Panelists illustrate strides in dry eye diagnosis and management at OSN New York’s 25th anniversary meeting

Dry eye disease is an area that 10 years ago was largely ignored. Now it is one of the most explosive areas in ophthalmology, according to Eric D. Donnenfeld, MD.

In this issue of Ocular Surgery News, Donnenfeld leads a panel of experts convened for the annual Cornea Health Round Table at the silver anniversary of OSN New York to discuss the latest developments in diagnosis and management of dry eye and ocular allergy.

Eric D. Donnenfeld, MD: Here is a classic patient presentation: A 74-year-old woman has cataract surgery with a multifocal IOL in the right eye. Her vision is 20/25. The patient says, “It’s a waste of money. The lens doesn’t work. I can’t drive at night. I really don’t read. I’m very unhappy with the loss of quality of vision.”

How would you manage this patient? Would you do an IOL exchange, implant a multifocal IOL in the left eye, do ocular surface disease testing, or do a limbal relaxing incision if needed? What would be the first thing you would do for this patient?

Image: Donnenfeld ED

Elizabeth Yeu, MD: Look at the cornea and assess how the visual axis aligns with the center of the cornea and what the actual higher-order aberrations are. Ocular surface disease testing is one of the most common causes, and diagnostics are key to managing this. Also, determine what residual refractive astigmatism or refractive error actually exists and then, of course, do the macular testing.

Donnenfeld: I do a lot of presbyopic IOLs in my practice, and when an unhappy patient comes in, I want to find out why the patient is unhappy before I see him or her. I want testing done. I want a topography. I want a tear osmolarity. I want MMP-9. I want to have an OCT of the macula done. So, when I first see that patient who is unhappy after surgery, I can say, “Mrs. Jones, I just looked at some of your results. You have very dry eyes, and you should be very unhappy with your results of surgery.” I am on their side right from the beginning, and I talk to them about how we are going to solve this problem together because once the patient-doctor interface is broken, it is very hard to repair. In this case, I agree, ocular surface testing would be the first thing I would do.

And this is kind of my bumper sticker: If you discuss a problem preoperatively, it is an expectation. If you tell them the same thing postoperatively, it is a complication. So, always tell the patient about risk factors before the surgery.

Kenneth R. Kenyon, MD: I concur, but apart from leading from the front, it is particularly important in these patients who are at risk for ocular surface disease problems that you see that patient first at the slit lamp in a virgin ocular surface setting because the testing, particularly if it involves even a drop of topical anesthetic or just a drop of non-anesthetic fluorescein, induces all manner of artifact that make it impossible to make the definitive assessment.

Donnenfeld: What we do is, before I see the patient and before any drops go in the eye, we get a topography and do objective testing, such as osmolarity and MMP-9. That way, I am already considering those results when I see the patient. This patient had high osmolarity, positive MMP-9, mild corneal staining, short tear breakup time and clogged meibomian glands — obvious dry eye.

Moving on, what point-of-service tests do you use for your patients with dry eye?

Cynthia Matossian, MD, FACS: Point-of-service tests for the diagnosis of ocular surface disease are very important. First of all, some patients are asymptomatic. And, for efficiency’s sake, I do not want to go into a room, see a patient, come out, have testing done and go back in. It prolongs the patient visit. So we educate our staff and we empower them to do this testing. Consequently, when I enter the room, just like Eric, these tests are already done, giving me added information to better treat the patient. Having this available from the get-go gives us ophthalmologists the picture we need to make a proper diagnosis as early as possible.

Thomas “TJ” John, MD: Often these patients are underdiagnosed because we are in the pattern of landing a slit lamp light right on the cornea first. I would recommend that you reverse the order of testing. If you land on the lid margin first, you pick up blepharitis. Then go to the tear meniscus to pick up dry eye. Then go to the conjunctiva and lastly go to the cornea. This way, even with just the slit lamp evaluation, you pick up a lot of patients whom you otherwise miss. Then postoperatively, as Eric said, if these patients are misdiagnosed, they will be more unhappy than if you pick them up earlier preoperatively and address the issue then. And, of course, supplement with the objective testing that we can do in the office setting.

Donnenfeld: Who are the most unhappy patients in your surgical practices? It is not the dry eye patient; it is the compensated dry eye patient preoperatively who is induced into dry eye with surgery. It is the normal-feeling patient who becomes an overt dry eye patient. Those are the ones who are miserable. Anyone can diagnose dry eye with central corneal staining, but diagnosing it early is the key, before the patient becomes overtly symptomatic.

