When I was a child, I had an imaginary friend. My imaginary friend was, in fact, a child warrior with wings who embarked on adventures around the globe. Whilst my fallacious friend was arguably ridiculous, and existed only within the confines of my mind, my parents neither laughed at me nor questioned her significant influence, even allowing me to feign a bellyache when I feared she was not present.
With limited exception, a disease with severe and multifactorial physical repercussions cannot exist in ones mind. A bellyache, such as the ones I endured, is hardly severe. But yet for years, dry eye disease, an immune-mediated ocular surface disorder whose symptoms can be devastating and debilitating, was once not considered a condition meriting acknowledgment, let alone classification as an ocular disease. Even today, many practitioners continue to deem it no more than a nuisance or a psychologically inspired ailment.
Textbooks like Schlaegel and Hoyt’s Psychosomatic Ophthalmology referenced that, “in 1960, between 40 and 100 per cent of recorded eye disorders were influenced by psychological factors. Intraocular pressure, for example, can be clearly associated with states of anxiety and emotional conflict. This has never been disproved, but advances in medical technology have drawn attention away from it.” While most doctors currently discard, along with other insanities such as electro shock treatment for homosexuals, such a baseless blanket statement as a historical curiosity, there are many doctors who resist considering dry eye to be a disease.
Having had said that, the inverse relationship has been proven: the emotional impact of dry eye disease can be just as burdensome as the physical impact, with the pain, anxiety, and deterioration of patients’ lives leading to psychological instability, or even suicide. Depression may be a co-morbid condition, but it is not the cause of Dry Eye for many patients. The alarming 63% increase in the suicide rate among middle-aged women over the past 15 years in the U.S. must be taken into account (NCHS Data Brief No. 241, April 2016).
Leejee H. Suh, M.D., Associate Professor of Clinical Ophthalmology, is the Director of both the Laser Vision Correction Center and the Cornea Fellowship Program at Columbia University’s Edward S. Harkness Eye Institute, argues that comprehensive diagnoses and treatment for dry eye is impossible unless a few colossal adjustments in the medical industry are introduced and more importantly, integrated. Having had said this however, she finds that a younger generation of doctors is compelling innovation and as a result, the tide is changing.
But not fast enough… To succeed in practical terms, Dr. Suh has very relevant suggestions to change the perception of dry eye disease and in turn, more effectively diagnose and treat patients. Some of her suggestions in practical terms:
- Need to define it as a disease and ensure a cohesive definition
Personally, when I was first introduced to the concept of dry eye, Googling the disease left me quite confused, since the multitude of sources presented me with grossly varying definitions. In addition, it was rarely classified as a disease, and Dr. Suh concurs, suggesting that many sources consider dry eye to be merely a nuisance rather than a disease because it does not normally lead to blindness.
Other ocular diseases that more readily lead to blindness, such as glaucoma, have been stratified and thus have a regimented plan for treatment down the whole value chain. To the contrary, since dry eye is loosely defined, not stratified and not generally classified as a disease, its management is often fragmented and haphazard, leaving patients “confused and frustrated.”
But let’s return to the root of the problem: why is dry eye loosely defined, keeping in mind the answer is simpler than the solution. Dry eye is multi-factorial and as such, its symptoms often mimic those associated with other diseases. A multi-factorial disease requires multi-faceted treatment. As a first step, Dr. Suh suggests, “For starters, we need to forego the almost knee-jerk reaction of recommending artificial tears. Instead, we must look at the current definition of dry eye: It’s not just a lack of tears, but a multifactorial condition of the tear system and ocular surface, with frequent symptoms of discomfort and disturbance in vision and instability of the tear film.” The TFOS DEWS II Report will update this definition in the coming months.
- Change Philosophy
Data has proven that the rise in dry eye disease incidence is significant and worrisome. In addition, for a disease that was known to traditionally affect middle-aged women, patients suffering from this disease have expanded to include a larger as well as more diverse demographic.
Visual cues are higher and we are constantly using our eyes. While technology has evolved, our physiology has not kept pace. As we cannot determine whether our eyes will adapt, in a Darwinian fashion, to a mutating environment, we are obligated to accept that this disease needs our attention. The alternative would be to eliminate smart devices, air conditioners, contact lenses, cosmetics and the like from our daily lives.
- Communicate, communicate and communicate once more.
We need to disseminate cohesive information regarding dry eye since, distressingly, Dr. Suh finds that the “word is not out yet on dry eye.”
How we can achieve this is dual pronged: more collaborative efforts such as the one undergoing with TFOS DEWS II, and more advertisement of TFOS. The later should be aggressively showcased as a group of experts who are leaders in research. She argues that TFOS is the only existing group that has a counsel of experts and as such, their obligation is to reach out to people and empower them with information. To do this however, we need to develop a human voice, one that proves we relate to patients and empathize with their suffering. Whilst reaching out to people, TFOS has to present doctors with algorithms so that the disease is easier to diagnose and treat. In this way, communication would work across several conduits.
Nominated as one of the top doctors in New York as well as one of the top doctors in the United States, perhaps we should consider what Dr. Suh, as a representative of the younger generation, proposes going forward.
Dominica Drazal
Director, TFOS Global Ambassador Program
