Learning from failures – My top 3 dry eye treatment mishaps

22 01 2014

Having practiced for over 10 years now, I’ve had the most success and most impact on my dry eye patients in the last 2 years.  I just celebrated a milestone of having helped 200 patients achieve a level of clinical stability and symptomatic relief of their chronic dry eye disease.  I attribute that success to the breadth of clinical knowledge and research that I’ve put into building the dry eye clinic in addition to the dramatic increased volume of peer reviewed science directed towards the study of dry eye disease and its causes. More than anything else, however I attribute my patients success to the cases that failed initial treatment.  A good scientist’s successes are shouldered by his or her failures.

In this brief article I want to share from my dry eye cases that responded poorly or not at all to therapy.  It’s funny but 3 specific cases always come to mind when I think about this subject.  One case involves Lyme disease, another was a male with ‘borderline-normal’ testosterone and the last was a case of ‘he said she said’.

corneaesthesia1) Patient S.A. had been battling a diagnosis of Lyme disease when she presented to my office and all clinical signs pointed to MGD.  Meibography showed mild truncation but nothing more than I had seen in my most successful cases, and they certainly had viable expression on forced palpation.  Despite effective clearing of obstruction using LipiFlow (confirmed on post meibography) and improved ocular surface staining, she remained with mild improvement in meibum expression.  Her symptoms, as often observed with dry eye disease failed to match the improved clinical picture.   Systemically she was also not improving which I attributed to her lack of improvement.  However on closer inspection corneal sensitivity pre-treatment and 6 months later had increased.  I had assumed that initial testing was basal and normal, however it was more likely that this patient had experienced hypoaesthesia on presentation and treatment resulted in increased surface threshold sensitivity – a return to normal feeling if you will.  Lesson:  Longstanding cases of DED with and without systemic involvement will at some point undergo neural upregulation (or dysregulation) which can and will confuse the clinical picture.  I’ve learned from this that staying the course in the interest of decreasing inflammation is prudent, despite a failing symptomatic picture.  Sometimes feeling anything is better then feeling nothing at all!

nomgd2) Patient M.H.  had been to 3 corneal specialists in the previous 5 years.  He had been on various doses of doxycycline, restasis, all artificial tears, plugs with little improvement and even less hope.  The lid margin was hyperkeratinized and expression was low volume but clear.  Without staining these lids, I could see why my 3 colleagues before me were frustrated.  I proceeded with lid margin debridmenet/scaling technique by Maharaj Triad technique.  Patient had mild relief lasting 3 days and symptoms returned to similar levels as previous.  The brief improvement validated my approach so we proceeded twice more 1 month apart each.  Each time relief was lasting longer but failing to provide any sustained comfort.  Finally he mentioned how depressed this was getting him and how he had experienced sexual dysfunction that had been worsening over the last few years (he was late 30’s).  On further questioning his energy had reduced greatly and he had been on and off anti-depressants.  I promptly requested getting his testosterone measured by his family physician.  This was the missing link and it proved to be a turning point in this patient’s disease state.  Lesson:  Men with dry eye disease with limited clinical signs should be screened for androgen insufficiency.  Increasing this patient’s zinc intake and making some lifestyle changes had a significant impact on the ocular surface and meibum volume.

3) Patient TS.  presented with severe symptoms and clinical signs of chronic mixed aqueous/evaporative DED.  Meibography showed a unique pattern mgprobingof atrophy, however the majority of the ductule and acini were intact.  She insisted on not having undergone any treatment other than some at home efforts with warm compresses and all the artificial tears on the market with little help from anything.  Although the atrophy was atypical, I proceeded to clear the meibomian gland obstructions using LipiFlow in addition to lid margin debridement/scaling.  All metrics showed that she should have overwhelming success.  She did not.  At month 1 her glands had not improved and there appeared to be increased keratinization at the margin accompanied by further atrophy and cicatricial changes.  The patient had no history of viral conjunctivitis and I was officially stumped.  She consistently returned to my clinic enthusiastic but always reserved and mixed up on her use medicines and on chronology of her appointments.   I smelled deception.  By probing further and being honest about my disappointment in her lack of success, she volunteered that she had undergone meibomian gland probing 2 weeks after having had LipiFlow with me.  This explained everything.  Lesson:  Honesty is the best policy, but shouldn’t always be assumed.  Patients can be deceptive for reasons of guilt, lack of understanding, overconfidence, or just plain confusion.  When the clinical picture doesn’t fit for your dry eye patient, probe and question further.  History is still the gold standard in choosing a path of treatment for these patients!