Henry D. “Hank” Perry, MD: This is especially true in our multifocal patients. Sometimes we do not listen to the patient. If they give any history of fluctuating vision or of having used artificial tears in the past and we do not do a thorough dry eye evaluation, then postoperatively we may get a significant surprise when they come in after receiving their multifocal and they are 20/200, with 3+ central corneal staining. If you cannot do point-of-care testing beforehand, it is imperative to at least do lissamine green staining or fluorescein, especially for patients receiving multifocal lenses.

Robert J. Noecker, MD, MBA: For glaucoma patients, I do all that testing because glaucoma adds just one more order of complexity when patients are on glaucoma drops. It is just an extra insult. I am probably doing something that is making their ocular surface worse.

Donnenfeld: I disagree; not “probably.”

Yeu: Definitely makes it worse.

Meibomian gland disease

Donnenfeld: Moving on to meibography. This has become maybe one of the best new innovations that I have seen in my practice, and it is something that we do not do enough of. We all look at the glands, but this is the best teaching tool I have ever seen that allows patients to understand meibomian gland disease.

Matossian: These images (Figure) help the patients understand their meibomian gland disorder. A picture says 1,000 words. This instantly communicates the disease process to the patient. They see their gland dropout. They understand their abnormal glands. Therefore they are much more open to following the treatment regimen that you are going to recommend for them.

Image: Donnenfeld ED, et al

Perry: One thing about doing meibography is that you learn that patients can have significant dropout and they can look like this (Figure) in their 20s. So this is a disease that can present early in life and just become more and more severe as time goes by. Meibography is a very good technique, one that is going to be used more and more in the future, especially as the price of the machine comes down.

Matossian: As you say, we are seeing this in younger and younger patients. We are seeing abnormal meibomian glands in patients in their 20s, and we are noticing an anecdotal association in contact lens wearers. I want to start tracking meibomian gland dropout in contact lens wearers.

Yeu: I think contacts are one factor. Another is that we stare at mobile devices. Ultimately, we are not blinking properly. We need a nice, full, thorough blink in order to allow the egress of the meibum. And because we are not having a complete blink, it causes a congestion. Add inflammation and that leads to this earlier MGD phenomenon that we are seeing.

Perry: There are some new studies coming out that show that MGD actually begins in the first decade of life and progresses with age. We have been using the BlephEx unit (BlephEx LLC) in our practice, and it seems to be helpful in about two-thirds to three-quarters of the patients. Most of the patients seem to understand that lid hygiene is a critical component to their treatment. Meibography with the BlephEx unit and a little explanation to patients go a long way to helping them understand their underlying meibomian gland disease and blepharitis, and make treatment of these patients much more effective as they buy in to the concept of lifelong lid hygiene.

New treatment

Donnenfeld: I have been a big proponent of cyclosporine for a long, long time, but we have a new medication now — lifitegrast (Xiidra, Shire).

Yeu: Lifitegrast targets inflammation. There are different ways to target the inflammatory cascade. Specifically, if you look at the ocular surface, the cornea, the conjunctiva as well as the lacrimal gland, on the actual epithelium there are little adhesion molecules called ICAM (intercellular adhesion molecules). They are basically like Velcro. T cells also exist in our tear film, but in an inactivated state — just roaming, just patrolling. When there is some kind of desiccating stress or inflammation, that triggers an upregulation of ICAM. There is a very specific binding between ICAM-1 of the cells with the LFA-1 receptor — like a lock and key mechanism. When those two bind, that triggers the inflammatory cascade. It causes upregulation of inflammatory cytokines into the tissue and greater T cell recruitment, which leads to a vicious cycle of more ICAM upregulation.

Lifitegrast competitively blocks the T cells from getting to ICAM. The onset of action is very quick, much more so than for some of the other anti-inflammatories.

Donnenfeld: Lifitegrast blocks the ability of the Velcro to attach, so the T lymphocytes cannot adhere to the ocular surface. The beautiful thing about that is that you do not have to cycle through a whole group of lymphocytes. It works in every step. It works on diapedesis, it works on aggregation, and it works on cytokine release, so it works rapidly. In two of the FDA trials, we saw that there was a statistically significant effect at 2 weeks. The one thing we heard a lot about regarding complications in the FDA trials was dysgeusia. It is prominent but not significant for most patients. We have all had some experience with it now.

