Eyeworld

EW FEATURE 52 Dry eye disease update • November 2017 AT A GLANCE • Using a questionnaire can be helpful for physicians to better pinpoint patients' dry eye symptoms, and there are a variety of questionnaires available. • With numerous testing options available, it's up to the surgeon to decide which tests fit best in their practice. • Tear osmolarity testing and MMP-9 testing are two popular tests often used in dry eye diagnosis. by Ellen Stodola EyeWorld Senior Staff Writer if it's really high or really low, this could be helpful. Depending on the patient, he will also use osmolarity testing, but Dr. Rapuano noted that osmo- larity can only be done on an eye that you haven't done anything to, like checking pressure, putting in fluorescein, etc. Oftentimes, he is not able to do osmolarity on the patient's first visit because by the time he sees the patient, too much has been done on the eye. MMP-9 point-of-care testing Dr. Bunya said that MMP-9 testing can potentially be useful in certain situations, such as evaluating asymp- tomatic patients prior to cataract or refractive surgery for subclinical dry eye disease, but she added that further studies are needed. "Also, if MMP-9 testing results are shown to be prognostic of results to different therapies, this would be clinically useful in guiding treatment," she said. "However, more studies are needed to clarify the role of MMP-9 point-of-care testing in dry eye dis- ease." One caveat that is important to keep in mind when interpreting MMP-9 results, she added, is that this test can be elevated in other ocular conditions, such as infection and allergic conjunctivitis. Dr. Rapuano thinks that In- flammaDry MMP-9 testing may be helpful to find evidence of inflam- mation, although he noted that he does not routinely use it. He said that a new osmolarity test from TearLab (San Diego), the Discovery There are other diagnostic tests available to quantify various aspects of tear film and ocular surface health, such as the LipiView, which quantifies lipid thickness, and the Pentacam (Oculus, Arlington, Wash- ington). The Keratograph (Oculus) is another potential diagnostic that can highlight meibomian gland atrophy, non-invasively measure TBUT and tear meniscus height, and quantify bulbar hyperemia. That said, Dr. Galor doesn't routinely use these imaging devices as part of her dry eye workup. Dr. Galor stressed that it isn't always about what test to use. "You should look at your practice and flow, then figure out what to do that's standardized," she said. Dr. Rapuano said it's nice to first have a questionnaire, adding that he tries to use the OSDI, but it some- times can be challenging to use this in a busy practice. He said the SPEED questionnaire is also helpful. Dr. Rapuano mentioned the UNC Dry Eye Management Scale, which has a line that has a sad face on the left and a smiley face on the right, and patients put an X where they think their symptoms are. In addition to questionnaires, Dr. Rapuano will use fluorescein staining and a slit lamp exam on ev- ery patient, as well as look at TBUT. Typically, he'll do lissamine green staining, which can pick up some of the earlier dry eye and ocu- lar surface problems on the conjunc- tiva. On the first visit, he will often do a Schirmer's test as well because questionnaires in dry eye diagnosis, specifically the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire and a modified Ocular Surface Disease Index (OSDI). The modified OSDI used at Virginia Eye Consultants has six additional ques- tions that further pinpoint history of allergy or blepharitis. Dr. Sheppard frequently uses os- molarity, MMP-9, and meibography testing, and all technicians at his practice are trained to do this. Dr. Bunya said that she current- ly has all of her dry eye patients fill out the OSDI questionnaire at every visit. "This allows me to follow their symptoms in a more quantitative manner," she said. "However, I also find it useful to take a detailed history and have patients describe factors such as what improves or worsens their symptoms and what activities are most limited by their dry eye disease." In select patients, she will use additional testing such as meibography, MMP-9 testing, or LipiView (TearScience, Morrisville, North Carolina). "All of my dry eye patients fill out an OSDI questionnaire at each visit, and I also perform a traditional ocular surface evaluation including tear breakup time (TBUT), ocular surface staining with fluorescein and lissamine green, and Schirmer's test- ing," Dr. Bunya said. "Depending on those results, I decide if additional testing is needed." Dr. Galor said that a compre- hensive but quick and standardized way of assessment is important for dry eye, especially because there are so many subsets of dry eye. She will start with a standardized question- naire. She then checks tear osmolar- ity and the presence of MMP-9 on the ocular surface with the Inflam- maDry (Quidel, San Diego). Dr. Galor evaluates eyelid anatomy and laxity and uses a penlight to retroilluminate meibo- mian gland anatomy. She follows this with a slit lamp examination noting TBUT, staining, tear lake height and location, conjunctival chalasis, and eyelid margin features. She uses a combination of these tests to group individuals into four main categories: (1) inflammatory/aque- ous tear deficiency, (2) evaporative deficiency/meibomian gland issues, (3) anatomical issues of the eyelids/ conjunctiva, (4) nerve dysfunction. Experts discuss some of the many testing options available for dry eye D ry eye continues to be a problem that often goes untreated in many patients. However, there are a variety of diagnos- tics and testing options available for patients. Vatinee Bunya, MD, co-director of the Penn Dry Eye and Ocular Surface Center, Philadelphia, Anat Galor, MD, Miami VAMC, and Bascom Palmer Eye Institute, Miami, Christopher Rapuano, MD, director of the cornea service, Wills Eye Hospital, Philadelphia, and John Sheppard, MD, president, Virginia Eye Consultants, Norfolk, Virginia, discussed which diagnostics may be best for certain patients and some of the tests they utilize in their prac- tices. Diagnostic tests for all patients There have been many advances in diagnostics and therapeutics, but Dr. Sheppard noted that some of the best information comes from a directed and complete history and physical exam. "We use an incred- ible array of diagnostics to further the suspicions that arise from dissecting the patient's symptoms and carefully looking for the most important signs on the ocular sur- face that will best direct therapy," he said. "Our goal is to make the right diagnosis the first time and give pa- tients the best chance of achieving a significant improvement in vision and lifestyle with the least amount of trial and error." Dr. Sheppard said that he uses Diagnostics for dry eye Diffuse corneal staining in a patient with Sjögren's syndrome Source: Anat Galor, MD

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