Eyeworld

EW CORNEA 42 February 2017 by Michelle Dalton EyeWorld Contributing Writer don't always correlate, and we need to catch those patients who may have inflammatory dry eye and treat them" before surgery, she added. For novice users of these tests, choosing which ones to use can be overwhelming but will serve patients better over the long run, Dr. Gupta said. Dr. Starr added that the time when patient complaints equated to artificial tears only is antiquated. Regardless of patient symptom- atology, "you will want to optimize the ocular surface to get the best refractive results," Dr. Farid said. "A poor ocular surface will cause vari- ability in the preop measurements, including biometry and topography. This can adversely affect calculations for toric lenses." Dr. Starr added, "If the ocular surface is not optimized or if you've missed early or subtle disease that might get worse after surgery, you're going to have a lot of headaches with the unhappy patient." Dry eye remains underdiagnosed in the sur- gical patient because it's simply not being screened enough, and practi- tioners may not realize it involves more than just red or scratchy eyes, Dr. Gupta said. She added that novice practitioners should start with the one test that resonates with them and embrace the technology. "You have to be educated if you're going to adopt these tools. Trust the test results," Dr. Starr said. Managing patient expectations can be easy; Dr. Gupta tells patients these tests are part of their "ocular He also recommends having office technicians review the answers and run the appropriate tests before the physician sees the patient. As Dr. Gupta became more confident with the newer tests, she began lowering her threshold to use them. "I used to just screen my symptomatic patients, but now I'm much more aggressive about testing my refractive and cataract surgical patients because I don't want to miss any sort of ocular surface disease," she said. Surgical patients—be it those in their 20s or 30s presenting for LASIK or those in their 60s who want refrac- tive cataract surgery—are at a "high risk for dry eye, and diagnosing the condition pre-surgery is necessary," Dr. Gupta said. Her cataract practice is predominantly refractive cataract surgery. She said, "Patients are look- ing for a specific outcome. In order to deliver on what you're promising to the patient, you have to ensure a healthy tear film." Dr. Farid also thinks using the tests to monitor improvement is necessary. "I use the InflammaDry on any patient who comes in for dry eye. I'll do follow-up testing on patients in a couple of months. Often when you show patients an objective sign of their disease, they're much more willing to be compliant with treatment," she said. She also performs an InflammaDry test on all new surgical patients "because the signs and symptoms of dry eye select the appropriate treatment course. "High tear osmolarity is one of the definitions of dry eye in the DEWS [Dry Eye WorkShop] report," she said. "Results from tear film testing can differentiate dry eyes from some other sort of masquerad- ing-type syndromes like conjuncti- vochalasis." The newest tests do help refine a diagnosis, yet "none of them can take the place of talking to a patient and examining a patient under the slit lamp," said Christopher Starr, MD, associate professor of oph- thalmology, director of the cornea fellowship, director of refractive surgery, and director of ophthalmic education, Weill Cornell Medicine, New York. "The clinical exam is still extremely important, and that's always going to be the case. These novel diagnostics can certainly help improve our accuracy, though, especially in atypical cases, subtle or early disease states, ruling out dry eye disease masqueraders, and with monitoring treatment efficacy." Perhaps equally important, Dr. Gupta said, is that the tests provide "so much information about how we should manage these patients." Ultimately, these tests will save practitioners and patients time, as "you're getting to the true diagnosis or diagnoses much more accurately and reliably. The proper treatment(s) can be initiated sooner," Dr. Starr said. Symptomatic patients are given the TearLab and InflammaDry tests initially by the technician. "Neither of those significantly disrupt the tear lake or the ocular surface, so when I ultimately see the patient, I'm not looking at an iatrogenically altered ocular surface because of those tests." Should all patients receive all tests? Not all patients will need extensive testing. "It's not appropriate to test every single person who walks in the door," Dr. Starr said. With so many overlapping symptoms, he recom- mends asking patients to complete a questionnaire, either written or verbally, to narrow down which symptoms are most problematic be- fore using all the latest diagnostics. Newer diagnostic tests help clinicians identify dry eye patients E valuating the ocular surface for dry eye before sched- uling patients to under- go surgery is becoming commonplace, but so is screening most patients for dry eye at their initial presentation. One rea- son is newer technology and devices have made screening a bit easier and much less invasive than earlier diagnostics. EyeWorld spoke to leading corneal specialists to find out which of the newer devices they use most often and how often they reevalu- ate patients. Of the newer devices, the InflammaDry (Rapid Pathogen Screening, Sarasota, Florida), the LipiView or LipiScan (TearScience, Morrisville, North Carolina), and the TearLab Osmolarity Test (TearLab, San Diego) are more commonly used than the Sjo test (Bausch + Lomb, Bridgewater, New Jersey). "Meibomian gland imaging can give clinicians a wealth of informa- tion," said Preeya K. Gupta, MD, assistant professor of ophthalmol- ogy, Duke University Eye Center, Durham, North Carolina. "Meibomian gland atrophy doesn't happen overnight, so if you see atrophy, you know that the un- derlying disease has been present for quite some time, while the patient may only have been symptomatic for a few months," she said. "Mei- bography will confirm that in the background there has been chronic inflammation, chronic dysfunction of the glands. That's valuable infor- mation." The newer diagnostic tests "are very effective at supplementing the exam. But a good exam for diagnos- ing dry eyes is still essential," said Marjan Farid, MD, director of cor- nea, cataract, and refractive surgery, vice-chair of ophthalmic faculty, and associate professor of ophthal- mology, Gavin Herbert Eye Institute, University of California, Irvine. For instance, Dr. Farid will run a full set of diagnostics on new patients who present with dry eye symptoms, but she relies on the tests to guide her diagnoses and help Diagnosing dry eye continued on page 45 Device focus " If the ocular surface is not optimized or if you've missed early or subtle disease that might get worse after surgery, you're going to have a lot of headaches with the unhappy patient. " –Christopher Starr, MD

• Cover