Dry Eye Dx and Tx

Adopt Changes Today to Help Patients Tomorrow, Part 1

BY AMBER GAUME GIANNONI, OD, FAAO

Occasionally, you come across a quick tip or two that is simple, effective, and makes you ask, “why didn’t I think of this?” This column will introduce you to a few tips that you can employ to help improve your diagnostic and therapeutic capability.

1. Lid Margin Exfoliation

Therapeutic meibomian gland (MG) expression can be accomplished using several methods. LipiFlow (TearScience, Inc.) is a device that heats the internal lids while fully expressing both lids simultaneously. Unfortunately, instrument cost is prohibitive for most eyecare practitioners.

An alternative method is to warm the lids externally and use a paddle expressor. This procedure is significantly less costly; however, it is often more uncomfortable, time-consuming, and likely provides only partial expression.

Regardless of the method used, we lightly scrape all lid margins prior to expression using an ophthalmic spatula. This loosens overlying debris and dead cells to improve treatment effect. In fact, a small study found that this procedure alone (i.e., not followed by gland expression) decreased symptoms and increased MG function compared to controls (Korb and Blackie, 2013). Staining the Marx’s line with lissamine green can improve visualization of the area to be exfoliated.

2. Diagnostic MG Expression

Many of us scan the lids and lashes during our slit lamp exam, and if everything appears normal, we assume the MGs must be normal, too. Unfortunately, this is not always the case, and direct observation of gland contents is necessary to evaluate gland health.

Meibum should be thin and clear, much like olive oil. Turbid or milky secretions are an early sign of reduced oil quality, which warrants intervention before the oil becomes thick and pasty and before permanent lid changes occur (i.e., redness, telangiectasia, and scalloping). Most of us are in the business of promoting ocular health and preventing disease, so give those lids a push on every single patient; I bet you’ll be surprised at what you begin to discover.

3. Actively Look for Demodex

We often suspect Demodex infestation when we observe cylindrical dandruff, but there hasn’t been a great way to obtain a precise diagnosis without a microscope. Mastrota (2013) suggests that twirling a single eyelash in circles forces the mite out of the follicle where it can be observed through the slit lamp. The next time you suspect Demodex, try this technique for a definitive diagnosis without epilation.

4. Add a Dry Eye Screening Device to Your Patient Workup

As busy practitioners, we tend to actively look for dry eye only when a patient reports symptoms. But, by the time a patient is symptomatic, the disease process has usually advanced and is more difficult to treat. So, why aren’t we assessing for dry eye on every single patient?

Tear production testing, vital dye staining, detailed lid margin assessment, and diagnostic meibomian gland expression can be extremely time-consuming to perform on everyone. This is where point-of-care devices can be beneficial to your practice. A staff member can employ one or more of these tests during the pre-exam workup to identify patients at risk for developing dry eye disease. These patients can then be scheduled for a medical workup at a later date.

In my next column, I will discuss point-of-care testing. CLS

For references, please visit www.clspectrum.com/references and click on document #225.

Dr. Gaume Giannoni is a clinical associate professor at the University of Houston College of Optometry and is the director of the Dry Eye Center at the University Eye Institute. She also sees patients in a private practice setting and has received authorship honoraria from Bausch + Lomb.