Awareness and Innovation May Address Underdiagnosed Dry Eye Population

Dry eye disease is notoriously underdiagnosed. It’s also a market with a strong upside potential. In a recent interview with OIS Weekly, internationally known anterior segment specialist William Trattler, MD, explored some of the reasons dry eye disease is so underdiagnosed and how eye-care providers can tap into this potential market.

Dr. Trattler, director of cornea at the Center For Excellence In Eye Care in Miami, said the main reason dry eye disease (DED) is underdiagnosed is that many patients believe they’re asymptomatic when in fact they’re experiencing ocular issues caused by DED. Most patients believe eye pain, irritation, foreign-body sensation, eye redness, and a feeling of eye dryness are the main symptoms of DED. But they’re unaware that DED may be the underlying cause of blurred vision, fluctuations in vision, eye fatigue, and watery eyes.

And, unless a patient reports symptoms, many eye-care providers don’t routinely perform a comprehensive evaluation for DED and meibomian gland dysfunction (MGD). Also, he said, in “asymptomatic” patients in whom DED is detected, many decline management since they’re not experiencing symptoms.

Market Opportunity
DED is projected to be a strong growth market. A Fortune Business Insights report projected the DED market will reach $7.73 billion in 2026, up from $4.22 billion in 2018. The report cited several factors that have contributed to the growth of the market, including the advancement of potential treatments.

A 2017 analysis of national health data estimated the diagnosis rate of DED at around 50%.1 About 16.4 million people have been diagnosed with DED, but the incidence is said to be around 34 million people.

Raising Awareness
If doctors assess for the signs and symptoms more closely in patient encounters, they may find obvious signs of DED, MGD, or blepharitis. Sometimes this can explain a patient’s symptoms such as tearing, or fluctuation of vision – atypical symptoms for DED, but symptoms that therapy could help.

“It’s all about awareness,” Dr. Trattler said. “When patients come in, especially if they are older, it’s surprising how many asymptomatic patients have scurf or collarettes on their eyelashes, which is a sign of blepharitis. They may have non-obvious MGD, which is only identified when pressure is placed on the eyelids to evaluate the meibomian gland secretions. Asymptomatic patients may have a low tear film volume and/or mild corneal staining.” To identify these findings, he added, providers need to change their routine examination at the slit lamp.

In a condition like Demodex blepharitis, which can be easily identified by the presence of collarettes on the eyelids, a diagnosis is still only valuable if an effective treatment is available. Tarsus Pharmaceuticals recently started recruiting for a Phase IIb/III study of TP-03, which Dr. Trattler described as “a very nice technology” for Demodex patients.

Asymptomatic Patients
Diagnosing asymptomatic dry eye and asymptomatic MGD can be a challenge, Dr. Trattler noted. “These diseases are progressive and can impact a patient’s quality of vision,” he said. “Since the impact is gradual, patients may not realize they’re not seeing as well, and may not realize that treatment can improve their quality of vision.”

He added, “If a patient is asymptomatic, certainly we’re going to check for normal eye pressure, but checking for asymptomatic DED and MGD is not always routine. Often patients will get fluorescein placed in their tear film to perform an intraocular pressure check. Clinicians who evaluate patients shortly after placement of fluorescein will typically identify corneal staining in dry eye patients.”

However, he explained, the use of automated tonometers to check intraocular pressure precludes many patients from getting fluorescein, furthering DED underdiagnosis.

“A similar situation exists with MGD, which requires the doctor to press on the eyelids and see the quality of the meibum that comes out of the meibomian glands, to be able to tell if the meibum secretions are normal, or thick and not flowing well,” Dr. Trattler added.

But a thorough patient history with the right questions may give doctors more information and lead to a suspicion of DED.

Symptomatic Patients
But, Dr. Trattler explained, symptomatic patients who present with eye pain or discomfort, or a foreign-body sensation, pose a different diagnostic dynamic. “We know those cues and we evaluate patients for dry eye and MGD in that situation,” he said.

DED should be suspected in patients with complaints such as fatigue while working on the computer, or quality of vision issues. Providers often fall back on thinking the problem is with the patient’s glasses, or a refraction problem, but in reality it could be dry eye.

He added that it’s important to look carefully for DED in cataract or refractive surgery patients. “DED impacts all of our testing as we plan for cataract and refractive surgery,” Dr. Trattler said. “It is therefore important to identify DED preop, even when the patient is asymptomatic.”

The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study2 was a multicenter screening study of patients scheduled for cataract surgery. Dr. Trattler was an investigator and said the researchers were surprised to find that more than 80% of patients coming in for cataract surgery consultations had pre-existing DED, despite only a small percentage reporting symptoms.

“There were a lot of patients with asymptomatic dry eye, and unless doctors are looking for it in patients coming in for cataract and refractive surgery consultation, they’re going to miss it,” he said.

1. Farrand KF, Fridman M, Stillman IÖ, Schaumberg DA. Prevalence of diagnosed dry eye disease in the United States among adults aged 18 years and older. Am J Ophthalmol. 2017;182:90-98.
2. Trattler WB, Majmudar PA, Donnenfeld ED, et al. The Prospective Health Assessment of Cataract Patients’ Ocular Surface (PHACO) study: The effect of dry eye. Clin Ophthalmol. 2017;11:1423-1430.