Eyeworld

EW CORNEA 32 April 2015 by Lauren Lipuma EyeWorld Staff Writer Corneal tattoos: An alternative procedure for end stage opaque corneas quality and function of the meibomian glands. Other possibilities When all else fails, Dr. Dhaliwal said she uses acupuncture for dry eye. This includes using needles in the ears and index fingers for a period of 45 minutes. The effect of this treatment, which includes 2 treat- ments one day apart, lasts about 9 to 12 months. For these difficult dry eye pa- tients, Dr. Dhaliwal said a discussion with the patient is particularly im- portant. Empathize with them, and give patients hope by telling them that they are striving for a long-term solution, but it does take time. Dry eye is a chronic disease. "You can control it, but it never really goes away," she said. EW Editors' note: Dr. Dhaliwal has financial interests with Abbott Medical Optics (Abbott Park, Ill.), Avedro (Waltham, Mass.), and Eleven Biotherapeutics (Cambridge, Mass.). Contact information Dhaliwal: dhaliwaldk@upmc.edu Dr. Dhaliwal suggested doing an external exam by pulling the pa- tient's lower lids down and having the patient look up and also pulling the upper lid up while the patient is looking down. She suggested checking the patient's left and right gaze. Lid margins are also critical, Dr. Dhaliwal said. To check the lid margins, she presses on the patient's lower lid with a Q-tip to see what comes out. After testing and the exam, Dr. Dhaliwal will place an artificial teardrop in the patient's eye, and if there is no relief, she will place a topical anesthetic. If there is still no relief, standard therapy is likely not going to be effective, she said. "Treatment is targeted based on what you found and what you heard," Dr. Dhaliwal said. Artificial tears on a sched- ule, topical mild steroids, topical cyclosporine, punctal plugs, and punctal cautery could all poten- tially be included in the treatment plan. If there is no response to these options, the physician may want to try an autologous serum. In patients with MGD, it is critically important to employ therapies to improve the "When taking the history, do not ask the patient an open-ended question," she said. Instead, patients might be asked to describe the top 2 symptoms that are bothering them the most. The physician should also determine if the symptoms are worse in the morning or at night. Dr. Dhaliwal suggested asking about air and cir- culation (which can be modified), as well as mucous discharge. Physicians should ask patients if there is anything that helps to improve symptoms, even briefly. "Medications are critically important," Dr. Dhaliwal said. It is important to review the list of medi- cations that can exacerbate dry eye. What testing to use In terms of testing, Dr. Dhaliwal said that a zone quick test is used, which is a phenol red thread test. "We no longer use Schirmer's testing," she said. The zone quick test is better tolerated and takes 15 seconds. On the test, anything less than 15 mm of wetting is concerning. The exam for these patients begins when the patient first enters the room and a history is taken. Patient history and testing plays a crucial role, as does the course of treatment D ry eye is a common issue that many ophthalmolo- gists face in a number of patients. During the 2014 American Academy of Ophthalmology (AAO) Cornea Subspecialty Day, Deepinder K. Dhaliwal, MD, LAc, Pittsburgh, discussed how to handle the difficult dry eye patient. "Dry eye patients exist in all of our practices," she said. Some pa- tients are difficult to treat because it is a chronic disease with symptoms often greater than signs. These more difficult patients often are dismissed or see a number of ophthalmolo- gists, hoping that one may be able to help them find a cure. What to ask patients Dr. Dhaliwal offered advice on taking patient history, testing, per- forming an exam, and administering treatment. by Ellen Stodola EyeWorld Staff Writer Dealing with difficult dry eye cases A close-up view of a tattooed cornea C orneal tattooing can ame- liorate the cosmetic issues surrounding a scarred or end stage edematous cornea effectively, said Charles "Chaz" Reilly, MD, San Antonio. A surgeon who has been performing corneal tattoos for 10 years, Dr. Reilly thinks that the procedure should be in every cornea specialist's armamentarium, and surgeons should think about those patients who might benefit from it. Speaking at the 2014 Combined Ophthalmic Symposium, Dr. Reilly described his corneal tattoo method and offered pearls for surgeons look- ing to adopt or refine the procedure. Indications The main indications for corneal tattoos are leukomas, aniridia, poly- coria, and corneal scars. Although tattoos are often given to patients who have end stage opaque corneas, the procedure can also be performed on patients with good vision. Dr. Reilly has used the proce- dure to reduce the symptomatic glare associated with laser periph- eral iridotomies (LPIs) by tattooing directly over the LPI. A cosmetic colored contact lens is usually a superior treatment, Dr. Reilly said, but if the patient is not contact lens tolerant, a tattoo is a better option. The corneal tattoo procedure is also a viable alterna- tive to a corneal transplant and a good adjunctive therapy that helps minimize the psychological impact of opaque corneas or cosmetically unacceptable scars. Surgical technique The tattoo procedure is performed under topical anesthesia. After an eyelid speculum is placed, the epithelium is removed mechan- ically with a cotton-tipped swab.

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