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Home , Conjunctivochalasis

OD OS Lids/Lashes 2+ 2+ blepharitis Clear, no injection 1-2+ injection, inferior conjunctival ridge Clear 3+ diffuse SPK, epithelial ridge, (-)dendrite Tear film Normal Decreased TBUT Anterior Chamber Deep and Quiet Deep and Quiet Clear Clear Corneal Sensitivity Normal Reduced OD OS Normal Normal C/D Ratio 0.3/0.3 0.3/0.3 Macula Normal Normal Vessels Normal Normal Periphery Pigmented superior holes, Scleral buckle in place, (-)fluid, (-)RD, (-) (-)RD/tear Vitreous Clear Clear

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Hyperplasia or irregularity of Recurrent or persistent Stromal involvement leads to epithelium epithelial defect , melting, -may evolve to punctate -usually superior half of cornea, perforation keratopathy, corneal edema, oval shape with smooth edges neovascularization, stromal scarring

Dry Eye: What to Look for When There is a • None Mismatch Between Signs and Symptoms Disclosures

Courtney Melchione, OD Cornea and Contact Lens Resident Specialty Eyecare Group, Seattle, Washington 2020 NW Residents Conference Forum

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The Dry Eye Patient The Dry Eye Work-Up

Elements evaluated Foreign Fluctuating Burning Pain Tearing body Patient experience Symptom surveys vision sensation Quality of tears TBUT, inflammatory markers, osmolarity

Quantity of tears Tear Meniscus Height, Schirmer’s, Light Phenol Red Thread Itching Dryness Grittiness Redness sensitivity Structural integrity Meibography

Damage from dry eye Vital dyes (Lid wiper epitheliopathy, Marx’s Line)

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Response to Dry Eye Therapy

Symptom Improvement Sign Improvement No Symptom Improvement

Shen Lee B, Kabat A, Bacharach J, et al. Managing Dry and Facilitating Realistic Patient Expectations: A Review and Appraisal of Current Therapies. Clinical . 2020; 14: 119-126. Bartlett J, Keith M, Sudharshan L, et al. Associations between signs and symptoms of dry eye: a systemic review. Clinical Ophthalmology. 2015 September; 9: 1719-1730. 5 6

1 Nonobvious Obstructive NOMGD Dysfunction (NOMGD) Desiccating stress • New model of pathogenesis • • Blackie and Korb 2010 Atrophy may be related to Unstable tear film exhaustion of acini • Evaluate function of meibomian glands • Mechanical obstruction from Upregulated meibum production • No signs of inflammation or obstruction thicker meibum • Possible precursor to obvious MGD Possible precursor to obvious MGD Higher protein content in meibum

Thick meibum

Blackie C, Korb D, Knop E, et al. Nonobvious Obstructive Meibomian Gland Dysfunction. Cornea. 2010 December; 29: 1333-1345.

Hwang H, Parfitt G, Brown D, et al. Meibocyte differentiation and renewal: Insights into novel mechanisms of meibomian gland dysfunction (MGD). Experimental Eye Research. 2017 February; 163: 37-45. 7 8

NOMGD Lid Seal

• How to identify • The Korb-Blackie Light Test • Standardized evaluation of • Method to identify incomplete lid closure meibomian gland function • Source of desiccating stress • Treatment • Improve quality and flow of meibum • Identify desiccating stress

Blackie C, Korb D. A Novel Lid Seal Evaluation: The Korb-Blackie Light Test. Eye and Contact Lens. 2015 March; 41: 98-100.

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Lid Seal Lid Seal Specialty Eyecare Lid Seal Prevalence • Korb 2017 prevalence in Symptomatic Asymptomatic • General population prevalence Severe, 1% Grade refractory dry eye and Grade study 3, 8% asymptomatic patients 2, 6% • 155 consecutive subjects, age Negative, Grade 3, Negative range 7 to 82 21% • Prevalence of lid seal 4 , 20% Grade 25% Moderate, 1, 6% • 79% had positive lid seal times greater in 39% Grade 1, • 40% moderate to severe refractory symptomatic 18% Grade 2, • group Negative, Two graders with similar results Mild, 38% 36% 80%

