NOV 2013

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

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Page 94 of 122

8 Advanced tear film testing: Improving diagnosis and patient treatment gland secretion scores, tear film breakup time, and reduction in dry eye symptoms.1 Strong dry eye/MGD testing protocols also directly impact outcomes. I have found that these testing protocols improve outcomes in both refractive and cataract surgery. The biggest concern I had with osmolarity when I first saw this test was that there was variability in the numbers. I wondered how a test can be good when one eye is 290 and the other eye is 314. However, there is a very good reason for this. The more severe the dry eye, the more unstable the tear film. Thus, there is minute-to-minute, day-to-day variation that is reflected in these variable numbers. A patient with normal osmolarity (no dry eye disease) will tend to have very consistent numbers, usually below the critical threshold of 308 mOsm. It is important to note that the variability is more important than the number itself. If you see a difference of more than 8, you are almost certainly dealing with dry eye disease. We can measure tear osmolarity extremely accurately. Dry eye disease and osmolarity are 85% to 90% correlated. Always measure both eyes. The higher of the two measurements is the reference. As severity increases, there is an increased chance that the left and the right eyes will be different, but due to the unstable tear film, the more severe eye may change from blink to blink, so treat both eyes the same. Hyperosmolarity should be addressed as it may compromise quality of vision, cause chronic inflammation, and potentially damage the ocular surface. "By offering these point-of-care tests, you allow patients to have expert care done in a timely fashion, and you practice smarter and better medicine." In osmolarity testing, variability is more important than the number itself. Red eye protocol Acute conjunctivitis is highly infectious. There are three major subtypes (viral, allergic, and bacterial) that often have a confusing presentation. It is accurately diagnosed only 27% to 50% of the time. The red eye protocol has three goals: • Improve diagnostic confidence with a point-of-care system to rule out or confirm the presence of adenovirus. The AdenoPlus (Nicox, Sophia Antipolis, France) detects adenovirus with 90% sensitivity and 96% specificity. • Minimize the risk of patients spreading disease. • Permit ophthalmologists to focus time with the patient on patient management strategies, make a more informed, evidence-supported diagnosis, and treat appropriately. Our red eye protocol includes the following steps: • The patient presents with red eye and is immediately triaged by the front desk to an isolated exam room. • The technician confirms the presence of acute conjunctivitis. • The AdenoPlus diagnostic test is performed. It is a two-minute test, and results are available in 10 minutes. If the test is positive, patients are given a written protocol for treatment that includes instructions to apply lubricating drops and cold compresses to the infected eye. No antibiotics are necessary, and many increase infectivity and duration of viral shedding. Consider using the antiviral Zirgan (ganciclovir, Bausch + Lomb, Rochester, N.Y.), which has been shown This supplement was produced by EyeWorld and supported by unrestricted educational grants from TearLab, TearScience, Nicox, and PRN. Copyright 2013 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS. in vitro to be effective against adenovirus. Patients are advised to refrain from work until the adenovirus is resolved. If the test is negative, continue the diagnosis to identify whether the conjunctivitis is bacterial or allergic. Consider antibiotic or antihistamine therapy (or a combination). Follow-up or refer if there is decreased vision, pain, or lack of improvement over seven days. Patients may return to work the same day. Exam rooms containing patients with confirmed conjunctivitis are vigorously cleaned with a dilute bleach to prevent epidemic spread. Every red eye has the AdenoPlus test done. It saves a lot of time, is cost effective, and allows our practice to be more efficient. Gaining information from these pointof-care diagnostic tests can increase diagnostic accuracy, allow effective treatment, and increase patient satisfaction. By offering these point-of-care tests, you allow patients to have expert care done in a timely fashion, and you practice smarter and better medicine. Reference 1. Lane SS, et al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012;31(4):386-404. Dr. Donnenfeld is in practice at Ophthalmic Consultants of Long Island and is clinical professor of ophthalmology, New York University Medical Center. He can be contacted at ericdonnenfeld@gmail.com.

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