Eyeworld

18 October 2018 EW NEWS & OPINION Chief medical editor's corner of the world by Eric Donnenfeld, MD, EyeWorld chief medical editor promote innovation and protect pa- tients, and I say, "Job well done." EW Editors' note: Dr. Donnenfeld has financial interests with Alcon. Contact information Donnenfeld: ericdonnenfeld@gmail.com Alcon took swift and decisive action. Stephen Lane, MD, Alcon's chief medical officer, stated in a company press release, "Based on this new in- formation, we are advising surgeons to immediately cease further im- plants with the CyPass microstent" and that this was, "in the patients' best interest and is the right thing to do." Now we have to decide how to manage these patients. These deci- sions should be made by the best clinicians—not the FDA or industry. As you'll see on pages 16–17 of this issue, a task force of ASCRS Glauco- ma and Cornea Clinical Committee members have worked together to create an independent physician guidance document for how these patients should be managed moving forward. The FDA, Alcon, and ASCRS have worked together seamlessly to our colleagues in other parts of the world have the opportunity to work with new technology. In the case of the CyPass, the FDA asked for a very reasonable 2-year follow-up prior to approval, then mandated that Alcon study the same patients for an additional 3 years to confirm safety. The 5-year safety study showed endothelial cell loss that was highly associated with the placement of the device and not seen in the 2-year results. When correctly placed, the endothelial cell loss was greater than in the control, but not worrisome When the device was more exposed in the anterior chamber, the cell loss was greater. Innovation is the backbone of all of medicine, especially in ophthalmology. New treatments are developed, and patients benefit from them. At the same time, it is unrealistic to expect that every inno- vation will be without setbacks. As clinicians and representatives of our patients, we ask that new devices and medications be evaluated care- fully but also approved in a reason- able time period. Overwhelmingly a 2-year study provides this reas- surance, but a 3-year post-approval surveillance trial provides additional certainty. The system worked because the FDA asked for the correct informa- tion and follow-up. The system also worked because we expect transpar- ency and honesty from the compa- nies we work with. In this case, as soon as the data became available, O n August 29, 2018, Alcon (Fort Worth, Texas) issued a voluntary global recall of the CyPass Micro-Stent, a suprachoroidal MIGS device for the surgical treatment of glaucoma. The announcement came after post-approval studies conduct- ed by Alcon, per the U.S. Food and Drug Administration (FDA), detected an increase in endothelial cell loss among patients who received the CyPass during cataract surgery 5 years earlier compared with patients who underwent cataract surgery alone. The action was swift and decisive. The initial impression by many was, "What went wrong?" At face value this seems a reasonable response. It's human nature to find a scapegoat when we face a problem so we can place blame. In reality, we should acknowledge—if not cele- brate—the fact that in this case, the system worked. Innovation requires testing new treatments, evaluating their effi- cacy, and following them for both short-term and long-term safety. The initial COMPASS trial was a 24-month study and evaluated 505 CyPass patients in 24 centers. It was a well-designed and thorough trial, and showed both safety and efficacy. Too often the FDA is chastised for delaying approval of devices while The system works Eric Donnenfeld, MD " The system worked because the FDA asked for the correct information and follow-up. The system also worked because we expect transparency and honesty from the companies we work with. " Preliminary ASCRS CyPass withdrawal consensus statement See pages 16–17 for the full text from the ASCRS CyPass Withdrawal Task Force. For the online version, complete with hyperlinks and supporting figures, go to ascrs. org/CyPass_Statement. View the EyeWorld CME and non-CME supplements at: cmesupplements. eyeworld.org supplements. eyeworld.org Moderator: Eric Donnenfeld, MD, practices with Ophthalmic Consultants of Long Island and Connecticut, and is clinical professor of ophthalmology, New York University, and trustee, Dartmouth Medical School. Supplement to EyeWorld October 2018 continued on page 2 Meibography Summit: Translating knowledge into practice Supported by an unrestricted educational grant from Johnson & Johnson Vision medially, and that is a cleaning mechanism. It is a pumping mechanism for the oil glands, too," said Paul Karpecki, OD. Patel et al. showed that people blink 4.5 times when using video display devices compared with 18 times in other situa- tions. 