Korb D, Blackie C, Nau A. Prevalence of Compromised Lid Seal in Symptomatic Refractory Dry Eye Patients and Asymptomatic Patients. Investigative Ophthalmology and Visual Science. 2017 March; 58: 2696. Kading D, Melchione C, He S. Population Prevalence of Lid Seal. 2020. Pending publication. 11 12 Dry Eye: What to Look for When There is a • None Mismatch Between Signs and Symptoms Disclosures

Courtney Melchione, OD Cornea and Contact Lens Resident Specialty Eyecare Group, Seattle, Washington 2020 NW Residents Conference Forum

1 2

The Dry Eye Patient The Dry Eye Work-Up

Elements evaluated Foreign Fluctuating Burning Pain Tearing body Patient experience Symptom surveys vision sensation Quality of tears TBUT, inflammatory markers, osmolarity

Quantity of tears Tear Meniscus Height, Schirmer’s, Light Phenol Red Thread Itching Dryness Grittiness Redness sensitivity Structural integrity Meibography

Damage from dry eye Vital dyes (Lid wiper epitheliopathy, Marx’s Line)

3 4

Response to Dry Eye Therapy

Symptom Improvement Sign Improvement No Symptom Improvement

Shen Lee B, Kabat A, Bacharach J, et al. Managing Dry Eye Disease and Facilitating Realistic Patient Expectations: A Review and Appraisal of Current Therapies. Clinical Ophthalmology. 2020; 14: 119-126. Bartlett J, Keith M, Sudharshan L, et al. Associations between signs and symptoms of dry eye: a systemic review. Clinical Ophthalmology. 2015 September; 9: 1719-1730. 5 6

1 Nonobvious Obstructive Meibomian Gland NOMGD Dysfunction (NOMGD) Desiccating stress • New model of pathogenesis • • Blackie and Korb 2010 Atrophy may be related to Unstable tear film exhaustion of acini • Evaluate function of meibomian glands • Mechanical obstruction from Upregulated meibum production • No signs of inflammation or obstruction thicker meibum • Possible precursor to obvious MGD Possible precursor to obvious MGD Higher protein content in meibum

Thick meibum

Blackie C, Korb D, Knop E, et al. Nonobvious Obstructive Meibomian Gland Dysfunction. Cornea. 2010 December; 29: 1333-1345.

Hwang H, Parfitt G, Brown D, et al. Meibocyte differentiation and renewal: Insights into novel mechanisms of meibomian gland dysfunction (MGD). Experimental Eye Research. 2017 February; 163: 37-45. 7 8

NOMGD Lid Seal

• How to identify • The Korb-Blackie Light Test • Standardized evaluation of • Method to identify incomplete lid closure meibomian gland function • Source of desiccating stress • Treatment • Improve quality and flow of meibum • Identify desiccating stress

Blackie C, Korb D. A Novel Lid Seal Evaluation: The Korb-Blackie Light Test. Eye and Contact Lens. 2015 March; 41: 98-100.

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Lid Seal Lid Seal Specialty Eyecare Lid Seal Prevalence • Korb 2017 prevalence in Symptomatic Asymptomatic • General population prevalence Severe, 1% Grade refractory dry eye and Grade study 3, 8% asymptomatic patients 2, 6% • 155 consecutive subjects, age Negative, Grade 3, Negative range 7 to 82 21% • Prevalence of lid seal 4 , 20% Grade 25% Moderate, 1, 6% • 79% had positive lid seal times greater in 39% Grade 1, • 40% moderate to severe refractory symptomatic 18% Grade 2, • group Negative, Two graders with similar results Mild, 38% 36% 80%

Korb D, Blackie C, Nau A. Prevalence of Compromised Lid Seal in Symptomatic Refractory Dry Eye Patients and Asymptomatic Patients. Investigative Ophthalmology and Visual Science. 2017 March; 58: 2696. Kading D, Melchione C, He S. Population Prevalence of Lid Seal. 2020. Pending publication. 11 12 NOP Differentials for Dry • Amniotic membrane Eye Symptoms • Subbasal nerve density improvement • Nonobvious Obstructive • 72% reduction in neuropathic pain Meibomian Gland Dysfunction lasting up to the 9 months of follow up • Lid Seal • Autologous serum • Binocularity and • 20% AST 8 times a day • 56% of subjects reported 90% • Conjunctival Chalasis improvement, 44% reported 40- 60% improvement • Neuropathic Ocular Pain

