NOV 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/220233

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6 Advanced tear film testing: Improving diagnosis and patient treatment Evidence-based medicine: Healthcare for the 21st century by Eric D. Donnenfeld, MD E vidence-based treatment using point-of-care diagnostic testing is the future of medicine because it provides objective measurements and a hard piece of information to rely on. Additionally, there's a strong correlation between point-of-care diagnostic testing and signs and symptoms. So we, as clinicians, can now emphasize other parts of our examination, and we improve the sensitivity and specificity of our diagnosis. The increased confidence in our diagnosis allows a more specifically targeted and aggressive treatment plan. In this rapidly changing healthcare environment, clinicians need to practice smarter, increase patient flow, and empower staff to perform testing based on physician-based indications. Then, when the physician examines the patient, the diagnosis has already been suggested, and only confirmation is needed. This permits the physician to spend less total time, but more quality time, with the patient. I spend more time talking to the patient about treatment rather than the diagnosis because I already have the diagnosis right in front of me. With the development of new point-ofcare testing, we need to re-evaluate how we are approaching the patient. At Ophthalmic Consultants of Long Island, we have instituted a dry eye/meibomian gland dysfunction (MGD) protocol and a red eye One goal of the new dry eye/MGD protocol is to improve diagnostic confidence with point-of-care testing to identify the type and extent of disease. We rely mostly on osmolarity levels for diagnosing dry eye, but lipid layer assessment plays a very important role, as do various topographic measurements. New testing, like MMP-9 and lactoferrin, is still being tested in our practice, but osmolarity has become the mainstay. This allows us to improve diagnostic confidence, spend time, make an informed evidence-based supportive diagnosis, and communicate better with the patient about disease management. Every other specialty besides ophthalmology couldn't practice without lab tests. If physicians suspect strep throat or high cholesterol, they don't treat until they have done diagnostic testing. In fact, lab testing impacts 70% of all medical decisions, except for ophthalmology and optometry. Eyecare practitioners do not have the luxury of using reference laboratories. Now, for the first time, lab tests are available, and we have become a CLIA testing laboratory. At Ophthalmic Consultants of Long Island, we see 180,000 patients a year (15,000 patients a month). Last month, 6,000 patients were positive for the dry eye protocol and received osmolarity testing in both eyes. So we performed 12,000 tests in our office last month. The dry eye/MGD protocol includes the following steps: • The patient presents with the complaint of dry eye. • He or she is given a standardized symptoms questionnaire. • A certified technician confirms that symptoms are present. • Noninvasive advanced tear film testing is performed based on standing physician orders. Tests include osmolarity levels, lipid layer thickness if necessary, tear breakup time, tear meniscus height, and inflammatory mediator assessment. • Results are interpreted from the tear film testing. • A slit lamp exam and invasive follow-up testing are performed in the lane with the ophthalmologist to confirm the diagnosis. • Treat accordingly. This has resulted in improved time and cost-effective treatment of dry eye disease. Based on new literature and our personal experience, I have become an ardent supporter of omega-3 fish oils. Omega-3 consumption is 25 times less than it was 100 years ago, and because of that, aqueous deficiency, dry eye, and MGD have become an epidemic in our country. always uniform in height due to inclusions, mucous, etc., image analysis can be performed to determine the average height. Additionally, tear film breakup time can be precisely documented and the level of dry eye automatically classified; the image detection and software can "see" the dark spots in the fluorescein-stained tear film by noting the distortions in the reflected image or grid. The viscosity of the tear film can also be determined by the Keratograph 5M using a "particle tracking" technology package. Individual particles in the tear film (meibum, dust, makeup residue, etc.) are tracked between blinks; their direction and the distance that they travel is an indication of tear viscosity. The Keratograph 5M can also perform meibography of the eyelids. Eversion of the lids is necessary because the external lid tissue blocks the entry of light on assessment, so one has to evert the lids while the patient is looking downward. The large working distance of the Keratograph 5M allows the observation and eversion of the upper and lower eyelid. The field of view is 24 mm to image the whole upper tarsal plates and the structures of the meibomian glands. The glands are quickly illuminated and image analysis is used to calculate their area and volume. protocol, both of which have worked very well. Dry eye/MGD protocol continued from page 5 Keratograph 5M The Keratograph 5M (Oculus, Arlington, Wash.) offers several ways to analyze the tear film. In addition to being an excellent Placido-based corneal topography unit, it has several new hardware and software upgrades that make it incredibly powerful in the assessment of dry eye. There are four different illumination systems and three magnification settings, depending on what aspect of dry eye is being evaluated. The tear meniscus height can be evaluated with the new magnification changer to provide an image of the curvature along the lid margin. As the tear meniscus is not

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