Dry Eye Program at Vance Thompson Vision
Dry Eye Video
Dry Eye Top Line
- Assess all patients for ocular surface disease, especially those being referred for surgery
- Utilize the SPEED questionnaire for dry eyes
- Institute tests in your practice to check for both aqueous deficiency and evaporative dry eye (remember, 86% of dry eye is evaporative)
- Click HERE for a tool designed to help diagnose and manage dry eye in patients.
What is Dry Eye Disease?
Dry eye disease, yes disease, is a chronic condition of either having a decrease aqueous production or an increase in evaporation. In fact, 86% of dry eye conditions are actually evaporative in nature. Pure aqueous deficiency is only about 10% of the cases. Many of the root causes of evaporative dry eye stem from patients having meibomian gland deficiency caused by not blinking appropriately. This causes stagnation in the glands, causing the meibom (oil) in the glands to harden, later to further leading to gland atrophy.
WHEN AND WHY TEST FOR DRY EYES?
To truly be able to understand what type of dry eye condition a patient might have, a complete (and consistent) dry eye evaluation needs to be conducted. Since 50% of patients are actually asymptomatic of having dry eyes, the process begins by using a standardized patient questionnaire to understand the subjective symptoms and to be able to track those symptoms over time. We use the SPEED (Specific Patient Evaluation of Eye Dryness) questionnaire, including asking specifically if the patient is having fluctuating vision. That is a major contributor to having meibomian gland disease. We then have our technicians use the Lipiview II (TearScience) to ascertain the patient’s meibomian gland function. This system allows us to visualize the meibomian glands themselves as well as looking at their lipid layer thickness and blink rate analysis. We then have the technicians check tear osmolarity using the TearLab system (TearScience), inflammation with InflammaDry, and perform an anesthetized Schirmers test. We recommend patients not wear any contact lenses or use any eye drops two hours prior to coming in for their appointment. This allows consistency and accuracy in our testing and we are able to better track how our treatment plans are working. The optometrist that next comes in to meet the patient, checks corneal staining with sodium fluorescein, conjunctival staining with lissamine green, and does manual expression of the meibomian glands. You need to remember to only press on the glands with the same pressure that is exhibited with a blink. The manual gland depressor (MGD by TearScience) is a good device to use to simulate that force.
We then meet with the patients and review the data thus far. Having the doctor educate patients on the testing results and explaining (with visuals) the type of dry eye condition they might have is instrumental in the process. The process of diagnosing, educating, and providing a customized treatment plan specific to their condition is what I believe sets us apart from most practices. Analyzing all the data regarding dry eye disease is analogous to analyzing all the data to diagnose glaucoma. For example, you look at IOP, CD ratios, pachymetry, NFL analysis, visual fields, gonioscopy, and hysteresis. You make an educated decision on how to treat each patient based on the findings. You do the exact same when managing dry eye disease too.
How is Dry Eye Treated or Managed?
DROPS: We like to start by recommending artificial tears with sodium hyaluronate. It’s a great lubricant and helps control inflammation. Blink (Bausch and Lomb) is the brand we tend to use most. In more severe cases, we use a compounding pharmacy to make 100% Healon into non-preserved eye drops that work well too.
PLUGS: For pure aqueous deficiency, we next recommend utilizing tear duct plugs, if there isn’t any inflammation present as determined by the InflammaDry test. We have access to about different 4-5 styles to choose from but the one we use most is Ultraplug. It comes in a variety of sizes, easy to insert, and actually is cost effective.
RESTASIS: We also prescribe Restasis (Allergan) to be used twice daily, especially if there is some inflammation and/or a decrease in the anesthetized Shirmers. If there is concern that the cause of a patient’s dry eye condition might be stemming from an autoimmune disease like Sjogren’s syndrome, the Sjo test (Bausch and Lomb) has been an invaluable add to the practice. We probably diagnose 5-10 new cases a month and then refer on to rheumatology.
