PART 2 OF A 3-PART SERIES
Ophthalmic Technician Continuing Education

Increasing Your Clinical Value:
Opportunities for Ophthalmic Technicians to Get Involved with Dry Eye Patients

By Marguerite McDonald, MD, and Matt Ruskin, BS, COA

Faculty/Editorial Board:

Marguerite McDonald, MD, and Matt Ruskin, BS, COA

Sponsors/Support:

Supported by an Independent Educational Grant from Allergan, Inc.

This course has been submitted to JCAHPO for consideration of CE credit.

This course is not sponsored by JCAHPO; only reviewed for compliance with JCAHPO standards and criteria and awarded continuing education credit accordingly; therefore, JCAHPO cannot predict the effectiveness of the program or assure its quality in substance and presentation.

Copyright 2012, Review of Ophthalmology^®. All rights reserved. The opinions expressed in this supplement to Review of Ophthalmology do not necessarily reflect the views, or imply endorsement, of the editor or publisher. Copyright 2012, Review of Ophthalmology. All rights reserved.

Affecting as much as 20 percent of the North American population,¹ dry eye goes by many names: keratoconjunctivitis sicca, ocular surface disease and tear film insufficiency. Our understanding of dry eye syndrome has changed over recent years: the condition was previously thought to be due to aqueous tear insufficiency, but we now know that it is a multifactorial disorder caused by inflammation of the ocular surface that may involve lacrimal gland, neurotrophic and meibomian gland dysfunction (MGD). Additional risk factors include diet low in omega-3 fatty acids¹; use of medications such as antihistamines, antidepressants¹, and diuretics¹; radiation therapy; hormone replacement therapy; vitamin A deficiency; Hepatitis C infection; and androgen deficiency. I've even heard one corneal specialist espouse the idea that dietary changes in cattle are at least partially responsible, since grass fed beef contains much higher concentrations of omega-3 fatty acids, and most cattle are now grain fed.

Any dysfunction of the lacrimal functional unit, which is comprised of the main and accessory lacrimal glands; the meibomian glands; eyelids; cornea; conjunctiva; goblet cells; and the interconnecting innervation, can contribute to it. Environmental factors such as ciga rette smoke, highly air-conditioned or heated areas, chlorinated pools, and even post alcohol consumption-related dehydration can also exacerbate this common condition. Fortunately for our patients, this knowledge has opened the door to the development of newer, more effective treatments.

While one of the most common disorders encountered by ophthalmologists, dry eye is also one of the most misdiagnosed; it is often mistaken for other common external eye diseases such as blepharitis or allergy because dry eye symptoms overlap with the symptoms of these conditions. It can be associated with inflammation of the surface of the eye, the lacrimal gland or the conjunctiva; any disease process that alters the components of the tears; an increase in the surface of the eye, as in thyroid disease; and/ or cosmetic surgery, if the eyelids are opened too widely.² Left untreated, dry eye can lead to other problems, such as corneal ulcers, neovascularization, and scarring. According to the National Institutes of Health's National Eye Institute, there are two types of dry eye:²

1. Aqueous tear-deficient dry eye, in which the lacrimal glands fail to produce enough of the watery component of tears to maintain a healthy surface.²
2. Evaporative dry eye, which may result from inflammation of the meibomian glands.²

Prevalence of Dry Eye

In 2000, a population-based study of adults aged 48 to 91 years found prevalence rates of 14 percent overall. Though it was only eight percent in those under 60 years, it was as high as 19 percent in those older than 80 years.³ As you will see below, however, more recent studies indicate that the prevalence has increased dramatically.

