The most common patients a comprehensive ophthalmologist will likely take care of in his or her practice are those with ocular surface disease, including dry eyes and blepharitis. Proper management of these patients often depends on identifying the primary problems and addressing all the contributing factors.
Here are a few tips for making the proper diagnosis and treatment in patients with ocular surface disease:
1. Listen to the patient. The patient’s history can often help you make the proper diagnosis and, in turn, direct the proper management. Given that there is significant overlap between the reported symptoms for various ocular surface conditions, it is sometimes helpful to ask the patient to identify the most severe symptom that they would like to be addressed. This can help identify the most likely primary problem, while also guiding your therapy.
For instance, itching, especially in the inner canthal area, is almost always a sign of allergic disease. Likewise, it is well known that patients whose symptoms are predominantly due to aqueous tear deficiency will often have foreign body sensation, which is worse later in the day. Conversely, patients with predominantly meibomian gland disease and concominant evaporative dry eye, have more burning and irritation, which is typically worse in the morning.
Fluctuating vision with worsening visual acuity after visually intensive activities is virtually diagnostic of an inadequate tear film.
2. Examine the patient before looking behind the slit lamp. Often, as we are pressed for time, we tend to bring the patient behind the slit lamp before adequately looking at the patient’s skin and eyelids. In addition to looking for signs of rosacea, it is very useful to notice how frequently the patient blinks, as well as his or her eyelid positions. Lower lid laxity is a major contributing factor in many patients with dry eye disease. Likewise, floppy eyelid is often overlooked as the etiology of chronic surface disease.
3. Check corneal sensation. A neurotrophic cornea can be both the cause and the consequence of chronic ocular surface disease. Patients who are neurotrophic will typically demonstrate significant ocular surface staining but minimal symptoms. It is often overlooked as the etiology of dry eyes in longstanding diabetic patients. Punctal occlusion is a very effective first-line treatment for these patients.
4. Use vital dye staining. All ophthalmology offices use fluorescein to look for staining on the cornea. However, Rose Bengal and Lissamine Green are actually more sensitive than fluorescein and can be used to diagnose dry eye disease at an earlier stage by looking for staining in the conjunctiva with white light. This may be useful, for instance, when screening patients before refractive surgery.
I prefer Lissamine Green since it is tolerated better by the patient. Both can be purchased in impregnated strips and used in a manner similar to fluorescein strips.
5. Be suspicious of superior corneal staining. Fluorescein staining that is more prominent in the superior cornea (which is typically covered by the upper eyelid) is almost never just due to dry eyes. Staining from dry eyes typically affects the interpalpebral zone much more significantly. Therefore, one should have a high index of suspicion in patients whose staining is more prominent superiorly.
Additional investigations should include everting the upper eyelid to check for floppiness and/or changes on the palpebral conjunctiva. Likewise, superior limbic keratoconjunctivitis should be considered by checking for staining and redundancy of the superior conjunctiva.
Finally, contact lens-induced limbal stem cell deficiency will typically present with staining in a whorl pattern starting in the superior cornea and limbus.
6. Emphasize and provide clear instructions on lid hygiene. As we are pressed for time, there is a tendency to jump to medical therapies without adequately emphasizing or instructing patients with blepharitis on lid hygiene. One strategy that is helpful is to make an illustrated handout that clearly demonstrates and explains your preferred technique.
7. Use anti-inflammatory therapy early. Inflammation plays a role in every form of ocular surface disease. In patients with obvious signs of inflammation, it is best to begin anti-inflammatory therapy early. My preference is to start with a short course of mild steroid such as loteprednol and start topical cyclosporine drops concomitantly.
This is also important if you plan to perform punctal occlusion, since punctal occlusion in the presence of inflammation will often exacerbate the patient’s signs and symptoms in the short run, given that it will keep more inflammatory mediators on the ocular surface. Therefore, it is better to control the inflammation first.
8. Minimize preservative toxicity. It goes without saying that patients with ocular surface disease are much more sensitive to preservatives, particularly benzalkonium chloride (BAK). In addition to using non-preserved topical lubricants, when prescribing antibiotics, steroids or glaucoma medications, I prefer to use non-preserved or non-BAK preserved eye drops whenever possible.
9. Use tetracycline based drugs at lower doses. There is enough evidence to indicate that medications such as doxycycline can be effective for the management of meibomian gland disease at much lower doses than previously thought. Although more expensive, doxycycline can be prescribed at 20 mg twice a day. If not affordable to the patient, then 50 mg twice a day generic version is also an option. Using lower dosages will improve compliance by minimizing the side effects, particularly gastrointestinal side effects.
10. Manage patient expectations and be persistent. Obviously, ocular surface diseases such as dry eyes and blepharitis are chronic conditions that, at best, can be controlled but rarely cured. Managing patient expectations is critical, given the tendency for patients to expect immediate improvement and give up too soon on their therapies. When dealing with ocular surface diseases, one has to be persistent and use combination therapies in order to reach the full treatment effect.
* * *
About the author: Ali R. Djalilian, MD, is on faculty at the Cornea Service at the Illinois Eye and Ear Infirmary and an assistant professor in the department of ophthalmology and visual sciences at the University of Illinois at Chicago. His research and clinical interests are in ocular surface disorders, particularly limbal stem cell biology and transplantation. He is the recipient of a career development award from the NEI, as well as Research to Prevent Blindness.