Matossian: I have been prescribing lifitegrast since it became available. My patients like it. They notice an improvement sooner, in some cases as early as 2 weeks. Very few of my patients have mentioned the bitter medicinal taste. I let them know that dysgeusia is a possibility at the time I prescribe it. I reassure them that this unpleasant taste is not an allergic reaction. Giving patients that kind of information ahead of time helps prevent potential callbacks. So far this new product has worked well in our office in patients with symptomatic and non-symptomatic ocular surface disease.

Perry: I have used it mainly in patients who are on Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) and have not been happy and in patients who have failed Restasis. Almost all the patients I have used it in have been difficult dry eye cases, and I have found it to be spotty. However, we have had some home runs, so I continue to use it, to evaluate it. I do not know where it is going to find a specific niche and in which group of patients it will be most indicated for, but at this point I think it is a good idea to at least try.

Yeu: Lifitegrast was approved for both symptoms and signs. When you look at the four different efficacy studies, where they hit the 2-week mark was in those patients who were more symptomatic. In my own clinical experience, that is where I am seeing that. The ones who are coming in more symptomatic, your younger patients who are complaining more of the symptoms, not only of fluctuating vision — they are the ones who are experiencing relief sooner. I have seen it earlier than 2 weeks, but not in everyone. As Hank said, it is going to be another tool in our armamentarium. But those symptomatic patients do seem to get that greater relief sooner with this medication.

Donnenfeld: I just want to again mention that dysgeusia is seen in about 16% of patients, so it is very important to tell patients about it first so they do not get upset. If you tell them about it first, then they do not worry about it.

I want to give a “shout out” to Shire for the way they have approached this in allowing patients to have access at no charge for the first month or two. That is remarkable and perhaps a paradigm shift that makes it easy for patients to start a new medication. That is a partnership that shows how industry and ophthalmology can work together.

Nutrition

Donnenfeld: Moving on to nutrition. As I have gained experience, I have become more and more of a proponent of nutrition. It has become my single primary therapy. And the important point here is that in the major studies, in the TFOS study and the DEWS study, both of them listed omega-3s as primary therapy. But there are some profound differences in fish oil.

Matossian: Most fish oils go through a chemical process to remove the contaminants, the heavy metals, the polychlorinated biphenyls and mercury. During that process, alcohol is added to the oil, and it becomes an ethyl ester, or EE form. This form of fish oil is not very bioavailable to our GI gut. It leads to fish burp and fish gas and other GI problems. Few companies go through the expensive process to re-esterify this EE into an rTG form, a re-esterified triglyceride form, to make it more bioavailable. In this format, there are fewer GI issues with better absorption.

Donnenfeld: All omega-3s are not the same, and there are some very important differences. We published a paper recently in Cornea — Alice Epitropoulos is first author and Hank Perry is senior author — looking at omega-3s and dry eye therapy, showing how efficacious it is.

Hank, take us through some of the changes that we saw here in this trial.

Perry: Too often when using this nutritional supplement we are focused on the eye and dry eyes and meibomian gland disease, but this supplement helps your whole body — your skin feels better, you get less arthritis. This is not just an agent that helps us in terms of the dryness of the eye for our patients. I take this personally, and I feel confident that it is reducing inflammation throughout my body.

One of the biggest findings in our study on omega-3 supplementation is proof that it affected the omega-3 index in our patients. We had a decrease in inflammatory markers in this study mirrored by a reduction of MMP-9 levels. Tear osmolarity and staining also decreased. There was also a statistically significant reduction in OSDI scores. So for the first time in the literature we have a randomized, controlled, multicenter study proving the efficacy of omega-3 fatty acids in the treatment of dry eye disease. To me, dry eye disease is blepharitis, meibomian gland disease and aqueous dysfunction. You cannot mention one of these conditions without the others. This study is the best study that has been published in terms of defining the parameters of improvement of dry eye disease with nutritional therapy.

Donnenfeld: So, if you are going to use omega-3s, at least educate your patients about it. If they are buying omega-3 at a superstore, they would have to consume 12 to 16 pills to have the same efficacy as four of the re-esterified supplements. I hear people say they have tried omega-3s and they have not worked. Overwhelmingly, it is because they are not getting good absorption.

Nasal stimulation

Donnenfeld: This is something new coming from Allergan: a nasal stimulation device to produce reflex tears, the first ophthalmic electroceutical. This makes sense.