There is a higher incidence of dry eye in patients with MGD⁴, older age,⁵ females,⁵ postmenopausal women,⁵ postoperative LASIK, cataract/refractive surgery patients,⁵ and patients with systemic diseases such as lupus, rheumatoid arthritis and rosacea.⁶

MGD is a chronic, diffuse abnormality of the meibomian glands, often characterized by qualitative/ quantitative changes in the glandular secretion and/or terminal duct obstruction. This may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation and ocular surface disease.⁷ MGD can lead to alterations in the normal lipid composition in meibomian gland secretions^8-11 and lipid abnormalities can lead to abnormalities of tear film composition and function, resulting in evaporative dry eye.¹² Whatever the cause, there is little doubt that the prevalence and/or diagnosis of dry eye is on the rise, particularly in light of newly released data.

New data documenting the prevalence of dry eye at 60 percent (Table 1) reinforce the fact that the majority of our patients already have dry eye.¹³ And as the population ages, we will spend more of our time managing the condition with every passing day. Without the latest diagnostic and treatment modalities, along with well-trained technicians to help us, the situation would be overwhelming. Fortunately, this is a great time to be working in the field of ophthalmology. Diagnostic and treatment advances in many areas have brought relief from discomfort and increased vision to more people than ever before. One area in which this is certainly applies is in the case of dry eye.

Points to Keep in Mind

When addressing a dry eye patient, remember that this condition can be quite debilitating and can cause symptoms such as filmy or blurry vision, fluctuating vision, foreign body sensation, pain in the eye, and even photophobia. It can affect a patient's reading, computer use, driving and television viewing. Patients are generally frustrated with this condition—specifically because it simply has not been addressed or because treatment they received in the past have not brought about significant improvement. A study that sought to compile an overview of the burden of dry eye found that dry eye symptoms become progressively troublesome and exert an increasing burden on patients as the condition progresses or increases in severity.¹⁴ The study researchers noted that as dry eye symptoms become more severe, additional aspects of life are affected on a clinically meaningful level, including perceptions of health, physical functioning and social functioning.¹⁴ It is perhaps understandable that dry eye has gotten "short shrift" in our offices in the past:

• There are no pathognomonic symptoms for dry eye; most of them overlap with other disease states.
• Until recently, there weren't good diagnostic tests to detect the earlier—though very vexing— stages of dry eye (advanced dry eye being fairly easy to diagnose).
• Until recently, there were only palliative approaches to treating dry eye; the first therapeutic agent (cyclosporine emulsion) became available only a few years ago.
• The profound impact of a pristine ocular surface on post-LASIK and post-cataract surgery outcomes (especially those involving multifocal IOLs) was only recently demonstrated.
• Only recently has the profitability of a dry eye practice—including both the direct profits and the indirect profits through the "halo effect"—been documented.

It is now clear that dry eye management is an important, exciting, and rapidly evolving field, but ocular surface disease patients can be time-consuming if you don't have a streamlined system in place and work as a team. Doctors and staff who make a concerted effort to develop an ocular surface disease clinic will likely be highly rewarded in terms of patient response and practice growth.

The best practices are investing from the top down: the ophthalmologists and their integrated optometrists are constantly educating themselves on the new diagnostic and therapeutic options through meetings, peer-reviewed journals, magazines, webinars and blogs. What's more, they are committed to providing educational opportunities to their technicians; educated technicians enjoy more professional fulfillment, are proud of their "cutting edge" doctors and practices, are more loyal to the practice, and—as the professionals with whom our patients spend the most time—are better suited to explain dry eye and answer questions. Their knowledge saves time for the doctors and increases the patients' compliance. Additionally, it has helped us foster a better teamwork relationship because the doctor and techs each know their roles.

First Impressions

As the usual first point of patient clinical contact, the technician's role is an important one in the evaluation of dry eye. As a technician, it is your role to provide the physician with the most information you can access from your patient workup. Patient history is an important piece of the puzzle for the doctor in making the diagnosis, so the role of the ophthalmic technician is critical in the dry eye practice.

