Perceptions of Dry Eye Disease Management in Current Clinical Practice

Jennifer F. Williamson, M.D.; Kyle Huynh, B.S.; Mark A. Weaver, Ph.D.; Richard M. Davis, M.D.


Eye Contact Lens. 2014;40(2):111-115. 

In This Article

Abstract and Introduction


Objective: To assess the perceptions of eye care providers regarding the clinical management of dry eye.

Methods: Invitations to complete a 17-question online survey were mailed to 400 members of the North Carolina Ophthalmology and Optometry Associations including community optometrists, comprehensive ophthalmologists, and cornea specialists.

Results: The survey was completed by 100 eye care providers (25% response rate). Providers reported burning (46.5%) as the most frequent symptom described by patients, followed by foreign body sensation (30.3%) and tearing (17.2%). Most respondents (80.8%) listed artificial tears as the recommended first-line treatment, even though providers reported high failure rates for both artificial tears and cyclosporine A (Restasis). Rheumatoid arthritis, Sjögren syndrome, affective disorders such as anxiety and depression, history of photorefractive surgery, smoking, and thyroid disease were acknowledged as common comorbid conditions.

Conclusions: The survey provided an informative snapshot into the preferences of eye care providers concerning the diagnosis and management of dry eye disease. Overall, burning was the most common symptom reported by patients. Providers relied more on patient history in guiding their clinical decisions than objective signs. The survey underscores the incongruence when comparing subjective symptoms with objective signs, thereby highlighting the urgent need for the development of reliable metrics to better quantify dry eye symptoms and also the development of a more sensitive and specific test that can be used as the gold standard to diagnose dry eye.


Epidemiologic studies reveal that dry eye disease (DED), or keratoconjunctivitis sicca, has a prevalence ranging from 7.8% to 14.6% in the United States. It affects approximately 4.91 million Americans aged 50 years and older, although the exact prevalence is unknown because of the variance in the definition of the disease.[1] The challenge that eye care providers face is the complexity of managing DED without a discreet laboratory measure by which to monitor the disease status, such as glycated hemoglobin used as a surrogate for diabetes control. The report from the 2007 International Dry Eye Workshop (DEWS) summarizes this dilemma stating that even when clinical tests are evaluated for efficacy, the study populations may have been affected by significant bias because there is no widely accepted gold standard for diagnosis.[2] The 2011 American Academy of Ophthalmology (AAO) Preferred Practice Patterns (PPP) publication on DED states that the epidemiological evidence is limited by the lack of uniformity in the definition of dry eye and the inability of any single diagnostic test or set of diagnostic tests to confirm or rule out the condition.[3] Moreover, many of the available tests have low repeatability and do not correlate well with patient-reported symptoms.[1] Alternatively, patient-reported symptoms have been shown to have greater repeatability than objective tests,[4] and clinically, symptoms may be considered the best method for following this condition over time.[1]

Multiple questionnaires, including the Ocular Surface Disease Index (OSDI), McMonnies dry eye index, and the Impact of Dry Eye on Everyday Life (IDEEL), have been developed over time to assess and better stratify DED symptom severity. The OSDI is a 12-item survey that assesses ocular discomfort and effect of DED on daily life over a 1-week period.[5] The McMonnies questionnaire is a 12-item instrument that queries not only symptoms but also risk factors associated with DED, such as thyroid disease and medicamentosa.[6,7] The IDEEL, which has 57 questions, was created as a patient-reported outcome measure for assessing the impact of DED on daily lives of the patients.[8] Although this is certainly not an exhaustive list of symptom questionnaires, in general, the aforementioned questionnaires and others have shown only moderate correlation with clinical signs. Even when an association has been proven, it is usually not possible to predict severity of symptoms based on objective signs and vice versa.[9] With the potential for great variability in clinical practice and the complexity of DED management, this survey was created as a litmus to assess the attitudes, perceptions, and current dry eye practice patterns of eye care providers in North Carolina. The goal of this survey was not to contribute to the development of a standardized set of treatment guidelines, rather, it was meant to generate insight on how eye care providers are treating DED as compared with the recommendations set forth by the 2007 DEWS report and the AAO Dry Eye PPP publication.