Preferred practice pattern

Dry Eye Syndrome Preferred Practice Pattern®

CORNEA/EXTERNAL DISEASE PREFERRED PRACTICE PATTERN® DEVELOPMENT PROCESS AND PARTICIPANTS

The Cornea/External Disease Preferred Practice Pattern® Panel members wrote the Dry Eye Syndrome Preferred Practice Pattern® guidelines (PPP). The PPP Panel members discussed and reviewed successive drafts of the document, meeting in person twice and conducting other review by e-mail discussion, to develop a consensus over the final version of the document.

Cornea/External Disease Preferred Practice Pattern Panel 2017–2018

Esen K. Akpek, MD

Guillermo Amescua, MD

Marjan Farid, MD

Francisco J.

FINANCIAL DISCLOSURES

In compliance with the Council of Medical Specialty Societies' Code for Interactions with Companies (available at www.cmss.org/codeforinteractions.aspx), relevant relationships with industry are listed. The Academy has Relationship with Industry Procedures to comply with the Code (available at www.aao.org/about-preferred-practice-patterns). A majority (70%) of the members of the Cornea/External Disease Preferred Practice Pattern Panel 2017–2018 had no financial relationships to disclose.

TABLE OF CONTENTS

• OBJECTIVES OF PREFERRED PRACTICE PATTERN GUIDELINES P291

• METHODS AND KEY TO RATINGS P292

• HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE P293

• INTRODUCTION P294

• Disease Definition P294

• Patient Population P294

• Clinical Objectives P294

• BACKGROUND P294

• Prevalence and Risk Factors P294

• Pathogenesis P296

• Associated Conditions P297

• Natural History P299

• CARE PROCESS P299

• Patient Outcome Criteria P299

• Diagnosis P299

  • History P301

  • Examination P302

  • Diagnostic Tests P303

• Classification of Dry Eye Syndrome P306

• Management

OBJECTIVES OF PREFERRED PRACTICE PATTERN® GUIDELINES

As a service to its members and the public, the American Academy of Ophthalmology has developed a series of Preferred Practice Pattern® guidelines that identify characteristics and components of quality eye care. Appendix 1 describes the core criteria of quality eye care.

The Preferred Practice Pattern® guidelines are based on the best available scientific data as interpreted by panels of knowledgeable health professionals. In some instances, such as when results of carefully conducted clinical

METHODS AND KEY TO RATINGS

Preferred Practice Pattern® guidelines should be clinically relevant and specific enough to provide useful information to practitioners. Where evidence exists to support a recommendation for care, the recommendation should be given an explicit rating that shows the strength of evidence. To accomplish these aims, methods from the Scottish Intercollegiate Guideline Network¹ (SIGN) and the Grading of Recommendations Assessment, Development and Evaluation² (GRADE) group are used. GRADE is a

HIGHLIGHTED FINDINGS AND RECOMMENDATIONS FOR CARE

Dry eye is a common ocular condition that has a substantial impact on the quality of life of afflicted individuals owing to discomfort and visual disability. Dry eye may compromise results of corneal, cataract, and refractive surgery.

No single test is adequate for establishing the diagnosis of dry eye. The constellation of findings from multiple tests can add greatly to the clinician's understanding of the patient's condition.

Pharmacological and procedural treatments are associated with

BACKGROUND

Dry eye, either alone or in combination with other conditions, is a frequent cause of ocular irritation that leads patients to seek ophthalmologic care.¹⁵ Even though these symptoms often improve with treatment, the disease usually is not curable, which may be a source of patient and physician frustration. Importantly, dry eye is also a cause of reduced visual function16, 17, 18, 19 and may compromise results of corneal, cataract, and refractive surgery.

APPENDIX 1. QUALITY OF OPHTHALMIC CARE CORE CRITERIA

Providing quality care is the physician's foremost ethical obligation, and is the basis of public trust in physicians.

AMA Board of Trustees, 1986

Quality ophthalmic care is provided in a manner and with the skill that is consistent with the best interests of the patient. The discussion that follows characterizes the core elements of such care.

The ophthalmologist is first and foremost a physician. As such, the ophthalmologist demonstrates compassion and concern for the individual, and utilizes

APPENDIX 2. INTERNATIONAL STATISTICAL CLASSIFICATION OF DISEASES AND RELATED HEALTH PROBLEMS (ICD) CODES

Dry eye includes entities with the following ICD-10 classifications:

APPENDIX 3. SJÖGREN SYNDROME

Sjögren syndrome is defined as dry eye and dry mouth associated with systemic immune dysfunction. About 10% of patients with clinically significant dry eye have an underlying Sj□gren syndrome.57, 58 A significant proportion of the patients may not have been diagnosed at the time they present to the ophthalmology clinic with dry eye complaints.

Sj□gren syndrome is characterized by infiltration of the lacrimal and salivary glands with lymphocytes with secondary compromise of gland function.

APPENDIX 4. DIAGNOSTIC TESTS

This appendix summarizes the applicability of currently utilized tests to diagnose tear film and ocular surface disorders. These tests include the tear break-up time test to evaluate tear film stability, ocular surface dye staining to evaluate ocular surface disease, the Schirmer test and fluorescein disappearance test to evaluate aqueous tear production and clearance, and the tear osmolarity test.

LITERATURE SEARCHES FOR THIS PPP

Literature searches of the PubMed and Cochrane databases were conducted in March 2017; the search strategies were as follows. Specific limited update searches were conducted after June 2018.

Dry Eye Syndrome:

(“dry eye syndromes”[MeSH Terms] OR dry eye[tiab])

Epidemiology:

(“dry eye syndromes/epidemiology”[majr:noexp]) OR (“dry eye syndromes/ethnology”[majr:noexp]) OR ((dry eye[tiab) AND (prevalence[tiab] OR epidemiolog*[tiab] OR ethn*[tiab]))

Etiology:

(“dry eye syndromes/etiology”[majr:noexp]) OR

RELATED ACADEMY MATERIALS

Basic and Clinical Science Course

External Disease and Cornea (Section 8, 2018–2019)

Patient Education Brochure

Dry Eye (2014)

Spanish Language Brochure: Ojo Seco (2014)

Preferred Practice Pattern® Guidelines – Free download available at www.aao.org/ppp.

Comprehensive Adult Medical Eye Evaluation (2015)

Pediatric Eye Evaluations (2017)