1. Morkin M, Hamrah P. Efficacy of self-retained cryopreserved amniotic membrane for treatment of neuropathic corneal pain. The Ocular Surface. 2017; 16: 132-138. 2. Aggarwal S, Kheirkhah A, Cavalcanti B, et al. Autologous Serum Tears for Treatment of Photoallodynia in Patients with Corneal Neuropathy: Efficacy and Evaluation with In Morkin 2018 Vivo Confocal Microscopy. The Ocular Surface. 2015 July; 13: 250-262. 25 26

References References

• Galor, A, Moein H, Lee C, et al. Neuropathic pain and dry eye. The Ocular Surface. 2018; 16: 31-44. • Meller D, Maskin S, Pires R, et al. Amniotic Membrane Transplantation for Symptomatic Conjunctivochalasis Refractory to • Shen Lee B, Kabat A, Bacharach J, et al. Managing Dry Eye Disease and Facilitating Realistic Patient Expectations: A Review and Appraisal of Medical Treatments. Cornea. 2000; 19: 796-803. Current Therapies. Clinical Ophthalmology. 2020; 14: 119-126. • Meller D, Tseng S. Conjunctivochalasis: Literature Review and Possible Pathophysiology. Survey of Ophthalmology. 1998 • Bartlett J, Keith M, Sudharshan L, et al. Associations between signs and symptoms of dry eye: a systemic review. Clinical Ophthalmology. November; 43: 225-232. 2015 September; 9: 1719-1730. • Blackie C, Korb D, Knop E, et al. Nonobvious Obstructive Meibomian Gland Dysfunction. Cornea. 2010 December; 29: 1333-1345. • Nettune G, Pflugfelder S. Post-LASIK Tear Dysfunction and Dysesthesia. The Ocular Surface. 2010 July; 8: 135-145. • Hwang H, Parfitt G, Brown D, et al. Meibocyte differentiation and renewal: Insights into novel mechanisms of meibomian gland dysfunction • Sajnani R, Raia S, Gibbons A, et al. Epidemiology of Persistent Postsurgical Pain Manifesting as Dry Eye-Like Symptoms (MGD). Experimental Eye Research. 2017 February; 163: 37-45. After Surgery. Cornea. 2018 December; 37: 1535-1541. • Blackie C, Korb D. A Novel Lid Seal Evaluation: The Korb-Blackie Light Test. Eye and Contact Lens. 2015 March; 41: 98-100. • Morkin M, Hamrah P. Eff icacy o f self-retained cryopreserved amniotic membrane for treatment of neuropathic corneal • Korb D, Blackie C, Nau A. Prevalence of Compromised Lid Seal in Symptomatic Refractory Dry Eye Patients and Asymptomatic Patients. pain. The Ocular Surface. 2017; 16: 132-138. Investigative Ophthalmology and Visual Science. 2017 March; 58: 2696. • • Reuff E, Sinnott L, Bailey M, et al. The similarity between symptoms of disorders and dry eye. Investigative Ophthalmology Aggarwal S, Kheirkhah A, Cavalcanti B, et al. Autologous Serum Tears for Treatment of Photoallodynia in Patients with and Visual Science. 2014 April; 55: 1990. Corneal Neuropathy: Efficacy and Evaluation with In Vivo Confocal Microscopy. The Ocular Surface. 2015 July; 13: 250-262. • Reuff E, King-Smith P, Bailey M. Can Binocular Vision Disorders Contribute to Contact Lens Discomfort? Optometry and Vision Science. 2015 • Rosenthal P, Baran I, Jacobs D. Corneal Pain without Stain: Is it Real? The Ocular Surface. 2009 January; 7: 28-40. September; 92: 214-221. • Sivanesan E, Levitt R, Sarantopoulos C, et al. Noninvasive Electrical Stimulation for the Treatment of Chronic Ocular Pain • Mimura T, Yamagami S, Usui T, et al. Changes of conjunctivochalasis with age in a hospital-based study. Am J Ophthalmology. 2009 Jan; 147: 171-177. and . Neuromodulation. 2018; 21: 727-734. • Le Q, Cui X, Xiang J, et al. Impact of Conjunctivochalasis on Visual Quality of Life: A Community Population Survey. PLOS ONE. 2014 • Balal S, Nitiahpapand R, Hassan A, et al. Finger-Prick Autologous Blood in the Treatment of Persistent Corneal Epithelial October; 9. Defects. Cornea. 2019; 00: 1-4. • de Almeida S, de Sousa L, Vieira L, et al. Clinic-Cytologic Study of Conjunctivochalasis and Its Relation to Thyroid Autoimmune Diseases. Cornea. 2006 August; 25: 789-793.

