dry eye file
The Dry Eye Workup
Thorough screening is crucial to detecting
M. Hom, O.D., F.A.A.O.
workups are well documented. Many tests are devoted to the detection, diagnosis
and monitoring of treatment, and every expert has his favorites and not-so
favorites. For me, the most critical space within the clinical realm of dry eye
is the screening. If you don't screen properly, the dry eye goes undetected.
dry eye workup starts with the general eye examination. I ask every patient
about dryness. If a patient experiences discomfort or if the dryness interferes
with activities, then we carefully look at dry eyes. One of the first priorities
is to establish a set of baseline findings. I like to monitor improvement or, in
some cases, regression. I divide the workup into two categories:
gold standard for monitoring treatment has been the Ocular Surface Disease Index
(OSDI). It's an easy and short (12 question) questionnaire to administer. My
assistants score the OSDI at every patient visit.
signs is a bit more involved. Here's what I look at:
Fluorescein staining is a must in my workup. Lissamine green staining
and Rose Bengal are actually optional to my thinking. A recent study by Koh
showed that fluorescein staining with a yellow filter was 75% better than Rose
Bengal for mild to moderate staining. I've seen cases where fluorescein picked
up staining areas that lissamine green missed.
tests. Tear break-up time is a favorite. Schirmer is not. Cho and Yap
looked at nine asymptomatic patients and tested their Schirmer II scores over a
two-week period. Almost 70% of the patients measured less than 6 mm (close to
severe dry eye). Four subjects measured 0 mm of wetting. For me, Schirmer II
testing is just too unreliable and too time consuming.
expression. Expressing the meibomian glands is important and not
performed enough, in my opinion. Express the glands firmly and observe the
quality and quantity of the oil to detect lid disease. If the meibum doesn't
look motor-oil like and puddles at the orifice, then you have meibomian gland
dysfunction (MGD). The patient can have MGD without any other associated
blepharitis or rosacea.
a thorough workup, don't forget these tests:
observation. Observing the way a patient blinks offers insight as to
whether distribution problems exist. Incomplete or infrequent blinks usually
indicate a need for lubrication. Many patients who have lagophthalmos will also
display an incomplete blink.
and mold counts. Monitoring pollen counts has helped me determine
whether allergies are playing a role in dryness. The National Allergy Bureau's
Web site (www.aaaai.org/nab/)
regularly reports on pollen and mold counts according to area. If the dryness is
occurs during times of high pollen and mold counts, I add a topical allergy
medication to the regimen.
After performing the tests, I
categorize the dry eyes into one of the following areas:
- lid margin disease
- no lid margin disease
- distribution problems.
If it's lid margin disease, I prescribe lid
hygiene and/or oral antibiotics. Mild distribution problems merit lubrication
during the day and at night. If there's no lid margin disease and mild dryness
is present, I use lubrication such as Allergan's Refresh Tears, Refresh Liquigel,
Refresh Endura or Alcon's Systane as a starting point. For moderate dry eye and
to increase tear production, I prescribe Allergan's Restasis.
available on request
DR. HOM HAS
WRITTEN OVER 100 PUBLICATIONS. E-MAIL HIM AT EYEMAGE@MMINTERNET.COM.
DR. HOM RECEIVES RESEARCH GRANT MONIES FROM ALLERGAN.
Optometric Management, Issue: September 2004