Eyeworld

AUG 2016

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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EW CORNEA 36 August 2016 by Michelle Dalton EyeWorld Contributing Writer Several devices are now available to treat lid margin and dry eye diseases P atients with ocular surface diseases tend to fall into 2 categories—those with newly identified and mild disorders who may only need artificial tears and nutritional supplementation to ease their symp- toms, and those who have been unsuccessfully treated by multiple clinicians and who have tried multi- ple treatment modalities to no avail. "Those latter complex patients have to be approached very scientif- ically, one intervention at a time," said John Sheppard, MD, president of Virginia Eye Consultants, Nor- folk, Virginia, and clinical director, Thomas R. Lee Center for Ocular Pharmacology, Eastern Virginia Med- ical School. Today's diagnostic test- ing can help organize and narrow some of the differential diagnoses, which may include aqueous defi- cient, evaporative, or mixed dry eye disease, blepharitis, or meibomian gland dysfunction (MGD). It's these complex patients who have likely failed lid hygiene, warm compresses, topical cyclospo- rine 0.05%, punctal plugs, or even intense pulsed light, said Stephen Pflugfelder, MD, professor and Elkins Chair in Ophthalmology, Bay- lor College of Medicine, Houston. "The earlier you treat these patients, the better," he said. For those with lid margin disease "if the glands are still capable of flowing, preventing them from becoming clogged should be the goal." Improving the health of the glands in these patients before ini- tiating more intense treatment may be beneficial, but to date "there's never been any controlled trial" for this indication, Dr. Pflugfelder said. Diagnosing these complicated patients is more than just having them undergo tests, Dr. Sheppard adds. "Clinicians have to analyze patients, their body, their medicines, their drops, their occupation, their hobbies, and all of the previous ther- apies they've had," he said. "Then determine if (a) they've followed previous recommendations and (b) if they stayed on any one interven- tion long enough to determine its effectiveness." People who don't consume enough "good" fats may benefit from nutritional supplementation with essential fatty acids, while others who don't blink enough may develop MGD. But oftentimes, Dr. Pflugfelder said, a correlation and diagnosis may not be that simple. Diagnostic and treatment options It's almost easier to treat patients who present for surgery with ocular surface issues since there is a "pleth- ora of information in the literature," Dr. Sheppard said. "We know which tests to use and how to treat, and we have a pallet of diagnostic tools to use as a point-of-service decision marker to move forward with the correct treatment plan for this par- ticular patient." For example, punctal plugs work quickly, whereas nutritionals take several months, but they can be used simultaneously because the effect of each treatment can be eval- uated individually. "I wouldn't use punctal plugs on a patient who wasn't also on an anti-inflammatory," Dr. Sheppard said. For lid margin disease, Dr. Pflugfelder thinks earlier diagnosis and treatment results in better out- comes for the patient. "If their glands are complete- ly blocked, patients are not good candidates for thermal pulsation," Dr. Pflugfelder said. "I want to see at least 50% of their glands secreting oil before I move onto more intense treatment," adding other physicians may have different thresholds. The ideal patient may be better identified after more studies are conducted on the technologies, he said. Dr. Sheppard wants to know dry eye patients' osmolarity, MMP-9 levels, and whether they're weak or strong allergy responders. "I want to know about surface topography," he said—and all the tests should be staggered because of reimbursement issues. For patients who are candidates for thermal pulsation, there is no gold standard for the number of treatments or the duration of treat- ment, which Dr. Pflugfelder thinks may be addressed down the road with more clinical trial data. Newer devices The past few years have seen a bevy of new tools introduced to diagnose and treat ocular surface disorders, including the InflammaDry (Rap- id Pathogen Screening, Sarasota, Florida), MiBoFlo Thermoflo (MiBo Medical Group, Dallas), TearScan lactoferrin test (Advanced Tear Diagnostics, Birmingham, Alabama), TearLab Osmolarity Test (TearLab, San Diego), LipiView/LipiFlow (TearScience, Morrisville, North Carolina), BlephEx (Lake Worth, Florida), and lysozyme testing. Most patients will get some symptomatic improvement from warm compresses, and some of the devices mentioned are "a more con- trolled way of heating the lid," Dr. Pflugfelder said. With no indepen- dent studies done and published on the outcomes, however, Dr. Pflugfelder is hesitant to definitively Tools for diagnosing and treating a variety of ocular surface disease Typical patient with chronic meibomian gland dysfunction with hyposecreting glands and severe lid margin and conjunctival inflammation Source: Stephen Pflugfelder, MD continued on page 38 Device focus

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