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Boys vs. girls. Mars vs. Venus. Or the more scientific, males vs. females. However you look at it, the truth is that we are always making the comparisons. I looked up and downloaded this week's abstract after reading the headline in the AOA First Look eblast "Women With Dry Eye May Have Lower Pain Tolerance." When taken in context, the title does restate a key finding. When taken out of context, which I did (and likely most readers did), the title seems to infer that women with dry eye could be perceived as, shall I say, wimpier? To that I ask, wimpier than what?

What is missing from the title is the comparison group, which in this case is women with lower dry eye survey results (via OSDI). NOT men. In fact, the study participants were only women. Dare I ask what the findings would be if we applied the same tests to men with and without dry eye symptom? This hypothetical study might indeed come to the same conclusion, that pain thresholds may be lower in dry eye patients. How a patient tolerates real pain was not the focus of the study, and as you all know, every human tolerates pain differently. It is well established that more women across all age groups have more prevalent dry eye than men, but men still get dry eye, also increasing with age. It is also well established that women utilize the health care system differently than men and tend to discuss problems with physicians earlier, and perhaps with more vigor, than male counterparts. Understanding these differences will ultimately help us be better practitioners.

What would I have titled the news article? Probably something like "Female twin study links dry eye and pain sensitivity" and in reality, with an accurate title like that, I (like you) probably would not have been inspired or fired up to open it and read it. So there you go, read on!

Kelly K. Nichols, OD, MPH, PhD

Editor's comment: Have you noticed that alternating issues of Ocular Surface News are Boys vs. Girls? It just so happened that way. Can you tell a difference?
August 29, 2013
Editor's Commentary
TFOS Global Campaign Promotes Blink Around the World

TFOS Elects New Board and Scientific Advisory Council Members

Clinician's Corner: Tear Osmolarity in Practice
Research Update: Commentary on Abstract of the Week
Dry Eye 101: Nuts and Bolts


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Order of diagnostic testing for ocular surface disease
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TFOS Global Campaign Promotes Blink Around the World
Dry eye awareness got a boost with the launch of a year-long social global campaign dubbed Blink Around the World. Eye health professionals around the world are joining the Tear Film & Ocular Surface Society (TFOS), to generate dry eye awareness with a new song and corresponding online campaign.

Dry eye disease is a global problem. Approximately twenty to forty million people live with dry eye in the United States, with Europe close behind and Asia nearly double in prevalence. The normal person blinks about 16,800 times a day, between 10 and 30 times per minute and approximately 1,200 blinks per hour. The simple act of blinking reduces dry eye symptoms by flushing fresh tears over the eye, re-moisturizing and keeping foreign matter and irritants out. Unfortunately, dry eye causes us to blink less and blinking is a self-help treatment, so we all need to blink more.

The new TFOS initiative is focused on increasing awareness of the importance of not only blinking, but also eye health. According to Amy Gallant Sullivan, Executive Director of TFOS, Blink Around the World is a fun and catchy way to remind people to blink their eyes. Sullivan is amassing a coalition of partners including scientists, clinicians, pharma and patients to help spread the importance of blinking and eye health.

The campaign website asks people to send a 5-second-video in which they blink in front of a recognizable monument or something original that is representative of their location. To help reinforce the message, TFOS has also launched a new song to promote global eye-health. TFOS collaborated with Italian pop singer Sabrina to create the new music single. "Blink Around the World," the song, can be purchased on Amazon.com or via iTunes. Proceeds from the sale of Blink Around the World will benefit the TFOS educational mission.

To find out more about the campaign, visit the campaign website: www.blinkaroundtheworld.com.

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TFOS Elects New Board and Scientific Advisory Council Members
The Tear Film & Ocular Surface Society (TFOS) members recently elected new members of the Board of Directors and the Scientific Advisory Council. The individuals elected are:

TFOS Board of Directors
Kelly K. Nichols (USA)
Debra A. Schaumberg (USA)

TFOS Scientific Advisory Council
Pablo Argüeso (USA)
Penny Asbell (USA)
Jennifer P. Craig (New Zealand)
Murat Dogru (Japan)
Erich Knop (Germany)
Jason J. Nichols (USA)
Fiona Stapleton (Australia)
Mark D.P. Willcox (Australia)

The new terms will begin on September 20, 2013, and will last for 3 years.

