Eyeworld

EW FEATURE 76 World Cornea Congress highlights September 2015 • Treatment for combined dry eye and blepharitis can involve lid hygiene, topical anti-inflammatories, topical cyclosporine, omega-3 fatty acids, and better attention to a balanced diet or environment. • Ocular pain is an underrecognized and undertreated component of dry eye. • If approved in the U.S., experimental therapies for dry eye could help ex- pand the treatment armamentarium. • Blepharokeratoconjunctivitis in children is often caused by bacteria, acne rosacea, and scalp dandruff. It usually requires collaboration with the child's pediatrician. • For mild limbal stem cell deficiency, physicians should aim to optimize the health of the ocular surface. More advanced cases may require limbal stem cell transplantation. by Vanessa Caceres EyeWorld Contributing Writer A soup to nuts look at OSD conditions I t can be hard to keep up with the latest diagnosis and treat- ment pearls for various con- ditions associated with ocular surface disease (OSD). EyeWorld has rounded up some insight and advice from experts on topics ranging from dry eye to ocular pain to limbal stem cell deficiency (LSCD) to blepharoker- atoconjunctivitis. Read on to get state-of-the-art guidance. Treating dry eye and blepharitis Anat Galor, MD, associate professor of clinical ophthalmology, Bascom Palmer Eye Institute, Miami, will examine both the eye anatomy and the tear film to try and get a better handle on the cause of a patient's dry eye and blepharitis—realizing that "dry eye" is a broad term that can have many subcomponents. On the anatomy side, she will look for eyelid laxity, conjunctival chalasis, and pterygium, among oth- er issues. For the tear film, she will evaluate the quality of oil, osmolari- ty, and tear volume. "I also have a lot of people come in who clearly have skin issues contributing to eye issues," she said. In those patients, Dr. Galor will work with a dermatologist to help treat rosacea or seborrheic dermati- tis. Usually, the treatment involves better lid hygiene, an antibiotic, and a low-dose steroid for 2–3 weeks. If Dr. Galor suspects that dry eye symptoms and signs indicate Sjögren's syndrome (SS), she will test for SS-related antibodies and treat with topical anti-inflammatories, artificial tears, and topical cyclo- sporine (Restasis, Allergan, Dublin, Ireland). She'll start the patient on fluorometholone for 1 month to prepare the eye for the use of cyclosporine. Neuropathic pain is often a problem in patients with OSD, and Dr. Galor has found successful treat- ment with autologous tears. The use of omega-3 fatty acid supplements are also part of the treatment plan to help fight inflammation. "I believe the eye is one piece of the puzzle for the rest of the body, and omega-3 fatty acids have a lot of benefits that go beyond eye health," she said. She will also advocate for patients to eat a balanced diet and to think about possible environmental causes of their dry eye symptoms. Ocular pain It can be a tangled web to diagnose and treat ocular pain, said Kristin M. Hammersmith, MD, associate professor of ophthalmology, Jefferson Medical College and Wills Eye Institute, Philadelphia. Ocular pain is also underrecog- nized, she thinks. Although a clinician may initially look for symptoms or signs associated with pain—including foreign body sensation, burning, and light sensitivity—the cause of ocular pain is not always clear, Dr. Hammersmith said. "In cases where signs don't match symptoms, we start to think about what compo- nent of this could be neuropathic pain. I don't think we do a great job of diagnosing or treating it," she said. The pain that these patients experience may be associated with pain syndromes such as fibromyalgia or depression. How- ever, even in those cases, the actual cause of pain can be murky. For example, she said, is the depressed patient with ocular pain overinter- preting normal sensations, does he or she have a charged-up nervous system causing more pain, or is he or she taking medications with ocu- lar side effects such as drying? Dr. Hammersmith will consult with a patient's primary care physi- cian when appropriate to prescribe medications like pregabalin to address pain. Sometimes the medica- tion helps—sometimes it doesn't. She has also seen some success with the use of the BostonSight PROSE (prosthetic replacement of the ocular surface ecosystem) lens, which creates a moisture chamber around the eye. Experimental therapies for dry eye Ophthalmologists in the U.S. currently have only one pharma- cologic agent approved for dry eye, said Deborah S. Jacobs, MD, medi- cal director, Boston Foundation for Sight, Needham, Mass. That makes clinicians eager for new dry eye ther- apies, she said. "We'd all like to find one drug that would work for all of these patients. Unfortunately, the experience in the last 10 to 20 years [has demonstrated that] it's hard to show effectiveness across broad Diagnosing and treating OSD effectively Patient with limbal stem cell deficiency due to longstanding atopic disease AT A GLANCE

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