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Home , Astigmatism

6/2/2019

• No Financial Discolsure

Dry eye? Not so dry! Work-up of dry eye patients

Maya Bitar, MD 06/08/2019

Course objectives: Patient 1 • Understanding dry eyes as a multifactorial disease • Understanding the importance of screening for dry eyes • 40 yo F banker c/o fluctuating vision, eyes • Learning to perform step by step dry eye work-up: feels tired 1. Taking an oriented history 2. Assessing dry eyes subjectively by dry eye questionnaires 3. check 4. Point of care testing for dry eyes 5. Shirmer test 6. Slit lamp exam • Fulfilling the technicians’ role as first-line educators

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Patient 2 Patient 3

• 60 yo M truck driver c/o eyes tearing • 70 yo F c/o eye not being able to open her eyes

• All these patients with different complains Tear Film Anatomy actually turned out to have . • Dry eye syndrome patients are not always just “dry”. • New definition for dry eyes : multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles

(TFOS DEWS II) https://www.researchgate.net/figure/Scheme-of-tear-film-according-to-recent- knowledge-with-regard-to-surfactant-proteins_fig3_236032886

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Burden of Dry Eye Syndrome

• DES impacts negatively on a person well-being, work productivity, finances (1). • Moderate to severe dry eye can cause decrease in the QOL comparable with that in dialysis, severe angina, and disabling hip fracture (2). • Severity of dry eye symptoms correlate with severity of dry eyes symptoms (3) . • Improvement in dry eye symptoms after treatment correlated with improvement in anxiety and depression (3).

https://vismed.trbchemedica.co.uk/business-professionals/understanding-the-tear-film/the-secretory-system

• Irregular tear film/corneal surface and high tear osmolarity can affect: Wavefront aberrations, Dry Eye Work-up Keratometry, and Central corneal thickness (4). => affect and laser outcomes

• There have been a proliferation of new prior and 1 month after dry eye treatment showing much more regularity of modalities of dry eye testing since then. astigmatism

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1. History Taking • Observe patient • Symptoms - checklist integrated in EHR

Redness • Systemic diseases associated with dry eyes like Burning thyroid disease, connective tissue Itching diseases/arthritis/Sjoegren’s, Bell’s palsy. Light sensitivity Excessive tearing/watery eyes • Eyedrops specifying brand/generic… Tired eyes/eye fatigue • Systemic medications that could affect dry Stringy mucous in or around the eye Foreign body sensation eyes like Antihistaminics, retinoids, Contact discomfort antidepressant, betablockers, diuretics, Scratchiness, grittiness, feeling of sand in the eyes anticholinergics, chemo. Fluctuating vision

• A positive answer triggers the dry eye protocol

2. Questionnaires

• SPEED questionnaire • Great for screening/new patients • Can be completed by patient in the waiting room

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• UNC Dry Eye Management Scale (DEMS) . Single item, quick questionnaire designed to be used in everyday clinical practice. . Take into account 3 parameters:  Severity of symptoms  Effect on daily life  Time frame: last week . Score /10 . Great to follow patient’s progression from visit to visit.

https://www.med.unc.edu/ophth/for-patients/clinical-specialties/unc-dry-eye-management-scale

. Administered by technician working-up the patient 3. Check vision

1. Identify the patient’s complaints and symptoms of …. But do not check pressure yet! dry eyes. 2. “ Take your symptoms that are most important to you and score them on a 1-10 scale according to their effect on your daily life over the last week; a “10” meaning, “I need to see a doctor immediately”, and a “1” meaning, “no problem, I can easily deal with it”

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Point of care testing 4. Point of care testing

• Most need to be administered before any drop or • MMP-9 testing touching the ocular surface. “pregnancy test” • Many new technologies are available. “shows how much your eyes are inflamed” . Result read at 10 min • 3 main functions: diagnosis, patient education, and treatment tracking. • • Each test a different factor of dry eye. Tear Osmolarity “ shows the amount of salts • Help direct treatment. in your tears” • Help engage patient in the treatment plan by . > 300 mOsm/L showing them objective parameters of their . Severity scale disease. . PPV 89% No eyedrop in the 2 hours prior to both tests

• Meibomography • Sjö test: “like taking a dental X-ray” Great for patient education, Blood test for Sjogren’s sd comprise novel staging the disease and antibodies expressed earlier compared to LipiView II Ocular Surface Interferometer For practice offering traditional SS biomarkers MGD procedures • Oculus keratograph:

• Tear film lipid layer TBUT measurement, inferior meniscus height interferometry Evaluate blink dynamics and lipid layer thickness

http://www.Lipiflow.com

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5. Shirmer test Limitations: • Shirmer I, without anesthesia • Some need CLIA waiver • Shirmer I, without anesthesia • Not always reimbursed by insurance: • Shirmer II, with nasal stimulation have symptoms check list, diagnosis and • Only needs to be done at the first visit. code built in HER, bill for each eye. • Measures tear secretion at 5 min • Time consuming for techs:

Try to have everything available in 1 room Place strips on lateral third • Uncomfortable for patients – which eyes Patient closes eyes are already irritated

6. Slit lamp exam 7. Treatment plan

• Treatment has usually multiple components

• Patient education ++ “No quick fix medication” Tear Break up time and tear meniscus eval Fluorescein/Lissamine dye staining Give analogies with other chronic diseases or dental health

• Have hand-outs listing the different treatment modalities recommended with directions examination: , , Meibomian gland evaluation closure, floppiness, morphology

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Workflow in my practice Dry eye symptoms checklist Tech as a first and last line educator Positive • Technicians are usually the first and last person the patient sees. Focused History Meds/diseases associated with dry eyes • Techs are not there just to administer the work-up: Dry eye questionnaire New patient: SPEED Return patient: UNC DEMS  Alerting clinician to red flags noted during work-up.  Detect difficulties that are hindering compliance Visual Acuity with treatment (return patients). Point of care testing  Advise patients on different treatment options New Patient: Osmolarity, Return patient: MMP-9 or as directed per available or how to make administer appropriately Shirmer I without anesthesia previous encounter a treatment.  Help motivate patients. External exam, IOP

Dry … References … is a complex disease 1. Miljanovic B, Dana R, Sullivan DA, et al.. Impact of dry eye … does not just manifest as dry eye syndrome on vision-related quality of life. Am J Ophthalmol. 2007;143:409–415. … affects patients quality of life, mental health and ocular 2. Buchholz P, Steeds CS, Stern LS, et al.. Utility assessment to surgical outcomes measure the impact of dry eye disease. Ocul Surf. 2006;4:155–161. … work-up needs to include subjective and objective 3. Bitar MS, Olson D, Li M, Davis R. The Correlation Between parameters, in a step-wise manner Dry Eyes, Anxiety and Depression: The Sicca, Anxiety and Depression (SAD) Study. 2019 Jun;38(6):684-689. … treatment relies on team approach and continuous 4. Lu et al. Changes of Corneal Wavefront Aberrations in Dry education Eye Patients after Treatment with Artificial Lubricant Drops. J Ophthalmol. 2016;2016:1342056 … patients are really grateful

 Technicians play a major role in dry eye practice

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