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Amber Gaume Giannoni, OD, FAAO

In busy practices, it is not uncommon to possess a "reactive" treatment approach when it comes to dry eye: "If they don't complain, they must be fine." However, deep down, we know that our patients don't bring up mild dry eye symptoms, especially when they're contact lens related, either for fear of being taken out of their lenses, or because they incorrectly believe it's a normal part of wear. This reactive approach may be why we haven't really seen a decline in the rate of contact lens drop-outs in our practices despite advancements in lens materials and care systems. Perhaps we need to do a better job in identifying higher risk groups and launching a preemptive strike.

We know that elevated tear film osmolarity (TFO) is a pro-inflammatory factor for the ocular surface and is predictive in dry eye disease (DED) diagnosis. With the introduction of the TearLab Osmolarity System (TearLab, San Diego CA), an in-office reading (CPT 83861) can be easily obtained in mere seconds at no discomfort to the patient (Figures 1 and 2). It is highly accurate in measuring the sample it obtains, so one can be confident that inter-eye variability is attributed to biological inconsistency (one of the hallmarks of DED) and not instrument variation. Results can aid DED diagnosis, or be used to monitor therapeutic regimen effectiveness. In the United States, TearLab is considered an in-vitro laboratory device, and appropriate Federal CLIA certification must be obtained. The process is very simple, and the company does provide assistance, if needed (www.tearlab.com).

Some practitioners may be hesitant to charge for additional dry eye testing, or even dry eye screening in an otherwise "asymptomatic" (non-chief complaint) patient, but I've found that most patients appreciate a doctor who stays current on new technology. You may find that by taking more of a proactive approach, your patients will follow your lead and actually become more eager and engaged in their own ocular health.

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Sruthi Srinivasan, PhD, BS Optom, FAAO

Pain is a multifaceted, complex sensory experience that is difficult to characterize as a single entity. The World Health Organisation defines pain as "an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage". Dry eye indeed is a multifactorial condition1 which can potentially cause pain, ocular surface irritation and damage. Does dry eye have a link with our body's general pain sensitivity or pain tolerance levels?

This week's abstract focuses on the association between dry eye symptoms and pain sensitivity. This study was conducted on large group women (identical and non-identical twins) at St. Thomas Hospital, London, UK. Quantitative sensory testing was conducted by placing a probe to provide heat stimulus on the upper central forearm which was used to assess pain sensitivity (heat pain threshold) and pain tolerance (heat pain supra-threshold). About 1,635 female twin volunteers, aged 20 to 83 years participated in this study. Of those participants who were included in the study, 438 (27.0%) were categorized as having dry eye from questionnaire responses (Ocular Surface Disease Index), with 354 (21.6%) having dry eye symptoms in the past 3 months, 260 (16.2%) using artificial tears, and 218 (13.2%) being diagnosed with dry eye by a physician. The result of this study showed that women with dry eye showed a significantly lower heat pain threshold and heat pain supra-threshold and hence had higher pain sensitivity—than those without dry eye. There was a strong association between the presence of pain symptoms and the heat pain threshold and heat pain supra-threshold.2

Management of dry eye is indeed complex and comprised of both pharmacological and non-pharmacological approaches. Studies of this nature will help physicians consider management of this disease with a comprehensive or "holistic" approach, rather than treating dry eye signs alone. The result from the above study is applicable for women, so further studies are required to understand the link between dry eye symptoms and pain sensitivity in men.

1. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007;5:75-92.
2. Vehof J, Kozareva D, Hysi PG, et al. Relationship Between Dry Eye Symptoms and Pain Sensitivity. JAMA Ophthalmol. 2013.

