Eyeworld Supplements

therapeutic solutions: Ocular surface disease and episodic flares of dry eye disease 10 | SUPPLEMENT TO EYEWORLD | MAY 2019 Case study 1 • 40-year-old female • Mild dry eye • Travels frequently for work • History of thyroid disease • Meibomian gland = mild • Fluorescein staining = 0 • Tear meniscus height = reduced • Osmolarity = 307, 302 (borderline) and/or what extra test would you order?" Elizabeth Yeu, MD, said she would initiate a two- tiered approach aimed at initially quiescing the flare, then implement maintenance strategy. "I would consider environmental control, such as moisture goggles, given her frequent travel, and I would also do whatever we could from an ergonomic standpoint with respect to computer use. I would prescribe lifitegrast to address the meibomian glands if she demonstrated MGD or architectural dropout." Richard Lindstrom, MD, said he would prescribe an im- munomodulator, lifitegrast or cyclosporine for maintenance therapy, but added that he would prescribe a short course of steroids to first get the pa- tient comfortable and educate her about dry eye disease. Similarly, Edward Hol- land, MD, said he would start the patient on a topical corticosteroid to get quick symptomatic relief and follow that with lifitegrast. "Then be- cause of the thyroid disease, I would make sure there was no exposure," he said. Dr. Lindstrom stressed that it is critical to capture patients such as this one to be sure they are treated and followed. Dr. Holland said, "Unfortunately, these people are led to believe that their Right eye slit lamp image, overall healthy ocular surface with low tear film and zero corneal staining symptoms are an unavoidable side effect of aging; we don't give dry eye the attention it deserves." Dr. Donnenfeld pointed out that patients such as the one in this case study have often already seen multiple eye doctors and have not been given the proper attention, and they feel as if they've been ignored. He reminded the panel, "If you can provide these patients with a therapeu- tic management program and solve their problem, it creates an opportunity for your prac- tice to grow." n Case study 2 • 20-year-old male • Professional gamer, active lifestyle • Significant irritation, uncontrol- lable blinking while gaming • Lids = 2+ MGD on expression • Lid closure = good • Conjunctival staining = 2+ lissamine green • Osmolarity = normal A 20-year-old male who is a professional gamer has significant irritation and uncontrollable blinking while gaming. He has tried artificial tears but hasn't gotten relief from them. His lids are normal, and his lid closure is good, but he has 2+ conjunctival staining. Eric Donnenfeld, MD, asked the panel of ocular F or the past year, this pa- tient has been managed with artificial tears, and she has intermittent flares that limit her activities. Eric Donnenfeld, MD, reminded the panel that the patient has thyroid disease and suggested that because of this she may be at risk for immunologic disease. He posed this ques- tion: "What diagnostic strat- egy would you implement, surface disease experts how they would diagnose and treat this patient. "This is a classic digital eye strain patient with secondary dry eye related to extended digital device use and a blink rate that is probably 8 when it should be 20," said Richard Lindstrom, MD. "Besides impacting the patient's ability to do what he does professionally, it's also causing conjunctival staining. This is a patient who should be captured and treated, and he needs both acute and chronic therapy." Terry Kim, MD, said the idea of dry eye disease as the domain of peri/post-meno- pausal women is clearly changing. "We need to realize continued on page 11

• Cover