MASKS: Again since most dry eye patients are evaporative in nature, much of what is recommended for treatments focuses on that being the root cause. Warming compress and lid message are using my first go to recommendation. We have a retail area in our practice where all the products I’ll mention next are sold. This helps with patient compliance and convenience and makes getting treatments initiated a much faster process. The warming mask we retail is the Fire and Ice mask. It has a removable fabric overlay that is washable and can be kept in the freezer for a cold mask, or microwaved for 10-15 seconds for a warming mask that lasts about 10 minutes.
LipiFlow: Since the meibomian glands are actually closer to the back of the eyelids, having a treatment like Lipiflow (TearScience) has been a much better way to go. Over the last year we have completed about 75 treatments on patients and have found that system to be very effective. Patients should know that they will still have this chronic condition and will need to go through the treatment again. They will have diminished symptoms, and by having a treatment, it will allow them to possibly use less at home therapies so they can get on with their lives. Regarding at-home warming masks, the vasculature in the skin and tarsal plate within the eyelid does prevent much of the effectiveness of the heat to diminish. It's the best that’s available though and definitely have patients stay away from other home remedies that include food items (hot potato, hard boiled eggs, rice packs, etc.) Keep those items for your mouth and not your eyes!
OMEGA-3's: If there is an inflammatory component to their eye lids or a rosacea/ocular rosacea present, we use Omega 3 fish oil. Most of our diets in the US consist of corn fed beef and processed foods, which are high in Omega 6 fatty acids. These actually promote inflammation and the ratio of Omega 3’s to Omega 6’s needs to be brought back into balance. PRN, Nordic Naturals, or Fortifeye are preferred products best because they are the pure triglyceride forms of the product, not the alcohol forms like most Omega 3’s on the market. I usually recommend taking at least 2000mg per day.
PRESCRIPTION MEDICATIONS: I also recommend using Azasite daily by having patients rub the eye drop into the lid margin. Oral doxycycline/minocycline at 50mg/bid is also effective in helping control inflammation. Remember though that these prescription medications are to help manage the condition and symptoms of inflammation, but they do not address root cause of the disease.
BROAD BAND LIGHT (BBL): Another great treatment we have available is BBL (Sciton) therapy to the eyelids. Utilizing light therapy has been proven to control inflammation within the skin by targeting superficial blood vessels. Heat is absorbed in the vessels and coagulates the cells, leading to a thrombosis of the blood vessels. It has in impact on the bacterial flora on the skin and eyelids, as well as increasing the skin temperature, all of which have a beneficial effect on the meibomian glands.
TOPICAL STEROIDS: For more severe cases of dry eye disease in which there is a persistent corneal keratitis present, a topical steroid (Lotamax – Bausch and Lomb) may be prescribed to be used four times a day for 1 week, then twice a day for 1-2 weeks.
AUTOLOGOUS SERUM TEARS: Autologous Serum Tears (AST) may be prescribed to be used every 1-2 hours. The compounding pharmacy we use can make these for about $350 for a 2-3 month’s supply for the patient. Our aesthetic skin clinic is also using Platelet Rich Plasma (PRP) for Collagen Induction Therapy (CIT), so if your clinic prescribes a lot of AST, I might makes sense to bring this in house and have your own system available.
AMNIOTIC MEMBRANES: Amniotic membranes have also been very effective in treating severe keratitis conditions. We use the Prokera slim and have the patient keep this on for 1 week. Remind them to keep their eye taped at night as this can possibly fall out.
Since we are an ophthalmology clinic and we also specialize in oculoplastics, taking into account the eyelid anatomy and positioning can definitely be a factor in many of the eye symptoms patients experience. Watering eyes can stem from blocked tear ducts, laxity or lagophthalmos, conjunctivochalasis, pinguecula, pterygia, and the like. Blepharitis is very common. Avenova (NovaBay) can be used to treat lid margin disease. It contains pure hypochlorous acid which can remove microorganisms and debris from the lids and lashes. It’s also great eradicating demodex and helps fight inflammation.
