At the completion of this article, the reader should be able to improve their diagnosis and management of dry eye disease (DED), including: 
- Review the implications of the definition of dry eye as a multifactorial disease.
- Be aware of the prevalence of asymptomatic dry eye.
- Recognise the importance of comprehensive diagnostic procedures for DED.
Joseph Nazarian
B.Optom., M,Sc(Optom.)
UNSW
Dry eye is entering an era where thorough assessment with innovative technology is essential to disease management. Optometrist JOSEPH NAZARIAN draws on recent case reports to demonstrate how the ZEISS ATLAS 500 enhances dry eye detection and treatment, particularly in asymptomatic patients.
It has been seven years since the Tear Film & Ocular Surface Society (TFOS) Dry Eye Workshop (DEWS) II defined dry eye as ‘a multifactorial disease.’*1 In the intervening years, most optometrists have come to recognise the diverse array of contributing factors to dry eye disease (DED) and acknowledge that detecting and measuring them is essential for developing treatment plans for their patients.
It’s an important recognition to make. The prevalence of DED is reported to be in the range of 5-15% of the Australian population,2 and it is one of the leading causes of patient visits to eyecare providers in Australia today. Bottom line: it’s the foremost medical condition driving patients to consult with eyecare professionals and is expected to continue to grow in prevalence.
However, dry eye is rarely straight-forward. Successful management of a multifactorial disease requires multifactorial approaches – approaches that can address the specific factors relevant to each patient. For dry eye, informed diagnostic procedures include careful history taking and examination and specific tests.
Symptoms of burning sensation, dryness, and stickiness are, of course, the most prevalent among dry eye patients. However, the percentage of patients with asymptomatic dry eye can be significant. As a 2023 study in the International Journal of Environmental Research and Public Health reported, up to 24% of patients were found to have asymptomatic dry eye.3 The disparity between what the patients report, and clinical findings, has been reported by other researchers as well. Nichols et al have discussed a lack of correlation between signs and symptoms of dry eye and have suggested that it probably varies with patients’ awareness and sensitivity toward the symptoms.4
As research continues to endorse the complexity of DED, three things have emerged which are essential for optometrists to embrace to ensure they are providing the best treatment of the condition.
1. Embrace the complexity
Only by understanding the central complexity of dry eye can optometrists develop more effective treatment plans tailored to each patient’s specific needs. At the same time, recognising dry eye as multifactorial encourages optometrists to stay up-to-date with the latest technological advances and treatment options.
2. Embrace patient education
It’s vital that optometrists commit to ongoing education and communication with patients. Despite the fact that eyecare professionals have, in the last decade, benefited from extensive leaps in the understanding of dry eye, patients’ comprehension of the condition significantly trails behind. For that reason, optometrists are in a unique position to empower their patients to actively participate in their treatment and achieve improved outcomes.
3. Embrace emerging technology
Due to the complexity of DED, detection, diagnosis, and treatment remain a considerable challenge for many eyecare professionals. Frequently, patients experience an overlap of disease aetiologies, coupled with fluctuating signs and symptoms over time. There is a need to adopt the newest advances in technology to assess and analyse multiple components of the ocular surface.
The ZEISS ATLAS 500 topographer, introduced in September 2023 at the O=MEGA23 trade fair in Melbourne, is one such advancement. It offers a variety of tests and clinical indicators, enabling optometrists to compare and observe key metrics, leading to informed diagnoses and tailored treatment solutions.
One of the key features of the ZEISS ATLAS 500 is its ability to provide a comprehensive dry eye report. The report includes detailed information on various parameters such as meibography, which calculates the area of loss; ocular redness, graded by the Nathan Efron scale; tear meniscus height; tear film break-up time; and the Ocular Surface Disease Index (OSDI) questionnaire. Additionally, the ZEISS ATLAS 500 can optionally input osmolarity data. In the clinic, it provides a clear, systematic approach to dry eye management which benefits clinical workflow, education and patient outcomes.
In the clinic
Because of its quick-to-capture, step-by-step guidelines, comprehensive analytics and a simple report generation feature, our patients are routinely screened with the ZEISS ATLAS 500 for DED as part of a comprehensive ocular assessment.
A pair of reports have been provided to illustrate how the ZEISS ATLAS 500 has been integrated into eye assessments at Nazarian Optometrists, providing a comprehensive evaluation of symptoms and enhancing the detection and treatment of dry eye of two patients who presented asymptomatically to the practice.
Case 1: Moderate evaporative dry eye
Patient NG is a 56-year-old female who presented for an annual eye examination. She had no complaints regarding her visual acuity or ocular surface health. Upon routine assessment, her unaided visual acuity was 6/6 in both eyes with unremarkable intraocular pressures (16 mmHg in both eyes), OCT and undilated ultra-widefield fundus imaging.
For a comprehensive ocular surface assessment using the ZEISS ATLAS 500, a detailed meibography and ocular redness examination was conducted. The meiboscale reported a third degree loss of area in the right eye, while a second degree in the left eye (56.2% and 47.9%, respectively). Efron grading indicated ocular redness of the conjunctiva on the right eye to be Grade 2 and Grade 3 for the left (see Figure 1A).
In the right eye, non-invasive first tear film break-up time (NIF-BuT) recorded 2.6 seconds and the non-invasive average break-up time (NIAvg-BuT) was 9.3 (see figure 1B). Her left eye demonstrated a NIF-BuT of 6.6 seconds and NIAvg-BuT of 12.4. Additionally, both tear meniscuses were unremarkable.
