Guideline:
Care of the patient with ocular surface disorders
Bibliographic Source(s)
- American Optometric Association. Care of the patient with ocular surface disorders. St. Louis (MO): American Optometric Association; 2002 Nov. 59 p. [117 references]
Guideline Status
This is the current release of the guideline.
It updates a previous version: American Optometric Association. Care of the patient with ocular surface disease. 2nd ed. St. Louis (MO): American Optometric Association; 1995. 58 p. (Optometric clinical practice guideline; no. 10).
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Health Plans
Optometrists
Guideline Objective(s)
- To identify patients at risk of developing ocular surface disorders
- To accurately diagnose patients with ocular surface disorders
- To differentially diagnose age drug environmental and systemic disease-related causes of ocular surface disorders
- To improve the quality of care rendered to patients with ocular surface disorders
- To reduce the prevalence and degree of disability from ocular surface disorders
- To inform and educate patients and other health care providers about the visual complications risk factors and treatment options associated with ocular surface disorders
Target Population
Adults suspected of having ocular surface disease
Interventions and Practices Considered
Diagnosis
- History and physical examination
- Ocular examination for dry eye
- Biomicroscopic examination
- Tear quantity tests (e.g. Schirmer tear test fluorescein staining rose bengal staining)
- Tear film stability tests (e.g. tear film breakup time tear-thinning time lactoferrin concentration tests lysozyme radial diffusion assay)
- Ocular examination for blepharitis
- External examination
- Biomicroscopic examination
- Examination of tear film
Treatment
- Ocular hygiene
- Topical treatment including tear supplements ointments and polymeric inserts
- Punctal occlusion
- Alternative methods including hydrophilic bandage lenses and collagen corneal shields moisture chamber goggles tarsorrhaphy estrogen replacement salivary gland transplant and limbal grafts
- Identification and elimination of environmental factors
- Anti-infective medications or antibiotic/steroid combination drugs (e.g. erythromycin bacitracin polymyxin B-bacitracin gentamicin tobramycin systemic tetracycline or doxycycline) pilocarpine gel for demodicosis
- Patient counseling and education
- Follow-up
Major Outcomes Considered
- Utility and accuracy of diagnostic tests for dry eye and blepharitis
- Patient comfort and symptom control
- Ocular damage
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
The guideline developer performed literature searches using the National Library of Medicine's Medline database and the VisionNet database.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not applicable
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analysis were not reviewed.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
The Reference Guide for Clinicians was reviewed by the American Optometric Association (AOA) Clinical Guidelines Coordinating Committee and approved by the American Optometric Association Board of Trustees March 23 1995 (1st edition) and on November 8 2002 (2nd edition).
Major Recommendations
- Diagnosis of Ocular Surface Disorders
- Patient History
- Ocular Examination for Dry Eye
- External view of the eye noting lid structure position symmetry and blink dynamics
- Biomicroscopic examination of the lid margins meibomian gland orifices and their contents
- Biomicroscopic examination of the tear film noting mucus debris interference patterns in the lipid layer and tear meniscus height
- Biomicroscopic examination of the cornea and conjunctiva both with and without sodium fluorescein and rose bengal or lissamine green staining.