Other tips:

1) Don’t wait to offer more than artificial tears and prescribed drops.   These aren’t restorative treatments but are palliative in nature.  Almost every patient I’ve treated has said, “I only wish I had this done sooner.”  The average patient has been seen by 3 doctors prior to showing up at the dry eye clinic.

2) Follow through – what patients don’t tell you is that it’s just not working or that they’ve lost confidence in the ‘same old approach.’  Like the contact lens patient that has been fitted in monthly CL’s for years from their optometrist, they will leave if offered a more comfortable 1 day disposable by the nearest competitor and they won’t tell you about it.  Tell your patients about new options for dry eye disease and give them a chance to say no.

3) Don’t let a patient become refractory to treatment!  A 50+ female wearing makeup and  reusable contact lenses with a history of eczema is (or will soon become) already a  DED patient.  A suspicious optic nerve get’s a glaucoma work-up, so why does the dry eye patient deserve anything less?  Tear film analysis and meibography are critical to staging the disease…and like glaucoma, the symptoms can be silent!

There it is -Some (certainly not all) of my learnings after spending over 600 clinical hours in the last 2 years at the dry eye clinc treating this challenging condition and the patients that live with it.  Confidence in understanding the physiology of dry eye disease allows the lessons of the failure of one patient to be the success of the next.  

In good health,

Dr. Richard Maharaj OD, FAAO

Cinical Director,

eyeLABS Optometry and Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

info@eyelabs.ca

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Do you suffer from acne? Bumps on your eyelids can be a sign

21 01 2014

zitDo you suffer with zits or chronic acne on your face or elsewhere on your body?  Are you obsessed with having and maintaining clear skin?  If you don’t already know, a zit or a pimple on your skin happens when the oils in your pores are trapped, built up and harden.  Your ‘pores’ on your skin are actually called sebaceous glands and are oil producing glands that give your skin the glowing complexion.  Irregular production and secretion of these oils can be caused by dirt from your hands and makeup and lack of proper cleaning of your skin from dead tissue or built up debris.  When these glands, or pores, become obstructed the skin tissue becomes inflamed turning red swollen and sometimes painful.  This inflammation is the body’s response to local trauma.  Now this isn’t the trauma caused from a hit or a poke, but microtrauma induced by the trapped oil and debris pushing on the surrounding wall of the gland and skin.  Some people with certain skin types have a strong inflammatory response which in biology is known as the triple response (of Lewis) which consists of:

  1. Red spot: due to small capillary dilatation
  2. Flare: redness in the surrounding area due to arteriolar dilatation
  3. Wheal: due to leakage of fluid from capillaries and venules

Those with a stronger response will be more likely to have stubborn acne that has limited responses to commercial products.  These cases usually require a skin specialist (dermatologist) to treat it medically.  People with eczema, asthma, psoriasis and rosacea (to name a few) are known to have a hypersensitive triple response.

