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## Complete Summary

#### GUIDELINE TITLE

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.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Ocular surface disorders, focusing on the two most common clinical
forms, dry eye and blepharitis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Optometry

#### 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**

1.  History and physical examination

2.  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)

3.  Ocular examination for blepharitis

    -   External examination

    -   Biomicroscopic examination

    -   Examination of tear film

**Treatment**

1.  Ocular hygiene

2.  Topical treatment, including tear supplements, ointments, and
    polymeric inserts

3.  Punctal occlusion

4.  Alternative methods, including hydrophilic bandage lenses and
    collagen corneal shields, moisture chamber goggles, tarsorrhaphy,
    estrogen replacement, salivary gland transplant, and limbal grafts

5.  Identification and elimination of environmental factors

6.  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

7.  Patient counseling and education

8.  Follow-up

#### MAJOR OUTCOMES CONSIDERED

-   Utility and accuracy of diagnostic tests for dry eye and blepharitis

-   Patient comfort and symptom control

-   Ocular damage

### METHODOLOGY

#### 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).

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

A.  **Diagnosis of Ocular Surface Disorders**

> 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.

1.  **Patient History**

> 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.

2.  **Ocular Examination for Dry Eye**

> 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:

-   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.

> Tear quantity tests are useful in confirming the diagnosis of aqueous
> deficient dry eye. The most frequently utilized procedures are:

-   Schirmer tear test

-   Fluorescein staining

-   Evaluation of the tear prism

-   Debris in the tear film

-   Rose bengal staining

> Other tests that may be used to evaluate tear quantity include:

-   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

> Several procedures are commonly used to evaluate tear film stability.

-   Tear film breakup time (BUT)

-   Tear-thinning time

-   Lactoferrin concentration tests: LactoPlate® and LactoCard®

-   Lysozyme radial diffusion assay: Quantiplate

> Other tests that may be used to evaluate the quality of the preocular
> tear film (POTF) are:

-   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

3.  **Ocular Examination for Blepharitis**

> 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:

-   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

> Each type of blepharitis has specific characteristics that help in
> making the diagnosis. These are described in detail in the original
> guideline document.

B.  **Management of Ocular Surface Disorders**

    1.  **Management of Dry Eye**

        a.  **Basis for Treatment**

> 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.

b.  **Available Treatment Options**

> 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:

-   Ocular hygiene

-   Topical treatment with tear supplements, ointments, and soluble
    polymeric inserts

-   Punctal occlusion

> Alternative methods for relieving symptoms specific to ocular surface
> disorders include:

-   Hydrophilic bandage lenses and collagen corneal shields

-   Moisture chamber goggles

-   Tarsorrhaphy

-   Estrogen replacement

-   Salivary gland transplant

-   Limbal grafts

1.  **Management of Blepharitis**

    a.  **Basis for Treatment**

> 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.

b.  **Available Treatment Options**

> 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:

-   Staphylococcal blepharitis

-   Seborrheic blepharitis

-   Seborrheic/staphylococcal blepharitis

-   Meibomian seborrheic blepharitis

-   Seborrheic blepharitis with secondary meibomianitis

-   Meibomian keratoconjunctivitis

-   Angular blepharitis

-   Demodicosis

2.  **Patient Education**

> 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.

3.  **Prognosis and 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)]{.underline}\
**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]{.underline}\
**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]{.underline}\
**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 occlusion

[Severe KCS associated with systemic disease]{.underline}\
**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]{.underline}\
**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]{.underline}\
**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]{.underline}\
**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]{.underline}\
**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]{.underline}\
**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]{.underline}\
**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.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### 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

#### 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.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### 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.

#### DATE RELEASED

1995 (revised 2002; reviewed 2007)

#### GUIDELINE DEVELOPER(S)

American Optometric Association - Professional Association

#### 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, **Altair**eyewear, 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](http://www.aoa.org/documents/CPG-10.pdf).

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>.

### DISCLAIMER

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Date Modified: 11/3/2008