- Schirmer tear test
- Fluorescein staining
- Evaluation of the tear prism
- Debris in the tear film
- Rose bengal staining
- Schirmer II (irritation)
- Lissamine green staining
- Tear volume measurements
- Lacrimal equilibration time
- Cotton thread test
- Phenol red thread test
- Fluorophotometry; fluorescein dilution
- Temporary punctal occlusion
- Tear film breakup time (BUT)
- Tear-thinning time
- Lactoferrin concentration tests: LactoPlate® and LactoCard®
- Lysozyme radial diffusion assay: Quantiplate
- Tear osmolarity test
- Conjunctival scraping and biopsy
- Mucin assay test (tear ferning)
- Specular reflection of the tear surface
- Impression cytology
- Tear protein analysis
- Lipid layer interference patterns
- Enzyme-linked immunosorbent assay (ELISA) tear protein profile
- Ocular Examination for Blepharitis
- External examination of the eye including lid structure skin texture and eyelash appearance; and evaluation for clinical signs of acne rosacea (i.e. telangiectasia pustules rhinophyma)
- Biomicroscopic examination of the lid margins the base of the lashes and the meibomian gland orifices and their contents
- Examination of the tear film for lipid layer abnormalities
- Management of Ocular Surface Disorders
- Management of Dry Eye
- Basis for Treatment
- Available Treatment Options
- Ocular hygiene
- Topical treatment with tear supplements ointments and soluble polymeric inserts
- Punctal occlusion
- Hydrophilic bandage lenses and collagen corneal shields
- Moisture chamber goggles
- Tarsorrhaphy
- Estrogen replacement
- Salivary gland transplant
- Limbal grafts
- Management of Blepharitis
- Basis for Treatment
- Available Treatment Options
- Staphylococcal blepharitis
- Seborrheic blepharitis
- Seborrheic/staphylococcal blepharitis
- Meibomian seborrheic blepharitis
- Seborrheic blepharitis with secondary meibomianitis
- Meibomian keratoconjunctivitis
- Angular blepharitis
- Demodicosis
- Patient Education
- Prognosis and Follow-Up
Patients with compromised ocular surfaces have greater potential for discomfort or further ocular damage. Early recognition of the signs of infection and prompt diagnosis minimize the potential for severe or chronic complications. Evaluation of a patient exhibiting dry eye symptoms or blepharitis includes many of the elements of a comprehensive eye and vision examination and a more in-depth evaluation of the ocular surface and adnexa. (Refer to the Optometric Clinical Practice Guideline on Comprehensive Adult Eye and Vision Examination.) The evaluation for ocular surface disorders includes a carefully detailed patient history an assessment of associated risk factors and an examination of the anterior ocular structures and their functions.
Demographic data about the patient should be collected prior to taking the patient history. Included in the patient history are the chief complaint ocular history general health history (which may include a social history and an extended review of systems) and family ocular and medical history. In addition environmental factors relating to climate season vocational setting and avocational pursuits should be reviewed.
Observations using external ocular examination techniques both without magnification and with the biomicroscope show characteristic early changes of the external eye. Evaluation for suspected ocular surface disorders may include but is not limited to the following:
Tear quantity tests are useful in confirming the diagnosis of aqueous deficient dry eye. The most frequently utilized procedures are:
Other tests that may be used to evaluate tear quantity include:
Several procedures are commonly used to evaluate tear film stability.
Other tests that may be used to evaluate the quality of the preocular tear film (POTF) are:
A thorough external examination of the lids and other parts of the adnexa including comparison of the eyes helps determine the severity of the inflammation. Differentiating among the various presentations of blepharitis requires the use of the biomicroscope to contrast the appearance of the anterior and the posterior lid margins. Evaluation of the patient with blepharitis may include but is not limited to the following:
Each type of blepharitis has specific characteristics that help in making the diagnosis. These are described in detail in the original guideline document.
Stepwise determination of the minimum intervention required to achieve results will help ensure a balance of patient compliance long-term success and cost-effectiveness. The management of dry eye is designed to reduce symptoms and inflammation and to re-establish a normal ocular surface. Efforts should be aimed at maintaining or restoring the preocular tear film and ridding the lids of potential sources of tear film destabilization. Whenever possible environmental factors contributing to dry eye should be identified and either modified or eliminated. When associated medical conditions are identified consultation with or referral to the patient's primary care physician or other health care provider may be indicated.
Attempts to relieve dry eye symptoms and re-establish a normal ocular surface have produced a myriad of possible remedies. Traditional approaches include both tear supplementation and tear conservation measures. Several alternatives have been used with varying degrees of clinical success:
Alternative methods for relieving symptoms specific to ocular surface disorders include:
Acute sequelae to blepharitis are usually the direct result of infection of the lipid-producing glands that open to the lid margin. Their clinical presentation includes internal and external hordeola. The treatment is relatively straightforward. Though essential lid hygiene alone may not resolve the problem. Depending upon the clinical findings an appropriate anti-infective drug can be administered topically systemically or in combination. On the other hand chronic blepharitis is a disease for which there is no complete cure. Aggressive therapy should initially include a minimum of 6 weeks of lid hygiene and appropriate anti-infective medications to gain control of the condition followed by continuing treatment to maintain control of chronic blepharitis.