meibglandNow that you understand what causes a pimple, you should also know that those sebaceous glands found on your skin are also found in your eyelid and are slightly modified to secrete oils for the eye’s surface.  Each eyelid contains 20-40 of these glands and have a very specialized function.  These glands are called meibomian glands and react the same way the pores on your skin react to debris, dirt, bacteria and general trauma.  What’s different about this area of the body however is that your eyelid is constantly moving and wiping away environmental debris from the ocular surface.  If you are a contact lens wearer, then it is also rubbing the plastic of the contact as well causing friction on the inner eyelid.  Considering what we know about trauma and what it does to our glands, imagine that this microtrauma happens every time you blink, every time you apply make up, every time you wear a contact lens and every time your eye is exposed to environmental debris.  That is pretty much every minute of every day!   The average human blinks seven to ten thousand times a day and for those people that have a heightened inflammatory response are more susceptible to the meibomian glands becoming obstructed which can lead to an eyelid pimple otherwise known as a stye.  These styes can get very large if untreated and become chalazion or an eyelid cyst which can in some cases require surgery.  Interestingly, a stye only happens when the blockage has gotten large enough to become visible to the human eye.  The blockage usually starts long before it becomes visible externally.

Unfortunately though, these meibomian glands are few and once blocked or inflamed can quickly become dysfunctional and die off. happysad The eyelid surface is uniquely situated close to the eyelash follicles.  Naturally occurring bacteria often accumulate in high numbers in this area due to built up dead skin, makeup and environmental debris.  This surface cannot be cleaned by commercial products with the precision required without causing harm to the eye (cleanser in the eye, removal pads can abrade the cornea, etc.).  Also the inner eyelid tissue known as the wiper is too sensitive to touch or use retail cleaning agents on without causing pain and or damage.  Basically this tissue is never really cleaned and these glands are under constant burden.

Your eyelid glands are just like your skin glands and need clinical attention to keep them functional and prevent meibomian gland dysfunction which causes up to 86% of dry eye disease patients.  In many cases it is a preventable condition, but only recently has clinical periocular hygiene emerged as a new effective maintenance treatment.  Using special dyes and instruments, the eyelid surface and glands can be treated comfortably in your eye doctor’s office.   New advances in this area allow even the most hardened blockages to be melted using prescribed heat and pressure simultaneously (LipiFlow thermal pulsation) in non-surgical painless procedure.

Bumps on your eyelid are exactly the same as pimples on your face, however the consequence of not treating it or preventing it are potentially vision threatening.  If left untreated eventual gland death can occur decreasing the stability and vitality of your tearfilm.  This puts the entire surface of the eye at risk for infection, chronic inflammation and even scarring of the conjunctiva or cornea.

Experts from around the world have now recognized meibomian gland dysfunction as being perhaps the most pervasive cause of dry eye disease around the planet.  These tiny delicate pores have a huge impact on our visual health.  Talk to your eye doctor about your glands and be proactive.  Having dedicated my career to the ocular surface and spending the last 2 years specifically developing treatments in this area, my advice is:  don’t let the symptoms start!

In good health,

Dr. Richard Maharaj OD, FAAO

Cinical Director,

eyeLABS Optometry and Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

info@eyelabs.ca





Think your eyelids are clean?….REALLY! Introducing Clinical Periocular Hygiene

16 01 2014

Beauty is in the eye of the beholder. Beauty is skin deep. It’s what’s inside that counts.   These phrases gets tossed around, yet people all over the world eyelidmascaraare investing billions into the cosmetic industry now more than ever.  Men and women paint our faces and in particular our eyes to create the smokey, butterfly lashes that magazines and TV tells us we need in order to be ‘current’.   But what is happening to the tissue underneath that paint – what happens after the smoke fades away?  I can tell you from my years of clinical experience and research that the eyes aren’t very forgiving and what you’re not seeing is the decline and deterioration of one of the most important organs in your body.  Your EYES!

So after years of piling pencil liner, mascara, shadow, concealer to and around your eyes, despite your best efforts to remove all of it from the area with cleansers and patented lotions and potions, the eyelid is unfortunately ends up carrying the burden of harboring microscopic bits of make-up debris and builds a breeding ground for bacterial growth which results in an aggressive inflammatory cascade that is so sneaky that the symptoms fail to present themselves until the disease is in full swing.  That disease is LID DISEASE – it encompasses blepharitis, meibomian gland dysfunction, lid wiper epitheliopathy and more generally dry eye disease.

