Eyeworld

6 Advanced diagnostics in action: Identifying ocular surface disease in cataract and refractive patients by Alice Epitropoulos, MD Case report: Using advanced diagnostics to distinguish mixed causes of dry eye before cataract surgery This patient's Schirmer's score was 3 in the right eye and 7 in the left eye. Tear osmolarity was abnormal: 310 mOsm in the right and 318 mOsm in the left eye. MMP-9 results were posi- tive. Meibography showed mild atrophy of the meibomian glands. present a case of a 47-year-old woman with a cataract as well as dry eye, dry mouth, dry nose, and arthritic discomfort. Her com- plaints included ocular burning, foreign body sensation, and intermittent blurred vision with prolonged reading. release of inflammatory cytokines and subsequent apoptotic cell death. 2 Although tear osmolarity does not differentiate between ADDE and EDE, it is an excellent measure of disease severity and treatment response. Diagnostic steps In our practice, all patients complete a dry eye questionnaire, which can be used to evaluate and document their response to treatment over time. If the SPEED score is 6 or higher, our technicians perform tear osmolarity, MMP-9 testing, and corneal topography before drops are instilled. 3,4 However, because many patients with dry eye do not have symptoms, we need to actively search for dry eye in everyone. We can examine the meibo- mian gland structure by transil- luminating the glands or with gland imaging, but meibography provides quality high-definition images. 5 We also assess the number of partial and incomplete blinks and look for an adequate lid seal. The hallmarks for accurate diagnosis remain a careful history and clinical examination. Lid and lid margin evaluation should be part of every examination. Traditional diagnostics such as tear breakup time, lid expres- sion, and staining also should be performed to help distinguish ADDE and EDE. Figure 1 shows an example of corneal staining in a case of mixed ADDE/EDE. Case report To illustrate a diagnostic protocol for mixed ADDE and EDE, I will By differentiating aqueous deficient and evaporative dry eye, diagnostic tools help clinicians customize treatment strategies E ighty-six percent of patients with dry eye have evaporative dry eye (EDE), but all patients should be screened for both EDE and aqueous deficient dry eye (ADDE) or mixed EDE/ ADDE. 1 Once the diagnosis is made, we can determine the subtype or subtypes and severity. Typically, ADDE can be diagnosed by low tear volume and production and hyperosmolarity. Tear hyperosmolarity in ADDE results from reduced tear production by the lacrimal glands with a normal evaporation rate. Increased tear osmolarity has been shown to be the principal factor causing damage to the epithelial cells, triggering the Figure 1. Corneal staining due to mixed ADDE/EDE Source: William Trattler, MD Alice Epitropoulos, MD

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