3 "So they are not getting that cleaning or meibomian gland expression," he said. Preeya Gupta, MD, and her colleagues reported that 42% of children ages 4–17 had gland atrophy. 4 "There were children who even had moder- ate to severe meibomian gland atrophy, and all these children were asymptomatic. The key for us as clinicians is to try to figure out when these patients are going to become symptomatic A s ophthalmologists observe the impact of meibomian gland dysfunction (MGD) in clinical practice, understanding of the condition continues to advance. 1 "MGD is the number one reason patients come into our office," said Eric Donnenfeld, MD, moderating the Meibog- raphy Summit during the 2018 ASCRS•ASOA Annual Meeting. "It is either a primary or a secondary complaint in about 40–50% of our patients." Defining MGD "The International Workshop on Meibomian Gland Dysfunc- tion described MGD as a chron- ic, diffuse abnormality of the meibomian glands commonly characterized by terminal duct Frank Bowden, III, MD, is founder of Bowden Eye and Associates, Jacksonville, Florida. Alan Carlson, MD, is professor, Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina. Douglas Devries, OD, is co-founder, Eye Care Associates of Nevada, adjunct clinical professor of optometry and residency director, Pacific University College of Optometry, Alice Epitropoulos, MD, is clinical assistant professor, Ohio State University Wexner Medical Center, Columbus, co-founder, Eye Center of Columbus, and partner, Ophthalmic Surgeons & Consultants of Ohio. Terry Kim, MD, is professor of ophthalmol- ogy, chief, cornea and ex- ternal disease division, and director, refractive surgery service, Duke University Eye Center, Durham, North Carolina. Preeya Gupta, MD, is associate professor of ophthalmology, Duke Uni- versity Eye Center, Durham, North Carolina. D. Rex Hamilton, MD, is director, University of California, Los Angeles, Laser Refractive Center, and clinical professor, cataract and refractive surgery division, Stein Eye Institute, Los Angeles. Edward Holland, MD, is professor of ophthal- mology, University of Cincinnati. Paul Karpecki, OD, is director of corneal services, Advanced Ocular Surface Disease Center and Research, Kentucky Eye Institute, Lexington, Kentucky, and practices in the ocular surface disease clinic, Gaddie Eye Centers, Louisville, Kentucky. William Trattler, MD, is in practice at the Center for Excellence in Eye Care, Miami. Donald Korb, OD, is president, Korb Associ- ates and Korb Research, and affiliated professor, University of California Berkeley School of Optom- etry. He is a co-founder of TearScience, which was purchased by Johnson & Johnson Vision. W. Barry Lee, MD, practices with Eye Consultants of Atlanta. Marguerite McDonald, MD, practices with Ophthalmic Consultants of Long Island, is clinical professor of Ophthalmology, NYU Lan- gone Medical Center, New York, and clinical professor of ophthalmology, Tulane University Health Sciences Center, New Orleans. John Sheppard, MD, is professor of ophthal- mology, microbiology and molecular biology, Eastern Virginia Medical School, medical director, Lions Eye Bank of Eastern Virginia, and president, Virginia Eye Consultants, Norfolk, Virginia. Elizabeth Yeu, MD, is assistant professor of ophthalmology, Eastern Virginia Medical School, and in private practice, Norfolk, Virginia. Faculty Marjan Farid, MD, is director of cornea, cataract, and refractive surgery, vice chair of ophthalmic faculty, and associate professor of ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine. Examining meibomian gland dysfunction and its impact EyeWorld recently gathered 17 experts on ocular surface disease at a special summit to discuss the current thinking on meibography and meibomian gland dysfunction. The Meibography Summit focused on the role of meibography as a diagnostic tool, as well as how best to integrate diagnostic findings into treatment paradigms in clinical practice. Summit participants were asked to try to achieve consensus on a number of key questions. Their responses are featured in graphic form throughout this supplement. obstruction and/or qualita- tive, quantitative changes in the glandular secretions," Dr. Donnenfeld said. 1 "It may result in alterations of the tear film, symptoms of eye irritation, clinically apparent inflamma- tion, and ocular surface disease (OSD)." Respondents to the 2016 ASCRS Clinical Survey indicated that 48% of dry eye patients have MGD. Estimates by the Meibography Summit partici- pants were considerably higher, with approximately 88% thinking that the prevalence of MGD is increasing. Fifty-six percent