Marguerite B. McDonald, MD, FACS: It is a way to stimulate a branch of the trigeminal nerve, and there are other neural pathways that are being uncovered at this time. But this is highly effective, all natural, a small unit and easy to carry. People who are in the dry eye business, who have a dry eye center of excellence or who just care about dry eye patients in their practices are waiting eagerly for this to become commercially available.

Donnenfeld: Any of you who play sports, you know that when you get smacked in the nose with a basketball, your eyes tear the rest of the day. That is what is happening here. You have stimulated a neural reflex.

Matossian: What is also interesting is that the tear that is produced through this neural stimulation step is a complete tear: It has the lipid, aqueous and mucin layer, so it is not just the watery component that is being stimulated. It is a complete, healthy tear.

Allergic conjunctivitis

Donnenfeld: We are going to shift gears and talk about allergic conjunctivitis. What is your first-line therapy?

John: First, you have to ask the appropriate questions to determine whether the patient has seasonal or perennial conjunctivitis. If it is seasonal, for instance, then you may want to tell patients to limit outdoor activities or roll up windows in the car during the seasons when they are affected. It goes back to the basics of being a clinician. Ask the appropriate questions and listen to the patient before we start blasting with all the ammunition that we may have in our armamentarium.

Patients with perennial allergies have issues inside the house, so then you have to focus differently. You want to use cool compresses and dilute the antigen with tears. I like a combination, for instance, a mast cell stabilizer with an antihistamine. If they are very symptomatic, you may want to add a topical steroid, maybe loteprednol. For some patients, you may even need to go to the last step, which is immunotherapy, but you have to keep in mind that it is a longer process and more involved.

So good questioning and making the right diagnosis, and then have your algorithm for treating these patients.

Matossian: We do allergy testing in our office to try to figure out what the patient is allergic to. This way we can very clearly say, “It’s feathers,” or “It’s pet dander,” or “It’s oak trees.” This way you can more specifically either recommend avoidance therapy or come up with a strategy to deal with that specific allergen.

Donnenfeld: I also find it is very helpful deciding when to give the topical antihistamine. If you are allergic to something that you are going to have access to at night, you take the drop before you go to sleep. If it is in the morning, you take it in the morning. So, if you are allergic to dust mites, take the drop before you go to sleep at night. If you have hay fever and you are going outside, take it when you wake up in the morning. So, it can affect the therapy as well.

Yeu: It is important, especially in patients who come in with epiphora, and you are trying to figure out if they have allergies, an outflow problem or dry eye. The problem is that a lot of our allergic conjunctivitis treatments, especially with oral antihistamines, exacerbate dry eye. Loratadine for 4 days has been shown to decrease the actual aqueous component of the tear film by 30%. So another important pearl here is to use oral Singulair 10 mg (montelukast sodium, Merck) as another adjunctive therapy. But diagnosing them through skin testing within our own clinic, with good reimbursement, is nice.

McDonald: A lot of times when you propose allergy testing, the patient will say, “Oh, I’ve had allergy testing by my dermatologist.” And I ask, “How long ago?” “Oh, 5 years ago.” Allergies can change in adulthood and I say, “We should do it. It’s time to do it again.” Plus, allergists test for lots of things that are not airborne such as shellfish allergy or a peanut allergy. We test for 100% allergy that is airborne, so a panel of 60 things from the region of the world where you live. I find it makes a huge difference to ask when they were tested and by whom.

Not dry eye

Donnenfeld: Here is another case: A 58-year-old man, chronic irritation, diagnosed with dry eye by eight different doctors, minimal conjunctival staining, Schirmer’s tests are high, osmolarity is low, MMP-9 is negative. When you have this situation, chronic irritation, diagnosed with dry eye, but they do not have the osmolarity or MMP-9 to go with it, what does it make you think about this patient?

John: You want to look for conditions other than dry eyes. One of the most underdiagnosed conditions is conjunctivochalasis, for instance. Of course, there is a whole list of other conditions (Table), but conjunctivochalasis is an entity that is highly underdiagnosed. Conjunctivochalasis occludes the forniceal tear lake and therefore compromises the tear reservoir and mechanically causes discomfort with each eyelid blink. The issue with this is, if it is misdiagnosed as dry eye disease, then you keep on treating the patient for dry eyes without any symptomatic relief, and the patient is dissatisfied. So proper diagnosis is essential in clinical practice and patient satisfaction.

Donnenfeld: The point here is that when the testing comes back negative, it is just as important as if it comes back positive. I am diagnosing many more of these occult conditions because now I am looking for them more aggressively.