When is the last time you visited your dentist or dental hygienist for a teeth cleaning?  Do you brush your teeth everyday?  This concept of oral debrishygiene is well accepted and widely known that the consequences of not cleaning your teeth can lead to gingivitis and several other oral issues.  The eyelid, both upper and lower, are complex structures that have hair follicles, 2 types of differentiated skin and several glands all that are responsible for keeping your cornea nourished, clear and comfortable;  the windshield wiper of your eye so to speak.  Yet  despite the importance of this structure in keeping your vision clear and protecting the eye from infection and damage, we plaster foreign material that is in some cases toxic to this sensitive tissue and still expect it to last a lifetime?  Well what actually happens is the eye lid skin and glands (known as meibomian glands) go through a process called keratinization and atrophy.  Basically the devitalized skin crusts and grows irregularly over the gland openings as well as within the glands themselves, eventually leading to gland death in the long term.  These glands are responsible for adding the much needed oil your tears need to prevent evaporation of the tears, buffer the friction between cornea and eyelid as well as balance inflammation at the surface of the eye.  When this surface isn’t properly cleared of debris, the keratinization process is started leading to breakdown of this gentle balance that keeps our eyes comfortable and clear.  Some studies have shown that as much as 60% of adults have incomplete eyelid closure when blinking, a process that is meant to assist proper clearance of debris and epithelium from the lid surface.

damageWashing your face and eye area is important to minimize the small particles of makeup debris that can and will transfer into the eye, however the lid margin is an area that without clinical instruments is near impossible to clear with causing damage.  In fact, without specific vital dyes, similar to the ones your dentist uses to highlight plaque on your teeth, damaged tissue is actually very difficult to see even under a microscope.  Don’t be fooled when you look at your lids under a magnifying mirror and think all the make-up is gone or if you cannot see any dead skin build up.

A new innovative area in eye care is emerging to manage this preventable problem.  Dry Eye Disease is reported in scientific literature in as much as 1 in 3 adults in North America.  The problem with that number is many cases of Dry Eye Disease can be prevented by clinical periocular hygiene.  At eyeLABS Center for Ocular Surface Disease, various techniques have been developed and adapted to clean and clear this area with clinical precision and effectiveness.  A comprehensive clinical periocular cleaning is the most effective way to keep this structure healthy and hygienic to date and is a non-surgical treatment for this surface.  As clinical director at eyeLABS, our patients have benefited from  hundreds of clinical hours spent refining our non-surgical periocular techniques as well as developing new ones making our center a first of its kind facility with specialty services in periocular hygeine and treatments.  Lid margin debridement/scaling is a technique used to clear keratinized tissue after being highlighted with specific ophthalmic dyes at the eyelid surface.  Obstructed glands can be cleared which give the oils a clear path to the tear film using various expression instruments with gentle pressure being applied.  In many cases, thermal pulsation is used if the obstruction is too hardened for routine expression to clear.  This 12-minute procedure is the only FDA approved therapy for non-surgical treatment of evaporative dry eye and eyeLABS was the first optometric center in the country to acquire this technology.  Eyelash follicles and roots are known areas where bacteria and mites (Demodex) make a home and can accumulate.  This can lead to inflammation at the eyelash base which worsens the nearby tissue inflammation and damage.  Loss of eyelashes can be a sign of bacterial or mite infestation.  Up to 80% of blepharitis patients have clinically documented Demodex infestation, depite good at home hygiene.  BlephEx is a new treatment method that allows clinical removal and cleaning of this area.

Clinical periocular hygiene is a growing area of non-surgical treatments for the eyelid and periocular region which is a proven effective means of keeping the delicate skin of the inner and outer eyelid healthy and vital to preventing lid disease and maintain good comfortable ocular health. Wear and tear to this area can and does happen without makeup application as well.  Incomplete blinking, contact lens wear, environmental debris, certain medications and health problems (diabetes, thyroid, arthritis) all increase the burden to this area.  Men are just as vulnerable as women to this problem.

Like every new area of medicine, many doctors don’t even know it exists and may prescribe artifical tears, antibiotic drops, lid scrubs or other at home warm compresses and baby shampoo however none of these at home solutions are able to clinically treat this area.  Like brushing your teeth daily (or twice daily), professional grade hygiene is required for proper oral health.  The most effective therapy is a combination of good home hygiene and regular clinical periocular hygiene.  The next time you book a facial to ‘clear your pores’, consider doing your eyes a favour and booking a comprehensive clinical cleaning for your eyes.  They’ll thank you for it!

In good health,

Dr. Richard Maharaj OD, FAAO

Cinical Director,

eyeLABS Optometry and Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

info@eyelabs.ca





Counterknowledge: Is Dry Eye a Disease or a Syndrome?

5 08 2013

The answer:  IT IS A DISEASE!

Language is important and how we treat a medical ailment depends very much on what we call it.  Terminologies like disorders, syndromes and diseases get mixed up and misused and interchanged depending on the literature or even the medical professional you are speaking to.   Defining a condition correctly will change the attitude of the patient suffering from it and the doctor treating it.  Brampton-20130205-00310Dry eye is one such disease that has been misrepresented as a syndrome in many arenas but let’s take a look at the definition of a disease versus a syndrome.

Syndrome:  a collection of signs and symptoms known to frequently appear together but without a known cause.  This grouping generally characterizes a disease or disease process

Disease:  a morbid entity characterized usually by at least two of these criteria:

  1. Recognized etiologic agent (cause)
  2. Identifiable group of signs and symptoms
  3. Consistent anatomic alterations

Dry eye disease, also known as Keratoconjunctivitis Sicca, is the term used by the internationally recognized Tear Film and Ocular Surface Society (TFOS).  It has very clear and identifiable signs and symptoms, anatomical changes are both diagnostic and prognostic of the disease itself.  The cause, or etiology, of dry eye is an often debated subject but as a culmination of decades of scientific study, it is well agreed that it can be distilled into one or a combination of aqueous deficiency, lipid or oil deficiency and/or cicatricial (scarring).  It is also generally accepted that dry eye is an inflammatory disease, which is why the majority of pipeline drugs are targeting inhibition of specific inflammatory pathways.

Why is this conversation relevant?  Too often a ‘syndrome’ get’s swept under the rug or trivialized by medicine and pop culture.  We are swift to group symptoms together and call it a syndrome which may be reason enough to take this side-stepping approach.  However when a real and clearly defined condition affects over 25 million US adults and over 100 million people world wide, AND science has elicited cause and effect then it should become an imperative to give it ‘disease’ status; not to scare or induce fear, but to appropriately identify and manage the process.

The next time you meet someone that has dry eye disease (DED), don’t define that person by the disease but rather understand the impact that it has had on her/his life.  Ask them how many doctor’s have actually given it the attention it deserves.

In a survey of 100 patients at eyeLABS Center for Ocular Surface Diseases, the average number of eye physicians/doctors the patient had consulted for DED was 3 prior to seeing me.  I intend to be their last.

sidenoteSideNote: The Ocular Surface is Skin – Treat it that way

Dry Eye Disease is a skin condition, not unlike many dermatological conditions.  The lid surface, meibomian glands and corneal tissue are variations of epithelium and sebaceous glands which will age, like the dermis does.  The lengths of cosmetics, creams, lotions and potions for the skin can help to preserve our skin, but what about the eye?  The science at eyeLABS is founded in ocular surface skin preservation and sustenance.  Lid Margin Debridement (click here for related article) and clinical gland expression provides a basis for the spectrum of treatment options and maintenance procedures available at our clinic.  Contact lens wearers in particular should actively seek these types of treatments out as they are more likely to develop lid related inflammatory conditions (lid wiper epitheliopathy) that directly impact the glands, cornea and therefore dry eye disease progression.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





eyeLABS featured on CTV: Dry Eye Clinic

19 07 2013

eyeLABS  was featured on CTV with Dr. Maharaj and fellow patients discussing the disease of dry eye and the merits of effective treatments focused on the eyelid.  LipiFlow, Lid Margin Debridement, and other therapies are found under one unique roof at eyeLABS center for ocular surface disease.  Click here or the image below to watch the CTV segment:  

