MANAGE DRY EYE DISEASE
FOLLOW THESE STEPS TO CREATE A COMPREHENSIVE PLAN FOR TREATING DED
AMI RANANI, O.D.
AFTER SEEING many patients, who suffer from blurred and fluctuating vision, light sensitivity, foreign-body, gritty and burning sensations, I decided to open a dry eye clinic at my practice last year. I knew that these patients would need to return a few times, sometimes often, after their comprehensive exam.
Here, I explain the basic steps of identifying and treating this prevalent condition, so you’ll have the necessary background to consider opening your own dry eye clinic.
IDENTIFY THE DISEASE
The first step in managing dry eye disease (DED) is to identify the cause. To accomplish this, gather information from the patient’s medical history, pre-testing and your diagnostic equipment to gauge the severity and whether the DED is evaporative, aqueous deficient or both. At my practice, we go through the following, adapting slightly for each individual patient.
Pre-testing: Gather baseline information to guide the treatment plan.
• Ocular Surface Disease Index questionnaire. Use this initial questionnaire to evaluate the patient’s history of DED symptoms, mentioned above. The questionnaire will help you decide what you’re dealing with.
• Refraction and VAs. Look for vision fluctuation when the patient blinks.
• Meibomian imaging. LipiView II (TearScience), Keratograph 5M (Oculus) and Platinum Iris System, with infrared module (Telscreen), which has a release date in September, all provide images of the meibomian gland.
DED can cause corneal ulcers.
• Osmolarity testing. (TearLab) This test enables you to determine whether the patient has hyperosmolarity.
• Corneal topography. Use this on all contact lens patients to see whether there is distortion of the ring pattern, and a sign that may indicate contact lenses as contributing to the problem. We also do specular microscopy on all our contact lens patients as part of fitting and yearly follow-up. If we notice endothelial changes, higher oxygen permeable lenses with a modified wear schedule are used.
Comprehensive exam: Continue the information-gathering process to arrive at a definitive diagnosis.
• Slit lamp exam. Examine the lashes and lids to rule out blepharitis. Also, evert the lids to check for lid epitheliopathy.
• Fluorescein eye staining. Use a cobalt blue light filter to look for stippling, punctate staining and corneal dellens.
• View lid margin pores. Express the glands to check the quality of meibum. Inspissated secretions indicate MGD.
• Patient education. Once you’ve arrived at the diagnosis, educate the patient on his or her condition, and use slit lamp images to increase the likelihood of patient adherence to your prescribed treatment(s) (described below).
• Blood tests. If your exam, thus far, points toward aqueous-deficient DED, order a blood test to rule out Sjögren’s syndrome and other autoimmune diseases that could be causing the patient’s DED.
Once you have identified the cause, or causes, of the DED, create a treatment plan. Some options, such as those listed under “Intermediate,” are prescribed in conjunction with others for the best outcome.
• Artificial tears. This is usually the first course of treatment. Be selective with artificial tears. For example, for incomplete blinkers, viscous drops, or tear gels are often a good choice, as they stick to the ocular surface providing longer-lasting relief.
• Steroid drops. These, which reduce inflammation, are often used in conjunction with cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) for immediate relief.
• Cyclosporine ophthalmic emulsion 0.05%. This drug slows the progression of the disease by quieting inflammatory markers.
• Punctal occlusion. This is often tried in the eye with the most discomfort, before proceeding to the other eye if this eye is less symptomatic. Punctal plugs block the drainage of natural tears, keeping them on the ocular surface longer.
• Lid hygiene scrub. This treatment rids the meibomian glands of the biofilm bacteria that can block their openings. (I often do this prior to a thermal pulsation treatment, as I find it enhances these treatments.)
• Thermal pulsation treatment. Thermoflo (MiBo Medical Group) or Lipiflow (TearScience). This is used to unblock meibomian glands.
• Supplements. Recommend omega-3 supplements with the right balance of DHA and EPA.
• Moisture goggles. Prescribe their use at home following/in between in office treatments.
• Scleral contact lens. This lens has become a great option to create a tear reservoir for DED patients.
• Autologous serum drops. Unique tears are made from the plasma of the patient’s blood, providing the patient with some of the biological benefits, such as vitamins and growth factors, of his or her natural tear.
• Amniotic membrane. The membranes promote healing of the ocular surface through regeneration of epithelial cells. This also might help with lubrication of the inner lid when it is abrasive on the cornea. Abrasion leads to recurrent erosions.
A woman in her 40s presented with dry eye symptoms and tremendous pain from a central corneal ulcer. I treated her with an amniotic membrane for four to five days, and antibiotics. She now has significantly less scarring and 20/20 VA. OM
DR. RANANI is owner of Somers Eye Center in Somers, N.Y., where he runs a dry eye center. He was honored as one of CooperVision’s 2015 Best Practices. He is a consultant to a research firm on the eye care industry. You can reach him at somerseye.com, or email him at firstname.lastname@example.org. To comment on this article, visit tinyurl.com/OMComment.