Mastering dry eye for GPs: tear-film layers, aqueous vs evaporative subtypes, triage questions and dual-action drops

Speaker

Celia — optometrist. Host Kyle introduces her (ASR also “Xenia”/“Senior”). Practice since 2016 (turned 10); dry-eye clinic from 2022; special interests contact lenses, myopia control, ortho-K; Dry Eye Society; QUT guest lecturing; earlier work with contact-lens mentor John Mountain (as spoken). Self-describes as “deeply superficial” — surface of the eye, not retina.

Host / sponsor context

Opening: CSL Seqirus-linked evening via United Clinical CPD (~16 hours total / ~8 per topic including measuring outcomes; certificate from external provider, not CSL). Soft product focus on Cationorm (ASR “caddy/CAD norm”) and mention of Sustain Complete.

Session context

Otter combined title Mastering Dry Eye Disease… / Mastering Iron Deficiency… · id 9AuHqoE9icqMRFoM9O_XKxgu8rI · ~57 min. At 57:31 host introduces Dr Joel Coll for the iron talk — transcript ends there. Iron content is not in this file and is not blogged.

Key messages for GPs

• Prevalence ~5–34%; younger patients increasingly affected; watery eyes can still be dry eye.
• Mental QoL impact is near depression on the comparator slide Celia showed — take the distress seriously.
• Symptoms come from inflammation after tear-film loss of homeostasis, not from “dryness” alone — a single moisturising drop often fails until inflammation is addressed.
• Two classical subtypes: aqueous-deficient vs evaporative (meibomian). Japanese society also discusses mucin-deficient; TFOS framing in the talk sticks to two.
• Triage: fluctuating vision / variable watering favour dry eye; relentlessly worsening itch/sting/glare or constant watering/blur favour other disease.
• Subtype questions are unreliable — either refer for testing or start a drop that covers both layers (Cationorm or Sustain Complete as named; Cationorm PBS-listed as spoken).
• IPL every ~2 weeks × ~6 with gland expression can hold for years in good candidates (meibography still shows glands).

Burden, QoL and risk factors

Celia’s learning aims: appreciate dry-eye burden and QoL, diagnose and differentiate subtypes, distinguish from other ocular disease, and apply treatments with cases.

• Affects about 5–34% of the population; “everybody seems to have dry eye”; younger cohorts rising (old 2005–2012 graph; she wonders if figures have roughly doubled by 2026 — opinion, not a cited new study).
• Risk links: blepharitis / Demodex, facial nerve palsy (incomplete blink), prolonged screens (~1 in 3 blinks are half-blinks), ocular surgery inflammation, contact lenses (esp. older materials / RGP; daily modern SiHy better), autoimmune disease (Sjögren — ASR “Showbread”, RA, lupus, scleroderma, GVHD), vitamin A deficiency, hepatitis C, thyroid disease, antihypertensives / antihistamines / antidepressants, low dietary omega-3, air-con / wind.
• Classic demographic she sees: female >50 contact-lens wearer.
• Symptom menu (patients pick and choose): grit, foreign body, sting/burn, photophobia, intermittent blur / fluctuating vision, excessive tearing, fatigue. Watering ≠ “not dry eye.”
• QoL slide: physical QoL similar to COPD / IBS; mental QoL worse than listed chronic conditions except depression.

Tear film: three layers, symptoms from inflammation

Not “just water on the eye”:

1. Mucin — goblet cells in conjunctiva; sticky base layer.
2. Aqueous — lacrimal glands under the brow; bulk of volume.
3. Lipid — meibomian glands (~20 upper / ~20 lower lid); oil floats on water like a greasy pan in the sink and slows evaporation.

Lose homeostasis → cell death → inflammation. Symptoms are from that inflammation cascade, which is why adding moisture alone often fails until you also settle inflammation and fix the subtype driver.

Aqueous-deficient vs evaporative

• Aqueous-deficient: lacrimal glands not delivering enough water.
• Evaporative: meibomian oil layer inadequate → tears evaporate too fast.
• Japanese Dry Eye Society framing (as mentioned): also mucin-deficient; TFOS-style teaching in the room focused on the two classical subtypes.
• Each subtype has different levers (punctal plugs / bandage or scleral lenses / moisture-chamber goggles / gels for aqueous retention; omega-3, oily drops, lid hygiene, manuka honey drops, IPL + expression, oral antibiotics for evaporative / lid margin disease).