Chief complaints containing symptoms such as "dry," "gritty," "irritated," "burning" and "scratchy" eyes, as well as "blurry" or "filmy" vision, and reports of foreign body sensation are common in dry eye patients. There are even patients who report excessive tearing—especially late in the day— who may, paradoxically, turn out to have dry eye. Dry eyes recover overnight, when the lids are closed. When the eyes open again in the morning, the dry spots on the cornea (superficial punctate kera-titis, or SPK) slowly accumulate. When a critical mass of SPK has accumulated, the eye senses that it has been injured and sends in the "emergency" tears in an explosive episode of tearing. These are not the sought-after "baseline" tears; these tears are a response to injury. Patients often find it difficult to understand why the doctor thinks they have dry eye when they have had explosive episodes of late afternoon/evening tearing. The technician can be invaluable in explaining this phenomenon.

The patient's chief complaint must be further investigated to help determine causality. Previous treatment for dry eye, a history of contact lens wear, frequency of typical symptoms, sensitivity to environmental stimuli such as smoke or high air-conditioning, use of systemic medications such as antihistamines and diuretics, a history of systemic disease such as Sjögren's syndrome and rheumatoid arthritis, and other comorbid eye problems such as MGD, glaucoma and anterior or mixed blepharitis all help point towards dry eye. All of these conditions have been linked to dry eye disease, either causally or symptomatically.

The validated questionnaire is an excellent tool for the collection of subjective information and can even be used prior to seeing the patient. Just have them complete one in the waiting room, or mail it out with new patient material. Patient responses are assigned values, which allows for dry eye severity to be scored, and later, with subsequent questionnaires, treatment effectiveness to be assessed. Two such questionnaires in common use are the Ocular Surface Disease Index (OSDI), Allergan, and the McMonnies Dry Eye Questionnaire.

There are many causes of ocular surface irritation and inflammation; as previously stated, the symptoms of dry eye are not pathognomonic; i.e., they overlap with many other conditions. In addition, there is a well known "disconnect" between signs and symptoms in dry eye.

To elaborate upon this important concept: we frequently encounter patients with the physical findings of advanced dry eye but with virtually no symptoms. The converse is also frequently encountered: patients with extreme symptoms and almost no physical findings at the slit lamp. I still find that a technician who is a skilled history taker can be of enormous help to me; they can shave minutes off each patient encounter by asking the right questions and by completing the necessary testing before I enter the exam lane.

In general, ophthalmic technicians should suspect dry eye in anyone 40 years of age or older, with a previous history of dry eye, with surface irritation complaints that might be dry eye, and anyone who is being worked up for surgery (cataract, LASIK, penetrating keratoplasty, DSAEK, etc.). The authors of a recent Japanese study that evaluated changes in corneal sensitivity, tear film function, and ocular surface stability in patients after phacoemulsification concluded that microscopic ocular surface damage during surgery seems to be one of the pathogenic factors that cause ocular discomfort and dry eye symptoms after cataract surgery.¹⁵

Most dry eye patients complain of dry, irritable, sandy eyes, with mild occasional itching. Some patients— especially those with evaporative dry eye—also complain of burning. There also appears to be a correlation between migraines and dry eye, as one particular study reported that an increased frequency of dry eye disease was found to occur in patients with migraine and that some migraine attacks may be aggravated in the presence of dry eye.¹⁶

One of my favorite questions for my patients is, "What time of day do your eyes look and feel their worst?" If in the evening, the patient is very likely to have dry eye. If in the morning, the patient is very likely to have either blepharitis or lagophthalmos/exposure keratitis. The last two can be distinguished by the presence of redness, crusting, and/or puffiness (blepharitis) or the presence of pure redness—and perhaps discomfort—without crusting or puffiness (lagophthalmos/exposure keratitis).