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Relationship Between Dry Eye Symptoms and Pain Sensitivity

Jelle Vehof, PhD; Diana Kozareva; Pirro G. Hysi, PhD; Juliette Harris, PhD; Ayrun Nessa; Frances K. Williams, PhD; David L. H. Bennett, PhD; Steve B. McMahon, PhD; Samantha J. Fahy, PhD; Kenan Direk, MSc; TimD. Spector, PhD; Christopher J. Hammond, PhD. JAMA Ophthalmol. 2013 Aug 1.

OBJECTIVE: To explore whether pain sensitivity plays a role in patients' experience of DED symptoms.

DESIGN, SETTING, AND PARTICIPANTS: A population-based cross-sectional study of 1635 female twin volunteers, aged 20 to 83 years, from the TwinsUK adult registry.

MAIN OUTCOMES AND MEASURES: Dry eye disease was diagnosed if participants had at least 1 of the following: (1) a diagnosis of DED by a clinician, (2) the prescription of artificial tears, and/or (3) symptoms of dry eyes for at least 3 months. A subset of 689 women completed the Ocular Surface Disease Index (OSDI) questionnaire. Quantitative sensory testing using heat stimulus on the forearm was used to assess pain sensitivity (heat pain threshold [HPT]) and pain tolerance (heat pain supra-threshold [HPST]).

RESULTS: Of the 1622 participants included, 438 (27.0%) were categorized as having DED. Women with DED showed a significantly lower HPT (P = .03) and HPST (P = .003)—and hence had higher pain sensitivity—than those without DED. A strong significant association between the presence of pain symptoms on the OSDI and the HPT and HPST was found (P = .008 for the HPT and P = .003 for the HPST). In addition, participants with an HPT below the median had DED pain symptoms almost twice as often as those with an HPT above the median (31.2%vs 20.5%; odds ratio, 1.76; 95%CI, 1.15-2.71; P = .01).

CONCLUSIONS AND RELEVANCE: High pain sensitivity and low pain tolerance are associated with symptoms of DED, adding to previous associations of the severity of tear insufficiency, cell damage, and psychological factors. Management of DED symptoms is complex, and physicians need to consider the holistic picture, rather than simply treating ocular signs.

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Jillian Meadows, OD, MS

Question: Can conjunctivitis masquerade as dry eye?

Answer: It can and often does. Only a few types of sensory neurons innervate the ocular surface, and inflammation can activate these neurons to varying degrees. Considering that conjunctivitis and dry eye can have overlapping inflammatory profiles, it should not surprise you that they can have common clinical signs and symptoms.

So how do you ensure that you are making the right diagnosis? Read on.
  1. Do a risk analysis during the case history. Strongly consider age, sex, race, systemic health conditions, medications, environmental exposures, and symptomatology to develop a tiered list of possible diagnoses before making any clinical observations.
  2. Know your clinical manifestations and stay current on the literature. New diagnostic tools are often developed, and your ocular surface evaluation should evolve alongside these advancements.
  3. Regardless of your diagnosis, you should be able to find a cause, or at least a risk factor, for the condition. Particularly with ocular surface disease, this step is frequently skipped. Yes, dry eye may be a common condition, but it does not strike haphazardly. It could be hormonal (postmenopausal females), concurrent with autoimmune disease (caution with episcleritis, scleritis, uveitis, etc.), iatrogenic (medication induced), structural (nocturnal lagophthalmos, conjunctivochalasis, others), environmental, or simply contact lens related. Though not an exhaustive list, many of these are modifiable risk factors that present an opportunity to target your therapy and improve your patient's comfort.
  4. When you initiate treatment, always schedule a follow-up. Return visits allow you to monitor the condition, confirm your diagnosis, and tailor your therapy if needed. Bonus—it also improves patient compliance, promotes patient loyalty, and profits your practice.
Lastly, remember that ocular surface diseases are not mutually exclusive. Poor response to treatment could be a sign of an incomplete diagnosis—not necessarily an incorrect one. Surface disease requires more than surface thought.

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