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PUBLICATION EXCLUSIVE: Corneal basement membrane dystrophy: Dry eye disease’s sticky wicket

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Our severe dry eye disease archetype, “Linda Blair,” has come to your office with her eyes aflame and her head a-spinning. She has marched into your exam room spewing horrific invective at any and all who sat on the other end of your Haag-Streit, but you were prepared. You read all three parts of our series on starting and building a dry eye practice, and you went all the way and put into place the advanced dry eye protocol along with your entire staff.

When Linda arrived, you evaluated her with tear osmolarity (elevated), MMP-9 inflammation testing (positive) and even a Schirmer (inconclusive). Your bravest tech held her head still so that you could do LipiView (low oil/never, ever blinks) and obtain meibomian gland imaging (mostly burned out ... get it?). Your next bravest tech held her in the slit lamp (tech No. 1 was now possessed) so that you could determine that she had a tear breakup time of 4 and diffuse superficial punctate keratitis.

Once you acquired all of your data, a care plan took shape. Linda was placed on your favorite treatment for inflammatory DED, Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) or Xiidra (lifitegrast ophthalmic solution 5%, Shire), mega-doses of re-esterified fish oil and an oil-based artificial tear like Retaine MGD (OcuSoft). This initial regimen improved her symptoms enough that she was able to sit by herself through a LipiFlow (TearScience) treatment session (good thing — with two techs now possessed, you were running out of help). A few weeks later the demonic specter of The Exorcist is nowhere to be seen. On follow-up examination, Linda now has a tear breakup time of 8, no superficial punctate keratitis, an osmolarity of 302 in each eye, and a barely registering InflammaDry (RPS). She seems almost happy, except for one thing: Linda still has pain.

•    Click here to read the full publication exclusive, The Dry Eye, published in Ocular Surgery News U.S. Edition, October 25, 2016.