27 28 Lid Seal Binocularity and Accommodation

• How to identify • Reuff 2014 • History: When do your eyes feel dry? • Completed OSDI and CISS How do you feel when you wake up • Positive correlation between survey outcomes in the morning? Do you use a fan or • Reuff 2015 CPAP? • Myopic SCL wearers with self reported DE • Korb-Blackie Light Test • Positive correlation between OSDI and CISS • Treatment • BV and dry eye testing • Seal mask • 48% of SCL wearers with DE symptoms had BV disorder • Lubricating ointment • Equally as likely to have BV disorder as DE signs • Environmental change 1. Reuff E, Sinnott L, Bailey M, et al. The similarity between symptoms of binocular vision disorders and dry eye. Investigative Ophthalmology and Visual Science. 2014 April; 55: 1990. 2. Reuff E, King-Smith P, Bailey M. Can Binocular Vision Disorders Contribute to Contact Lens Discomfort? Optometry and Vision Science. 2015 September; 92: 214-221. Blackie C, Korb D. A Novel Lid Seal Evaluation: The Korb-Blackie Light Test. Eye and Contact Lens. 2015 March; 41: 98-100. 13 14

Binocularity and Accommodation 32 yo WF

• Emerging presbyopes • Presented to clinic for AEE • Vertical phorias • Habitual glasses low plus near only correction (+1.00 DS OU) • Discomfort in CL number one • CC: dry eye, noted most discomfort when working on the computer reason for drop out • VA: 20/20 OD, OS SC distance, 20/20 OU CC at near • How to identify • Dry retinoscopy: +4.00 DS OU • BV screening • Aseg: No obvious signs of dry eye • Treatment • Address underlying problem with • Plan: Recommended patient wear habitual RX FT for one week, RTC near RX, vision therapy, prism for DEE and finalize glasses RX at that time

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98% 99% 99% 100% 94% Follow up Conjunctival Chalasis 90%

(CCH) 71% • Patient reported good adaptation to full time wear of habitual RX, DE • Population prevalence 62% symptoms resolved • By age 40-50, 90% prevalence • VA: 20/20 OD, OS distance and near • More common in women 36% with habitual RX • Higher association with • Patient was able to accept +2.50 DS autoimmune thyroid disease OU for FT wear • Most common temporal 7% • All dry eye testing normal 1. Mimura T, Yamagami S, Usui T, et al. Changes of conjunctivochalasis with age in a hospital-based study. Am J Ophthalmology. 2009 Jan; 147: 171-177. 2. de Almeida S, de Sousa L, Vieira L, et al. Clinic-Cytologic Study of Conjunctivochalasis and Its Relation to Thyroid Autoimmune Diseases. Cornea. 2006 1-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 August; 25: 789-793. 91-100

Mimura 2009 17 18 CCH CCH • Impact of CCH on Vision Quality of Meller and Tseng CCH Grading Scale • Effects of CCH Life Grade 0 No persistent fold • Decreased tear clearance rate • Compared DE, CCH, and controls • Grade 1 A single, small fold • DE and CCH had significantly worse OSDI • Mechanical irritation and V-QOL surveys • Inflammation Grade 2 Two or more folds, but not higher • Nasal and central CCH, nasal occlusion than the tear meniscus • Decreased goblet cell density

by CCH, and more severe grades of CCH 1. Le Q, Cui X, Xiang J, et al. Impact of Conjunctivochalasis on Visual Quality of Life: A Grade 3 Multiple folds and higher than the Community Population Survey. PLOS ONE. 2014 October; 9. had higher symptom scores tear meniscus 2. Meller D, Tseng S. Conjunctivochalasis: Literature Review and Possible Pathophysiology. Survey of Ophthalmology. 1998 November; 43: 225-232.