Most of my patients are office workers who sit at their desks for a good part of the day. I tell dry eye patients to strike a match (assuming they aren't near an oxygen tank or flammable gases or liquids) just where their head is located when they are seated at their desk. If the flame flickers, they have a draft that is making their dry eye worse. They can close the overhead vent with a broom handle, or ask housekeeping/engineering to close it for them. They can also ask to be moved to a draft-free area, or turn their chair and desk 90˚ to 180˚ so the draft at least hits the back of their head. I also advise them to lower their computer screen as far down as possible, so that they have less ocular surface exposed, which leads to less evaporative tear loss. Lastly, I tell patients to keep their artificial tears right next to their keyboard as a reminder and for ease of use. Women should also keep a small magnifying mirror near their keyboard to check their makeup after application of artificial tears.

It is important to counsel patients who appear to have risk factors such as blepharitis about proper care of their eyes and lids. These are many patients who can prevent or ameliorate severe dry eye with proper lid hygiene. Show them the different types of warm compresses they can buy over the counter, or stock and sell some options in your own clinic.

When conducting any pretesting—or even during the history taking—it is important to look at the patient's blink for completeness and blink rate. This factor is a major contributor to the likelihood of ocular surface disease.

Once the technician has completed all necessary pre-testing, the next step is for the dry eye patient to see the physician. At this time, the staff can assist in further testing as ordered.

Accurate investigation of dry eye is crucial to correct management of the condition and the latest diagnostic tests are invaluable.

Diagnostically Speaking

The availability of rapid, in-office tear osmolarity testing (TearLab Osmolarity System, TearLab Corporation) has made it easier to diagnose early and/or asymptomatic patients and to track the response—and compliance—of all patients who are placed on therapy. It is important to understand tear film instability in dry eye disease; in dry eye patients, osmolarity changes rapidly over time and between eyes. In fact, inter-eye variability is the hallmark of dry eye; greater than 8 mOsms/L is consider abnormal (Table 2). The tear osmolarity test is easy and quick for the technician to perform, and there are no out-of-pocket expenses for the patient, as it is billed under the patient's medical plan, not the vision plan.

Dry eye syndrome is a disease caused by tears that are inadequate either in their composition or their quantity or both. We know that the pathogenesis of the condition involves inflammation; the over-expression and over-activity of corneal matrix metalloproteinase 9 (MMP-9) is a marker for this inflammation. The InflammaDry Detector from RPS is a rapid, point-of-care test that is useful in detecting dry eye because it detects the presence of MMP- 9 in the tears, which is elevated in the tears of patients with dry eye disease.¹⁷ Other conditions may cause MMP-9 to be elevated, so it is important for the clinician to take a proper history and to perform a thorough slit lamp exam. While this test is not currently available in the United States, 510(k) review by the FDA is pending.

The patient's tear film should be evaluated objectively for both quality and quantity. Besides lubricating the eye, the tear film helps fight infection, provides nourishment and creates a smooth surface on the cornea, keeping vision clear by optimizing the eye's optics. A clinically useful predictor of dry eye is tear film osmolarity, previously a difficult test logistically, because samples needed to be sent to a laboratory. However, the recent availability of "lab-on-a-chip" technology such as TearLab has enabled tear film osmolarity measurement directly in the office.

Because any eye drops, palpation, contact lenses, manipulation, bright lights or other disturbances to the eye can cause reflex tearing, tear film osmolarity is usually best evaluated early in the exam, and thus often falls to the ophthalmic technician. A disposable probe is touched to the tear lake at the lower lid margin and a nanoliter-size sample is collected and analyzed right there on the chip. The probe is then placed in a base unit and the results displayed. Done properly, the test is quite non-invasive and reflex tearing can be minimized. Results of 307 mOsms/L or less are considered normal, while values greater than 307 mOsms/L indicate dry eye. Repeated measurements over time can help judge treatment efficacy. Also, widely varying tear film osmolarity between eyes (greater than 10 mOsms/L difference) is a good indicator of dry eye.

