Have you ever had one of your technicians literally skip into the hallway looking for you? I just did. Lenora’s feet barely touched the ground as she came around the corner:
“Come on back into the room! You have to hear this. I know why so-and-so’s eyes are dry, and I know how to fix it so we can do his cataract surgery!”
Now, to be truthful, all of our technicians are on the lookout for dry eye in our preop patients, and to a person they have a great deal of pride in their ability to find everyone who might stumble in the postop period from dryness. But skipping? Doesn’t happen.
Our patient is a large man with sleep apnea who has intense inferior corneal staining. We will need to have some DED treatment before we get to any pre-cataract measurements, and because he is interested in a presbyopia-correcting IOL, we have a whole protocol that automatically kicks in. What made Lenora get excited is that she asked that critical “next” question about his CPAP machine and whether it was leaking around the seal. He has a new kind of CPAP that only connects to the nose and pushes air directly into his nostrils. There was no leak that he could remember, but he was noticing a “fluttering” of his upper lids as he fell asleep.
Yup, you (and Lenora) guessed it: He has incompetent canalicular valves. Some of his positive pressure flow is going up his tear ducts and flowing across his closed eyes while he sleeps. Great pick-up, huh?!
Lenora wasn’t quite done yet. While I was chatting with our patient, she came back into the room with a punctal plug set-up. “Ya gotta do this, right? This is the perfect solution!” We did, indeed, plug the inferior punctum on both eyes in addition to starting up both intense lubrication and Xiidra (Shire) (per his insurance coverage); he had positive MMP-9 activity and elevated osmolarity. With his dryness dramatically improved, he is on the launchpad for his first eye. All because my tech was still asking the extra question at the end of the day.
Disclosure: White reports he is a consultant to Allergan, Shire, Sun, Kala, Ocular Science, Rendia, TearLab, Eyevance and Omeros; is a speaker for Shire, Allergan, Omeros and Sun; and has an ownership interest in Ocular Science and Eyevance.