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





20/20 isn’t everything: See why every child MUST have a comprehensive eye exam to prepare for school

17 10 2013

Dr. Richard Maharaj and Dr. Chris Schell demonstrate some common vision problems that children struggle with everyday in the classroom. A very important message on why comprehensive eye examinations (not a vision screening) must happen for each child prior to (or at the very least, as soon as possible) school age. Vision screenings are well-intentioned, but as shown in the video, may miss these subtle diagnoses and give parents a false sense of security. Their little eyes are starting a 12+ year marathon which will serve the basis of learning.  You wouldn’t run a real marathon without preparing your muscles and endurance would you?  Why do we assume newly developing eyes should be treated with less concern or preparation.  See a Doctor of Optometry for a comprehensive eye examination.





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





A Child’s Vision: How important is it to you

19 08 2013

Only 14% of children under 6 in Canada have had a comprehensive eye exam yet 80% of learning is visual. In preparation for a 12+ cycle of education is this how do we equip our kids? We should expect more. Many common learning disabilities have been shown to be hidden undiagnosed visual dysfunction. Schedule your child’s eye exam today!





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





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