Eyeworld

45 EW CORNEA February 2017 vital signs," a term that patients readily understand and accept. Determining treatment strategies Asymptomatic patients are likely to be treated differently than symp- tomatic ones, especially if there are abnormal diagnostic test results. "If we wait to treat patients un- til they're symptomatic, we're miss- ing a whole category of patients," Dr. Gupta said. "Dry eye is so much easier to treat when it's earlier in the disease state. If we could prevent a whole generation of people from getting to that moderate to severe stage by diagnosing them earlier, that's a win for everyone." She recommends making treatment decisions based on more than one single test, and often a combination of tests can lead to a diagnosis. For instance, if the patient has normal osmolarity but high symptoms and elevated MMP-9 levels, the patient may have an inflammatory condition—like superior limbic keratoconjunctivitis, or recurrent erosions due to map-dot fingerprint—that may masquerade as dry eye. Dr. Farid stressed clinicians must take the whole patient into consid- eration when developing treatment strategies. "Testing should supplement the exam," she said, but clinicians should continue to treat the symptoms. Using older diagnostic tools Newer tests don't necessarily mean throwing out the older ones. Staining is "still very valuable," Dr. Starr said, as is tear break-up time (TBUT). If the patient has fluorescein staining on the ocular surface, "it's already a late-stage finding," Dr. Farid said. Dr. Gupta "routinely" measures TBUT and uses corneal flu- orescein staining because "patients tolerate it well and it's inexpensive." She'll also use lissamine green, but only for select cases where she's looking for specific evidence of inflammatory conditions. Schirmer's, on the other hand, is more error-prone. "Schirmer's doesn't give you a whole lot of strong evidence," Dr. Farid said. "Reflex tearing can affect the result," as can meibomian gland dysfunction. Rose bengal is still use- ful in cases of herpetic eye disease, she said. With optical coherence tomog- raphy and keratography that can noninvasively measure the tear me- niscus height, area, and volume, and other tests to differentiate between aqueous deficient and evaporative dry eye, Dr. Starr said tests like Schirmer's are becoming obsolete. "In those patients with suspected aqueous deficiency dry eye disease, we should have a very low threshold for ruling out Sjögren's syndrome in both men and women," he added. "What's more important is if I do a test, I want to see how it's going to change my management," Dr. Gupta said. "There are very few times that Schirmer's changes my management." EW Editors' note: Dr. Farid has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Allergan (Dub- lin, Ireland), Rapid Pathogen Screening, and Shire (Lexington, Massachusetts). Dr. Gupta has financial interests with Rapid Pathogen Screening, TearLab, and TearScience. Dr. Starr has finan- cial interests with Allergan, Bausch + Lomb, Rapid Pathogen Screening, Shire, Sun Pharma (Mumbai, India), and TearLab. Contact information Farid: mfarid@uci.edu Gupta: preeya.gupta@duke.edu Starr: cestarr@med.cornell.edu 840 Walnut Street Philadelphia, PA 19107 1-877-AT-WILLS This 18-year-old bullet was still trying to kill him. He was an innocent bystander, hit in the eye by a stray bullet in 1998. He was lucky to be alive. The bullet was deemed by others too risky to remove. He lived with it lodged behind his right eye all of these years. But the bullet came back to haunt him. It was the source of recurring infections that threatened his remaining sight, and possibly his life. See what happens at www.willseye.org/mysteries Diagnosing continued from page 42

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