October 01, 2013
2 min read

BLOG: Choosing treatment based on exam, v1.0

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Read more dry eye blog posts from Darrell E. White, MD

The slit lamp exam and our ancillary tests allow us to fine tune the treatment we offer to our dry eye or ocular surface disease patients. The original SkyVision dry eye syndrome protocol was based on our exam findings at the slit lamp.

A Schirmer test, tear, level, tear break-up time and an evaluation of corneal and conjunctival staining were combined with a detailed examination of the miebomian glands in order to choose a first pass treatment program. Our initial goal is to try to determine whether the primary cause of the dry eye is aqueous- or lipid-based.

Our protocols began with the Schirmer test using topical anesthesia. We considered the Schirmer to be normal if the test strip was moistened to a level greater than or equal to 8-10mm. Below 8mm is considered abnormal for us, and below 6mm generally calls for punctual plugs as our first line Rx.

A low Schirmer test result also is a strong indicator that the primary pathology lies on the aqueous side of the ledger, and a patient may someday require Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan). A normal Schirmer will certainly rule out treatment with plugs, of course.

Tear break-up time is the next toggle in our protocol. More than 6 seconds is clearly abnormal, while  less than 10 seconds is essentially normal. We have always found it difficult to make a strong commitment to a treatment based solely on a TBUT of 7 to 9 seconds.

A short TBUT in the presence of meibomian gland dysfunction is highly suggestive of a lipid-based pathology or underlying cause, and these, when combined with a normal Schirmer test, would drive us toward a treatment regimen geared strongly toward the Meibomian glands. Fish oil supplements and Azasite (azithromycin with DuraSite, Merck) apply here.

The presence or absence of staining, in our case with the use of fluoroscein, is not diagnostic of either a lipid-based or an aqueous-based cause. Rather, we think the presence of staining is a clear indication of severity.

The level of aggression we choose for our initial treatment is strongly influenced by the degree of corneal and conjunctival staining. It’s very useful at this point to remember that Lotemax (loteprednol etabonate ophthalmic gel 0.5%, Bausch+Lomb) is FDA-approved for the treatment of superficial punctate keratopathy.

No Tear Osmolarity available in your clinic? No problem. Consider dividing your initial treatment along the lines of lipid- vs. aqueous-based etiologies and divide the two based on your lid, tear level, Schirmer, TBUT and staining findings on slit lamp examination.

Do you have Tear Osmolarity in your clinic? Well, we have v2.0 for that.