CTVRMpic

Meibomian gland dysfunction is a commonly overlooked disease entity and can be inconspicuous even under microscopic examination.  Clinical expression by your optometrist or ophthalmologist is the only true way to identify blocked glands.  These glands, once blocked, will eventually atrophy or die which can lead to permanent scarring of the glands inner architecture.

The image below is a scale commonly used at eyeLABS to classify the severity of meibomian gland atrophy (Meibo-Scale).  It is important that patients and doctors intervene early enough in the disease to prevent natural progression, which is certain if left untreated.  Eye drops do little other than cover up the symptoms.  Clinical clearing of the gland is the most effective treatment and LipiFlow Thermal Pulsation is the only FDA approved therapy for MGD.

meiboscale

Dr. Maharaj has treated patients from across the country and has profoundly changed lives by offering ground breaking procedures like LipiFlow and creating new and innovative maintenance therapies like his signature Lid Debridement technique.  eyeLABS is an instruction facility for doctors in training and Dr. Maharaj has trained other LipiFlow doctors at other Toronto clinics in its use and advances in the treatment of Dry Eye Disease.

If you know someone who complains of even mild ocular discomfort with or without contacts, watery and or burning eyes then do them a favour and refer them for therapy they deserve.

eyeLABS center for ocular surface disease is a referral based clinic.  Call 905-456-9333 or Fax referrals to 905-456-9332 to book a consultation.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Center for Ocular Surface Disease

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





In the midst of a paradigm shift

10 04 2013

Thomas Kuhn was an American physicist, historian, and philosopher.  His 1962 book “The Structure of Scientific Revolutions” stood to define what we know today as a paradigm shift.  Essentially, when the prevailing winds of science have resulted in the build up of anomalies that cannot be explained by existing theory eventually a new wind blows the sail in the right direction.  For example, prior to Hellenistic Greece, the concept of a spherical earth was remote at best.  The paradigm shifting to a spherical planet changed conventional wisdom and set the stage for a new era of science.

As scientist and a great seeker of the undiscovered, I look at my profession, optometry, as in the midst of great change.  On a daily basis I hear from colleagues that are anxious about internet driven competition, big box optical competition and corporate competition.  I meet with new and soon to be graduates about the climate they are entering into and hear great fear.  The prevailing winds are blowing but with every build up of anomalous threat comes new opportunity.

This post, unlike many of my others is not a clinical directive and might be assumed by some to be just rhetoric – but let me share my short story and you be the judge.

A little over 1 year ago, my life got flipped upside down.  I was a partner in an established practice and professionally was content but not satisfied that I was being authentic in the care I was delivering.  I still practiced 1 day in a hospital setting which the patient base was lower income, ethnically diverse and the staff were less organized and more emotional.  My partner and I decided to part ways due to increasing tension and discord.  Our practice philosophies were decidedly different which I now can look back and see that were reflections of our personal philosophies.   So we parted amicably and I changed gears and decided to build a clinic dedicated to the ocular surface.  No retailing of any kind – a medical optometry clinic.  In ONTARIO?  It stirred the waters quietly among my colleagues both optometry and ophthalmology alike.  It stirred the waters in my home as well.  My wife and I had a 6 month old child and financially this was a high risk manoeuvre as she wasn’t working either.  This resulted in an immense change in the ‘comfort’ we had grown accustom to and resulted in a cascade of stresses that both my wife and I hadn’t experienced before.  The prevailing wind in my life was blowing me over the edge.   On a personal level this was one of the most uncomfortable times in my life.  I put my wife through the same.

