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





A Tale of Two Cities: Treating the Travelling Corneal Abrasion

12 09 2013

The kids are back in school and hopefully everyone is settling into routines like an old man into  warm bath.  With our kids back to school and hopefully learning with perfect bilaterally corrected vision (having already been comprehensively examined by an optometrist), it’s time for Eye on Eyes readers to do some learning.

The case being shared in this article is not one of an unusual pathology, but the route of management.  It speaks to the capability and compassion of optometrists across the country in helping one patient to feel comforted in a time of uncertainty.  This 62 year old female presented for the second time in 4 months with a left corneal abrasion (see photo).  Image

She had underlying epithelial basement membrane dystrophy and had been using hyperosmotic ointment at night once a week previous to this incident.  On presentation the epithelium had a crescent-shaped break consistent with her fingernail that had accidentally brushed her cornea while rubbing her eyelid.  The surrounding loose epithelium (~3mm) layed above  3+ stromal edema which created a potential for a full circumscribed abrasion with the slightest touch or blink.  She was able to keep her eye closed until coming into the clinic 15 minutes after the incident.

Certainly a worrisome cornea with the potential for infection to set in, however there was no evidence of contamination of the wound and there hadn’t been a lot of time for the eye’s natural flora to cause further insult.  Managing this required wound protection and prophylaxis measures to prevent infection.  The monkey wrench was that this patient was flying to Calgary later the same day and I was left with a potential ulcer, scarring and related vision loss if this wasn’t followed promptly and compliance with my treatment wasn’t followed.

This scenario required some “outside of the box” thinking and in fact outside of the province thinking.  Luckily, my esteemed colleague, classmate and friend Dr. Dwayne Lonsdale who practices near Calgary (North Hill Optometry) was just a facebook message away and was available to follow up and be her on-call travel optometrist while she was in his area.   With the patient’s consent, I sent Dr. Lonsdale (http://www.northhilloptometry.com/) the above image (taken using my smartphone behind slitlamp) for reference and follow up until she could return to my care back in Toronto.

Once her travel-care was arranged, I placed a bandage contact lens on eye, provided her with  antibiotic topical coverage and Muro 128 qid + ung qhs and sent her safely into the slit lamp of another.  With recurrent corneal abrasions it is important to heal the wound first by protecting it from chronic insult.  In this case repeated mechanical trauma of blinking would cause this epithelium to slide right off and leave an open wound waiting for a biological enemy to invade and infect.  During this time treat with topical antibiotic coverage (4th generation qid) and hyperosmotic agent to reduce edema.

Dr. Lonsdale reported her progress and removed BCL by day 3 and wound recovery was excellent.  BCVA had improved from her initial 20/40- to near 20/20.  Once the wound had closed, a topical antibiotic/steroid was added to reduce inflammation further while retaining coverage.Image

On returning from her trip to see me, her prescribed medications were reduced to hyperosmotic ointment nightly and non-preserved 1% hyaluronic acid to replenish the epithelium.  She is fully recovered and eternally grateful for the care she received at home and while travelling in Canada.  We are discussing options to prevent further RCE by using oral doxycycline combined with hyperosmotic ointment nightly to reduce ocular surface inflammation.

What is interesting here is that without smartphone anterior segment photography, social network communication and the close optometric community that we have, I would not have been comfortable with this patient travelling and would have cautioned her to postpone this trip.  Leaving a BCL on an eye with an open wound with the potential for an opportunist infection and sending her on a plane without confirming receptive eye care on her arrival would be a liability to say the least.  But instead she travelled confidently, she healed and we all learned what is possible when people work together.

Here’s hoping our kids will learn to do the same this year!

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@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





Leaving a Legacy – The passing of Dr. William Samis

13 06 2013

The Montreal Gazette April 30th 1975On June 12th 2013, we lost a very good man and a groundbreaking surgeon – Dr. William Samis.  In 1975, he became  the first ophthalmologist in Ontario to perform phacoemulsification surgery for cataract patients and one of the first in the world to adopt this then groundbreaking technique and associated lens implants.  Indeed a visionary, he cultivated an environment which bred future leaders in the his field.  I joined his practice (partnered with Dr. Steve Arshinoff MD) in 2005 and was touched by his generosity as a human being, his style and sense of humour.  Unbeknownst to him, I absorbed a great deal from this man as an eye doctor and as a person through his words of wisdom and through the eyes of his patients, many of which I adopted after he stopped seeing patients from being ill 2 years ago.  Each an everyone would comment on his candor and caliber as a friend first, and a physician second and every last one would sing his praises as a surgeon decades after having had cataract surgery by his hands.