Because each category of blepharitis is actually a separate condition each is addressed individually in the original guideline document. Treatment approaches for the following forms of blepharitis are discussed in greater detail in the guideline document:
When there is no previously known local or systemic cause for the ocular findings the patient should be educated about other conditions possibly associated with the ocular surface disorder and assisted in obtaining further diagnostic evaluations.
When topical treatment for dry eye is prescribed the patient should be given the rationale for treatment along with the specific dosages frequency and duration. The patient should be made aware of the expected results and given instructions to follow in case of adverse effects. A follow-up examination of the patient should be scheduled to assess treatment effectiveness.
The treatment of blepharitis requires close ongoing cooperation between the patient and the practitioner. Thorough discussion of the causes the rationale for treatment and the expected results is essential in the management of this condition. Most patients with blepharitis have a significant improvement in their symptoms when the appropriate hygiene topical and/or systemic treatments are instituted. Because there is no cure for the chronic forms of blepharitis patients must actively participate in steps to control the inflammatory process. Thorough explanation of both the chronicity of the disease and the rationale for the therapy helps encourage patient compliance. Specific instructions and realistic expectations for the abatement of symptoms should be reinforced by scheduled follow-up.
Follow-up visits for treatment of blepharitis may be as frequent as every few days at the outset tapering off to once or twice a year after stabilization of the condition. The frequency and composition of evaluation and management visits for dry eye are summarized in the table below.
Table 1. Frequency and Composition of Evaluation and Management Visits for Dry Eye
Type of Disorder
Mild Keratoconjunctivitis sicca (KCS)
Frequency of Examination: Annual or as necessary (p.r.n.)
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein rose bengal breakup time (BUT) up to p.r.n.
Management: Preserved or unpreserved tear supplements daily (q.d.)Moderate KCS
Frequency of Examination: Every 6-12 months or p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein rose bengal BUT Schirmer test
Management: Unpreserved tear supplements 4-5 times a day up to p.r.n.Severe KCS
Frequency of Examination: Every 3-6 months or p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein rose bengal BUT Schirmer test
Management: Unpreserved tear supplements p.r.n.; ointment at bedtime (h.s.) punctal occlusionSevere KCS associated with systemic disease
Frequency of Examination: Every 1-3 months or p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Supplemental Testing Plan: Fluorescein rose bengal BUT Schirmer test
Management: Unpreserved tear supplements p.r.n.; ointment at bedtime (h.s.) punctal occlusion; refer to primary physician
Table 2. Frequency and Composition of Evaluation and Management Visits for Blepharitis
Type of Disorder
Seborrheic blepharitis
Frequency of Examination: Weekly until stable then p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene three times per day (t.i.d.) until improved then daily
Staphylococcal blepharitis
Frequency of Examination: Twice a week until cleared then p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Antibiotic or antibiotic/steroid ointment (ung.) h.s. to t.i.d.; tear supplements p.r.n.; steroid drops or ung. if infiltrates; lid hygiene t.i.d. until improved then q.d.
Seborrheic/staphylococcal blepharitis
Frequency of Examination: Twice a week until controlled; then every 6 months or p.r.n.
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Antibiotic or antibiotic/steroid ung. h.s. to t.i.d. then lid hygiene q.d. to t.i.d. for control
Meibomian seborrheic blepharitis
Frequency of Examination: Twice a week until stable then as part of preventive care
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene up to t.i.d.; scalp shampoo q.d.; meibomian express q.d.; antibiotic or antibiotic/steroid ung. h.s. to t.i.d.