The clinic has been open for 9 months now and much to my dismay, the cup did not overflow with patients like I thought.  The tax incentives I had planned for were denied and I was in an even worse position that I originally predicted.  I feared what this meant for my family but with support I carried on working tirelessly at carving my niche, my dream of what optometry meant to me; creating what I wanted it to look like.  I created a research division at my clinic and  developed novel techniques for treating a condition I spent my entire career avoiding.  Most importantly I starting making a difference in peoples lives by examining what they needed most.  I decided that I can’t do it all, but dedication to this specialized area of eye care I could do great things.  I am doing great things.

To be clear, I’m not a millionaire or even close.  The clinic is still growing, but my practice has become a reflection of  me and that has made all the difference.  I do – my practice does – my family does.  From this adversity I was able to free myself creatively.  To not be bound by someone else’s rationale.  I was able to grow professionally at an exponential rate.  I surrounded myself with the greatest minds in the eye industry from  Donald Korb to Steve Arshinoff to Stuart Richer to Larry Alexander.  My colleague and phenomenal speaker Kent Prete gave a recent presentation that allowed me to fully reflect on the last year and realize that out the deconstruction that was my life grew a new subset of practice.  Though I didn’t realize it, I had inspired others to do the same.  It has become contagious and I believe we are witnessing a paradigm shift as I write this post.

What’s the point of this post?  I have never shared this story before and I’m not entirely sure what type of reaction it will attract.  I hope that it lights a fire under some like the one that is under me. In the face of this uncomfortable, unpredictable, unprecedented time I encourage new grads to older colleagues to embrace the change because the discomfort may be driving your patients out of their contact lenses, it will keep you on the edge of your seat wanting more.

 

 

Sincerely,

Eyelabs_Promo_Richard1_web

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.c

 





Thinking of Having LASIK? Be Clear with your Doctor on WHY

20 03 2013

“Have you considered having LASIK because you’re tired of your contact lenses?”  Think about what this popular marketing question is asking.  Are you tired of the inconvenience of taking proper care of your contact lenses or are your eyes tired and fatigued from wearing them all day long?  Are you tired of the discomfort that contact lenses cause you?  These are very different questions and can be the difference of being a good candidate or a poor candidate for surgery.  Let’s look at a patient case after having LASIK over a year ago complaining of significant discomfort which is preventing her from an increasing number of the routines in her daily life.lasik

Lasik 1 year ago.  Current presentation:

Almost a year after having LASIK (she self referred to a local center), this 40+ female was referred to me for complaints related to dry eye.  Her LASIK surgeon had prescribed all forms of over-the-counter eye drops and finally treated her dry eye with Restasis (cyclosporine 0.05%) for 90 days with no improvement in her symptoms in that time.  Her vision was corrected to 20/20 in each eye so what’s the problem right?  I’ve heard many times over the years from various ‘experts’ that developing dry eye after LASIK as being a mild problem and that having to use eye drops for the rest of your life is a small price to pay for 20/20 vision.  This patient would vehemently disagree.

During her consultation with me, it came out that she suffers with atopic dermatitis (eczema) and has since a child.  She is a caucasian female with northern European descent and has auburn hair.  This combination of demographic information and her dermatological history are pearls for why this patient should have been screened more thoroughly prior to having LASIK.  In further discussion as to her motivation for LASIK, she mentioned never being comfortable with any contact lens which caused fatigue and frustration.  Another pearl!

For the doctors reading this article, do you have a differential diagnosis in mind?

On clinical examination, she presented with bilateral epithelial basement membrane dystrophy (EBMD) with right eye being more severe clinically and symptomatically.  Symptom scores using SPEED evaluation were 19 (normal is under 6) and lipid thickness from interferometry was 50 in her right and 75 in her left (normal being above 80).  Eyelid evaluation revealed moderate meibomian gland stasis and anteriorly thickened Marx’s line, which is indicative of progressive lid disease causing evaporative dry eye.  Her tear volume 5mm in the right and 7mm in the left by Schirmer indicating an aqueous component to her dry eye.  She also exhibited mild ocular rosacea with some facial pattern acne.

