson explained. For example, “neuropathic pain likely plays a significant role in dry eye symptoms and is often overlooked by the clinician,” he said.
The Pain and Sensation Report “provides a perspective of [dry eye disease] focused on pain,” the authors explain. “Pain can be divided into nociceptive and neuropathic pain. Nociceptive pain occurs in response to actual or threatened damage to tissues. However, neuropathic pain occurs due to a lesion within the somatosensory nervous system and does not have biological value.”
The Management and Therapy Report incorporates all evidence to date in “a staged management algorithm…that presents a step-wise approach to implementing the various management and therapeutic options according to disease severity.”
The TFOS DEWS II Introduction paper provides a relatively short general overview of the workshop’s methodology, and the Clinical Trial Design Report, after reviewing existing and needed research, lays out standards for future clinical trials, such as a reliance on the disease’s new classification.
“Studies with patients with signs and symptoms, patients with symptoms without signs, and patients with just symptoms alone are needed,” Dr Nelson told Medscape Medical News. Different presentations may indicate different diseases and etiologies. “The failure of past treatments has been due to the recruitment of heterogeneous patient populations or recruiting patients whose underlying etiology is unrelated to the treatment being tested.”
The Epidemiology Report, with risk factors and global trends of the disease, also makes recommendations for future research. The Iatrogenic Report reviews drugs and medical interventions, such as contact lenses or corrective eye surgery, that may contribute to dry eye disease, and the Tear Film Report dives deeply into the details of the tear film’s role in the disease.
In addition to exploring reasons for the higher prevalence of dry eye disease among women, the Sex, Gender, and Hormones Report addresses the importance of understanding the difference between sex and gender in patients. Although commonly confused, they are distinct, and both “affect [dry eye disease] risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health,” the authors write.
Finally, the Pathophysiology Report “is interesting for those interested in really getting into the research of the current state of knowledge,” Dr Nelson said. It describes the “vicious circle” of dry eye disease, illustrated in a visual to show how “individuals can enter the circle at any particular point and get an interruption of tear film homeostasis,” he explained.
Funding for the TFOS DEWS II came from unrestricted donations from Alcon, Novartis, Shire, Allergan, Bausch+Lomb, Akorn, CooperVision, Dompé, Horus Pharma, Lubris Biopharma, Oculeve, TearLab, Laboratoires Théa, SIFI, Sun Pharma, Johnson & Johnson Vision Care, Carl Zeiss Meditec, Quint Health, Scope Ophthalmics, and Senju. Dr Nelson reports having consulted for TearSolutions, in which he has a personal financial interest, and Santen, which has provided him financial support. He is also editor in chief of Ocular Surface.
Ocular Surface. July issue. Table of contents
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