Kenyon: The problem of conjunctivochalasis is, if not quite ubiquitous, certainly underdiagnosed. It not only disturbs the inferior meniscus dynamics, but it can even mechanically occlude the inferior puncta. These patients can have as much epiphora complaint as dry eye complaint. My initial treatment strategy is to attempt minor pharmacotherapy interval with some steroid and perhaps some astringent decongestant. But when it comes to conjunctival resection — either with or without amnion membrane — straightforward resection, especially of the inferior segments, is quite effective.

McDonald: I used to resect and put in amniotic membrane, etc., etc. Now, I just take off a thin crescent, thinner than you think — you do not have to take off that much — and then use bipolar cautery. The case takes about 4 minutes. A lot of the tissue that I would have clipped off in the past gets shrunk and destroyed, so to speak, with the bipolar cautery. So it is the world’s fastest case. There are no sutures. There is no glue. There is no amniotic membrane.

Yeu: You can do this easily as an office procedure, too. I would not suggest it for someone who has 4+ chalasis. When there is that much chalasis that it actually obstructs centrally, then you have a lot of redundancy. When you pull their lid margin down, you can see how much of it is actually bunched up by the fornix. If they have 1 to 2+ chalasis, you can see that their inferior tear film has been obliterated somewhat nasally and/or temporally, or they have epiphora issues plus the obliteration of the pre-lid margin tear film, the conjunctivochalasis can be managed as a minor procedure. You can numb the conjunctiva with 4% lidocaine and use your hand-held hot temp cautery and curved tying forceps to treat the redundant conjunctiva. It takes 5 minutes. It improves their symptoms easily by 30%.

Donnenfeld: I use lidocaine gel. I do not even inject them.

Glaucoma and dry eye

Donnenfeld: Let’s finish with glaucoma. We all agree that glaucoma medications worsen dry eye. What are the glaucoma medicines that are the worst or the most toxic to the corneal epithelium, and what are the ones that are best for the corneal epithelium?

Noecker: The traditional teaching is that the culprit is the preservatives, benzalkonium chloride, which is in more than 80% of the drops, but often it is also the pH of the formulation. So if you have an eye drop that is at the 5 pH level, for patients who have tear films that cannot neutralize that quickly, the pH can be a factor for that patient. Also, the active ingredient in prostaglandin analogues causes inflammation of the lids and you can see telangiectasia of the meibomian glands. But certainly benzalkonium chloride is the common denominator; it is also dose-dependent and duration-dependent.

I concur that glaucoma medications contribute to worsening of the corneal epithelium 100% of the time, but it is manageable, and we can make choices to minimize that, either by changing dosing regimens or choosing agents that are more potent so we do not have to use as many different agents. We recognize the problem; in our glaucoma patients, it just takes on a different order of magnitude.

Donnenfeld: You have been a big proponent of microinvasive glaucoma surgery. How effective is it at eliminating drops or reducing drops and improving the ocular surface?

Noecker: Common to the themes we have talked about, you have to set expectations preoperatively. “My job is to increase your probability that I can decrease your medication” is the way I phrase it. I do not tell patients that I am going to eliminate their eye drops. I do not say that I will cure their glaucoma. But if I can reduce IOP and decrease the medication load, then that is a very favorable thing. It is something that any patient who has glaucoma who is undergoing cataract surgery should have addressed. Cataract surgery alone is a good thing to do in a glaucoma patient. That often leads to a beneficial effect in terms of IOP control. But also consider doing one of the MIGS procedures; there is little downside compared with my traditional therapies. If you poll any of us whether you would have one of these MIGS procedures performed on you at the time of cataract surgery, I think we all would say yes.

• References:
• Donnenfeld ED, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000803.
• Epitropoulos AT, et al. Cornea. 2016;doi:10.1097/ICO.0000000000000940.

