Eyeworld

365 Curriculum Supported by unrestricted educational grants from Allergan, Shire, TearLab, and TearScience assist in our dry eye assessments continue to be evaluated. Incorporating biomarker testing In our practice, we evaluate every patient having cataract surgery for DED, which must be treated before we perform preoperative measurements. When patients return for preoperative measurements, I per- form corneal staining, osmolarity, manual K readings, IOLMaster measurements, and topography. If measurements do not correlate well or there is corneal staining, I continue ocular surface treatment. When integrating point-of- care testing, ophthalmologists need to empower their techni- cians. As they obtain the patient's history, they need to ask appropri- ate questions. For example, using a survey, patients should be asked about fluctuating vision and reflex tearing, symptoms patients may not associate with DED. With this test, a negative result is a single blue line. A pink line in addition to the blue line is a positive result, indicating the presence of the the inflammato- ry marker in the tears (Figures 2 and 3). In addition to assisting in diagnosis, MMP-9 testing can help ophthalmologists make treatment decisions. For example, in patients with positive results, we may prescribe steroids or cyclosporine rather than inserting punctal plugs. After we begin treatment, MMP-9 testing is useful in moni- toring treatment efficacy. During dry eye examina- tions, clinicians may also perform TearScan MicroAssay tests for IgE and lactoferrin to diagnose ocular allergies and dry eye. High IgE lev- els may indicate allergies, which may cause symptoms mimicking DED or exacerbate symptoms of DED. Lactoferrin levels are used to detect aqueous deficiency. Other biomarkers that may one day Figure 3. Positive InflammaDry test; note the blue and pink lines visible Positive result Figure 2. Negative InflammaDry test; note only blue (control) line visible Negative result If symptoms are present, the technician can begin the dry eye workup. In my office, technicians start with osmolarity testing. Subsequently, I perform corneal staining and tear breakup time with fluorescein. If MMP-9 testing is necessary, I may schedule this on the next appointment. Due to obvious time and patient flow is- sues, it is not practical to perform every dry eye test on the initial visit. Although I perform MMP-9 and Schirmer's early in the course to help me direct treatment, they can also be performed on a fol- low-up visit. I do not order MMP-9 testing based specifically on the osmolari- ty score or any other individual test. Rather, if I find anything that could indicate inflammation, whether it is staining or high osmolarity, or if the symptoms warrant a dry eye evaluation, I order a baseline MMP-9. MMP-9 testing not only helps us identify inflammation and monitor treatment results, it can have a hidden value. Patients with DED are often dissatisfied because other eyecare professionals have not resolved their problem. If you can effectively manage DED, you will build your reputation among optometrists and patients. References 1. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the Interna- tional Dry Eye Workshop (2007). Ocul Surf. 2007;5:75–92. 2. Sambursky R, et al. Prospective, multicenter, clinical evaluation of a point- of-care matrix metalloproteinase-9 test for confirming dry eye disease. Cornea. 2014;33:812–818. Dr. Beckman is director of corneal services, Comprehensive Eye Care of Central Ohio, and clinical assistant professor of ophthalmology, The Ohio State University, Columbus, Ohio.

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