Eyeworld

EW FEATURE 58 Ocular surface disease • February 2016 have an obstruction or an anatom- ical problem where the tears don't stay in the eye. In addition, there is a type of conjunctivochalasis commonly referred to as superior limbic kera- toconjunctivitis (SLK), Dr. Jeng said. This involves redundant tissue on the superior bulbar conjunctiva. "It's a mechanical rubbing of the under- side of the upper eyelid, and it is Inflammatory eye diseases such as uveitis require a multi- disciplinary approach. Ocular symptoms may be the first clue to serious and undiagnosed systemic conditions. The patient's total health is the key. Wills Eye Hospital has built a world renowned network of clinician/investigators dedicated to stopping uveitis in its tracks. We're improving lives. 840 Walnut Street Philadelphia, PA 19107 www.willseye.org 1-877-AT-WILLS Sunir Garg, MD Retina Service James P. Dunn, MD Director, Uveitis Unit Christopher J. Rapuano, MD Chief, Cornea UVEITIS IT TAKES A TEAM UVEITIS IT TAKES A TEAM Looking beyond from page 57 redundant tissue, so there's friction," Dr. Jeng said, adding that this causes inflammation on both the bulbar and the tarsal conjunctiva, the latter of which takes on a velvety appear- ance. Many times, before getting the right diagnosis, these patients have been treated for dry eye by as many as 5 different practitioners. "They have been given all sorts of artificial tears, but lubricants aren't going to work," Dr. Jeng said. To treat this, he finds that conjunctival excision to remove the redundant tissue, which is sagging and loose, is the definitive answer. Dr. Dhaliwal said that in addi- tion to looking for bulbar conjunc- tival staining for SLK under the lid, some patients may have an exposed concretion. In these cases, biological material gets encased in a cyst, and if this ruptures the material becomes exposed and irritates the eye. "You flip their lid, you see an exposed concretion, you pop it out with a little forceps, and they think you walk on water because you just cured them," she said. In identifying this, Dr. Dhaliwal stressed the need to use fluorescein strips moistened with balanced salt solution rather than a drop of stain, which puts more ve- hicle in the eye and can mask some cases. Another irritating condition to watch for is giant fornix syndrome. This relatively rare condition typical- ly occurs in older patients who have deep superior conjunctival fornices. "Organisms like bacteria are harbored up in that area and form a biofilm, and it's very diffi- cult to eradicate this infection," Dr. Dhaliwal said. "You have to break through the biofilm and oftentimes have to use a combination steroid antibiotic drop." For some patients, Dr. Dhaliwal uses a betadine rinse or the anti-inflammatory antiseptic agent Avenova (NovaBay Pharma- ceuticals, Emeryville, Calif.), which has activity against biofilm. Dr. Jeng said that to tackle these structural cases, when patients come in complaining of dry eye, it's important to think beyond the obvious. "I always tell residents that just because patients say they have dry eyes doesn't mean they actually do," Dr. Jeng said. "Do a complete exam and always check and make sure that they close their eyes all the way and that they blink all the way down." EW Editors' note: Dr. Dhaliwal has financial interests with Abbott Medical Optics (Abbott Park, Ill.), Dompe (Milan, Italy) and NovaBay Pharmaceuticals. Dr. Jeng has no financial interests related to this article. Contact information Dhaliwal: dhaliwaldk@upmc.edu Jeng: BJeng@som.umaryland.edu

• Cover