• For more information:
• Eric D. Donnenfeld, MD, can be reached at Ophthalmic Consultants of Long Island, 711 Stewart Ave., Suite 160, Garden City, NY 11530; email: ericdonnenfeld@gmail.com.
• Thomas “TJ” John, MD, can be reached at 16532 South Oak Park Ave., Tinley Park, IL 60477; email: tjcornea@gmail.com.
• Kenneth R. Kenyon, MD, can be reached at Eye Health Vision Center, 51 State Road, Dartmouth, MA 02747; email: kenrkenyon@cs.com.
• Cynthia Matossian, MD, FACS, can be reached at Matossian Eye Associates; email: cmatossian@matossianeye.com.
• Marguerite B. McDonald, MD, FACS, can be reached at Ophthalmic Consultants of Long Island, 360 Merrick Road, Lynbrook, NY 11563; email: margueritemcdmd@aol.com.
• Robert J. Noecker, MD, MBA, can be reached at Ophthalmic Consultants of Connecticut, 1375 Kings Highway, Fairfield, CT 06824; email: noeckerrj@gmail.com.
• Henry D. “Hank” Perry, MD, can be reached at Ophthalmic Consultants of Long Island, 2000 N. Village Ave., Rockville Centre, NY 11570; email: hankcornea@gmail.com.
• Elizabeth Yeu, MD, can be reached at Virginia Eye Consultants, Norfolk Office, Office & Surgery Center, 241 Corporate Blvd., Norfolk, VA 23502; email: eyeulin@gmail.com.

Disclosures: Donnenfeld reports he is a consultant for Abbott Medical Optics, AcuFocus Alcon, Allergan, AqueSys, Bausch + Lomb, Beaver-Visitec International, Carl Zeiss Meditec, Elenza, ForSight, Glaukos, Icon Biosciences, Kala, Katena, LacriPen, LensGen, Mati, Merck, Mimetogen, NovaBay, Novaliq, OcuHub, Odyssey, Omega Ophthalmics, Omeros, Pfizer, Physician Recommended Nutriceuticals, PogoTec, Rapid Pathogen Screening, Shire, Strathspey Crown, TearLab, TLC Laser Centers, TrueVision and Versant Ventures; and has ownership interest in AcuFocus, AqueSys, Elenza, Foresight, Glaukos, Icon Biosciences, Kala, Katena, LacriPen, Mimetogen, NovaBay, OcuHub, Omega Ophthalmics, Omeros, Physician Recommended Nutriceuticals, PogoTec, Rapid Pathogen Screening, Strathspey Crown, TearLab, TrueVision and Versant Ventures. John reports he is a consultant for Allergan, Bausch + Lomb and Bio-Tissue; receives royalties from Asico and Jaypee Publishers; reports ownership interest in Bio-Tissue; and is on the speakers bureau for Allergan, Bausch + Lomb and Bio-Tissue. Kenyon reports he is a consultant for Beaver-Visitec International and has ownership interest in TissueTech. Matossian reports she is a consultant for Abbott Medical Optics, Alcon, Allergan, Bausch + Lomb, Marco, Physician Recommended Nutriceuticals, Shire and TearLab; is on the speakers bureau for Abbott Medical Optics, Alcon, Allergan, Bausch + Lomb, Ocular Therapeutix, Physician Recommended Nutriceuticals, Shire and TearLab; does contracted research for Abbott Medical Optics, Glaukos, Icon Bioscience, i-Optics, Ocular Therapeutix, Physician Recommended Nutriceuticals, Shire, Softec and TearLab; and has ownership interest in CheckedUp, Imprimis, Ocular Therapeutics, Physician Recommended Nutriceuticals, Rapid Pathogen Screening, Strathspey Crown (Alphaeon) and TearLab. McDonald reports she is a consultant for Abbot Medical Optics, Alcon, Allergan, Bausch + Lomb (Valeant), Focus Laboratories, Oculus Surgical, OcuSoft, Orca Surgical, Shire, TearLab and TearScience; and has ownership interest in AcuFocus and Calhoun Vision. Noecker reports he is a consultant for Aerie Pharmaceuticals, Alcon, Allergan, Beaver-Visitec International, Diopsys, Glaukos, Inotek Pharmaceuticals, Iridex, Katena, Ocular Therapeutics, Optovue, Solx and Sun; is on the speakers bureau for Alcon, Allergan, Glaukos, Iridex and Katena; and does contracted research for AqueSys, Glaukos and InnFocus. Perry reports no relevant financial disclosures. Yeu reports she is on the speakers bureau for Abbott Medical Optics, Alcon, Allergan, Bio-Tissue, Ocular Therapeutix, Omeros, Shire and TearLab; has ownership interest in Modernizing Medicine, Rapid Pathogen Screening and Strathspey Crown; and is on the advisory board for Abbott Medical Optics, Alcon, Allergan, ArcScan, Bausch + Lomb (Valeant), Bio-Tissue, Eyekon E.R.D. Ltd., i-Optics, Kala, Ocular Therapeutix, OcuSoft, TearLab and TearScience.

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