Another recent technological advance that has shown great promise is the LipiView Ocular Surface Interferometer from TearScience, Inc. Their treatment and business model is predicated on the idea that most dry eye is evaporative (about 2:1 evaporative to aqueous defi-cient, though there is considerable overlap between the two types), and that the majority of the evapo-rative dry eye is due to a deficient lipid layer in the tear film, which is in turn most often caused by MGD.¹⁸ The pre-treatment evalua tion involves the assessment of the patient's symptoms, oil layer, and glands. Then, the patient is given a quick, one-minute questionnaire to fill out (the SPEED Test). If the symptoms warrant it, the LipiView diagnostic system is then utilized. The LipiView system dynamically evaluates the thickness of the oily layer that coats the tear film, which is mainly composed of meibum. It also documents the completeness of the blink, and how the lipid spreads with each blink. If the quantity or quality of the lipid layer is found to be deficient, the meibomian glands are evaluated for function with mild pressure from a hand held unit, the Meibomian Gland Evaluator (TearScience), which delivers a standard amount of mild pressure to the lower lid. Three sections of both lower lids are tested as part of the evaluation.

While having fallen out of favor with some physicians in recent years because of poor repeatability and its tendency to induce reflex tearing, Schirmer testing remains an accepted tool for evaluating tear film quantity. Small strips of scored sterile filter paper are hung over the lower lids towards the lateral canthi, and the distance the paper is wet through capillary action over a given time (usually 5 minutes) is recorded. This test may be performed with or without anesthetic. Without anesthetic it is largely a measure of reactionary tearing, while when performed with anesthetic it more closely tracks basal tearing, though some reactionary tearing may still occur. Normal basal tearing usually wets a Schirmer strip between 10 mm to 20 mm in five minutes time in most people's eyes. Again, widely disparate data between the eyes can be indicative of dry eye. Another similar, though less invasive, test is the Zone-Quick Phenol Red Thread (PRT) Tear Test (FCI Ophthalmics). Instead of paper strips, this test uses a cotton thread treated with phenol red dye, which turns red in the presence of slightly alkaline tears. But its short measurement time, typically only 10 seconds, has inspired debate as to how much of the tears recorded on the thread were already present in the eye at the test's inception versus actual tear flow produced during the test.

The following testing can not be performed after checking the patient's intraocular pressure with direct contact after instilling an eye drop: tear meniscus height assessment, osmolarity testing, fluorescein dye and/or lissamine green dye, tear film break-up time, meibomian gland expression, Schirmer's tear test (non anesthetized) in potential Sjogren's patients, Zone-Quick technology, topography or wavefront imaging. Take care in making sure you do not compromise the results of any testing that may be needed. If the patient has been on a steroid drop, you much check pressure before he leaves your office.

A non-contact tonometer that does not use a numbing drop (which can still be harsh to the surface of the eye) is a great addition to an eye care clinic. Ophthalmic technicians should assist the physician as they examine the patient. It is helpful for staff members to instill various dyes and drops as needed to continue the flow of the exam.

Inside the Dry Eye Toolbox

As a staff member in a dry eye clinic, you should become comfortable with the various options for treating dry eye that can range from over-the-counter tears to prescription alternatives. Treatments may not be limited to drops and can also include Omega-3 supplements and long- or short-term oral antibiotic therapy with agents such as doxycy-cline. These traditional treatments for dry eye are still effective for many people.