MDF_LASIKOS

MMP-9 is a particular matrix metalloproteinase  found in high concentrations on  diseased ocular surfaces.  MMP-9 is known to be a catalyzing agent (among others) in ocular inflammation and corneal erosions ( Dursun D, Kim MC, Solomon A, et al, Am J Oph 2001).  At present in Canada, we can’t test for its presence, however it is becoming widely claimed as a hallmark protein  in patients with dry eye disease.  There is some correlation between patients with atopic disease and higher concentrations of MMP-9 on the ocular surface.

From this information, this patient having had symptoms of dry eye without obvious clinical signs of EBMD pre-surgery was convinced that contact lenses were her problem, however the current clinical picture suggests that she was exhibiting symptoms of ocular surface inflammation due to a mixed component dry eye combined with contact lens use.  This patient was better suited for photorefractive keratectomy (PRK) or no surgery at all given the strong likelihood of underlying corneal disease.  A key pearl in her history is the discomfort due to contact lens wear.  She was lead, like a moth to a flame, by clever marketing suggesting that being ‘tired of contact lenses’ made her an excellent LASIK candidate but in fact it was quite the opposite.

All patients considering LASIK should be properly evaluated for the presence of underlying lid disease in addition to seemingly unrelated medical conditions.  Without assessing meibomian gland depth, expression, quality of secretions in addition to anatomical indicators of progressive lid disease like Marx’s line, an important aspect was missing in determining this patients candidacy for LASIK.  It is true, that the body of science pointing to a direct correlation between eczema and corneal dystrophy is small, in my clinical experience I have seen this correlation to be strong.  Add to that an ocular surface with increasing inflammatory proteins due to poor aqueous and lipid content and a traumatic event like LASIK, her present clinical picture now makes sense.

So what can be done? Treatment:

She is currently being treated to minimize MMP-9 with a combination of low-dose doxycycline 50 mg po in addition to topical loteprednol bid 1 month. Oncotic pressure reduction with hypertonic sodium ointment applied at night ( Muro 128 5% Bausch & Lomb) will help on more chronic basis .  Treating the mgd  will have the biggest impact on her symptoms so this patient will undergo LipiFlow OU as manual expression and lid debridement has already been performed with mild improvements to her symptomology.  Maintenance of the lid surface with Cliradex eye wipes has also been added to manage the external inflammation (rosacea) with its active component  4-Terpineol, an organic compound that has demonstrated good efficacy at eradicating demodex as it relates to blepharitis and mgd.  PTK ( phototherapeutic keratectomy) is a more invasive option here which is very effective at recalcitrant erosion cases but our patient opted for more conservative therapies (Sridhar MS, Rapuano CJ, Cosar CB, et al Ophthalmology 2002).

Take home:

So what can be learned from this lesson?  History is key and marketing is clever.  If you’re a patient considering LASIK, do speak with your eye doctor about your reason for wanting surgery and be thorough because buried within your rationale may be a very clear reason as to why you shouldn’t have it done.  If you’re a doctor, be sure to assess for non-obvious MGD or accessories to dry eye and consider that even mild cases will advance given the perfect sequence of events like my patient above.

LASIK is an amazing life changing procedure that is absolutely the right choice for the right patient.  I spent a major part of my career specifically managing complex LASIK cases so by no means am I commenting on the effectiveness of the procedure or on the millions of lives that have been changed for the better from having it done.

Minimizing the impact that dry eye disease can have is, for me, like trivializing depression and the importance of mental health.  Too often are these patients told that ‘it’s in your head’ or to ‘live with it,’ when we know that when left untreated this condition doesn’t get better.  When eye care providers put value in our patients’ symptoms and consider the impact of what many of us take for granted like walking through a mall without your eyes burning, or not being  woke up in the middle of the night with extreme discomfort, we empower them to be honest to take control of their ocular health.  This will inevitably create happier patients.

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca