Eyeworld

57 EW FEATURE February 2016 • Ocular surface disease up into their upper fornix to get the mucus out, while others will use a rolled up Kleenex or handker- chief to do this. "It's amazing how much trauma patients do to their ocular surface," she said. Treating this requires breaking the cycle of removing the mucus. "I tell patients, 'Promise me you won't touch your eyes for 1 week. There's a high like- lihood that you're going to feel a lot better if you do that,'" she said. Other ocular abnormalities Dr. Jeng finds that conjunctivochala- sis is another commonly overlooked condition related to structural dry eye. "The common conjunctivocha- lasis that most people think about is where there is baggy conjunctival tissue," he said, adding the redun- dant tissue can cause friction, mak- ing the patient's eye feel irritated. "It causes a lot of tearing because the tissue can sag over the eyelid mar- gin," Dr. Jeng said. "There's no place for the tears to collect, and the tears drip off onto the cheek." Sometimes, the sagging tissue actually blocks the lower punctum, also causing tearing. With all of this tearing, patients are sometimes misdiagnosed. Practi- tioners may erroneously think that patients are tearing because they are dry, but in reality it's because they Dhaliwal explained. She also tries to move the slit lamp around so they're not focused on any one thing. Bennie H. Jeng, MD, professor and chair, Department of Ophthal- mology and Visual Sciences, Univer- sity of Maryland School of Medicine, Baltimore, concurs. He stressed the importance of just watching the pa- tient. Dr. Jeng finds that incomplete blinking goes along with a nocturnal lagophthalmos where patients may sleep with their eyes partially open. "I see that pretty frequently, and that's something I check for in every new patient who comes in," Dr. Jeng said. Even if the issue is confined to incomplete blinks, it's still going to affect the area that the eyelid does not reach. "I tell people it's like the part of the windshield that never gets the wiper," he said. "That's what the open area looks like on staining when they don't blink all the way down or they have lagophthalmos." To treat such patients, he begins by just asking them to remember to blink. This is not an option for noc- turnal lagophthalmos, and different approaches are needed. "You can offer them ointment at bedtime," he said, adding that many, however, will complain that if they get up to go to the bathroom at night, their vision is blurry. Another alternative is to tape the eyelid down. For this, Dr. Jeng recommends using Breathe Right snoring strips because they are super sticky on the ends. Patients can put one end on the upper lid and the other on the cheek, he explained. A third alternative is to sleep with tight-fitting swim goggles. "What happens is it becomes a humid chamber," he said; however, this is not a favorite of patients. In some cases, surgical tightening may be the answer. "Sometimes it's the lower lid that is sagging a bit and needs to be lifted," he said. Other times, the eyelids can be closed a touch with a lateral tarsorrhaphy, but this is not a favorite of patients either, he finds, because it chang- es their appearance a bit. "You're pinching the eyelids closed a little bit from the side," he said. "So you're making the eyes appear a little bit smaller." Dr. Dhaliwal finds that another underdiagnosed structural condition contributing to dry eye is floppy eye- lid syndrome. "We get patients who come in with super floppy eyelids and are getting eversion at night," Dr. Dhaliwal said, adding that they wake up with dry eye symptoms. She finds that this occurs more often in patients with keratoconus as well as those who have sleep apnea. "It's important when you diagnose floppy eyelid syndrome to ask about sleep apnea," she said. Dr. Dhaliwal theorizes that the overlap between the 2 conditions is likely the result of lax collagen. The treatment here is straight- forward. "You have to make sure patients stop rubbing their eyes," Dr. Dhaliwal said. "These floppy eyelid syndrome patients are often chronic eye rubbers." This is something that links them to keratoconus patients, who also frequently rub their eyes. Dr. Dhaliwal can often tell the side that the patient sleeps on. This is usually the result of patients push- ing on their lid skin while they're sleeping, which causes it to evert. To treat such patients, Dr. Dhaliwal has them use nighttime lubrication such as ointment or gel. "In some cases, we also have them use an eye shield when they sleep," she said; this keeps the lubrication on the eye and stops patients from rubbing their eye against the pillow while they sleep. Another condition that is often related is called mucus fishing syn- drome. "These people have floppy lids and chronic inflamed conjunc- tiva and mucus in their fornices," she said. To determine if they have the condition, Dr. Dhaliwal asks patients if they have a lot of mucus. If they say they do, she follows up by asking how they remove this. "It is shocking to hear what they often say." She has had some patients who will take their finger and reach EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line. Poll size: 202 continued on page 58 Common treatments for mild cases include warm compresses, lid hy- giene, artificial tears, and omega-3 fatty acid supplements. More advanced cases can benefit from treatments such as intense pulsed light therapy, LipiFlow, Restasis, topical steroids, and oral doxycycline. Topical steroids and mast cell stabilizers Topical cyclosporine Topical tacrolimus Incomplete eye closure does not affect the ocular surface Floppy eyelids are associated with keratoconus and sleep apnea Conjunctivochalasis should not be considered as a cause for tearing Giant fornix syndrome is a rare condition that typically occurs in younger patients Referral to allergist All of the above It is possible to cure and eradicate evaporative tear dysfunction. Ocular rosacea is a related condition that is underdiagnosed.

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