Eyeworld

C ORNEA 30 | EYEWORLD BONUS ISSUE | OCTOBER 2025 Relevant disclosures Khandelwal: AbbVie, Dompe Contact Khandelwal: Sumitra.Khandelwal@bcm.edu with redundancy to the conjunctiva superiorly and occasionally blepharospasm with it. "It's treated completely differently. Drops only may not help this patient," Dr. Khandelwal said, explaining that they typically need an anti-in- flammatory, an immunomodulator, cauteriza- tion, and/or botulinum toxin A to help with the blepharospasm. Other dry eye masqueraders include Demodex and staph blepharoconjunctivitis. "If patients have a lot of staph and have ocular rosacea on their eyelids, if they have Demodex collarettes, they need to be treated differently than your typical dry eye patient." Salzmann's nodules or epithelial basement membrane dystrophy can masquerade as dry eye on Placido topography as well. "The epi- thelial basement membrane dystrophy can be very subtle. It can present with negative stain- ing, instead of just frank cysts and map-dot. You want to look at that and match it up with the topography to understand if the patient's symptoms are something on the ocular surface. It could be from these little hills and valleys that have developed over the years, and they would need superficial keratectomy if typical medical management doesn't work." Neurotrophic keratitis is another condition that is frequently mischaracterized. "It's easy to say the patient has dry eye, but in reality, the neurotrophic keratitis patient has more of a lack of reactive reflex tearing and loss of their typical immunomodulators that are in the tear film," Dr. Khandelwal said. Sometimes they get better with dry eye treatment, but sometimes they plateau. When patients continue to have a lot of staining despite treatment, it's important to check their corneal sensation. Awareness of neurotrophic keratitis is on the rise due to an increase in education and because there are treatment options. "I think for any patient who comes in and the stain- ing pattern on their cornea is more than their symptoms—it's staining without pain or staining with minimal pain—to me, that's a red flag they have neurotrophic keratitis," Dr. Khandelwal said, adding that if their Placido disc topog- raphy looks suspicious, it is a stopping point for technicians to not put drops in their eye. If drops have already been put in the patient's eye, Dr. Khandelwal said she asks the patient if their eyes often feel dry. If they say their eyes ache every now and then, she'll check corneal sensation upon their arrival next time prior to any drops. Some inflammatory conditions, Dr. Khan- delwal noted, can overlap with dry eye but are more significant than "just dry eye." Other conditions that are more than "just dry eye" in- clude things like limbal stem cell deficiency and ocular cicatricial pemphigoid. Limbal stem cell deficiency can present as a few clock hours of superiorly or subtle corneal neovascularization and a whorl-like staining pattern. Many of these patients are long-time contact lens wearers who have focal limbal stem cell deficiency. Patients with cicatricial pemphigoid often present late, but Dr. Khandelwal said ocular symptoms start somewhere. "If I see a patient in the clinic who has dry eye and hasn't gotten better, and they have some little focal areas where there's a thicken- ing to the conjunctiva and maybe even a little early symblepharon formation, I do a conjunc- tival biopsy. If that comes back with a loss of goblet cells, it is just ocular surface disease. But I've had several patients through the years who have early ocular cicatricial pemphigoid. It's got a classic pathology with immunofluorescence staining," she said. These tips can help providers to remember not all dryness is dry eye. Watch out for these masqueraders, and always keep them on your differential for a patient not improving with typical ocular surface treatment, Dr. Khandelwal said. continued from page 28 Superior limbic keratoconjunctivitis (SLK) Source: Stephen Pflugfelder, MD

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