Le Q, Cui X, Xiang J, et al. Impact of Conjunctivochalasis on Visual Quality of Life: A Community Population Survey. PLOS ONE. 2014 October; 9. 19 20

CCH Neuropathic Ocular Pain (NOP)

• How to identify • Treatment • NOP is a disease of the • History: Do your eyes feel • Cyclosporine/lifitegrast, somatosensory nervous system. steroid, lubrication worse at end of day or hurt • Can involve reduced or heightened all day? Do your eyes feel • Surgical sensitivity AND spontaneous pain worse when you are • AMT with conjunctival • Peripheral versus central blinking? Do you feel like resection in 47 eyes, total sensitization something is in your eye? relief of symptoms in 96.6% • Increased risk with female and other • Evaluate location and of eyes severity chronic pain conditions 1. Meller D, Maskin S, Pires R, et al. Amniotic Membrane Transplantation for Symptomatic Conjunctivochalasis Refractory to Medical Treatments. Cornea. 2000; 1. Galor, A, Moein H, Lee C, et al. Neuropathic pain and dry eye. The Ocular Surface. 2018; 16: 31-44. 19: 796-803. 2. Rosenthal P, Baran I, Jacobs D. Corneal Pain without Stain: Is it Real? The Ocular Surface. 2009 January; 7: 28-40. 2. Meller D, Tseng S. Conjunctivochalasis: Literature Review and Possible Pathophysiology. Survey of Ophthalmology. 1998 November; 43: 225-232. 21 22

NOP NOP • How to identify • Treatment • Triggers • Comorbidity of • Cyclosporine/lifitegrast • depression, anxiety, • Autologous serum Post surgical (LASIK, PRK, CE) chronic pain conditions • 34% of patients had persistent post surgical pain 6 mos after CE • History of corneal • Amniotic membrane • Symptoms of DE found in 20-40% of LASIK patients 6 mos post op surgery • Systemic management • Topical anesthetic (gabapentin, • Chronic DE • Common symptoms: antidepressants) • Chronic inflammation burning pain, light and • Omega 3 wind sensitivity • Herpes Zoster • Electrical stimulation • Pain survey • Scleral lenses • Genetic component • Confocal microscopy

1. Galor, A, Moein H, Lee C, et al. Neuropathic pain and dry eye. The Ocular Surface. 2018; 16: 31-44. 2. Nettune G, Pflugfelder S. Post-LASIK Tear Dysfunction and Dysesthesia. The Ocular Surface. 2010 July; 8: 135-145. 1. Galor, A, Moein H, Lee C, et al. Neuropathic pain and dry eye. The Ocular Surface. 2018; 16: 31-44. 2. Sivanesan E, Levitt R, Sarantopoulos C, et al. Noninvasive Electrical Stimulation for the Treatment of Chronic 3. Sajnani R, Raia S, Gibbons A, et al. Epidemiology of Persistent Postsurgical Pain Manifesting as Dry Eye-Like Symptoms After Cataract Surgery. Cornea. 2018 Ocular Pain and Photophobia. Neuromodulation. 2018; 21: 727-734. December; 37: 1535-1541. 4. Rosenthal P, Baran I, Jacobs D. Corneal Pain without Stain: Is it Real? The Ocular Surface. 2009 January; 7: 28-40. 3. Rosenthal P, Baran I, Jacobs D. Corneal Pain without Stain: Is it Real? The Ocular Surface. 2009 January; 7: 28-40. 23 24 NOP Differentials for Dry • Amniotic membrane Eye Symptoms • Subbasal nerve density improvement • Nonobvious Obstructive • 72% reduction in neuropathic pain Meibomian Gland Dysfunction lasting up to the 9 months of follow up • Lid Seal • Autologous serum • Binocularity and Accommodation • 20% AST 8 times a day • 56% of subjects reported 90% • Conjunctival Chalasis improvement, 44% reported 40- 60% improvement • Neuropathic Ocular Pain

1. Morkin M, Hamrah P. Efficacy of self-retained cryopreserved amniotic membrane for treatment of neuropathic corneal pain. The Ocular Surface. 2017; 16: 132-138. 2. Aggarwal S, Kheirkhah A, Cavalcanti B, et al. Autologous Serum Tears for Treatment of Photoallodynia in Patients with Corneal Neuropathy: Efficacy and Evaluation with In Morkin 2018 Vivo Confocal Microscopy. The Ocular Surface. 2015 July; 13: 250-262. 25 26

