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





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