Eyeworld

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Hill, MD, FACS "There is simply no better way for tapping into the expertise of my colleagues." Uday Devgan, MD "It's like having grand rounds with ophthalmology's best thinkers." W. Lee Wan, MD "There's not an ophthalmologist in the world that won't learn from this forum." Richard L. Lindstrom, MD EWAD4 EW FEATURE 36 the disease. "In terms of dry eye dis- ease, this has changed a lot for us because we were used to mild, mod- erate, and severe, and now there are four levels," he said. "The DEWS sys- tem acknowledges the different lev- els and the variability and classifies things by symptomatology such as mild, moderate, and severe, fre- quent, and disabling." While the categories are dis- tinct, there are instances where there is some repetition. "We understand that there may be significant overlap between these categories," Dr. Sheppard said. "But the visual symp- toms vary proportionately such as they're episodic for mild disease or constant and disabling for severe or level 4 disease." For the specialist, he thinks that all of this may be second nature. "It's instinctual to experienced cornea specialists and ophthalmolo- gists who perform surgery on pa- tients and treat a lot of dry eye to know to what degree the patient is suffering," Dr. Sheppard said. "But even for experienced doctors it's use- ful to write down a grading scheme. For less experienced doctors or for those who are just not sure, it's help- ful to refer to the different levels and allow themselves to judge the ag- gressiveness of therapy based on the level of disease." Following the system Dr. Sheppard makes it clear to pa- tients that it's important that they stop the disease at whatever level it is at. "What I tell patients who have mild disease is, 'All of my patients with severe disabling disease used to be mild like you—do you want to get there?'" he said. "That motivates patients to be compliant with their medications or therapeutic interven- tions, or to stop smoking, turn the fan off, get the dog out of the bed, or whatever it takes." He finds that it's pretty straight- forward to determine what level the patient is currently at. "A brief slit lamp examination by an experi- enced practitioner is all that it takes," Dr. Sheppard said. "It isn't difficult to identify the depressed meniscus or punctate keratopathy of the aqueous deficient patient or to identify a red, thickened lid margin with malfunctioning meibomian glands, as well as a classic superficial punctuate keratopathy distribution seen more at the limbus and inferi- orly, where the lower lid is juxta- posed on the cornea." While there is a wide variation and overlap in both, he thinks that experienced cli- nicians can easily figure this out. Dr. Dhaliwal likewise thinks the four-level dry eye grading system is easy to follow. "Just look for the signs—it's very clear," she said. "The staining pattern of the cornea and other signs on the ocular surface are indicative of what stage patients are at." She described the approach as a stepwise one. "We know in level 1 we can treat with artificial tears four times a day," Dr. Dhaliwal said. "If that isn't working, in level 2 we keep adding therapy." One new element of the DEWS system is the recommendation for earlier use of Restasis (cyclosporine, Allergan, Irvine, Calif.). "Don't wait for severe dry eyes to start Restasis," Dr. Dhaliwal said. "It's recom- mended in stage 2 even." This is im- portant because otherwise patients may fall into the trap of abusing ar- tificial tears. "If they use artificial tears every hour, basically they get dishpan eyes," she said. "They're washing away all of the natural oils that exist and making it worse." She thinks that it's important to not only give patients Restasis but to educate them. "It will sting when they use it for the first few weeks," Dr. Dhaliwal said. "I tell patients to refrigerate it because then it stings less." Practitioners can also use a steroid initially to help to calm the ocular surface. "Once the Restasis starts kicking in you can stop the steroid," Dr. Dhaliwal said. Eyeing progression Dr. Sheppard thinks that age is the primary reason that patients progress from one DEWS level to an- other. "Age is the number one rea- son," he said. "I think the addition of environmental, medicinal, or oc- cupational hazards is important, and clearly the seasons of the year have an impact on the nature of the dis- ease as well as the severity," he said. "Looking for concomitant allergic disease will simplify the regimen by eliminating environmental antigens to which the patient has been hy- persensitized, and we tend to forget that." In addition to age, Dr. Dhaliwal stressed that hormonal influence can play a big role here, particularly for post-menopausal women. "That's huge," she said. "Another factor is the ancillary medications that they're taking." She pointed out that a patient may start out on an antide- pressant then perhaps go on a di- uretic, or start to take an anti-allergy medication such as Claritin (lorata- February 2011 OCULAR SURFACE April 2011 Leveling continued from page 35 The Delphi panel categorizes dry eye (pictured here) into four levels in order to stage and treat the disease Source: Peter J. McDonnell, M.D., and the Delphi Task Force Paying their DEWS M ost practitioners hope to catch dry eye disease early and con- tain it to the lower DEWS levels. Unfortunately, it doesn't always work out that way. Dr. Sheppard put forth the following scenario. A patient who is doing fairly well initially presents with level 1 disease. This patient, who is a contact lens wearer and a little bit intolerant, is begun on environmental control and taken off of her topical Patanol (olopatadine, Alcon, Fort Worth, Texas) eye drops because they are drying. The patient is using tears and environmental control for her low-grade allergies and stopped oral anti-allergy medicine, Claritin OTC or Allegra (fex- ofenadine HCl, Sanofi-Aventis, Bridgewater, N.J.), and does very well. Unfortunately, the patient continues to use contact lenses and shows up post-menopausally 5 years later with horrific ocular surface disease. She had decided to go to the store to get the red out. "This is the worst thing that she can put in her eye because it's preserved," Dr. Sheppard said. "Unlike Resta- sis, which is non-preserved, this contains a vasoconstrictor to which patients become dependent, and it is toxic to the surface of the eye. She is giving her- self something that is making her worse rather than better." Such a patient has allowed the disease to undergo the normal progression of time and an- drogen senescence coupled with a lack of professional care. "Three out of four dry eye patients find it difficult to identify their eyecare provider," Dr. Sheppard said. "These patients are either slowly deteriorating, assuming that it's part of the aging process, or are risking severe complica- tions." continued on page 38 032-047 Feature_EW April 2011-DL_Layout 1 4/10/11 8:00 AM Page 36

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