Lost Hope Found With a Change in Care

Dry eye disease (DED) is a multifactorial, chronic, progressive condition that falls under the category of ocular surface disease (OSD). Other commonly charted OSD conditions that may contribute to or coexist with DED include anterior blepharitis, ocular rosacea, meibomian gland dysfunction (MGD), nocturnal lagophthalmos, conjunctivochalasis, and ocular allergies.

Many patients with DED present with one or more common ocular symptoms: irritation, burning, itching, eye fatigue, eye pain, foreign body sensation, redness, light sensitivity, or watery eyes. Early detection and intervention of these symptoms is important to protect the surface of the eye. In this article, I explain the protocols we follow at Beverly Hills Optometry Advanced Dry Eye Center, and I share a patient case to demonstrate how our methods pursue a slow and steady approach to symptomatic relief and optimal success.

STANDARD PROCEDURE

Although our protocol continues to evolve, we follow a typical systematic approach during a consultation for a patient with DED or OSD.

Our goal is to properly identify, diagnose, and treat the root cause of the patient’s DED. At the beginning of a dry eye consult, every patient fills out a standardized dry eye questionnaire, a lifestyle questionnaire, and an intake form with their personal systemic and ocular history. By gathering in-depth information (eg, lifestyle habits, medications, cosmetic use, screen time, contact lens wear, use of eye drops, etc.), we gain useful insights into contributing risk factors and potential comorbidities, which aid with patient counseling. Additionally, understanding the duration, frequency, and severity of the patient’s symptoms is often helpful in designing a customized treatment plan.

During the examination, our team primarily performs a series of diagnostic tests to evaluate the quality, consistency, and stability of the tear film. Tests include tear meniscus height, tear osmolarity, meibomian gland function, and noninvasive tear breakup time. We also observe and document the ocular surface structures with external photography, vital dye staining, and meibography imaging.

Once a diagnosis is confirmed, we begin compiling appropriate treatment options, which may include one or more of the following: intense pulsed light therapy (OptiLight, Lumenis) for its antiinflammatory properties; heat expression with the LipiFlow Thermal Pulsation System (Johnson & Johnson Vision), TearCare (Sight Sciences), or Systane iLux MGD Thermal Pulsation System (Alcon) to target obstructive MGD; and eyelid exfoliation techniques for removal of bacteria or Demodex, plaque, and biofilm from the eyelids and eyelashes.

CASE EXAMPLE

A 60-year-old woman who had undergone cataract surgery in the left eye 5 years ago stated that she had multiple systemic conditions that were controlled with medications. She was taking losartan (Cozaar, Merck) for hypertension, evolocumab (Repatha, Amgen) for hyperlipidemia, metformin for type 2 diabetes, and levothyroxine to manage hypothyroidism. The patient also mentioned that she had reduced visual acuity of 20/40 in her right eye secondary to a dense nuclear sclerotic cataract. Due to the signs and symptoms of her condition, her cataract surgeon advised her to wait to have refractive lens exchange until her ocular surface health had improved.

According to the patient, her OSD symptoms began 14 months previously. Before visiting our office, she had had no relief with punctal plugs, over-the-counter lubricating drops, or commercially available at-home eyelid hygiene wipes.

Transfer of Care

We took over the patient’s dry eye care in April and noted that her entering score on the Standardized Patient Evaluation of Eye Dryness (SPEED) questionnaire was 24 out of 28 and her tear osmolarity scores were 335 mOsm/L and 333 mOsm/L in the right and left eyes, respectively, which are in the abnormal range. Her most notable symptoms were dryness, burning, and eye fatigue, which were constant and intolerable in both eyes, although she said her right eye felt worse.

Upon examination, the patient had mild central punctate epithelial defects in each eye, bilateral mild to moderate diffuse bulbar conjunctival staining with lissamine green (Figure 1), and evidence of lid wiper epitheliopathy (LWE) on all four eyelids. Additionally, meibography showed that both the right and left lower eyelids had two-thirds gland atrophy or truncation (Figure 2). Meibomian gland function for all four eyelids was significantly inspissated, and noninvasive tear breakup time was severely reduced in both eyes (Figure 3).

After 6 weeks and one session each of BlephEx (Alcon), LipiFlow, and OptiLight, the patient’s punctate epithelial defects had resolved, lissamine green staining and LWE were reduced to trace amounts, meibomian gland function was clear and liquid, her SPEED score dropped to 18 out of 28, and tear osmolarity was reduced to 304 mOsm/L and 305 mOsm/L for right and left eye, respectively.

Remarkably, 16 weeks after her first visit, and after two additional sessions of OptiLight, the patient reported that her SPEED scores had dropped to 7 out of 28 after the second session and to 0 out of 28 after the third session.

GETTING TO THE ROOT OF THE MATTER

Before visiting our office, this patient had nearly lost hope that anything could be done to resolve her symptoms. Thankfully she trusted our protocol, our practice, and our team. With that trust, her hope is now restored, and her ocular dryness is well managed. She is grateful to enjoy her daily activities without her symptoms constantly interfering. She is excited for the opportunity to regain the vision in her right eye, and we have cleared her to return to her surgeon for cataract removal.

As with this patient, DED can significantly affect the quality of life of many individuals. By embracing modern diagnostic equipment and therapeutic alternatives, we have the opportunity to offer a treatment approach that targets the root cause of each patient’s condition by improving their ocular health.