I like to think I’ve learned even an ounce of what this man had taught me and the many surgeons who walked through his doors or were privileged enough to have learned their surgical skills as his resident.

I have a hard time accepting that he is gone, however I have a harder time believing that for 6 years I was able to work closely with a true game changer – an individual who literally transformed modern eye surgery to make it faster, safer while producing better outcomes.    Some people wish to win a lottery – I believe I did.

My deepest sympathies go out to his family, his wife Jane, and dear friend and colleague Dr. Steve Arshinoff.  We were all in the presence of greatness.

RM





Just another BRVO?

21 05 2013

A 39 year-old male of South Asian decent reported to the clinic reporting blurry vision in his right eye starting 3-4 days previous.  Vision measured OD 20/50 OS 20/20 (uncorrected – this patients was previously 20/20 OD and OS).  Patient history revealed self reported ‘mild’ hypertension which was not medically managed nor had it been indicated in previous visits with his primary care physician.   IOP was 17 mmHg OD/OS and pupils were normal.  Flurescein angiography study showed no ischemia, however a conservative approach was taken to monitor the macula edema for resolve rather then consider anti-VEGF or therapeutic laser options at the time.

Fundus photo and OCT are shown below OD as well as contrast sensitivity testing.

ODBRVOwMEThe BRVO and to a lesser extent the macular edema is obvious on fundus examination.  On closer inspection though another area off inferiorly and nasal to the disc shows vascular retinopathy in the form of a cotton wool spot and nerve fibre hemorrhages.  This is not associated with the BRVO and signals the chronicity of his systemic hypertension which resulted in an interesting turn of events for this otherwise carefree individual.

Macular edema2ndBRVO

The OCT of the macula  clearly shows the cystic edema associated with this inferior BRVO.  Because of its inferior location this fluid will likely drain away from the macula and be reabsorbed in natural course.

Notice the difference in CS vs. SF curve.  This test was done for monitoring purposes only – it was not a diagnostic test.  It was needed to monitor the quality of his vision in this case as the fluid reduced at his macula.  The retinal surgeon and myself  will rely on this in addition to his objective findings downstream to help in guiding treatment options in the event of poor resolution of edema.

ContrastSensitivityBRVO

Follow up and Discussion:

From a bird’s eye view, I would say this case is worthy of follow up but not a unique set of findings.  What followed was however very interesting.  I examined this patient on a Thursday.  I called his family doctor but was unable to speak to her.  I sent a report and advised to follow up on his hypertension at next visit which turned out to be the next day.   This patient was very proactive and I would argue, his proactive nature helped to save his own life.   Serial BP testing demonstrated an avg BP of 180/160 and the final measurement of the day climbed past 200/180 sending this patient to the emergency room at the local hospital.  He was admitted to CCU over the next 3 days in an  attempt to urgently reduce his risk of stroking out and to steer this patient away from certain death.  After an intense 3 days his BP had come down to 130/85 in response to his medical therapy and it was maintaining.  The patient reported  that his multiple daily headaches had stopped and his quality of sleep was markedly improved.

I am following him regularly until complete resolution, however I believe there is a lesson learned here.

Better communication – For years, this  man was told he was ‘fine’ but had mild hypertension.  His cultural background supported a holistic approach to managing one’s body.  Through mind and inward discipline he was confident that he was in good health.   He hadn’t followed up regarding the ‘mild’ hypertension for at least 2 years because it wasn’t a concern for his doctor so why should it be a concern for him?   In fairness, there was no way to predict that he would suffer from hypertensive crisis years later so the ‘see your doctor when there’s a problem’ approach seemed prudent here.

My communication as his eye doctor to his family doctor was difficult and I haven’t yet received a report on this potentially critical patient whom I referred for urgent care.    To be clear I don’t believe this to be a problem with this doctor specifically but with the system at large.  This is what I believe needs to change.  How we relay information to each other; whether it is two teenagers tweeting their breakup because of broken communication or a doctor to her or his patient or physicians reporting over the care of a patient we are all too busy, too slavish to outdated protocol, too pre-occupied with all about us to listen.

For this lucky young man, I suspect he is listening to his body more than ever.  He told me he and his wife are finally going to take their honeymoon which is years overdue and will slow things down a little at work.  For the record I am biased to the sense of sight,  but I think we could all do a little better to listen to the world around and within us.

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca





25.8 Million US with Diabetes vs. 23 Million with Dry Eye Disease

16 05 2013

In June 2012, eyeLABS center for Ocular Surface Disease became the first optometry clinic in Canada to offer LipiFlow Thermal pulsation treatment – the only FDA approved treatment for evaporative dry eye.  eyeLABS is a unique facility because we don’t sell glasses – we manage the ocular surface of patients far and wide and we do so with an array of options that allows for a customized approach to managing a very complex disease – Dry Eye Disease.

eyeLABS year 1 clinical results:

Looking  just over 100 eyes treated using a combination of LipiFlow, lid management techniques, and medicine we have achieved a 90% rate of significant improvement in clinical signs and patient symptoms, 8% with mild to moderate improvement and 2% minimal to no change.  This was defined in our clinical study by validated patient symptom scores, gland scores, corneal staining, tear film break up time and visual acuity.  As a result we continue to educate as many physicians and patients as possible about the shift in approach of managing dry eye from exclusively cornea to the eyelids and glands.

Prevalence of DED vs. Diabetes

According to NDEP (National Diabetes Education Program) there are 25.8 million Americans living with diabetes.  According to a Marketscope 2011 Comprehensive Report on the Global Dry Eye Products, there are 23 million patients living with Dry Eye Disease.  Of course the comparison in the impact of two diseases on the body isn’t fair, but the impact on quality of life (QoL) is eerily similar.  A 2012 study examining 87 dry eye patients and 71 healthy volunteers found that vision-related QoL in dry eye patients was impaired and was correlated with anxiety and depression( Li, M Invest Ophthalmol Vis Sci. 2012 Aug 17).  Countless studies examining QoL within the diabetic subset show strong correlations to anxiety and depression due to the daily burden of medicine, monitoring and management.

Dry eye is too often dismissed by physicians as insignificant and ‘not as important’ as other ocular ailments like cataracts or glaucoma and patients have become embarrassed to mention it.  In fact, when eyeLABS Dry Eye Clinic patients were surveyed, the most common reason for not talking about dry eye with other doctor was embarrassment.  Embarrassment that their doctor wouldn’t think it was important.  Interestingly all patients reported social anxiety about the cosmetic appearance of their red eyes to colleagues, family, friends etc. and had sought out medical attention to treat the anxiety as a result.  eyepicture

The social impact of these two diseases are  far-reaching.  Given that the prevalence of the disease is near equivalent why is it that dry eye is swept under the rug?  It is possible that medical options of dry eye have been limited and expert agreement on the cause is divided has resulted in doctor’s complacency towards this growing epidemic.

Being in the position that I’m in seeing dry eye and ocular surface day in day out I can say that this condition does deserve attention and undivided attention at that.  My patients are physicians, teachers, celebrities, pilots, mothers, fathers and and they have all opened up about the anxiety that dry eye has caused them.  One might assume that those listed above are ‘professionals’ and would never leave the disease to take over their lives but many  patients have even considered suicide prior to having treatment because of how limited their lives had become.   For the first time they have had relief and I feel grateful for the opportunity to change their lives.

When one considers the impact of a disease on mental health, the mental health should be then considered a co-morbidity.  Diabetes, Dry Eye Disease and many other ailments all have the common denominator on reduction in quality of life and an increase in depressive and anxious tendencies.  Almost 50 million Americans share this common denominator between diabetes and dry eye, but those with dry eye don’t have nearly as many resources for dealing with their condition.  Considering the success I’ve had with my patients in this last year, I submit that we can do a better.

In good health,

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca