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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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





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





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





eyeLABS Turns 1: Happy Birthday!

4 06 2013

I just wanted to take a moment to thank my colleagues, patients, friends and family for supporting this exciting new clinic.  Today we officially turn 1.  This marks the beginning of a new year with new opportunities to treat and learn from patients and to evolve as eye care evolves.  eyeLABS has been fortunate to receive the accolades from the professional community with a growing group of referring doctors from both far and near.  Most importantly the patients that have entered our doors and who’s lives we’ve changed in the last year have demonstrated to me, my wonderful staff and colleagues alike that indeed we are changing the surface of the eye for the better.  Thank you so much!

 

As always –

 

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





CBS The Doctors, featuring LipiFlow

6 05 2013

Click here  to view CBS, The Doctors – featuring LipiFlow

On May 6th 2013, CBS aired an episode of The Doctors, which highlights the revolutionary LipiFlow Treatment to the masses. eyeLABS is proud to be the first optometry clinic in Canada to offer LipiFlow treatment in an environment that is exclusively dedicated to the ocular surface – not LASIK, or other refractive surgery – just dry eye. Call 905-456-9333 or visit http://www.eyelabs.ca to see if you are a candidate.