Eyeworld

6 The impact of ocular surface dysfunction on surgical outcomes: Evidence-based insights on diagnostic tools to guide treatments Ocular surface testing insights: Inflammatory markers by Kenneth Beckman, MD, FACS A lthough many patients have ocular surface dysfunction, it often remains undetected during eye examina- tions. Inflammation is associated with dry eye disease (DED). 1 As part of the diagnostic process, I have found it helpful to test the tear film for the presence of inflammatory biomarkers such as matrix metalloproteinase- 9 (MMP-9). MMP-9 and other inflammatory biomarkers are produced when epithelial cells are under stress, degrading the epi- thelium and preventing epithelial healing. Research has shown that MMP-9 testing is highly effective at detecting inflammation and that it is well correlated with other measures of DED. For example, MMP-9 testing helps clinicians identify inflammation and monitor treatment results Kenneth Beckman, MD, FACS in a study of 237 patients, tear breakup time, Schirmer's, corneal staining, and the Ocular Surface Disease Index (OSDI) test were used to confirm mild DED. When the same subjects were tested with InflammaDry, a tear film test for MMP-9, the positive agreement was 81% and the negative agree- ment was 98% (Figure 1). 2 structure is absent or atrophied, a single 12-minute LipiFlow thermal pulsation treatment was less effec- tive compared with results in pa- tients with more than 1/3 of their gland structure remaining.3 In this study, outcomes were measured as improvement of symptoms and gland function. Meibography is also an excel- lent patient education tool and helps guide our discussion with patients, allowing them to see what their glands look like versus what they should look like. If they have advanced damage, I disclose that they may not respond as well to treatment as they would in the early stages. Meibography reveals the current structural integrity of the glands. Treatment for MGD would not be expected to result in regrowth of meibomian glands; it is expected to slow the atrophying process due to obstruction. Thus, meibography is not an effective short-term metric for treatment response. Incorporating meibomian gland imaging When deciding whether to incor- porate meibomian gland imaging for all patients, we need to ask ourselves why we would wait for patients to report a problem if we could intervene early and prevent progressive damage.4 Meibomian gland imaging can be incorporated easily into any workup before the patient sees the ophthalmologist. I have my patients complete a SPEED questionnaire, and if patients are symptomatic with a score greater than 7, the technician performs point-of-care testing, such as tear osmolarity, MMP-9 testing, or meibomian gland imaging. Patients who are known to be at high risk for meibomian gland disorder and ocular surface disease should be assessed routinely for MGD with gland evaluation and imaging if possible. High-risk pa- tients include cataract and refrac- tive surgery patients, contact lens wearers, and those with glaucoma or DED. Early detection, early intervention Meibomian gland imaging offers numerous benefits, enabling early detection of MGD and guiding treatment decisions. These images help patients understand how their meibomian glands function and encourage them to follow through with recommended treat- ment. When treating MGD, early intervention is important because ocular surface disease can have a major impact on our surgical outcomes. References 1. Foulks GN, et al. Improving awareness, identification, and management of meibo- mian gland dysfunction. Ophthalmology. 2012;119(10 suppl):S1–12. 2. Murakami DK, et al. The prevalence of meibomian gland dysfunction in a Caucasian clinical population. ARVO 2015. 3. Finis D, et al. Evaluation of an automated thermodynamic treatment (LipiFlow) system for meibomian gland dysfunction: a prospective, randomized, observer-masked trial. Ocul Surf. 2014;12:146–154. 4. Blackie CA, et al. Treatment for meibo- mian gland dysfunction and dry eye symp- toms with a single-dose vectored thermal pulsation: a review. Curr Opin Ophthalmol. 2015;26:306–313. Dr. Epitropoulos is clinical assistant professor, The Ohio State University Wexner Medical Center, Columbus, and co-founder, the Eye Center of Columbus. continued from page 4 Figure 1. Results of MMP-9 testing from Sambursky et al 2 Positive agreement Negative agreement Patients considered to have dry eye with tear breakup time, Schirmer, corneal staining, and OSDI 81% 98% Patients considered to have dry eye with tear breakup time, Schirmer, and corneal staining, without OSDI 86% 97% continued on page 7

• Cover