Eyeworld

I DRY EYE DEVELOPMENTS N FOCUS 44 | EYEWORLD | JUNE 2019 by Ellen Stodola EyeWorld Senior Staff Writer/ Meetings Editor "Your exam algorithm, including additional point-of-care tests, also depends on your goals," Dr. Galor said. In the clinical setting, you're try- ing to figure out how to best treat the patient, but in a research setting, you might be more interested in understanding the pathophysiolo- gy behind dry eye. "For example, elevated tear osmolarity is involved in the pathophysiology of dry eye, but I wouldn't necessarily chose a treatment based on an osmolarity value," she said. "As such, I find the test more useful in the research setting and less so in the clinical setting." When considering which tests to use, Dr. Galor said you need to identify what you want out of a test and what makes sense for your practice. "With dry eye, it's not one size fits all," she said. "My goal in using point-of-care tests is to try to understand contributors to dry eye symptoms so I can tailor therapy." For example, if she suspects that a patient has Sjögren's, she orders blood tests looking for early (anti-CA6, PSP, and SP-1) and late markers. Focusing on the ocular surface, Dr. Galor evaluates for ocu- lar surface inflammation with the InflammaDry (Quidel), as a robust pink strip leads her to try an anti-inflammatory agent, such as topical cyclosporine or lifitegrast, with or without a short course of corticosteroids. Dr. Galor likes imaging the meibomian glands if she is consid- ering a treatment to improve their health, such as LipiFlow (Johnson & Johnson Vision) and/ or intense pulsed light (IPL) therapy. Significant gland dropout on imaging makes improvement with these therapies less likely and thus, she uses the findings on meibomian gland imaging to council patients prior to treatment. Dr. Galor likes the ease of the Keratograph (Oculus), as it can non-invasively quantify breakup time and tear lake height, however, these metrics can also be captured with fluorescein relatively quickly. Overall, she incorporates point-of-care tests to make treatment decisions but doesn't use any one value in isolation. Regarding the extra costs that can be associated with point-of-care tests, physicians have different models for how they recover costs associated with the tests. InflammaDry W hen assessing dry eye patients, physicians have a number of tests available to use in the of- fice. The choice of which tests to use may vary depending on the practice flow, subspecialty, and other factors. Two physi- cians shared with EyeWorld how they approach point-of-care testing for their patients, which tests they like to use, and how they use ques- tionnaires to treat dry eye disease. Anat Galor, MD Dr. Galor thinks that "questionnaires are the most relevant test we do because we're not treating a number, we're treating a patient." She said she first wants to know exactly what the patient is complaining about—whether it's pain, poor visual quality, or something else. Dr. Galor noted that there are many differ- ent questionnaires that physicians can use. She prefers the Dry Eye Questionnaire 5 (DEQ5), which asks about dryness, discomfort, and tearing, and the Ocular Surface Disease Index (OSDI) questionnaire, which asks about pain, poor vision, and impact on function. But she doesn't like to see a sum score and instead looks at individual responses to get a sense of specific patient complaints. In addition, Dr. Galor said it's important to understand what is happening on the ocular surface. "We all have our own standardized algorithms that quickly and efficiently evaluate the patient," she said. In the clinic, the exam starts when Dr. Galor enters the room, evaluating blink rate and noting skin abnormalities, like rosacea. She then looks at eyelid position and function, evaluating for laxity and lagoph- thalmos. She places a small drop of fluorescein and under the slit lamp looks for conjunctivochalasis, assesses tear breakup time, and examines the tear lake and eyelid health. It's important to look at these parameters in a systemic way to get a sense of what's going on. At a glance • In addition to tests, question- naires can be helpful to de- termine a patient's symptoms and signs and exactly how he/ she is feeling. • Some point-of-care tests may be reimbursable, while others have extra costs associated with them, so it's important to discuss this with patients. • With point-of-care tests, it's important for physicians to be able to interpret the results, so an exam must be combined with the objective quantities given by the tests. Using point-of-care and imaging testing in the office Testing for ocular surface inflammation with the InflammaDry Source: Harrison Dermer

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