CORNEA EWAP DECEMBER 2022 23 by Liz Hillman Editorial Co-Director A breakdown of evaporative and aqueous tear deficient dry eye Contact information Bunya: vatinee.bunya@pennmedicine.upenn. edu Gupta: preeyakgupta@gmail.com Matossian: cmatossianmd@icloud.com Aqueous tear deficient dry eye and evaporative dry eye— distinguishing between the two, knowing when both are at play, and treatment options are of growing importance as more patients are identified with some form of dry eye and as certain refractive procedures depend on a healthy ocular surface. “Dry eye is ubiquitous. It is common to see patients with dry eye disease of all different severities,” said Cynthia Matossian, MD. “It is no longer the post-menopausal woman who has this diagnosis. The face of dry eye is changing, and it is becoming more common in younger ages, including patients in their 20s and 30s. It increases in prevalence and incidence with age, [and] there are a number of contributing factors.” Dr. Matossian, Preeya K. Gupta, MD, and Vatinee Bunya, MD, MSCE, shared their insights on the nuances of diagnosis and treatments for evaporative and aqueous tear deficient dry eye. Evaporative dry eye Evaporative dry eye, Dr. Matossian said, stems from some form of meibomian gland dysfunction. Identification starts with being a good listener, she said. Questionnaires can be filled out by patients ahead of their visit or in the office, and technicians can be helpful contributors to this process as well. “Technicians can be empowered to ask questions, and we need to become astute listeners because our patients truly don’t know how to express what’s going on. Often they say their vision is blurry and think they need new spectacles when the reason for the blurry vision is the dry eye,” Dr. Matossian said. When warranted, point-of- care testing should be done, Dr. Matossian continued, noting that this could include meibography, MMP-9 testing, ocular surface and tear osmolarity testing, and a slit lamp exam with vital dyes. She also said to look, lift, push, pull (LLPP), per the ASCRS Cornea Clinical Committee’s Preoperative OSD Algorithm. “Looking at the quality and expressibility of the meibum helps identify these patients,” Dr. Matossian said. In terms of treatment, Dr. Matossian said the first step is patient education. “If the patient does not understand what’s going on, they’re not going to be compliant with anything we recommend to them, let alone pay cash for their deductibles of prescription medications or cash-pay in-office procedures,” she said. Dr. Matossian thinks oral omega-3 supplementation is important for improving the quality of the meibum. From there, keep the orifices of the meibomian glands open with procedures like microblepharoexfoliation and at-home remedies with lid scrubs including tea tree oil or hypochlorous acid. “These all work in combination and synergy together,” she said, adding that use of a heated moisture mask This article originally appeared in the September 2022 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. Meibography of a 21-year-old recent college graduate with severe gland dropout. Source: Cynthia Matossian, MD
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