References References

• Galor, A, Moein H, Lee C, et al. Neuropathic pain and dry eye. The Ocular Surface. 2018; 16: 31-44. • Meller D, Maskin S, Pires R, et al. Amniotic Membrane Transplantation for Symptomatic Conjunctivochalasis Refractory to • Shen Lee B, Kabat A, Bacharach J, et al. Managing Dry Eye Disease and Facilitating Realistic Patient Expectations: A Review and Appraisal of Medical Treatments. Cornea. 2000; 19: 796-803. Current Therapies. Clinical Ophthalmology. 2020; 14: 119-126. • Meller D, Tseng S. Conjunctivochalasis: Literature Review and Possible Pathophysiology. Survey of Ophthalmology. 1998 • Bartlett J, Keith M, Sudharshan L, et al. Associations between signs and symptoms of dry eye: a systemic review. Clinical Ophthalmology. November; 43: 225-232. 2015 September; 9: 1719-1730. • Blackie C, Korb D, Knop E, et al. Nonobvious Obstructive Meibomian Gland Dysfunction. Cornea. 2010 December; 29: 1333-1345. • Nettune G, Pflugfelder S. Post-LASIK Tear Dysfunction and Dysesthesia. The Ocular Surface. 2010 July; 8: 135-145. • Hwang H, Parfitt G, Brown D, et al. Meibocyte differentiation and renewal: Insights into novel mechanisms of meibomian gland dysfunction • Sajnani R, Raia S, Gibbons A, et al. Epidemiology of Persistent Postsurgical Pain Manifesting as Dry Eye-Like Symptoms (MGD). Experimental Eye Research. 2017 February; 163: 37-45. After Cataract Surgery. Cornea. 2018 December; 37: 1535-1541. • Blackie C, Korb D. A Novel Lid Seal Evaluation: The Korb-Blackie Light Test. Eye and Contact Lens. 2015 March; 41: 98-100. • Morkin M, Hamrah P. Eff icacy o f self-retained cryopreserved amniotic membrane for treatment of neuropathic corneal • Korb D, Blackie C, Nau A. Prevalence of Compromised Lid Seal in Symptomatic Refractory Dry Eye Patients and Asymptomatic Patients. pain. The Ocular Surface. 2017; 16: 132-138. Investigative Ophthalmology and Visual Science. 2017 March; 58: 2696. • • Reuff E, Sinnott L, Bailey M, et al. The similarity between symptoms of binocular vision disorders and dry eye. Investigative Ophthalmology Aggarwal S, Kheirkhah A, Cavalcanti B, et al. Autologous Serum Tears for Treatment of Photoallodynia in Patients with and Visual Science. 2014 April; 55: 1990. Corneal Neuropathy: Efficacy and Evaluation with In Vivo Confocal Microscopy. The Ocular Surface. 2015 July; 13: 250-262. • Reuff E, King-Smith P, Bailey M. Can Binocular Vision Disorders Contribute to Contact Lens Discomfort? Optometry and Vision Science. 2015 • Rosenthal P, Baran I, Jacobs D. Corneal Pain without Stain: Is it Real? The Ocular Surface. 2009 January; 7: 28-40. September; 92: 214-221. • Sivanesan E, Levitt R, Sarantopoulos C, et al. Noninvasive Electrical Stimulation for the Treatment of Chronic Ocular Pain • Mimura T, Yamagami S, Usui T, et al. Changes of conjunctivochalasis with age in a hospital-based study. Am J Ophthalmology. 2009 Jan; 147: 171-177. and Photophobia. Neuromodulation. 2018; 21: 727-734. • Le Q, Cui X, Xiang J, et al. Impact of Conjunctivochalasis on Visual Quality of Life: A Community Population Survey. PLOS ONE. 2014 • Balal S, Nitiahpapand R, Hassan A, et al. Finger-Prick Autologous Blood in the Treatment of Persistent Corneal Epithelial October; 9. Defects. Cornea. 2019; 00: 1-4. • de Almeida S, de Sousa L, Vieira L, et al. Clinic-Cytologic Study of Conjunctivochalasis and Its Relation to Thyroid Autoimmune Diseases. Cornea. 2006 August; 25: 789-793.

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