The Dry Eye

The New Year’s resolutions of a dry eye doc

It is almost the end of January when you are reading this, but I wrote it at the end of a Thanksgiving weekend when I had a bit too much time on my hands. Although to be honest, it is always nice to be a little bit ahead of the deadline divas at Ocular Surgery News, especially around the holidays. So without any further ado, I offer to you one dry eye doc’s New Year’s resolutions for 2020, the year of eye care.

Darrell E. White, MD
Darrell E. White

1. I resolve to record more podcasts in a more timely fashion. This is nothing more than pure self-preservation. Doing so will save me from being subjected to Tal Raviv’s rapier wit.

2. I resolve to test more when I am taking care of DED patients. As good as we have been at SkyVision over the years, we still miss the opportunity to use tear osmolarity and MMP-9 results to direct our care. More than that, I resolve to figure out how to graph trends in both of these measurements, with or without the help of our electronic medical record. Likely without.

3. I resolve to include blood work in my evaluations, especially at the outset of DED care. Quite frankly, I fear that it is nothing more than inertia that has kept us from doing a Sjö test (Bausch + Lomb), to look for an early diagnosis of Sjögren’s disease, and an Omega-3 Index test (OmegaQuant), to determine the blood level of omega-3 fatty acid, on every patient. As an extension of this resolution, I will do my best to make better friends with our local rheumatologists by bringing the Sjö test to their attention; perhaps B+L will join me in that effort.

4. I resolve to utilize DED patient surveys more consistently in 2020. Even at SkyVision, an eye care practice that has grown through a dedication to the treatment of DED, we are remarkably and regrettably inconsistent in obtaining an OSDI or SPEED survey on each of our follow-up visits. Here, too, we can learn how to graph these results looking for trends.

5. I resolve to incorporate intense pulsed light into our DED offerings in 2020. Since I am writing this over Thanksgiving, let me say how thankful I am that Dr. Alice Epitropoulos has been willing to see and treat our patients in Columbus (2 hours from Cleveland). It is time for us to provide this treatment to our patients with meibomian gland dysfunction. I am looking forward to asking my friend Rolando Toyos for his help and guidance.

6. I resolve to think of using autologous serum tears earlier in our treatment protocols. Once again, when the going got tough (both of our local compounding options folded their programs and the national lab in California stopped as well), the tough quit. I am indebted to my CEDARS/ASPENS colleagues, especially Dr. Gregg Berdy, for introducing us to Saving Sight in St. Louis. While autologous serum tears are not covered by health insurance, the folks at Saving Sight offer reasonable prices and a great patient-friendly service. We will move autologous serum tears up in our protocols.

7. I resolve to figure out the TrueTear puzzle. We are batting about .900 when it comes to symptomatic success for the patients who are using TrueTear (Allergan) prescribed at SkyVision. What is the patient profile that should prompt us to think about this treatment earlier in our severe DED patients’ journey? How can we present this option in a way that the awkward business model is a lesser barrier to using TrueTear? We have been impressed by how well it works in moderate neurogenic pain patients.

8. I resolve to find a team of neurologists here in Cleveland with whom I can partner in the care of neurogenic pain patients whose symptoms originated in DED. This should be easy; I live in Cleveland, home to two large academic institutions with active neuro programs. Sadly, the consolidation in health care brought about by Obamacare has disincentivized both doctors and their large institutions from caring for this type of complex, highly hands-on patient. Still, I will try to find willing teammates for this battle.

9. I resolve to more fully enter the conversation about neurogenic pain following LASIK. A part of that involvement will necessarily mean exposing myself to the attacks of a media world always seeking the sensational, especially when it involves bad medical outcomes. Fortunately, this is at least as rare as post-LASIK ectasia, a problem that has become ever more rare as we have succeeded in identifying preop findings that may increase its risk for occurring. There must be something for which we can screen to also decrease the incidence of post-LASIK pain syndromes. We know that both LASIK and PRK cause a decrease in corneal nerve density that takes many months to resolve. Does the answer somehow lie there, in the nerves? Dr. Pedram Hamrah at Tufts wonders the same thing; as with Rolando, I look forward to seeking Pedram’s counsel.

10. And finally, in 2020, as I have done for the many years since my “sabbatical,” I resolve to continue to represent you, the ophthalmologist or optometrist who just goes to work and takes care of their patients. I resolve to continue to bring the view that exists in those sacred 6 inches between our eyes and those of our patients into the boardrooms of our industry partners, into the privileged palaces of our cloistered academics and hopefully to a governmental bureaucracy that too often makes decisions without understanding that view. For as long as you will have me, I will do my best to tell the truth as it looks through the eyes of doctors who take care of patients.

In the year of the eye, Happy New Year to everyone who wakes up each day in the hope that his or her work will lead to a brighter world.