For cases of mild dry eye, minimizing exposure to exacerbating environmental factors such as heavy air conditioning or cigarette smoke, combined with palliative therapies such as artificial tears, gels and ointments can be quite effective. And for people whose dry eye is mainly evaporative, nutritional therapies such as increasing Omega-3 fatty-acid intake can be similarly helpful. Many formulas are available, though my favorite is TOZAL (Atlantic Medical, Inc.), which is by prescription and covered by most patients' insurance programs. It is the formula that NASA developed for its astronauts, and also contains lutein and zeaxanthin. For many with aqueous deficiency, punctual occlusion—be it with plugs or through cauterization—can bring great relief. I also continue to use palliative therapies, including preserved and unpreserved tears (unpreserved for the more severe cases); bland ointments for nighttime use; and the hydroxypropyl cellulose ophthalmic insert (Lacrisert, Valeant Ophthalmics) for advanced cases. I frequently recommend liposome spray q.i.d. OU; this is especially helpful in evaporative dry eye and was recently recommended by the International Task Force on Meibomian Gland Disease for stage 2 and higher MGD. My favorite is Tears Again Advanced Liposome Spray (OCuSOFT, Inc.), which is available over-the-counter and carried by several chains, including CVS. Once again, it is important to review these therapies one by one, explain their importance, and to demonstrate their use with samples; my technicians are invaluable in this regard.

If there are enough extant but poorly functioning or clogged meibomian glands, the LipiFlow Thermal Pulsation device (Tear-Science) may be used. This device is a heating and massaging unit attached to all four lids, and through gentle pulses of heat and pressure, the meibomian glands are expressed and unclogged throughout the 12-minute treatment. The ability to evaluate, and moreover treat, evaporative dry eye directly in the physician's office is a boon, and largely takes patient compliance out of the equation. Many patients are able to stop or greatly reduce their medications and lid hygiene regimen for months after each Lipi-Flow session; patients are delighted to abandon their costly medications and the drudgery of their "soaks and scrubs" regimen, both of which lead to non-compliance.

There are some drawbacks: mainly the procedure's out-of-pocket costs and the current uncertainty about the duration of relief the treatment will provide before needing to be repeated (the manufacturer states that while most patients feel better immediately, it may take one to two months before reaching its maximum level—a longer time for more longstanding cases—and the relief lasts from six to 36 months, with an average of 18 months). However, everyone I have spoken to who has had the procedure said their eyes felt better (admittedly anecdotal and a limited sample size). Dr. McDonald has had the treatment herself, and is quite impressed with her improvement over the six weeks since treatment. We had been sending our patients into Manhattan for treatment, but our practice has recently purchased two of the LipiView/ LipiFlow units, and now we are offering the treatments to our more severe dry eye and blepharitis patients. So far, patients have been quite pleased with this natural, "holistic", non-invasive therapy, and we have had no complications.

Cyclosporine ophthalmic emulsion 0.05% (Restasis, Allergan) was approved nearly nine years ago; it was—and still is—the only prescription medication that specifi-cally targets and treats the underlying cause of dry eye. In my opinion, this first-in-class medication qualifies as a "disruptive technology", as it radically changed the paradigm for treating dry eyes; everything before it was merely palliative. I tell my patients that it helps them to produce more of their own tears, and higher quality tears. The medication is administered b.i.d. from unit dose unpreserved vials. I usually start cyclosporine with a one-month tapering dose of loteprednol etabonate ophthalmic suspension 0.5% (Lotemax, Bausch + Lomb) q.i.d. for two weeks then b.i.d. for two weeks. This accomplishes two things: it masks the stinging that sometimes accompanies the first few weeks of cyclosporine therapy, and it gives immediate symptomatic relief. Cyclosporine is very effective and safe, but it takes the average patient one month to notice relief; during that period, the topical steroid is providing symptomatic relief. Just as the patient stops the loteprednol, the cyclosporine effect will be clinically significant. I rely heavily on my technicians to explain how cyclosporine is packaged, how to use it, when to expect relief, etc., as well as why and how the lotepre-dnol is to be used.