Seborrheic blepharitis with secondary meibomianitis
Frequency of Examination: Twice a week until stable (up to 8 weeks) then as part of preventive care
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene up to t.i.d.; antibiotic or antibiotic/steroid ung. h.s. to t.i.d.; oral tetracycline or doxycycline (taper)
Meibomian keratoconjunctivitis
Frequency of Examination: Twice a week until stable (up to 2 weeks) then as part of preventive care
History: Yes
Slit Lamp Biomicroscopy: Yes
Management Plan: Lid hygiene; antibiotic or antibiotic/steroid ung. h.s. to t.i.d.; oral tetracycline or doxycycline (taper)
Clinical Algorithm(s)
An algorithm is provided in the original guideline document for Optometric Management of the Patient with Ocular Surface Disorders.
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
The guideline serves as a practical aid in the management of patients who present for help with ocular surface diseases. Educating patients about dry eye and blepharitis is a key element in successful control of these ocular problems. With careful diagnosis treatment and proper patient education the long-term comfort of these patients can be maintained.
Potential Harms
Tear supplements may cause adverse effects including reduction of the desired effect allergic response and toxic reaction.
Ophthalmic preservatives used in artificial tear solutions and their potential adverse effects are:
- Thimerosal--hypersensitive reaction in an estimated 10-25 percent of users
- Benzalkonium chloride--Preocular tear film instability lowered breakup time (BUT) and disrupted corneal epithelial cell functions when dosed at commercial concentrations more frequently than three times daily
- Chlorobutanol--evaporation corneal epithelial cell changes
- Ethylenediaminetetraacetic acid (EDTA)--contact allergy
- Chlorhexidine digluconate--storage in the corneal and conjunctival epithelium
- Ointments placed in the eye may cause blurred vision
Subgroups Most Likely to be Harmed:
- Patients allergic to wool may react adversely to lanolin.
- Tetracycline and its derivatives should not be given to children or pregnant or nursing women.
Qualifying Statements
- Clinicians should not rely on this Clinical Guideline alone for patient care and management. Refer to the references and other sources listed in the original guideline document for a more detailed analysis and discussion of research and patient care information.
- This Guideline describes the optometric care provided to a patient with ocular surface disorders. The components of patient care described are not intended to be comprehensive because professional judgment and the individual patient's symptoms and findings may have a significant impact on the nature extent and course of the services provided. Some components of care may be delegated.
Description of Implementation Strategy
An implementation strategy was not provided.
Implementation Tools
Clinical Algorithm
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Optometric Association. Care of the patient with ocular surface disorders. St. Louis (MO): American Optometric Association; 2002 Nov. 59 p. [117 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
Funding for the Guidelines has been provided by the Vision Service Plan (VSP) family of companies that are all committed to the success of the private eyecare practice including VSP Altaireyewear Eyefinity and the VSP Optical Laboratory.
Guideline Committee
American Optometric Association Consensus Panel on Care of the Patient with Ocular Surface Disorders
Composition of Group that Authored the Guideline
First Edition Committee Members: Clifford A. Scott O.D. M.P.H.; Louis J. Catania O.D.; K. Michael Larkin O.D.; Ron Melton O.D.; Leo P. Semes O.D.; Joseph P. Shovlin O.D.
Edited and Revised by: Leo P. Semes O.D. (Principal Author); David C. Bright O.D.; C. Denise Pensyl O.D. M.S.
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
It updates a previous version: American Optometric Association. Care of the patient with ocular surface disease. 2nd ed. St. Louis (MO): American Optometric Association; 1995. 58 p. (Optometric clinical practice guideline; no. 10).
According to the guideline developer this guideline has been reviewed on a biannual basis and is considered to be current. This review process involves updated literature searches of electronic databases and expert panel review of new evidence that has emerged since the original publication date.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the American Optometric Association Web site.
Print copies: Available from the American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141-7881
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on December 2 1999. The information was verified by the guideline developer as of January 31 2000. The summary was updated on April 10 2003. The information was verified by the guideline developer on April 28 2003.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions as follows:
Copyright to the original guideline is owned by the American Optometric Association (AOA). NGC users are free to download a single copy for personal use. Reproduction without permission of the AOA is prohibited. Permissions requests should be directed to Jeffrey L. Weaver O.D. Director Clinical Care Group American Optometric Association 243 N. Lindbergh Blvd. St. Louis MO 63141; (314) 991-4100 ext. 244; fax (314) 991-4101; e-mail JLWeaver@AOA.org.
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