Eyeworld Supplements

Editors' note: Dr. Epitropoulos is clinical assistant professor, Ohio State University, Columbus, and in private practice, Ophthal- mic Surgeons & Consultants of Ohio at the Eye Center of Columbus. She has financial interests with Alcon, Allergan, Bausch + Lomb, BlephEx, Bruder, Eye Care & Cure, Kala, Omeros, PRN Neutraceuticals, Shire, Sun Ophthalmics, TearLab, Johnson & Johnson Vision, and Thermi. She can be contacted at aepitrop@columbus.rr.com. Identifying the underlying causes of ocular surface disease for more accurate diagnosis and treatment 66 Develop a consistent diagnostic protocol to detect DED by Alice Epitropoulos, MD mal tear osmolarity is considered less than 308 mOsm/L, or if there is an inter-eye difference less than 8 mOsm/L. Following tear osmolarity testing, our technicians administer an MMP-9 (Inflam- maDry, Quidel, San Diego) test to detect the presence of matrix metalloprotein- ase-9. MMP-9 is usually elevated in tears with DED. Another MMP-9 test, Discovery (TearLab, San Diego), is in the pipeline and expected to be released soon. This new product goes beyond testing for the pres- ence of MMP-9, with the potential to pro- vide a quantitative measurement. This will help us both diagnose dry eye and monitor its response to treatment over time. Meibography is another excellent point-of-care test. It helps to identify pa- tients with meibomian gland dysfunction (MGD) early before there is irreversible damage. The visuals also help facilitate a discussion with the patient about the extent of the disease and the best course of action going forward. Topography is another essential test that we should be performing especial- ly for our pre-cataract patients. Corneal pathologies such as irregular astigmatism, keratoconus, and epithelial basement membrane dystrophy (EBMD) can be iden- tified via topography, and we can't always pick up those pathologies via keratometry, biometry, or slit lamp exams. Although today's diagnostics are vastly improved in comparison to what we once had, obtaining a thorough history and performing a careful clinical exam remain the hallmark of DED detection. Evaluation of the lids, the lid margins, and the tear film should be incorporated in every patient exam. Evaluating for any preexisting conditions such as EBMD is also a must. Conclusion OSD is pervasive and underdiagnosed in cataract patients, and it reduces our surgi- cal predictability and can adversely affect A n un- healthy tear film can lead to unpredict- able preoperative measurements, delayed healing, and suboptimal results postoperatively. The pervasiveness of dry eye among preop- erative cataract patients 1 and the under- standing that hyperosmolar patients have a greater variability in their K readings and IOL power calculations compared to nor- mal osmolar patients 2 demand that cataract surgeons develop a consistent diagnostic protocol to detect DED. DED does not discriminate. While we see it prominently in older patients, peri- and post-menopausal women, contact lens wearers, and patients who have had refractive surgery, the widespread use of computers and digital devices has been the great equalizer with respect to exponential growth of DED among all age groups. Screening is key to identifying symp- tomatic and asymptomatic patients. The first thing patients do when they walk into my office is fill out a dry eye questionnaire. My technicians are empowered to perform point-of-care testing if patients are symp- tomatic. This helps to improve my ability to diagnose and treat DED more efficiently as well as to monitor the response to treat- ment over time. Improved diagnostics The point-of-care options that we have at our disposal to evaluate dry eye today are more sensitive and effective than their predecessors. In combination, these tests provide substantial information about the state of the patient's ocular surface. For in- stance, tear osmolarity point-of-care testing is a very accurate way to evaluate dry eye severity and therapeutic response. A nor- our surgical outcomes. Developing a consis- tent protocol to help identify and diagnose DED will help improve both outcomes and patient satisfaction. References 1. Trattler WB, et al. The Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study: effect of dry eye. Clin Ophthalmol. 2017;11:1423–1430. 