OD OS Lids/Lashes 2+ blepharitis 2+ blepharitis Conjunctiva Clear, no injection 1-2+ injection, inferior conjunctival ridge Cornea Clear 3+ diffuse SPK, epithelial ridge, (-)dendrite Tear film Normal Decreased TBUT Anterior Chamber Deep and Quiet Deep and Quiet Lens Clear Clear Corneal Sensitivity Normal Reduced OD OS Optic Disc 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, (-)tears (-)RD/tear Vitreous Clear Clear 1 2 3 Hyperplasia or irregularity of Recurrent or persistent Stromal involvement leads to epithelium epithelial defect corneal ulcer, 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 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. 9 10 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. 9 10 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 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.