Treating ocular surface disease an involved but rewarding experience
The term ocular surface disease is a useful one to me and includes dry eye disease, ocular allergy and blepharitis/meibomian gland dysfunction. There is significant overlap in these diagnoses, and many patients suffer from more than one of them or even all three.
Years ago, in the American Academy of Ophthalmology-commissioned RAND Study, it was estimated that 40% of a comprehensive ophthalmologist’s or optometrist’s daily office visits included dealing with one or another form of ocular surface disease. The overlap of these diagnoses is further illustrated by the finding of Michael Lemp, MD, that as many as 86% of patients with dry eye disease have an evaporative form associated with MGD. In addition, we clinicians are fully aware that while allergy causes ocular itching, so does dry eye and MGD. And while burning is usually associated with MGD, many patients with dry eye disease also report burning. The classical foreign body sensation associated with dry eye is also present in many patients with ocular allergy or MGD. The itchy, burny, gritty eye can be any of the three, two of the three or even all three.
All of the ocular surface diseases are associated with eye redness and in some cases conjunctival and/or lid edema, and all are associated with ocular surface inflammation. It is no wonder that many well-done studies suggest that even well-trained cornea specialists frequently misdiagnose ocular surface disease. The literature suggests that dry eye disease occurs in 8%, allergic conjunctivitis in about 30% and blepharitis/MGD in as much as 40% of the population.
As a cornea specialist for more than 40 years, I believe that when subjected to a careful history and clinical examination, one could argue that nearly 100% of the adult population at some time during the year in some environment suffers from some form of ocular surface disease. There is nearly no one who is allergic to nothing. While I do not have classical seasonal or perennial allergic conjunctivitis, I am allergic to cats and lilacs and get severe acute allergic conjunctivitis if I pet a cat and touch my eyes. I do not have classical dry eye, but in the Minnesota winter when I am traveling in a blizzard for hours with the window defroster in my car on high, I develop dry eye symptoms. And, like everyone approaching age 70, I have some age-related changes in my meibomian glands that could be put in a medical record as being consistent with mild MGD, which to me is a natural aging change for patients. So, ocular surface disease is ubiquitous and in the most challenging environments likely affects 100% of the adult population at some time every year. It is also increasingly prevalent in children, likely related at least partially to our Western diet heavy in saturated fats, sugar and excess calories.
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Of interest, most Americans treat their own ocular surface disease with over-the-counter medications, both tablets and drops, obtained at their local pharmacy. The market leader is Visine (Johnson & Johnson), which is advertised as being appropriate for the relief of red, irritated, itchy, dry or watery eyes. Our patients and the pharmacists who assist them also frequently make the wrong diagnosis. There are several variations of Visine, including Visine Original, Visine Maximum Strength, Visine Allergy, Visine Advanced, Visine Tired Eyes, Visine Dry Eye, Visine Comfort and Visine Contact Lens, to name a few. Next to these at every drug store and many food markets are an amazing array of OTC alternatives for patients who choose to treat themselves, which is the majority of Americans who experiment with many drops using a trial-and-error basis. When self-treating patients become frustrated or their ocular surface disease is more severe with greater morbidity and impact on their daily life, they finally seek professional help. Thus, most patients who see ophthalmologists have already tried several OTC medications and many have also seen more than one eye care provider or primary care physician without satisfactory relief. So, it makes sense to me to be well prepared as an ophthalmologist to deal with ocular surface disease because I know I am going to see a lot of it, it can have a significant impact on my patients’ quality of life, and if we are astute clinicians and treat it well, we really can have a very positive impact on many long-suffering members of our community.
The accompanying round table discussion in this issue contains many useful pearls, so I will simply add a few personal thoughts.
Because the differential diagnosis of ocular surface disease is difficult, it is a no-brainer to me to have available the newer point-of-service tests that help with the differential diagnosis. These, for me, include tear film osmolarity, MMP-9 and meibography. A chief complaint and history of present illness are of course critical to every patient encounter, but we now have validated ocular surface disease surveys that can help us diagnose and follow the therapeutic outcome of our ocular surface disease treatments. My favorites include the UNC Dry Eye Management Scale, the SPEED questionnaire and the Ocular Surface Disease Index. Of course, the external and slit lamp examinations are critical, but do not forget to look at the patient’s hands and face so as not to miss obvious rheumatoid arthritis, acne rosacea and lid abnormalities, including ectropion, floppy lid syndrome and the like. Staining with fluorescein is useful, but rose bengal and especially lissamine green, my favorite, are better. Simple in-office allergy testing and screening for Sjögren’s syndrome are also now available and useful for the clinician who sees a lot of dry eye and allergy and wants to take the next step.
In regards to treatment, the best way to put any ocular surface disease into remission rapidly is a short but intense course of topical steroids. There is always inflammation associated with significant ocular surface disease. Dry eye disease, ocular allergy and blepharitis/MGD nearly always respond rapidly to a 1- to 2-week course of topical steroid. Many eye doctors are very “steroid shy,” but if I have ruled out herpes simplex or other active infection, I am comfortable treating aggressively and putting the disease into remission with a short course of steroid drops. The key is “short course,” never more than 30 days and usually only 1 to 2 weeks. Patients are universally appreciative to finally find a doctor who takes their disease seriously and treats it aggressively. The steroids are rapidly tapered and the patient transitioned to long-term maintenance therapy.
Palliative therapies including lid hygiene are effective, and I especially like the Bruder mask for heat and Avenova (NovaBay) for lid hygiene. I am an advocate of omega-3s extracted from pelagic fish such as the PRN and Nordic Naturals brands. They must be taken in adequate doses, 2 g a day, and every day forever to be effective. Although expensive, when insurance coverage is adequate, I am impressed with the efficacy of topical Xiidra (lifitegrast, Shire) and in select cases Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) for long-term therapy. I find my patients using artificial tears less frequently, replacing them with Avenova and topical AzaSite (azithromycin, Akorn), lifitegrast or cyclosporine. Punctal plugs in aqueous deficient dry eye disease remain a valuable adjunct. In ocular allergy, the combined antihistamine/mast cell stabilizers are great for seasonal allergic conjunctivitis and are best given prophylactically. Most patients have associated allergic rhinitis, and this should be treated as well, usually with nasal sprays. Those with severe symptoms benefit from seeing an allergist.
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An underutilized medication that I find safe and effective for many patients with more severe disease is Lotemax (loteprednol etabonate ophthalmic suspension 0.5%, Bausch + Lomb), especially the 0.2% drop and the non-preserved ointment. I am using BlephEx (BlephEx LLC) in combination with heat and manual lid expression or LipiFlow (TearScience) in an increasing number of blepharitis/MGD patients. When patients can afford it, LipiFlow reliably generates impressive symptomatic relief for as long as a year.
Ocular surface disease in my practice is managed much like glaucoma, with visits every 3, 6 or 12 months depending on severity, point-of-service testing such as tear film osmolarity at every visit, an objective validated symptom questionnaire to measure subjective symptom response to therapy, a careful slit lamp examination with lissamine green staining, and encouragement to stay on effective long-term maintenance therapy. Like in glaucoma, lack of long-term compliance is a common problem.
Today, it is an increasingly rewarding experience to manage ocular surface disease, and these once neglected patients are worth capturing in one’s practice.
Disclosure: Lindstrom reports he is a consultant to, receives royalties from and has ownership interest in Bausch + Lomb.