Tests: dyes, meniscus, meibography, TBUT, OSDI

• Fluorescein — pools where cells have sloughed (corneal wounds, papillae bases).
• Lissamine green — stains dead/dying cells (e.g. lid-wiper epitheliopathy from blink friction).
• Tear meniscus height (photo calipers) preferred over classic Schirmer / phenol red thread — Schirmer irritates and can spuriously increase wetting.
• Meibography — grades gland length/dropout; no glands left → poor IPL candidate. Consumer attachment options (~$500 as spoken) bringing this into more practices.
• TBUT: normal ~12 seconds; symptomatic evaporative often 2–3 seconds. Invasive fluorescein TBUT vs newer non-invasive instruments.
• Osmolarity devices exist but one colleague called theirs a “random number generator.”
• OSDI questionnaire for QoL / severity (also used in PBS pathways for agents such as cyclosporine as mentioned).

Triage questions when you lack equipment

Without slit-lamp kit you can still separate dry eye from many lookalikes:

• Itch — dry eye or allergy? Context matters.
• Sting/burn — dry eye vs foreign body / lens problem — ask what got in the eye / CL wear.
• Watering — variable → dry eye; constant → think blocked duct.
• Blur — fluctuating blink-blur-clear cycle → dry eye; progressive/constant → cataract, Rx, etc.
• Glare — worsening through the day → uveitis / keratitis / infection territory; up-and-down → more dry eye.

Rule of thumb as spoken: if itch/sting/glare keep getting worse → not dry eye. If constant blur or watering → not dry eye. Fluctuating / stationary-or-improving after a wait → more dry-eye-like.

Catch: questions to pick aqueous vs evaporative (worse on waking, worse with screens/wind/AC) do not reliably subtype — both subtypes can answer yes. Refer for testing or choose dual-action therapy.

Treatment by subtype — and when you can’t tell

• Aqueous-focused lubricants: viscosity agents, hyaluronate-type moisture (as discussed).
• Evaporative-focused: lipid-containing drops, omega-3, lid wipes, manuka honey drops (Optimel — ASR “optimal”), heat/massage, IPL + express, oral antibiotics for staph lid disease.
• Behaviour: reduce screen marathon where possible, humidify, ease air-con, Mediterranean-style diet, blink training — Post-it saying “blink” on the monitor; literature-supported (as claimed).
• When subtype unclear: products that address both layers — named Cationorm and Sustain Complete. Only Cationorm was said to be PBS-listed among that dual-action set (verify current PBS).
• Cationorm pitch (speaker favourite): cationic emulsion (oil + water) with positive charge attracted to negatively charged ocular surface → better retention without heavy gels that blur vision and jam meibomian glands; preservative-free bottle option; contact-lens compatible (even ortho-K bowl as anecdote). Soft promo — see caveats.
• Dosing: no hard “max 4×/day” rule for the PF dual-action drop in her answer; patients self-titrate as surface stabilises.

IPL + expression

• Story origin (anecdotal): dermatologist treating rosacea noticed dry eye improved — later studied for meibomian disease.
• In her protocol: metal shields over the ocular surface; treat skin under inferior lids (not the eyeball); warm then express glands; fibroblast activation framing; needs residual gland length on meibography.
• Her schedule: every ~2 weeks × ~6 treatments (literature often ~4 fortnightly then a later booster — she adds one). Effect can hold years.
• Works in 60s–70s if glands remain; useless if glands already gone.
• Becoming more mainstream (Specsavers mention as upcoming).

Two case snapshots

JR — 55F, 30-year CL wearer, busy clinic day: dry with and without lenses; post-menopausal (aqueous suspicion) + short meibomian glands / computer (evaporative suspicion). Limited exam: inferior corneal staining, plugged glands, short meibography, good modern daily SiHy fit. Could not subtype fully → trial Cationorm BD (on waking / behind lenses and after removal). Two weeks: symptoms and staining resolved — monotherapy win without full work-up.

MN — 29F, air-con office, allergies, occasional CL, post retinal laser coincidence: full work-up. OSDI 50 (severe; >33 threshold as spoken); TBUT 2.5 s; low Schirmer <2 mm; mild gland change → mixed, aqueous-leaning. Pulse topical steroid (FML) TDS ×1 week rapid taper to break inflammation, then Cationorm, omega-3, Optimel (discontinued for sting). Six weeks: TBUT 2.5→6 s (symptomatic threshold ~>5 s as spoken), OSDI 50→32, deeper meniscus. Maintenance: omega-3 + Cationorm BD.

GP clinic checklist

1. Ask about fluctuating vision, variable watering, grit/burn — and screen time / CL / autoimmune / culprit meds.
2. Use triage: worsening ≠ dry eye; constant watering/blur ≠ dry eye.
3. Don’t rely on questions alone for aqueous vs evaporative — refer or use dual-action lubricant.
4. Prefer preservative-free when dosing frequently or with CL; warn gels can blur and congest glands.
5. Advise blink training, humidity, omega-3, lid hygiene; consider optometry referral for meibography / IPL.
6. Remember QoL — mental load can approach depression-range scores on comparator tools.
7. Do not use this page for the iron half of the evening — it was not captured.

Transcript caveats

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