Eyeworld

365 Curriculum Supported by unrestricted educational grants from Allergan, Shire, TearLab, and TearScience by Christopher Starr, MD, FACS Diagnostic tools for OSD: Getting the information you need to make the right treatment decisions Although the workup typically begins with the patient's symp- toms, we need to keep in mind that there is often a disconnect between patients' signs and symp- toms. Some patients with extreme signs have very few symptoms and vice versa. Therefore, our diagno- ses often will be incorrect if we base them on symptoms alone. We recommend using a val- idated questionnaire or having technicians ask key questions regarding OSD. In addition to asking about traditional symptoms (dryness, tearing, redness, itching, etc.), it is important to elicit visual symptoms such as aberrations and fluctuations. If the patient's symptoms suggest DED or OSD, we suggest tear osmolarity as the first test, followed by MMP-9 testing, which are both easy for technicians to perform. The DEWS report in 2007 defined DED as involving both inflammation and hyperosmolari- ty, so testing for both is reasonable because these tests are inexpen- sive, easy to use, and reimbursable. Abnormal results on osmo- larity and/or MMP-9 give the clinician a high degree of certainty that DED is present, how severe it is, and whether or not the eye is inflamed. If osmolarity is high but MMP- 9 results are negative, the patient may have early DED without inflammation. In this case, punc- tal plugs or artificial tears may be warranted. If results for both are nor- mal in a symptomatic patient, masqueraders may be present; this leads to a new path in the algorithm. However, if osmolarity is normal and MMP-9 results are high, the patient has inflam- mation but may not have DED, which may direct the user to an- other path in the algorithm. When DED is confirmed, we need to differentiate between aqueous deficient and evaporative New tool will guide ophthalmologists and technicians in diagnosing dry eye disease and ocular surface disease I t has been an amazing decade in the realm of ocular surface disease (OSD) and dry eye dis- ease (DED) in particular, with many seminal publications and many new diagnostics and treatments. Despite these advances, an- nual ASCRS Clinical Surveys have shown that, in general, clinicians have been slow to adopt the updated guidelines and novel diag- nostics (Figures 1). Although it is exciting to have all of this new information, it can be a bit overwhelming for ophthal- mologists to digest it all and apply it in their practices. To help fill this educational gap, the ASCRS Cornea Clinical Committee is developing a DED and OSD management algorithm to help clinicians easily and more accurately diagnose and treat OSD utilizing the newest technologies. Algorithm overview At this writing, the algorithm has not been released, but the following is a brief overview of the process. Christopher Starr, MD, FACS Figure 1. In the 2015 ASCRS Clinical Survey, members responded to the question: "Do you follow the Delphi/DEWS guidelines for treating aqueous deficient dry eye and MGD?" Figure 2. ASCRS survey respondents responded to the following question: "What are the barriers to incorporating advanced tear film diagnostics into your practice? (Select all that apply) 0% 10% 20% 30% 40% 50% 60% 70% 80% Safety and efficacy – I do not see any differences Cost CLIA waiver application is too complicated Increases my chair time Practice flow disruption None, I use advanced tear film diagnostics in my practice DED to tailor our treatments. In addition to the traditional exam- ination techniques such as visual tear meniscus height, meibomian gland expression and inspection, Schirmer testing, and dye-based staining and tear breakup time (TBUT), there are many modern diagnostics that are more precise and objective. These can be per- formed by a technician before the clinician meets the patient. These newer tests include noninvasive TBUT and tear meniscus height/ area/volume, lipid interferometry, meibography, tear lactoferrin and continued on page 4 I don't know what the guidelines say 0% 10% 20% 30% 40% I am probably following them, but I'm not certain I regularly consult the guidelines and adhere closely to them I know what they are but use my own treatment protocols All U.S. Non U.S. All U.S. Non U.S.

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