This is just a snapshot of what can, and needs to, go into diagnosing and managing dry eye patients. The science around this practice of medicine has definitely changed over the years and has really changed my thinking of how to help these patients. New products and technologies are emerging like Lifitegrast and Oculeve. Analysis of the human tear and its protein content will increase as the understanding of the roles of these components are better understood. Point-of-care diagnostics will continue to advance like testing for lactoferrin or IgE in the tears. The real challenge will be how to determine how to use all of these new diagnostic endpoints into your practice. Will there be new diagnostic tests to determine the cause of dry eye disease – whether aqueous deficient, evaporative, or both? All remains to be seen. Embrace the new frontier of the “dry” eye care practice.
Dry Eye and Refractive Surgery
WHAT IS THE CONDITION?
Dry eye disease is a chronic condition that is widespread in every optometric practice, but is perhaps one of the most commonly under-diagnosed and least aggressively treated disease we deal with. In the field of refractive surgery, the diagnosis of dry eye is recognized as a key factor in poor refractive outcomes, decreased patient satisfaction, and increased surgical risk.
WHEN AND WHY DO WE ASSESS FOR THIS?
Diagnosis and treatment of dry eye before, during, and after surgery has become one of the most important aspects of refractive surgery patient care. Our rule of thumb is that patients with evidence of surface disease are not considered refractive surgery candidates until the ocular surface can be optimized. We have three different opportunities to determine and deal with dry eye signs and symptoms: pre-operatively, peri-operatively, and post-operatively.
HOW IS DRY EYE TESTING PERFORMED?
Pre-operative Assessment and Treatment:
The pre-op assessment should include a very thorough history, paying specific attention to any existing condition that may be related to dry eye, including blepharitis, rheumatoid arthritis, acne rosacea, allergic conjunctivitis and the use of antihistamines, oral anxiety medication, perimenopause, lagophthalmos and history or signs of epithelial basement membrane dystrophy. We recommend that you have your patients not wear contact lenses or use eye drops 2 hours prior to their appointment to get most accurate results with your testing.
We look very closely at the lid margins, and we use lid pressure to express the meibomian glands. This helps in the detection of any meibomian gland dysfunction and hence evaporative dry eye. We pay special attention to patients that are contact lens intolerant (more often than not, the reason that they want refractive surgery) and scrutinize the ocular surface very closely. We use specific testing including using TearLab and InflammaDry, anesthetized Schirmer’s, corneal and conjunctival staining (fluorescein and lissamine green) tear break-up time (TBUT) and, in borderline cases, we use computerized tear analysis (Lipiview) to analyze tear film chemistry including lipid layer thickness, blink rate analysis, and visualization of the meibomian gland structures to determine tear deficient dry eye or evaporative dry eye. Based on the level of dry eye, we recommend artificial tears, punctual plugs* and Restasis (cyclosporine) for tear insufficient dry eye. We treat evaporative dry eye with hot compresses, lid massage, Azasite, Doxycycline (50 mg bid). Other, more aggressive therapies to treat dryness include Lipiflow, BBL (Broadband Light), and /or Maskin Probing techniques. PRN (an oral supplement containing omega 3 fatty acids) is also used to help improve inflammation in the glands and improve tear production and retention. Sometimes with chronic epithelial keratitis conditions, amniotic membranes are used (Prokera or Amnio disk) on the cornea for about a week to help with epithelial regeneration. Autologous Serum Tears can be used in conjunction or separately every 1-2 hours to assist in improving the ocular surface.
For situations where the dry eye condition might be suspected of an autoimmune disorder (Sjogrens or Rheumatoid arthritis), we sometimes run blood serum panels to check for diagnostic markers that signify immunosuppressive disorders.
Allergy can also be misdiagnosed as dry eye, so we also offer ocular allergy testing.
Every LASIK patient will temporarily have a neurotrophic cornea. Patients with dry eye are much more prone to epithelial separation and abrasion during surgery. We do several things peri-operatively to help reduce epithelial injury. We delay the application of anesthetic until just before the procedure. The femtosecond laser flap maker tends to reduce the trauma to the epithelium and reduces the risk of epithelial abrasion or separation. We use preservative free Vigamox as our intra-operative antibiotic, and we instill Celluvisc immediately following the procedure.
When we have successfully diagnosed and treated dry eye to optimize the ocular surface preoperatively and peri-operatively, it is reflected as patients do much better postoperatively. However, we do often need to add to our preoperative regimen when epithiopathy is present following surgery. We instruct patients to use artificial tears liberally, even though they may not have typical symptoms of dry eye. The most frequent complaint from patients initially is fluctuating vision and with punctate keratopathy present, decreased vision, and reduced best corrected vision. By keeping preservatives at a minimum frequent use of preservative free artificial tears can help. Often, we will add night time ointments and occasionally superior temporary collagen plugs if permanent inferior plugs have already been placed. We also educate the patient about the increased sensitivity to dry eye following LASIK. Patients who understand the lifestyle and environmental impacts that can exacerbate their dry eye symptoms, such as lower humidity in winter and certain environments (airplanes/airports, hospitals, shopping malls and extended computer use) will be better about lubrication and blinking. It is also important to discuss with patients the use of ceiling fans and humidity levels in their home, as these two factors can greatly increase the amount of dryness.
Having a consistent process and utilizing multiple diagnostic tests (similar approach to diagnosing glaucoma) will be your best approach to diagnosing and managing dry eye patients.
The following are other pearls for dry eye and refractive surgery:
- Greater changes in corneal curvature (high myopes and high hyperopes) can change ocular surface wetting. Pay special attention to these patients postoperatively.
- When patients are complaining of decreased vision and think that they may need an enhancement, check for dry eye. The compromised ocular surface may appear to have more residual refractive error. Research has found a highly significant correlation between epithelial defects and regression of effect and the need for enhancement.
Interesting Dry Eye Facts, Pearls and Tips…
- Never underestimate dryness. Always check for dryness if there are any complications.
- 35% of patients have dry eye syndrome.
- 75% of people over 65 years of age have dry eye syndrome.
- Dry eye syndrome affects women more than men.
- Dry eye can cause epithielial ingrowth in LASIK patients.
- Dry eye can cause striae or a dislodged flap in LASIK patients.
- Dry eye can cause the following symptoms in LASIK patients:
- Regression of effect/residual refractive error
- Fluctuating vision
- Inconsistent refraction
- Light sensitivity
- Reduced BCVA
- Glare, halos, ghosting, increase in high order aberrations (HOA)
- Dry eye can delay epithelialization in PRK patients.
- Dry eye can cause recurrent corneal erosion and must be treated prior to PTK.
- Dry eye and surface irregularities can decrease effectiveness of multifocal IOL’s.
- Remember TBUT (normal = 10 seconds or greater) must be greater than blink rate. If TBUT is less than the blink rate, the corneal surface is exposed and can be compromised.
- Sodium fluorescein stains areas of corneal epithelial cell loss; whereas, lissamine green stains epithelium that is mucin-deficient or degenerating. Thus, lissamine green can many times reveal dry eye earlier than fluorescein.
- Restasis does not work immediately. It takes a minimum of 6 to 8 weeks to start having an effect.
- You CAN use Restasis with plugs.
- Remember to educate your patient that Restasis will sting, but this stinging typically subsides after 2-3 weeks.
- We usually instruct our patients to reuse their Restasis to reduce the cost. One should be able to get 1 drop bid OU for a whole day out of a single vile. Instruct the patient to refrigerate the vile between usages to avoid contamination.
- When performing a Schirmer’s, it is important to use two to three drops of anesthetic to make sure the eye is sufficiently anesthetized. If the patient reports any discomfort during the first Schirmer’s test, it may be necessary to repeat the test to get accurate results. Make sure to absorb all excess tears and drops from the lower culdasac with a tissue or a cotton tip applicator before inserting the Schirmer’s strips. Failure to do so will lead to falsely high readings. Since the Schirmer’s test is only one of many factors that we need to take into consideration when diagnosing dry eye syndrome, a normal Schirmer does not mean the patient does not have dry eye. A patient can have a normal Schirmer and still have dry eye syndrome.