Eyeworld

foreign body sensation, burning, redness, epiphora, preoperative cataract or LASIK, and patients post infection. The examination is key. The lid exam is now the longest part of my slit lamp examination. Exam fea- tures include an examination of lids and diagnostic expression of meibo- mian glands to determine quality of secretions, meibomian gland health, tear film height and quality, and a choice of in-office tests based on history and findings. Based on results from the exam, the next step is to refine the treat- ment plan and provide an aggressive treatment to improve the ocular surface prior to a preoperative exam. R efractive cataract surgeons can't afford to ignore ocular surface disease, and it doesn't need to be that hard to deal with. First, ask patients about their problems. Testing only when patients complain of dryness is absolutely insufficient because between 40% and 60% of people with objective evidence of dry eye are asymptomatic. Cataract surgery patients often complain of fluctuat- ing vision rather than dryness or foreign body sensation. Traditional diagnostic testing has low objectivity, low specificity, and no reimbursement, with more time required per patient to do these tests. Meanwhile, with advanced point of care diagnostics, the time required to perform the tests is low, the specificity and objectivity are high, and often there is reimburse- ment. Dry eye is a multifactorial dis- ease of the tears and ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. Tear analysis should be done be- fore exposing the eye to any positive stimuli, dyes, dilation, direct con- tact, or bright lights. We need to em- power staff to perform testing based on physician ordered indications so the physician can diagnose quickly and begin ocular surface disease management right away. I use osmolarity in my practice for every patient with a dry eye complaint or a history of dry eye, by Elizabeth Yeu, MD How to implement point of care diagnostics for dry eye into a practice Elizabeth Yeu, MD, has received a retainer, ad hoc fees, or other consulting income from: Allergan, Bausch & Lomb, and TearLab Corporation. Using diagnostics to drive treatment of dry eye disease However, some new biomarkers (i.e., salivary protein-1, carbonic an- hydrase, and parotid secretory pro- tein) have been identified and are expressed earlier in the disease with higher specificity and sensitivity. A new in-office blood testing kit can measure these traditional and new biomarkers. The serum specimens can then be sent to a lab to get re- sults in a week to confirm or rule out the diagnosis of Sjogren's syndrome. Finally, lipid layer analysis provides both a quantitative and qualitative analysis of the lipid layer of the tear film. The diagnostic device measures the thickness of the lipid layer of the tear film (ICU in nanometers) with interferometry and provides real-time video of the tear film along with blink analysis in about 20 seconds per eye. The clini- cian should combine this with mei- bomian gland expression at the slit lamp to observe the ease of gland expression and quality of secretion. The results can help confirm the diagnosis of meibomian gland dysfunction and guide therapy with thermal pulsation devices. Some tests that are already being used in the office can help with dry eye diagnosis, including corneal topography, wavefront aber- rometry, and OCT. Corneal topogra- phy maps and their accompanying Placido disc images can provide a noninvasive and objective measure of the ocular surface and TBUT. Wavefront aberrometry provides another approach to look at the tear film surface and TBUT as well as its impact on higher order aberrations and quality of vision. Although OCT is available in most offices, its ability to measure tear meniscus height has not yet been widely utilized in dry eye disease diagnosis. With the availability and clini- cal utility of these new diagnostics for dry eye disease, I think our paradigm is moving away from using some of the more traditional (and outdated) tests, including Schirmer's testing and fluorescein staining. These new advanced devices increase the specificity and positive predictive value (PPV) of the diagnostic assessments for dry eye and demonstrate how point of care testing can allow the clinician to make appropriate treatment decisions regarding dry eye therapy more easily, quickly, and reliably. Dr. Kim is professor of ophthalmology at Duke University School of Medicine, and director of fellowship programs, cornea and refractive surgery services at Duke University Eye Center, Durham, N.C. He can be contacted at terry.kim@duke.edu. This includes customized treatment that takes into account long-term needs of the patient. The ASCRS Cornea Clinical Committee is developing a more de- tailed point of care testing protocol with goals of improving the ability to identify the type and extent of the disease, making a more informed and evidence-supported diagnosis, focusing doctors' time with patients on management strategies, and better communicating with patients regarding dry eye disease. Clinicians should increase suspicion of dry eye and MGD in the cataract population and lower the threshold for treating prior to surgery. Advanced point of care diagnostics provide quick, objective and highly specific results that are easy to use and to explain to pa- tients. Protocols are evolving; how- ever, clinicians don't have to wait for the perfect protocol to begin implementing advanced diagnostics. New tests are commercially available and can be integrated into your practice now. Dr. Yeu is in private practice at Virginia Eye Consultants in Norfolk, Va., and specializes in cornea, cataract, and refractive surgery. She is an assistant professor at Eastern Virginia Medical School. She can be contacted at 757-622-2200 or at eyeulin@gmail.com. This CME supplement is supported by unrestricted educational grants from TearLab, TearScience, Rapid Pathogen Screening, and Nicox. Advanced point of care diagnostics may improve objectivity and specificity while reducing the time required to perform the tests. EW Ocular care Supplement July 2014-DL2_Layout 1 6/30/14 8:59 AM Page 53

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