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.

It is almost the end of January when you are reading this, but I wrote it at the end of a Thanksgiving weekend when I had a bit too much time on my hands. Although to be honest, it is always nice to be a little bit ahead of the deadline divas at Ocular Surgery News, especially around the holidays. So without any further ado, I offer to you one dry eye doc’s New Year’s resolutions for 2020, the year of eye care.

Darrell E. White, MD
Darrell E. White

1. I resolve to record more podcasts in a more timely fashion. This is nothing more than pure self-preservation. Doing so will save me from being subjected to Tal Raviv’s rapier wit.

2. I resolve to test more when I am taking care of DED patients. As good as we have been at SkyVision over the years, we still miss the opportunity to use tear osmolarity and MMP-9 results to direct our care. More than that, I resolve to figure out how to graph trends in both of these measurements, with or without the help of our electronic medical record. Likely without.

3. I resolve to include blood work in my evaluations, especially at the outset of DED care. Quite frankly, I fear that it is nothing more than inertia that has kept us from doing a Sjö test (Bausch + Lomb), to look for an early diagnosis of Sjögren’s disease, and an Omega-3 Index test (OmegaQuant), to determine the blood level of omega-3 fatty acid, on every patient. As an extension of this resolution, I will do my best to make better friends with our local rheumatologists by bringing the Sjö test to their attention; perhaps B+L will join me in that effort.

4. I resolve to utilize DED patient surveys more consistently in 2020. Even at SkyVision, an eye care practice that has grown through a dedication to the treatment of DED, we are remarkably and regrettably inconsistent in obtaining an OSDI or SPEED survey on each of our follow-up visits. Here, too, we can learn how to graph these results looking for trends.

5. I resolve to incorporate intense pulsed light into our DED offerings in 2020. Since I am writing this over Thanksgiving, let me say how thankful I am that Dr. Alice Epitropoulos has been willing to see and treat our patients in Columbus (2 hours from Cleveland). It is time for us to provide this treatment to our patients with meibomian gland dysfunction. I am looking forward to asking my friend Rolando Toyos for his help and guidance.

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6. I resolve to think of using autologous serum tears earlier in our treatment protocols. Once again, when the going got tough (both of our local compounding options folded their programs and the national lab in California stopped as well), the tough quit. I am indebted to my CEDARS/ASPENS colleagues, especially Dr. Gregg Berdy, for introducing us to Saving Sight in St. Louis. While autologous serum tears are not covered by health insurance, the folks at Saving Sight offer reasonable prices and a great patient-friendly service. We will move autologous serum tears up in our protocols.

7. I resolve to figure out the TrueTear puzzle. We are batting about .900 when it comes to symptomatic success for the patients who are using TrueTear (Allergan) prescribed at SkyVision. What is the patient profile that should prompt us to think about this treatment earlier in our severe DED patients’ journey? How can we present this option in a way that the awkward business model is a lesser barrier to using TrueTear? We have been impressed by how well it works in moderate neurogenic pain patients.

8. I resolve to find a team of neurologists here in Cleveland with whom I can partner in the care of neurogenic pain patients whose symptoms originated in DED. This should be easy; I live in Cleveland, home to two large academic institutions with active neuro programs. Sadly, the consolidation in health care brought about by Obamacare has disincentivized both doctors and their large institutions from caring for this type of complex, highly hands-on patient. Still, I will try to find willing teammates for this battle.

9. I resolve to more fully enter the conversation about neurogenic pain following LASIK. A part of that involvement will necessarily mean exposing myself to the attacks of a media world always seeking the sensational, especially when it involves bad medical outcomes. Fortunately, this is at least as rare as post-LASIK ectasia, a problem that has become ever more rare as we have succeeded in identifying preop findings that may increase its risk for occurring. There must be something for which we can screen to also decrease the incidence of post-LASIK pain syndromes. We know that both LASIK and PRK cause a decrease in corneal nerve density that takes many months to resolve. Does the answer somehow lie there, in the nerves? Dr. Pedram Hamrah at Tufts wonders the same thing; as with Rolando, I look forward to seeking Pedram’s counsel.

PAGE BREAK

10. And finally, in 2020, as I have done for the many years since my “sabbatical,” I resolve to continue to represent you, the ophthalmologist or optometrist who just goes to work and takes care of their patients. I resolve to continue to bring the view that exists in those sacred 6 inches between our eyes and those of our patients into the boardrooms of our industry partners, into the privileged palaces of our cloistered academics and hopefully to a governmental bureaucracy that too often makes decisions without understanding that view. For as long as you will have me, I will do my best to tell the truth as it looks through the eyes of doctors who take care of patients.

In the year of the eye, Happy New Year to everyone who wakes up each day in the hope that his or her work will lead to a brighter world.

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.