of Meibography Sum- mit participants reported that 60–75% of their cataract surgery candidates have MGD, and 82% reported that more than 75% of their OSD patients have MGD (Figures 1 and 2). However, some suspect increased awareness accounts for the increase. "If you look at Michael Lemp's publications on the prevalence of MGD, we know it increases with age and we know this is the most com- mon cause of dry eye disease," said Terry Kim, MD. 2 However, he thinks MGD is still underdi- agnosed because many clini- cians are not looking for it. Others contend that addi- tional factors are at work. "There are few sources for it, but modern risk factors are very real," said Elizabeth Yeu, MD. Many people use digital devices more than 5 hours a day, she said, leading to decreased and incomplete blinking. "When people blink, nor- mally the lower eyelid moves Supplement to EyeWorld March 2018 surface," Preeya Gupta, MD, said. There is some- times confusion on how to use these tests. They can help to push the needle in terms of your Supported by unrestricted educational grants from Shire, TearLab, and TearScience Customizing modern OSD therapies to individual patient needs Accreditation Statement This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continu- ing Medical Education through the joint providership of the American Society of Cataract and Refractive Surgery (ASCRS) and EyeWorld. ASCRS is accredited by the ACCME to provide continuing medical education for physicians. Educational Objectives Ophthalmologists who participate in this activity will: • Evaluate current protocols for screen- ing, diagnosis, and classification of OSD • Modify protocols as necessary • Match therapeutic classes to associated diagnosis Designation Statement The American Society of Cataract and Refractive Surgery designates this enduring materials educational activity for a maximum of 1.0 AMA PRA Category 1 Credits. ™ Physicians should claim only credit commensurate with the extent of their participation in the activity. Claiming Credit To claim credit, participants must visit bit.ly/2E60E7R to review content and download the post-activity test and credit claim. All participants must pass the post-activity test with a score of 75% or higher to earn credit. Alternatively, the post-test form included in this supplement may be faxed to the number indicated for credit to be awarded, and a certificate will be mailed within 2 weeks. When viewing online or downloading the material, standard internet access is required. Adobe Acrobat Reader is needed to view the materials. CME credit is valid through July 31, 2018. CME credit will not be awarded after that date. Notice of Off-Label Use Presentations This activity may include presentations on drugs or devices or uses of drugs or devices that may not have been approved by the Food and Drug Administration (FDA) or have been approved by the FDA for specific uses only. ADA/Special Accommodations ASCRS and EyeWorld fully comply with the legal requirements of the Americans with Disabilities Act (ADA) and the rules and regulations thereof. Any participant in this educational program who requires special accommodations or services should contact Laura Johnson at ljohnson@ascrs. org or 703-591-2220. Financial Interest Disclosures Zaina Al-Mohtaseb, MD, has received a retainer, ad hoc fees or other consulting income from Allergan and is a member of the speakers bureau of Alcon. Preeya Gupta, MD, has received a retainer, ad hoc fees or other consulting income from Alcon, Allergan, Aurea, Bio-Tissue, Johnson & Johnson Vision, NovaBay Pharmaceuticals, Ocular Science, Shire, TearLab, and TearScience. Terry Kim, MD, has an investment interest in Ocular Therapeutix, Omeros, and TearScience. He has received a retainer, ad hoc fees or other consulting income from Acucela, Aerie, Alcon, Allergan, Avellino Labs, Bausch + Lomb, BlephEx, CoDa Therapeutics, Foresight Biotherapeutics, Kala Pharmaceuticals, NovaBay, Novartis, Ocular Systems Inc., Ocular Therapeutix, Oculeve, Omeros, PowerVision, Presbyopia Therapies, Shire, TearLab, and TearScience. Francis Mah, MD, has an investment interest in Sydnexis. He has received a retainer, ad hoc fees or other consulting income from Abbott, Aerie, Alcon, Allergan, Bausch + Lomb, CoDa, NovaBay, Ocular Science, Okogen, Omeros, PollyActiva, Shire, Sun Pharma, and TearLab. Dr. Mah is a member of the speakers bureau of Abbott, Alcon, Allergan, Bausch + Lomb, Shire, and Sun Pharma. He has received research funding from Abbott, Allergan, and Ocular Science. Staff members: Kristen Covington, Laura Johnson, and Ellen Stodola have no oph- thalmic-related financial interests. continued on page 2 together information in addition to a slit lamp exam. "I look at diagnostic and point-of-care testing as getting a snapshot of the health of the ocular pacts patient satisfaction in postop cataract and refractive patients. Other survey questions asked about primary therapy for moderate and severe dry eye, as well as treat- ment options for meibo- mian gland dysfunction (MGD). Additionally, 83% of respondents indicated that they would find an algorithm for ocular sur- face diagnostics valuable. A lot of patients who have dry eye are often asymptomatic, Zaina Al-Mohtaseb, MD, said. This is why in addition to subjective questionnaires, objective tests like MMP-9 and osmolarity are im- portant. Physicians have access to various diag- nostic tests that can be used collectively to piece Clinical Survey and introduction Terry Kim, MD The ASCRS Clinical Survey was completed in May 2017 to assess clini- cal opinions and practice patterns. Data from the survey indicates that 91% of ASCRS respondents think mild to moderate dry eye significantly im- " Data from the survey indicates that 91% of ASCRS respondents think mild to moderate dry eye significantly impacts patient satisfaction in postop cataract and refractive patients. " —Terry Kim, MD 64 65 Surgeons see OSD treatment as integral to practice success G reater than 25% of cata- ract patients present with asymptomatic dry eye preoperatively, and 1 in 5 cataract patients present for their preoperative consultation symptomatic of OSD that re- quires intervention beyond artificial tears, according to the ASCRS Clinical Survey on ocular surface disease (OSD). Respondents say more than half— 53%—of their dry eye patients have a mix of meibomian gland dysfunction (MGD) and aqueous deficient dry eye disease (ADDE). Thermal lid expression and lid hygiene are the most common treatments for MGD; artificial tears and lubricants followed by oral omega-3 supplements are the most common treatments for moderate dry eye (Figure 1). A related survey found that queried cataract and refractive surgeons think it is very important to understand the etiology of their patient's OSD, whether it be MGD, ADDE, or both MGD and ADDE, and most are either very confident or somewhat confident in their ability to appropriately match treatments to the etiology and se- verity of OSD. Approximately 65% strongly agree that anterior segment imaging such 65 by Marjan Farid, MD as topography and meibography can help guide therapy and patient education about OSD, and a notable 82% agree that treating OSD can benefit their surgical practice. When asked what they consider to be the greatest barrier to more consistently evaluating the tear film, lids, and mei- bomian glands in preoperative patients, the leading cause was not having access to advanced tear film or other diagnostic testing in their office, and the second most frequent factor was limited time during the preoperative work-up period. This supplement presents advice from leaders in our field on the diagnosis and management of dry eye. Editors' note: Dr. Donnenfeld practices with Ophthalmic Consultants of Long Island, is professor of ophthalmology, New York University, and is a trustee, Dartmouth Medical School. He has financial interests with AcuFocus, Allergan, Alcon, AqueSys, Avedro, Bausch + Lomb, Beaver-Visitec, CRST, Elenza, Foresight, Glaukos, Icon Biosciences, Johnson & Johnson Vision, Kala, Katena, LacriPen, LensGen, Mati Pharmaceuticals, MDback- line, Merck, Mimetogen, Mynosys, NovaBay, Novaliq, OcuHub, Ocular Therapeutics, Odyssey, Omega Ophthalmics, Omeros, Oyster Point, Pogotec, PRN, RPS, Shire, Strathspey Crown, Sun, TearLab, TLC Laser Centers, TrueVision, Versant Ventures, Visionary Ventures, and Zeiss. He can be contacted at ericdonnenfeld@gmail.com. Identifying the underlying causes of ocular surface disease for more accurate diagnosis and treatment Supplement to EyeWorld October 2018 digital.eyeworld.org e news magazine of the American Society of Cataract & Refractive Surgery by Eric Donnenfeld, MD The role of tear film instability, inflammation, hyperosmolarity, and neurosensory abnormalities in OSD D ry eye disease (DED) is defined by the Tear Film & Ocular Surface Society (TFOS) DEWS II Report as "a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperos- molarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles." This follow-up re- port represents insights from 150 research- ers based on knowledge accrued since the original DEWS findings were promulgated a decade ago. DEWS II stresses the pivotal role of hyperosmolarity in ocular surface disease (OSD) and suggests that the earlier the diagnosis and management of OSD, the better the outcome. The goal of treatment is to break the cycle of inflammation and restore tear homeostasis. Mechanisms and management The central mechanism of DED is an evap- orative water loss that leads to hyperosmo- lar tissue damage and loss of homeostasis. Direct or indirect insult to the ocular surface via inflammation can cause loss of epithelial and goblet cells, and this results in decreased surface wettability with rapid tear breakup time, which initiates tear film instability and amplified hyperosmolarity. DED can be initiated by a variety of causes including Sjögren's syndrome, rheumatoid arthritis, lupus, decreased an- drogen levels in postmenopausal women, MGD resulting in a poor lipid layer of the tear film, allergy medications, and contact lens wear. LASIK and other ocular surgeries that cut corneal nerves can exacerbate pre-existing subclinical dry eye disease as well. 1 All of these are capable of triggering a cascade of pro-inflammatory cytokines resulting in hyperosmolarity; thus the goal of OSD treatment is restoration of the tear film homeostasis. 2 Visual fluctuations due to increased tear breakup time (TBUT) and the resulting hyperosmolarity are one of the most common, and often overlooked, symp- toms of DED. Other factors that influence hyperosmolarity include the lipid layer thickness, palpebral aperture width, blink interval, tear film stability, environmental conditions, and body hydration. When a hyperosmolar tear film is not treated and homeostasis is not reached, epithelial cells recruit inflammatory cells to the ocular surface, exacerbating inflam- mation and causing reduced expression of glycocalyx mucins. This leads to ocular surface staining and rapid TBUT, as well as apoptosis of surface epithelial cells and loss of goblet cells. The DEWS II difference DED has traditionally been divided into primary aqueous deficient dry eye or evaporative dry eye. DEWS II indicates that these are not mutually exclusive. In fact, up to 85% of DED patients who have aqueous deficiency have some degree of meibomian gland dysfunction (MGD) as well. Diagnosing DED starts with categoriz- ing patients into asymptomatic or symp- tomatic categories and performing testing based on their symptom presentation, then further categorizing them and developing a treatment plan based on their place in the spectrum of symptoms. DEWS II makes slight changes to the classic definition of tear film. Previously it was described as a three-layer system en- compassing the lipid layer, aqueous layer, and mucin layer. In DEWS II it is described as a two-layer system comprising the lipid layer and a muco-aqueous layer, which contains biomarkers potentially useful in the diagnostic process. Conclusion DED is a multifactorial disease, and there is no single one size fits all treatment. It must be diagnosed and treated early in an effort to break the cycle of inflammation and restore tear homeostasis. References 1. Bron AJ, et al. TFOS DEWS II pathophysiology report. Ocul Surf. 2017;15:438–510. 2. Craig JP, et al. TFOS DEWS II definition and classifi- cation report. Ocul Surf. 2017;15:276–283. Editors' note: Dr. Farid is director of cornea, cataract, and refractive surgery; vice-chair of ophthalmic faculty; director of the cornea fellowship program; and associate professor of ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine. She has financial interests with Allergan, BioTissue, Johnson & Johnson Vision, Kala, Shire Phar- maceuticals, and SightLife Surgical. She can be contacted at mfarid@uci.edu. ASCRS Cornea Clinical Committee algorithm focuses on OSD in preoperative cataract and refractive surgery patients by Christopher Starr, MD A chieving a pre- mium surgical outcome is impossible in the absence of a premium ocular surface. The mission of the ASCRS Cornea Clinical Committee's Preoperative OSD Cataract and Refractive Surgery Algorithm is to aid busy surgeons in identifying and reversing potentially visually significant OSD preoperatively. Proactive screening While the TFOS DEWS II diagnostic algorithm and treatment rubric are appropriate for the general dry eye disease (DED) and/or ocular surface disease (OSD) patient, there are special considerations required for preoperative refractive surgery patients with OSD. Symptoms are a primary component of most general DED algorithms and are a key driver in obtaining further diagnostic testing. It's known that a high percentage of preoperative cataract surgery patients are asymptomatic and yet often have fairly advanced visually significant DED and/or OSD. Thus, the ASCRS Cornea Clinical Committee algorithm emphasizes point-of-care testing (osmolarity and MMP-9) and other objective testing in addition to a novel surgery-specific symptom questionnaire in all patients during their pre-surgical office visit. If visually significant OSD is detected by the algorithm, refractive measurements and surgery are delayed until it is fully treated. Aggressive treatment An important commonality between TFOS DEWS II and the ASCRS Cornea Clinical Committee algorithm is that both recommend identifying the DED subtype, evaporative dry eye (EDE) or aqueous deficient dry eye (ADDE) disease, in addition to any other DED masqueraders (e.g., floppy eyelid syndrome, epithelial basement membrane dystrophy, allergy, conjunctivochalasis) to best tailor effective treatment. In TFOS DEWS II, the first step for most patients with DED is low level palliative treatment. Conversely, the ASCRS Cornea Clinical Committee stresses that patients who are having refractive surgical interventions do not have the luxury of time to start slow and increase treatment incrementally as this will lead to unacceptably long surgical delays. When managing preoperative patients with visually significant OSD, the ASCRS Cornea Clinical Committee recommends starting treatment at the TFOS DEWS II Step 2 level with more advanced interventions and to use a multifaceted approach to achieve a more rapid response. A combination of prescription medications (e.g., topical immunomodulators, steroids, antibiot- ics, etc.) as well as procedural interven- tions (e.g., blepharoexfoliation, thermal pulsation, intense pulsed light, punctal plugs, therapeutic contact lenses, etc.) are typically required for rapid reversal of OSD preoperatively. Manage expectations The ASCRS Cornea Clinical Committee stresses that surgical patients should know in advance that their vision may fluctuate postoperatively and their OSD may worsen, and thus should expect to continue OSD treatment for at least 3–6 months after surgery. The take-home message is: Diagnose early, educate the patient about their OSD, treat aggressive- ly, and maintain appropriate postopera- tive surveillance and treatment. Editors' note: Dr. Starr is associate professor of ophthalmology, director of refractive surgery, director of ophthalmic education, and director of the cornea, cataract, and refractive surgery fellowship, Weill Cornell Medicine, New York Presbyterian Hospital, New York. He has financial interests with Allergan, Alcon, Bausch + Long, Sun, Shire, Kala, Bruder, BlephEx, TearLab, and RPS. He can be contacted at cestarr@ med.cornell.edu. Six steps to establishing a Dry Eye Center of Excellence by Marguerite McDonald, MD Given these circumstances, cataract surgeons should treat every patient as a dry eye patient. We have two choices: Create a Dry Eye Center of Excellence to ensure optimal outcomes in your surgical patients, or refer your pre-surgical patients to col- leagues who will optimize their ocular sur- face and send them back to you. If you opt to create a Dry Eye Center of Excellence, I recommend the following steps. Stepwise strategy 1. Have a team meeting to let your staff know that focusing on dry eye is im- portant to you and that it will benefit the practice and the patients. Encourage buy-in by explaining that it can be a lucrative endeavor, and the healthier the practice, O cular surface disease (OSD) is per- vasive, with at least one study showing that 87% of patients scheduled for cataract surgery are diagnosed with dry eye disease (DED). 1 Even mild OSD can lead to suboptimal refractive outcomes after cataract surgery, and the signs and symp- toms of OSD are often poorly correlated; therefore, patients with OSD may be missed if clinicians rely heavily on symptomatolo- gy for diagnosis. 2 continued on page 65 continued from page 64 continued on page 66 64 Meibomian gland imaging • Look for duct dilation, gland constipation, curling and shortening (atrophy), hazy appearance, dropout • Powerful tool to motivate patients to accept/perform preventive care EARLY STAGE MGD/NON-OBVIOUS LATER STAGE MGD/DRY EYE GLAND LOSS Figure 1. Meibomian gland imaging in the first frame shows early stage MGD with a small amount of duct dilation. The second frame shows curling, shortening, and gland atrophy. The third frame shows end stage truncated glands. EARLY STAGE MGD/ NON-OBVIOUS LATER STAGE MGD/DRY EYE GLAND LOSS the greater the likelihood of staff bonuses and pay raises. 2. Visit another Dry Eye Center of Excellence. Bring your office manager and lead technician along, and take notes. Make sure the practice is an hour or more away, so they won't consider you as com- petition. Be gracious; buy the staff lunch. You may want to visit again in a year to observe with fresh eyes. Primary therapies and treatments for managing moderate dry eye disease 100% 80% 60% 40% 20% 0% AT/ lubricants Oral omega-3 Cyclosporine Lifitegrast Punctal occlusion 94% 63% 53% 58% 54% Figure 1. Respondents use various treatment options to treat dry eye disease.

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