2. Epitropoulos AT, et al. Effect of tear osmolarity on repeatability of keratometry for cataract surgery plan- ning. J Cataract Refract Surg. 2015;41:1672–7. Case study with Alice Epitropoulos, MD A 68-year-old female presented complaining of fluctuating vision. She is a lead technician on my staff and had hyperopic LASIK 15 years earlier. We are looking at her left eye in this case study, however, her symptoms were binocular. Symptoms included fluctuation in vision, burning, and tearing, with a SPEED score of 20. Exam and testing revealed high tear os- molarity (295/324), abnormal MMP-9, unstable tear film, inspissated meibo- mian glands, and significant corneal staining. Corneal topography showed irregular mires and a fair amount of astigmatism. In cases such as this, I recommend a good quality oral omega-3 supple- ment to patients and start them on an immunomodulator and pretreat them with a topical steroid for 2 weeks. I also recommended and performed LipiFlow thermal pulsation treatment (Johnson & Johnson Vision, Santa Ana, Cali- fornia). Her symptoms improved, but she had persistent blurred vision with irregular topography. I subsequently initiated neurostimulation three to four times per day. On follow-up, the patient reported experiencing symptom relief and im- proved vision lasting for 4–5 hours fol- lowing neurostimulation. A recheck of her topography after treatment revealed significant reduction in her pseudo-cyl- inder and improved mires. OS before OSD treatment • Power: 46.1 D • Radius: 7.33 mm • Steep K: 47.12 D @40 • Flat K: 44.75 D @130 • Astigmatism: 2.37 D • CIM: 4.45 • Shape factor: 0.79 OS after OSD treatment • Power: 46.0 D • Radius: 7.33 mm • Steep K: 45.00 D @90 • Flat K: 44.37 D @180 • Astigmatism: 0.63 D • CIM: 0.82 • Shape factor: 0.95 3. Implement a simple marketing strategy. Have the staff wear buttons on their uniform that say "Ask me about dry eye." Place posters throughout the practice calling attention to dry eye symptoms and treatment options. Include a sheet along with every invoice announcing your new Dry Eye Center of Excellence. The dry eye product companies are delighted to provide these materials because your success is their success. 4. Have every patient answer a dry eye questionnaire. When a patient responds affirmatively to even one question, the technician should proceed with osmolarity testing. MMP-9 testing for matrix metallo- proteinase-9 is another easy, inexpensive testing option. MMP-9 is an excellent method for sorting out the patients who have dry eye-like symptoms but normal osmolarity. This tells the clinician to look for another diagnosis, such as allergic conjunctivitis. 5. Add meibomian gland imaging to the process using one of the available units: Keratograph 5M (Oculus, Wetzlar, Germany), LipiView/LipiScan (Johnson & Johnson Vision, Santa Ana, California), HD Analyzer (Visiometrics, Costa Mesa, Califor- nia), and SL-D701 (Topcon, Oakland, New Jersey). Being able to show patients the extent of their OSD (Figure 1) and where it's headed in the absence of treatment is a major wake-up call for them. After seeing this, they usually agree to whatever treat- ment plan you recommend. 6. Offer in-office therapeutics, starting with professional lid cleaning with Swab- stix (OCuSOFT, Richmond, Texas), and moving on to microblepharoexfoliation (BlephEx, Franklin, Tennessee) and thermal pulsation therapy with LipiFlow (Johnson & Johnson Vision). BlephEx and LipiFlow work well when done back to back, in one visit. Bring in additional technologies as needed. Conclusion Ultimately, there are several worthwhile reasons to pursue the Dry Eye Center of Excellence path: You can help your patients who are suffering; you can vastly improve your surgical outcomes; and it can be ex- tremely profitable. For instance, a thermal pulsation treatment provides the same profit margin as LASIK, with zero-to-no medicolegal risk. References 1. Trattler W, et al. Incidence of concomitant cataract and dry eye: prospective health assessment of cataract patients. 2010 World Cornea Congress. 2. Brissette AR, et al. The prevalence of abnormal tear testing in cataract surgery patients with minimal to no symptoms of ocular surface disease: Prospective observational study. 2017 ASCRS•ASOA Symposium & Congress. Editors' note: Dr. McDonald is clinical profes- sor of ophthalmology, NYU Langone Medical Center, New York, clinical professor of oph- thalmology, Tulane University Health Sciences Center, New Orleans, and is in private practice, Ophthalmic Consultants of Long Island, New York. She has financial interests with Alcon, Allergan, Bausch + Lomb, BlephEx, Focus Labs, Johnson & Johnson Vision, Mallinckrodt, NDC, NTK, OCuSOFT, Orca Surgical, Quidel, Shire, and TearLab. She can be contacted at margueritemcdmd@aol.com. continued from page 65

• Cover