Eyeworld

I DRY EYE DEVELOPMENTS N FOCUS 46 | EYEWORLD | JUNE 2019 Contact information de Luise: vdeluisemd@gmail.com Hovanesian: johnhova@gmail.com Nijm: lmnijm@uic.edu Periman: lperiman@comcast.net by Liz Hillman EyeWorld Senior Staff Writer growth serums; and observes lash quality, which could indicate use of toxic glues, or cosmetics or over curling. On the posterior aspect of the lid margin, she looks for hyperkeratinization. On the back side of the lid, Dr. Periman also looks for lissamine green staining, which could indicate lid wiper epitheliopathy. She evaluates meibomian glands with a Meibomian Gland Evaluator (MGE) (Johnson & Johnson Vision). "I use the MGE instead of my fingers because you can use too much pres- sure, and all you've demonstrated is expressibili- ty under pressure," she said. When it comes to therapy, Dr. Periman starts at the same foundational approach designed to address the inflammation that underscores the double vicious circles of dry eye disease and MGD—with omega fatty acids and Restasis (cyclosporine, Allergan) or Xiidra (lifitegrast, Shire), or the soon to be available Cequa (cyclosporine, Sun Pharmaceutical). "Even though we only can measure one component of the inflammatory burden, MMP- 9, as a point-of-care test at this point, we know myriad of other inflammatory cytokines are at play that are effectively lowered with these medications. Most patients with dry eye disease can lower their inflammatory burden with these immunomodulators," she said. Dr. Periman explained that confocal mi- croscopy studies have revealed inflammatory cells surrounding meibomian glands, which secrete inflammatory cytokines, making the meibomian gland stem cells sick. Lowering the inflammatory burden doesn't always translate into symptom improvement, but it may be the key to preventing disease progression. After establishing the foundational thera- py, Dr. Periman directs treatment to identified comorbid disease such as lid laxity, exposure, allergies, and rosacea, to name a few. Rosacea patients benefit from intense pulsed light (IPL) therapy. If you see lid margin telangiectasias, think ocular rosacea and go to IPL, Dr. Periman said. If patients have MGD without rosacea, she'll go to BlephEx, followed by LipiFlow (Johnson & Johnson Vision) or TearCare (Sight Sciences), especially for situations where D ozens of conditions can cause dry eye symptoms and what's often referred to as the umbrella term "lid margin disease." As such, dozens of treatment options correspond with each of the various conditions. It can be overwhelming for phy- sicians, said Laura Periman, MD. "Dry eye disease, lid margin disease, MGD—there are probably about 20 differ- ent diseases in there. That's where things get messy," Dr. Periman said. In this article, Dr. Periman, John Hova- nesian, MD, Vincent de Luise, MD, and Lisa Nijm, MD, JD, provide their perspectives on lid margin disease diagnosis and the therapeutics they use to address it. Laura M. Periman, MD According to Dr. Periman, tackling lid margin disease (and dry eye disease in general) can be broken into four steps: (1) Ask questions via questionnaires that can assess a patient's symp- toms. (2) Assess the patient's risk factors; look at his/her medication list, medical history, age, general health, smoking status, etc. (3) Conduct diagnostic testing, including osmolarity, MMP- 9, fluorescein and lissamine green staining, slit lamp examination, and meibomian gland imag- ing if necessary. (4) Diagnose and treat. "It's those four easy steps. I think if we can teach that, it will help lower the bar for entry for doctors who know they need to be more aggressive with managing dry eye disease, but there is so much in the market that it can feel overwhelming," she said. Dr. Periman begins her assessment before she even looks at the lid margin. She observes the patient's natural blink pattern; looks for signs of sleep apnea; evaluates the quality of the skin (dry skin could be a sign of over strip- ping or overuse of warm compresses). She then moves to the slit lamp and looks for evidence of Demodex, foam cells that could indicate a high bacterial burden; notes discoloration under the eyelid skin that could indicate abnormal vas- cularization from inflammation or pigmentation at the lash base that could suggest use of lash Lid margin disease Diagnostic and therapeutic update At a glance • The landscape of lid margin disease diagnostics and ther- apeutics has grown within the last decade, and it continues to evolve. • While the number of options can make treating lid margin disease overwhelming, physicians say it's important to at least start addressing the issue as it can improve patient quality of life as well as the outcomes of other procedures. • Most experts interviewed by EyeWorld take a stepwise treatment approach, starting with patient-driven warm com- presses and lid hygiene thera- py, followed by more involved treatments such as mechanical gland warming/expression, systemic medications, and/or probing.

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