Eyeworld

C ORNEA 28 | EYEWORLD BONUS ISSUE | OCTOBER 2025 About the physician Sumitra Khandelwal, MD Professor Department of Ophthalmology Baylor College of Medicine Houston, Texas by Liz Hillman Editorial Co-Director what's causing some of their symptoms. It's not necessarily dry eye that needs to be treated with drops," she said. This could be lagophthalmos, entropy onto the eyelid, or subtle trichiasis. These are things that Dr. Khandelwal said can be missed if the physician goes straight to the slit lamp exam. Another item to focus on is the conjunctiva. Dr. Khandelwal said this can reveal conjuncti- vochalasis, especially on the temporal edges. "When it's lid issues causing it … you'll see that the tear film no longer sits correctly. It's not uniform. So conjunctivochalasis can be a dry eye masquerader." If you were to try drops in these eyes, they wouldn't coat the surface; they would sit in the bottom of the conjunctiva and ultimately fall out, Dr. Khandelwal said. She also said to lift the upper eyelid to look at the superior bulbar conjunctiva. "There are a couple of conditions that we know about from residency but we forget about in real practice. One of them is superior limbic kerato- conjunctivitis, also known as SLK. It's a classic example where there is staining that's focused on the superior bulbar conjunctiva." Dr. Khandelwal explained that these patients have more of an inflammatory condition, sometimes W hile this bonus issue of EyeWorld delves into the diverse aspects of dry eye, the Editorial Board thought it was important to call out dry eye masqueraders —conditions that might initially seem like dry eye but aren't. EyeWorld spoke with Sumitra Khandelwal, MD, to gain insights on these dry eye decoys. Working at a tertiary care center, Dr. Khandelwal said she sees a lot of people for second and third opinions for dry eye. "There's a real pattern that I have noticed when it's not straightforward dry eye," she said. "It's not that patients don't have a component of dry eye—I think we can agree that we all have a little dry eye nowadays with our screen time and envi- ronmental changes—but that's not what is caus- ing them to have symptoms, whether it's blurry vision or eye pain." Dr. Khandelwal said there are several dry eye masqueraders. To identify some of them, she said, it's important, before putting any drops in the eye, to step back and re-evaluate the com- prehensive anterior exam. Look at the lids and lid positioning. "I'll have patients who have dry eye symptoms … but when you look at it, they have subtle lid positioning issues, and that's Dry eye decoys: don't be fooled continued on page 30 Conjunctivochalasis Source: Stephen Pflugfelder, MD

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