EyeWorld Asia-Pacific March 2017 Issue

58 EWAP DEVICES March 2017 Views from Asia-Pacific Kyung Chul YOON, MD, PhD Department of Ophthalmology, Chonnam National University Hospital 42 Jebong-ro, Dong-gu, Gwangju 61469, South Korea Tel. no. +82-10-9220-0234 Fax no. +82-62-227-1642 kcyoon@jnu.ac.kr C onventional diagnostic tests for dry eye including tear film breakup time (BUT), Schirmer test, and ocular surface staining have been considered a common and easy way in most clinical practice. Recently, newer diagnostic tests can give much information with accuracy to identify dry eye patients. Measurement of osmolarity or inflammation using TearLab Osmolarity and InflammaDry tests can confirm the hyperosmolar and inflammatory nature of dry eye. However, according to a recent concept of dry eye definition, the role of unstable tear film as well as tear hyperosmolarity and inflammation has become increasingly important; therefore, measurement of tear film stability using invasive or noninvasive BUT should be empathized. I don’t think all patients need these new expensive tests. In my clinic, all patients are screened with a symptom questionnaire and then examined with measurement of tear volume, tear breakup time/pattern, and ocular surface staining. For ocular staining, I use mixed fluorescein and lissamine green solutions to examine both corneal and conjunctival pathology simultaneously. On the other hand, osmolarity test can be recommended in patients who need to differentiate dry eye from other ocular surface diseases. InflammaDry test is mainly done in suspicious cases with Sjӧgren’s syndrome and cases with lower BUT and Schirmer test values with positive ocular surface signs. I think, in evaporative dry eye with short BUT and normal Schirmer values, evaluation of tear breakup pattern only can give much information on the causative tear film layer and selection of treatment agents. There is a debate regarding the use of fluorescein BUT or noninvasive BUT. Of course, fluorescein BUT is familiar with most clinicians as a key diagnostic method. However, subjective assessment and resulting variability are the test’s main weakness. Recently, objective measurement of noninvasive BUT has been introduced and is now recommended as one of the basic diagnostic tests. The introduction of automated keratography using Placido disc images can give more accurate information on noninvasive BUT as well as meibomian gland structure. In my experience, the differences between two BUT measurement values are small in shorter BUT cases, while the differences are large in longer BUT cases. So I think although noninvasive BUT is accurate in short BUT cases, fluorescein BUT measurement is still needed in all patients with dry eye. Finally, I believe that traditional and new dry eye tests should be performed in patients undergoing cataract and refractive surgery. Optimization of the ocular surface is important to achieve better postoperative visual and refractive results. This is especially important in patients who are scheduled to receive multifocal intraocular lens implantation surgery. Editors’ note: Dr. Yoon is a consultant for Novartis (Basel, Switzerland) and Santen (Osaka, Japan), but has no relevant financial interests. Diagnosing- from page 57 surgery. She said, “Patients are looking for a specific outcome. In order to deliver on what you’re promising to the patient, you have to ensure a healthy tear film.” Dr. Farid also thinks using the tests to monitor improvement is necessary. “I use the InflammaDry on any patient who comes in for dry eye. I’ll do follow-up testing on patients in a couple of months. Often when you show patients an objective sign of their disease, they’re much more willing to be compliant with treatment,” she said. She also performs an InflammaDry test on all new surgical patients “because the signs and symptoms of dry eye don’t always correlate, and we need to catch those patients who may have inflammatory dry eye and treat them” before surgery, she added. For novice users of these tests, choosing which ones to use can be overwhelming but will serve patients better over the long run, Dr. Gupta said. Dr. Starr added that the time when patient complaints equated to artificial tears only is antiquated. Regardless of patient symptomatology, “you will want to optimize the ocular surface to get the best refractive results,” Dr. Farid said. “A poor ocular surface will cause variability in the preop measurements, including biometry and topography. This can adversely affect calculations for toric lenses.” Dr. Starr added, “If the ocular surface is not optimized or if you’ve missed early or subtle disease that might get worse after surgery, you’re going to have a lot of headaches with the unhappy patient.” Dry eye remains underdiagnosed in the surgical patient because it’s simply not being screened enough, and practitioners may not realize it involves more than just red or scratchy eyes, Dr. Gupta said. She added that novice practitioners should start with the one test that resonates with them and embrace the technology. “You have to be educated if you’re going to adopt these tools. Trust the test results,” Dr. Starr said. Managing patient expectations can be easy; Dr. Gupta tells patients these tests are part of their “ocular vital signs,” a term that patients readily understand and accept. Determining treatment strategies Asymptomatic patients are likely to be treated differently than symptomatic ones, especially if there are abnormal diagnostic test results. “If we wait to treat patients until they’re symptomatic, we’re missing a whole category of patients,” Dr. Gupta said. “Dry eye is so much easier to treat when it’s earlier in the disease state. If we could prevent a whole