May 20, 2021 • 8 minutes read

The optometrist’s role in treating dry eyes

Dr Fredrik Källmark

Optometrist in clinic behind a computer

Introduction

Photo of Dr Fredrik Källmark
With
Fredrik Källmark

It seems that dry eye has gained more and more interest in the world of optometry in the past decade. And rightly so, as it affects at least 344 million people worldwide and is one of the main reasons why people visit eye care practitioners. Reason enough to speak to one of the leading figures in the Nordics when it comes to dry eyes: Dr Fredrik Källmark, owner of Källmarkskliniken, the first and only dry eye clinic in Sweden, and global ambassador for the Tear Film & Ocular Society. About dry eye disease, the DEWS reports, and about the role of optometrists in treating the condition.

Read Fredrik's bio

You’re one of very few with the degree Doctor of Optometry in the Nordic region. What’s your focus in your work these days?

Photo of Dr Fredrik Källmark
Fredrik Källmark

Leonardo da Vinci wrote: “My eyes are an ocean in which my dreams are reflected”. When I diagnose the eyes of my patients who experience discomfort yet have dreams of their own, I see a glimpse of those dreams in their eyes. Treating those eyes and protecting those dreams means a lot to me. My focus areas are dry eyes, ocular surface diseases and the people suffering from these conditions.

Treating those eyes and protecting those dreams means a lot to me.

The topic ‘dry eye’ has been an increasing focus within optometry the last five to ten years, and there are no signs that this focus seems to decrease. What do you think is the reason for this? Dry eye isn’t something new that hit humanity only in the last years.

Photo of Dr Fredrik Källmark
Fredrik Källmark

I think that the increased focus has various reasons. One reason is the more health-conscious population in general, and the second is an increasing number of people affected by several systemic diseases such as diabetes and rheumatoid arthritis. Also, the ageing population is one of the reasons.

On top of this, we see that many people of all ages sit in front of screens, resulting in less blinking, which, in its turn, promotes dryness. All these people are now seeking more help from doctors and therefore spark interest in the topic.

You have a central part in developing the Dry Eye Workshop (DEWS) reports, the gold standard for dry eye detection and management. Please tell us more about this.

Photo of Dr Fredrik Källmark
Fredrik Källmark

As a global ambassador for the Tear Film & Ocular Society (TFOS), I’m involved in constantly gathering material to better understand the dry eye problem, how to diagnose, examine, and treat it in the best possible way. The next TFOS Workshop is entitled “A Lifestyle Epidemic: Ocular Surface Disease” and will focus on the consequences of the lifestyle choices we make, directly or indirectly, on the ocular surface.

What are the focus areas of DEWS besides making contact lenses work better?

Photo of Dr Fredrik Källmark
Fredrik Källmark

As I mentioned before, with the DEWS, we’re aiming to better understand the dry eye problem, how to diagnose, exam and treat it – so that’s much more than just making contact lenses work better. To complete the list, these will be the subtopics of the next TFOS workshop:

  • Digital environment
  • Cosmetics
  • Nutrition
  • Elective medications and procedures
  • Environmental conditions
  • Lifestyle challenges
  • Contact lens wear
  • Societal challenges
  • Public awareness

DEWS clearly define dry eye as an eye disease. Optometrists are now taking a bigger responsibility in treating dry eyes, using the DEWS report as a common guideline. At the same time, there’s a discussion in the European countries about how much responsibility optometrists should be allowed to have in medical treatment and co-management. It seems like dry eye is at the forefront of this modern way of thinking!

Photo of Dr Fredrik Källmark
Fredrik Källmark

Yes, dry eye is definitively at the forefront of this way of thinking. Today, all European countries but Sweden have accepted dry eyes as an eye disease (DED). This has also led to an increased need for eye care professionals to see the higher number of dry eye patients. The different levels of education in Europe, especially in optometry, make this an interesting question. However, the level of education has become more and more equal. Optometrists with a Master of Optometry or Doctor of Optometry are well equipped to handle dry eye and ocular surface diseases. They should therefore be more involved in co-management/shared care with ophthalmologists.

Optometrists with a Master of Optometry or Doctor of Optometry are well equipped to handle dry eye and ocular surface diseases. They should therefore be more involved in co-management/shared care with ophthalmologists.