Below are the usual guidelines we follow when treating our dry eye patients:

For mild level 1 dry eye, as defined by the Dry Eye Workshop (DEWS) Report,¹⁹ I advise the "as needed" use of bottled artificial tears that are gently preserved. One of my favorites is Refresh Optive Advanced Lubricant Eye Drops (Allergan, Inc.), which has the aqueous and lipid components necessary to treat aqueous deficient and/or evaporative dry eye. I recommend nutritional supplementation with TOZAL Eye Health Formula (Atlantic Medical, Inc.) and the environmental alterations described above. I caution them to use wraparound sunglasses to decrease evaporative tear loss when outdoors, and to avoid noxious situations (smoky rooms, etc.). An air cleaner used indoors to filter dust and other particles helps to treat dry eyes by not aggravating them with foreign bodies, which they are less able to clear than healthy eyes. Additionally, a humidifier may also help by adding moisture into the air.

For level 2 dry eye, I prescribe all of the above, but I ask the patient to take their artificial tears as needed on a routine of four times a day (breakfast, lunch, dinner, and mid-to-late evening), whether they think they need them or not.

If the patient is routinely using tears more than four times a day (high level 2), I switch them to preservative-free tears, as the preservative in bottled tears can cause superficial punctate keratitis (SPK) if used too often. I also advocate the use of Tears Again Advanced Liposome Spray (OCuSOFT, Inc.) q.id. The patient sprays the mist onto gently closed lids q.id. from a distance of 8 to 10 inches and rubs the mist into the lid margins. Women wearing makeup can spray in the morning and night with rubbing, and twice in the middle of the day without rubbing; they will still get most of the effect. The lipo-somes are studded with vitamins A, C, and E; with each blink, they migrate into the tear film from the lid margin and dissolve, spreading lipid across the superficial layer of the tear film to prevent evaporation.

At level 2, I also prescribe cyclo-sporine emulsion b.i.d. OU, with the accompanying one-month tapering course of loteprednol described above. The patient is asked to return in four to eight weeks; if they are improved but still symptomatic, I add punctal plugs. Usually I insert four at once, but if there is any doubt, I add the lower plugs first. For those patients, I ask them to return again in four to eight weeks to determine if upper plugs are necessary.

At level 3, I add bland ointment at night and/or Lacrisert. Some patients are intolerant/allergic to ointment; for these patients, I recommend Genteal Gel (Novartis Pharmaceuticals Corporation). Though it only lasts four hours at most, these patients can reapply it at least once in the middle of the night to achieve the same effect as ointment, which lasts approximately eight hours.

At level 4, I add autologous serum tears and swim goggles at night, though some patients need the goggles even during the day. Some level 4 patients may also need bland ointment every one to two hours while awake, in spite of the fact that it blurs vision. Frequent trips to the cornea specialist will also be needed, to remove painful filaments (long strings composed of mucous and epithelial cells that are attached at one end to the cornea; they move with each blink and cause great discomfort). A cryopre-served amniotic membrane that is suspended on a symblepharon ring (Prokera, Bio-Tissue, Inc.) may also be inserted in the office when these patients have exacerbations.

Most level 3 and 4 dry eye patients have at least some element of MGD as well. I recommend lid soaks and scrubs b.i.d. as baseline therapy for all MGD patients. For level 2 MGD and higher, I prescribe azithromycin solution (AzaSite, Merck) rubbed into the lid margins b.i.d., immediately following the soaks and scrubs. For high level 2 and higher, I often prescribe doxycycline orally as well. The usual dose is 20 mg to 50 mg p.o. q.d., though some patients need 100 mg p.o. b.i.d. for seven to 10 days before dropping the dose to 20 to 50 mg p.o. q.d. or b.i.d. I usually prescribe oral doxycycline therapy for at least six to 12 months before attempting to discontinue it. The Ocudox kit (OCuSOFT, Inc.) is a great way for patients to get 60 tablets of doxycycline 50 mg, OCuSOFT lid scrub pads and Tears Again Advanced Liposome Spray all in one kit, and is covered by most patients' insurances. About half of the level 3 and 4 patients will be able to discontinue it after a few months of therapy, saving it for the occasional flare up (at which point I give one month of therapy). Some level 3 and 4 patients are quickly symptomatic again, and must go back on low dose oral doxycycline therapy indefinitely.

