EyeWorld India March 2017 Issue

57 EWAP DEVICES March 2017 by Michelle Dalton EyeWorld Contributing Writer Diagnosing dry eye Newer diagnostic tests help clinicians identify dry eye patients E valuating the ocular surface for dry eye before scheduling patients to undergo surgery is becoming commonplace, but so is screening most patients for dry eye at their initial presentation. One reason is newer technology and devices have made screening a bit easier and much less invasive than earlier diagnostics. EyeWorld spoke to leading corneal specialists to find out which of the newer devices they use most often and how often they reevaluate patients. Of the newer devices, the InflammaDry (Rapid Pathogen Screening, Sarasota, Florida), the LipiView or LipiScan (TearScience, Morrisville, North Carolina) and the TearLab Osmolarity Test (San Diego) are more commonly used than the Sjo test (Bausch + Lomb, Bridgewater, New Jersey). “Meibomian gland imaging can give clinicians a wealth of information,” said Preeya K. Gupta, MD , assistant professor of ophthalmology, Duke University Eye Center, Durham, North Carolina. “Meibomian gland atrophy doesn’t happen overnight, so if you see atrophy you know that the underlying disease has been present for quite some time while the patient may only have been symptomatic for a few months,” she said. “Meibography will confirm that in the background there has been chronic inflammation, chronic dysfunction of the glands. That’s valuable information.” The newer diagnostic tests “are very effective at supplementing the exam. But a good exam for diagnosing dry eyes is still essential,” said Marjan Farid, MD , director of cornea, cataract, and refractive surgery, vice-chair of ophthalmic faculty, and associate professor of ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine. For instance, Dr. Farid will run a full set of diagnostics on new patients who present with dry eye symptoms, but she relies on the tests to guide her diagnoses and help select the appropriate treatment course. “High tear osmolarity is one of the definitions of dry eye in the DEWS [Dry Eye WorkShop] report,” she said. “Results from tear film testing can differentiate dry eyes from some other sort of masquerading-type syndromes like conjunctivochalasis.” The newest tests do help refine a diagnosis, yet “none of them can take the place of talking to a patient and examining a patient under the slit lamp,” said Christopher Starr, MD , associate professor of ophthalmology, director of the cornea fellowship, director of refractive surgery, and director of ophthalmic education, Weill Cornell Medicine, New York. “The clinical exam is still extremely important, and that’s always going to be the case. These novel diagnostics can certainly help improve our accuracy, though, especially in atypical cases, subtle or early disease states, ruling in DED-masqueraders, and with monitoring treatment efficacy.” Perhaps equally important, Dr. Gupta said, is that the tests provide “so much information about how we should manage these patients.” Ultimately, these tests will save practitioners and patients time, as “you’re getting to the true diagnosis or diagnoses much more accurately and reliably. Thus, the proper treatment(s) can be initiated sooner,” Dr. Starr said. Symptomatic patients are given the TearLab osmolarity and InflammaDry tests initially by the technician; “neither of those significantly disrupt the tear lake or the ocular surface, so when I ultimately see the patient, I’m not looking at an iatrogenically altered ocular surface because of those tests.” Should all patients receive all tests? Not all patients will need extensive testing. “It’s not appropriate to test every single person who walks in the door,” Dr. Starr said. With so many overlapping symptoms, he recommends asking patients to complete a questionnaire, either written or verbally, to narrow down which symptoms are most problematic before using all the latest diagnostics. He also recommends having office technicians review the answers and run the appropriate tests before the physician sees the patient. As Dr. Gupta became more confident with the newer tests, she began lowering her threshold to use them. “I used to just screen my symptomatic patients, but now I’m much more aggressive about testing my refractive and cataract surgical patients because I don’t want to miss any sort of ocular surface disease,” she said. Surgical patients—be it those in their 20s or 30s presenting for LASIK or those in their 60s who want refractive cataract surgery— are at a “high risk for dry eye, and diagnosing the condition pre- surgery is necessary,” Dr. Gupta said. Her cataract practice is predominantly refractive cataract continued on page 58