Eyeworld

93 EW CORNEA April 2016 Editors' note: Dr. Milner has financial interests with Allergan (Dublin), Shire (Lexington, Massachusetts), Bausch + Lomb (Bridgewater, New Jersey), TearScience (Morrisville, North Caroli- na), Aldeyra Therapeutics (Lexington, Massachusetts), Eleven Biotherapeutics (Cambridge, Massachusetts), Kala Pharmaceuticals (Waltham, Massachu- setts), and Refocus Group (Dallas). Contact information Milner: eyecentermm@hotmail.com The last coconspirator that Dr. Milner discussed was floppy eyelid syndrome, which is usually seen in overweight patients, Dr. Milner said. It's associated with sleep apnea and with those who have a history of sleeping with their face buried in the pillow. Key therapy options include topical lubrication or ointment at bedtime, using an eye shield at bed- time, and lid tightening procedures. Staining is critical to help physicians make the diagnosis of the coconspirators, Dr. Milner concluded. EW by Ellen Stodola EyeWorld Senior Staff Writer tissues, or cotton swabs. Rose bengal and lissamine green staining are important, Dr. Milner said. Most importantly, stop the fishing, he said. The physician may also want to treat any allergies and use topical lubrication. Contact lens-related toxicity is associated with contact lens over- wear or chronic use. Rule out tight fit, solution toxicity, or cracked or torn contact lenses, he said. The patient should limit or stop contact lens wear, fix any problems with the contact lens, and may want to use topical lubrication. Chemical toxicity is associated with chronic exposure to fumes or chemicals. This is a condition that is rarely considered, Dr. Milner said, so history is critical. Use topical lubrication and limit or stop the chemical exposure, he said. Allergic/atopic conjunctivitis is one of the main coconspirators. Physicians can use topical steroids, topical mast cell stabilizers, topical cyclosporine, or topical tacrolimus. Conjunctivochalasis is often overlooked, Dr. Milner said. It has many symptoms of dryness and tearing. Key therapies include topical lubrication, a topical anti-in- flammatory, topical antihistamines, patching, or excision. At Hawaiian Eye 2016, Dr. Milner discussed some diseases that may add to or masquerade as dysfunctional tear syndrome D uring a presentation at Hawaiian Eye 2016, Mark Milner, MD, Hamden, Connecticut, highlighted some of the "dry eye co- conspirators," and discussed diseases that may masquerade as or contrib- ute to dysfunctional tear syndrome. He listed 9 different issues in this category, including superior limbic keratoconjunctivitis (SLK), medica- mentosa, Thygeson's superficial punctate keratitis (SPK), mucus fish- ing syndrome, contact lens-related toxicity, chemical toxicity, allergic/ atopic conjunctivitis, conjunctivo- chalasis, and floppy lid syndrome. Dr. Milner offered several pearls for dealing with SLK. Pull the slit lamp away and have the patient look down. Sometimes it is easier to see the superior injection with the naked eye, he said. Staining can help in these cases, and key therapies include lubrication, anti-inflamma- tories, silver nitrate, cautery, and excision with or without amniotic membrane. Medicamentosa is not often thought about, Dr. Milner said, but may be noticed when a patient comes into the office with a bag of medications. Key therapies for this include lubrication, getting the pa- tient off all medications and starting again, and using non-preserved medications when possible. Thygeson's SPK is often found by a diagnosis of exclusion, and the symptoms are often greater than the findings. Key therapies include lubrication, topical steroids, topical cyclosporine, and topical tacrolim- us. Cyclosporine is a "home run" in these cases, Dr. Milner said. Mucus fishing syndrome may be a problem as it features chronic irritation with a continued period of no improvement. The patient has usually been digging in the inferior fornix with his or her fingernail, Dysfunctional tear syndrome "coconspirators" Superior injection seen with SLK. At times, this is easier to see without a slit lamp. Source: American Academy of Ophthalmology 9 dry eye coconspirators 1. Superior limbic keratoconjunctivitis (SLK) 2. Medicamentosa 3. Thygeson's superficial punctate keratitis (SPK) 4. Mucus fishing syndrome 5. Contact lens-related toxicity 6. Chemical toxicity 7. Allergic/atopic conjunctivitis 8. Conjunctivochalasis 9. Floppy lid syndrome Presentation spotlight

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