The Devil is in the Details

While we certainly do see patients with newly developed dry eye, most of the patients with dry eye have had it for quite some time, often years. Many have tried treatments in the past, whether prescribed by a doctor or purchased over the counter.

There is a dizzying array of artificial tears, gels and ointments available out there, and inquiry should be made as to which, if any, the patient has tried or is using. There is often a direct correlation between the frequency of artificial tear use and severity of dry eye.

A patient using tears every few hours is likely to have much more severe dry eye than someone who uses artificial tears once a week. And someone using a gel tear or an ointment is similarly more likely to have a worse case of dry eye than someone who is only using aqueous artificial tears. Additionally, someone who tells you they have tried various artificial tears but stopped each one almost immediately because they didn't experience any relief is unlikely to keep up with a new treatment regime unless it provides some immediate relief. This is one of the reasons many doctors, Dr. McDonald included, will put a patient on loteprednol as well as cyclosporine for the beginning of the treatment period. Cyclospo-rine often takes months to provide relief, but loteprednol will usually give some symptomatic relief im mediately, giving the cyclosporine time to be effective at treating the underlying disease. Alternatively, a patient who has been using drops regularly in the past is likely to comply with a new regimen. Unlike with hedge funds, when treating dry eye, past performance is a good predictor of future results.

Many patients have never administered an eye drop. Most have never administered an ointment, sprayed their lids with a product, scrubbed their lid margins or placed a Lacrisert in their inferior cul de sac. These are therapies that all require instruction and demonstration by the technician; time-consuming, but extremely important tasks that require patience, kindness and repetition. As with most things, the devil is in the details; if the patient is not taught the proper techniques for these therapies, the treatment plan will fail.

Patients should always be told not to take doxycycline within ± one hour of a meal containing dairy products, as dairy inactivates it. They should also be told that doxycycline makes them more sun sensitive, so they should always wear sunblock, a shirt, wraparound sunglasses and a hat when outdoors.

After the physician has diagnosed the patient, you want to be sure to review the doctor's instructions— written on an instruction sheet— with the patient before they leave. Let them know that they have a true ocular disease and although it is chronic, it can be managed, and that you will watch them closely. We let patients know that ocular surface disease conditions can be managed, so there is hope, but we also need to remind them that these are long-term conditions, so they have to have the proper expectations.

As mentioned above, write out a detailed list of all medications and therapies that the physician would like to start. Make sure the patient understands which therapies to discontinue, which ones they are to begin, and when to take them. Take extra time to explain tapering medications such as steroid drops, as a slow taper is vital to the success of the treatment. Encourage patients to call if they have any decreased comfort or new/worsened symptoms. It's also a good idea to review the symptoms of a pressure spike (extremely unlikely if they follow the instructions) and tell patients that if they experience this, they should call immediately. Remind them that these treatments may take a while to work—sometimes as long as a few months. Finally, urge patients to call if they experience any issues with medications so you can let the physician know and guide them in how to discontinue or change medications in the future.

The Value of Collaboration

While dry eye is rarely a sight-threatening condition, it has a significant impact on the quality of our patients' lives and should be viewed as such. Our dedication to dry eye has grown our practice, and it's been a wonderful experience to see the results as patients who have suffered for years or decades now experience—for the first time—relief from dry eye disease. The "doctor-technician-educated patient" interaction, with the integration of new diagnostic and therapeutic modalities along with the old, is critical in the successful treatment of this challenging condition.

Dr.McDonald is clinical professor of Ophthalmology at New York University in Manhattan, and is an adjunct clinical professor of Ophthalmology at Tulane University Medical School in New Orleans. She is also in private practice with Ophthalmic Consultants of Long Island in Lynbrook, NY.

Mr. Ruskin has a BS in Biology from Columbia University. He is currently the technical supervisor for Ophthalmic Consultants of Long Island's Rockville Centre office, where he has worked for the last 15 years

References

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