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Follow back up with your patient in about a month to assess progress, and to modify the treatment plan as needed. • If none of your rational therapeutic interventions alter the symptoms, then consider “neuropathic pain” as the etiology. No eye doctor can successfully “treat” this somatosensory neurological disease. These are relatively rare patients, but they are out there, so be attentive to these recalcitrant patients. A second opinion may be in order. • The focus of managing dry eye disease is attending to foundational meibomian gland dysfunction. While meibography is optional, practically speaking, it is desirable; however, keep in mind that there is a high probability of meibomian gland disease accompanying and/or causing dry eye. We recommend starting with this approach: use your golf club spud to scrape back and forth three or four times along the top of the eyelids where the orifices of the meibomian glands are. No anesthesia is required for this maneuver. Of note, there is no CPT for it either. Then, guide the patient to use very warm compresses for at least five minutes, and then to perform gentle to moderate SECTION II: ANTERIOR SEGMENT CARE Practical Pearls for Managing Dry Eye Disease Control the inflammation and you’ll fast-forward symptomatic control. DED TESTING TO DYE FOR • “Of all the available dry eye tests, corneal fluorescein staining is reportedly the most commonly performed, and the conjunctival lissamine green is the least commonly used test.” • “This could be due to ease/ difficulty of access to these dyes or perhaps lack of knowledge or awareness regarding the significance of each.” • “The degree of baseline conjunctival staining was a significant predictor of the worsening in corneal staining after sustained reading.” • “Subjective symptoms showed the strongest correlation with baseline conjunctival staining of all the dry eye parameters. Conjunctival staining needs particular attention when evaluating patients for dry eye.” —Ophthalmology, October 2018 (see ref. 7) Our take: This further supports our perspective that dry eye disease diagnosis is very straightforward without the need for superfluous ancillary tests. We all need to appreciate the usefulness of lissamine green dye in our dry eye disease evaluations. LOTEPREDNOL EFFECTS ON DRY EYE DISEASE • Using 0.5% loteprednol QID for one month was sufficient to control ocular surface inflammation • “No cases showing a significant increase of IOP were detected.” • “Pflugfelder and associates reported no clinically significant changes in IOP in any patient who received topical loteprednol four times daily for one month.” • Summary: Loteprednol can provide greater anti-inflammatory effects and clinical benefits through reduction of ocular surface inflammation without serious adverse events. —AJO, December 2014 (see ref. 6) As can be readily seen, this dry eye patient has a scant lacrimal lake. REVIEW OF OPTOMETRY JUNE 15, 2020 21 eyelid massage.
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