The dry eye report agglomerated each component of NG’s ocular surface assessment and was able to concisely display the right and left eye deficiencies in meibomian gland area, conjunctival redness, and tear film break-up time.
From this information, we were able to diagnose her with moderate evaporative DED. The patient was advised of environmental factors that may exacerbate her dry eye including air conditioning, smoking and digital device use. She was also advised of lid hygiene by way of hot compresses and tear film supplements, including liposomal sprays in the event that symptoms of blurred vision or gritty foreign body sensations commence.
Case 2: Evaporative and aqueous
deficient DEDs
Patient MG is a 68-year-old female who attended her optometry annual review with no notable changes in her vision since her last visit and no symptoms of dry eye. Her unaided visual acuity was unchanged at 6/7.5 in both eyes with each recording intraocular pressures of 15 mmHg. A further comprehensive posterior check of the macula and optic disc, through OCT, was also found to be unremarkable.
The ATLAS 500 was utilised for a full ocular surface health check. Ocular redness was determined to be a Grade 3 for the right conjunctiva and Grade 2 on the left. Meibomian gland loss in the right eye was 33.6% (classified as a Grade 2) with the left eye analysis also demonstrating a 35.3% loss (Grade 2, see Figure 2A). Tear meniscus height for the right eye (0.22 mm) was within normal limits (i.e >0.2 mm), however, the left eye registered a deficit at 0.19 mm. This reduction in tear meniscus height was measured without instilling fluorescein or any form of pharmacological drops. NIF-BuT for the right eye was documented at 3.6 seconds with 1.1 seconds in the left.
The dry eye report is a clear visual representation of ocular surface health, allowing practitioners the ability to have a quick glance at summarised patient data. The ATLAS 500 also allows the examiner to perform the Ocular Surface Disease Index (OSDI) questionnaire directly using the software, rather than printing multiple pages and manually tallying up scores.
Patient MG was diagnosed with a combination of evaporative and aqueous deficient DEDs. This was found to be moderate to severe. Similar to treatment advice for Case 1, a thorough explanation was given to MG on the possible causes of her dry eye and similar lid hygiene and tear supplement education were intensively discussed. She was provided relevant ocular lubricants and will be reviewed in a further three months’ time for a comparative assessment.
It is widely understood that many patients do not routinely present to an eyecare professional describing the feeling of ‘dryness’ or ‘discomfort’ unless prompted. This means that the ability to identify asymptomatic dry eye patients is important within eyecare to prevent further exacerbation of symptoms and ocular surface damage. From this article, both Case 1 and Case 2 demonstrate patients who fit within the asymptomatic group of DED, as they did not verbally express any overt clinical features.
Conclusion
The ZEISS ATLAS 500 was found to be a great tool in the evaluation of ocular surface disease. Further to the information provided in the above cases, this device provides an additional section to document the patient’s osmolarity, although this requires manual input and must be captured by a separate device. At Nazarian Optometry, we do not have access to an osmolarity measuring tool, and so, this information was not included in the cases above.
Despite the intricacies of the data captured, quantified, analysed, and presented on the screen, I have found the ZEISS ATLAS 500 requires minimal training through its on-screen prompts and guides. This makes it quite easy to integrate into any clinical workflow and the ideal time saving solution for clinical staff. With optimisation for a seamless integration into the ZEISS medical ecosystem, the ZEISS ATLAS 500 allows existing FORUM users additional connectivity benefits, including dry eye PDF report generation to view all key patient information anywhere in the practice.
By providing a wide range of measurements and analysis tools, the ZEISS ATLAS 500 empowers optometrists to better understand the underlying factors contributing to DED. This, in turn, allows them to develop more effective treatment plans tailored to each patient’s unique needs, ultimately improving patient outcomes. This could further be applied to the management of cataract pre- and post-operatively while allowing an ophthalmologist to choose an appropriate IOL without being hindered by inconsistent readings due to DED. At Nazarian optometry, staff are embracing complexity, education and technology for the best treatment and management of this multifactorial and complex disease.
* Full quote as published in the published in The Ocular Surface journal in 2017: ‘a multifactorial disease of the ocular surface characterised by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.’
More reading
Considerations for low-dose atropine for myopia control in a non-Asian population
Insights from an Australian gonioscopy workshop – Part 2
Gonioscopy primer: Insights from a gonioscopy workshop (Part 1)
References
1. Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II report executive summary. The Ocular Surface. 2017; 15 (4): 802-812.
2. Chia EM, Mitchell P, Rochtchina E, Lee AJ, Maroun R, Wang JJ. Prevalence and associations of dry eye syndrome in an older population: the Blue Mountains Eye Study. Clin Exp Ophthalmol. 2003; 31 (3): 229-32.
3. Wróbel-Dudzińska D, Osial N, Stępień PW, Gorecka A, Żarnowski T. Prevalence of dry eye symptoms and associated risk factors among university students in Poland. International Journal of Environmental Research and Public Health. 2023 Jan 11; 20 (2): 1313. doi:10.3390/ijerph20021313
4. Nichols KK, Nichols JJ, Mitchell GL. The lack of association between signs and symptoms in patients with DED. Cornea. 2004; 23: 762–70.