In Australia, there’s a common guideline for optometrists and ophthalmologists about how to detect and treat glaucoma. Are there some similarities with the approach to the work TFOS is now doing, describing detection and treatment from “easy level to advanced”?

Photo of Dr Fredrik Källmark
Fredrik Källmark

In the DEWS I and II reports and the upcoming workshop, TFOS has already strived to provide guidelines describing the detection and treatment of dry eyes. When it comes to detection and diagnosing, the guidelines will be identical for optometrists and ophthalmologists since they’re supposed to have the same knowledge regarding this condition. The matter of treatment can differ, depending on the education of the optometrists and what kind of medication and in-house treatment they can use. In that matter, optometrists and ophthalmologists will be more or less on the same platform, and it won’t be mandatory for optometrists to refer a DED patient.

Let’s talk about where the split is between what optometrists are doing and what ophthalmologists can do with dry eye. It seems like there has been a load of new medications coming onto the market for ophthalmologists to use. What do optometrists need to know about them?

Photo of Dr Fredrik Källmark
Fredrik Källmark

Once again, depending on their education level, the optometrist is allowed to use different treatments. In-house treatments can vary from manual expression, BlephEx treatment and PBM. All of these are more or less available for optometrists.

When we talk about drugs, it could be good to know for optometrists that the most commonly prescribed drugs are antibiotics and corticosteroids. There’s definitely an overuse of antibiotics, with a high risk of resistance. Other drugs could be, for example, Ciclosporin and Ikervis. Ikervis is used as a treatment for severe keratitis in adult patients with chronic dry eyes. Another drug is autologous serum (AS) tears or autologous serum eye drops (ASEDs): customised drops made from a patient’s own blood diluted in sterile saline or hyaluronic acid. Because the serum is composed of a complex mix of growth factors, proteins, antioxidants, and lipids, it’s used to stimulate healing in the cornea and decrease inflammation.

In most cases, we can also treat dry eyes successfully without prescribing drugs.

Further, we have a new drug called Lifitegrast – also sold under the name Xidra. It inhibits an integrin, lymphocyte function-associated antigen 1, from binding to intercellular adhesion molecule 1. This mechanism downregulates inflammation mediated by T lymphocytes.

All these drugs and more are available for most ophthalmologists and some optometrists and can earn their place in the treatment of dry eyes. But do remember that in most cases, we can also treat dry eyes successfully without them. Also, it’s essential to look at the patients from a holistic point of view and remember that the reason for malfunction in glands often comes from systemic diseases, skin diseases, bowel diseases, hormonal changes, and so on. Therefore, optometrists and ophthalmologists should – to a greater extent – establish interprofessional collaborations.

It’s essential to look at the patients from a holistic point of view and remember that the reason for malfunction in glands often comes from other diseases.

Will this mean that optometrists should refer more patients to ophthalmologists than they’re doing now for medical treatment with drugs?

Photo of Dr Fredrik Källmark
Fredrik Källmark

No, on the contrary. Optometrists need to take more responsibility and use their knowledge and education that has prepared them for these kinds of tasks. They’re also trained to know when they reach their limitations in what type of treatment they can or are allowed to give – and then refer.

Another interesting discussion is the use of photobiomodulation (PBM) in dry eyes. Can you explain what this is?

Photo of Dr Fredrik Källmark
Fredrik Källmark

PBM is a light-based technology that stimulates bioenergetic output in targeted tissues. Selected wavelengths of light in the far-red to near-infrared spectrum (500–1,000 nm) modulate biologic function through direct and indirect cellular effects on mitochondrial respiratory chain components. This is to promote tissue repair, decrease inflammation and stimulate the Meibomian glands. It has proven to be a safe and very effective treatment. However, it’s not a stand-alone treatment, and to gain the best results to restore tear film homoeostasis, we must include warm compress therapy and eyelid hygiene.

Photobiomodulation for dry eye has similarities with the same technique as for AMD with the new Valeda system. So, can we claim that if we can use this technique for dry eyes, we can also use it for AMD – if in a proper quality system together with ophthalmologists?

Photo of Dr Fredrik Källmark
Fredrik Källmark

Theoretically, I believe this could be the case, where optometrists can take a lot of burden from the pressure ophthalmologists experience today due to the increasing number of AMD cases.

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