Specialists compare approaches for ocular surface disease, rehabilitation
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Welcome to another edition of CEDARS/ASPENS Debates. CEDARS/ASPENS is a society of cornea, cataract and refractive surgery specialists, here to discuss some of the latest hot topics in ophthalmology.
This month, Alanna Nattis, DO, discusses interventional management for ocular surface disease, while Laura M. Periman, MD, focuses on medical management. We hope you enjoy the discussion.
Kenneth A. Beckman, MD, FACS
OSN CEDARS/ASPENS Debates Editor
Interventional management
For ocular surface disease, I typically start with medical management first. However, there are conditions in which that is not enough. Medicine or lubricants alone are not always sufficient to rehabilitate these corneas. In these cases, you need some form of more aggressive therapy in addition to medical management.
We see this all the time in our clinic, whether it is for complaints of dry eye or if a patient comes in before cataract surgery and needs ocular rehabilitation prior to preoperative measurements. After initiating medical therapy, in most cases, my next step (and usually my go-to) for patients with recalcitrant dry eye in either case is amniotic membrane. I use a decent amount of Prokera amniotic membrane (BioTissue), as well as free amniotic membrane under a contact lens. I find that it tends to give a quick rehabilitation of the ocular surface, and it can be used in addition to medical therapy. It also has a wide use. We can use it for severe dry eye, neurotropic keratopathy, ocular surface burns or nonhealing corneal ulcers. Not every patient can tolerate Prokera because of its larger and thicker size, which is why it is great to have the option of free amniotic membrane placed under a bandage lens.
Some patients come in with conditions such as anterior corneal dystrophies or recurrent erosion — something physically wrong with the cornea (often in addition to dry eye complaints). Treating these patients could involve a superficial keratectomy (SK), which can usually be done in the office with the placement of a bandage contact lens. In some of these cases, we can also concomitantly place an amniotic membrane, which can accelerate healing. The idea behind performing a SK in these patients is that it creates a more regular corneal surface in addition to providing symptomatic relief for the patient — these patients have conditions that usually will not resolve with medical therapy alone. SK is ideal if you are consulting these types of patients before refractive or cataract surgery.
Another option we have is to perform phototherapeutic keratectomy (PTK) in patients who may have anterior corneal dystrophies, recurrent erosions or superficial scars. It can be gratifying to actually provide visual acuity improvements in these patients. After PTK, we typically place a bandage contact lens, which can be used by itself or with amniotic membrane. Sometimes, PTK may be performed in conjunction with PRK in order to smooth the corneal surface as well as provide visual rehabilitation. Finally, if we have a patient with severe ocular surface disease patient who is not responding well to any therapies, we may have to consider a temporary or permanent tarsorrhaphy or even a conjunctival graft (ie, Gundersen flap), which can be reversed, to give patients a chance to rehabilitate the ocular surface.
- For more information:
- Alanna Nattis, DO, can be reached at SightMD New York, 500 W. Main St., Suite 201, Babylon, NY 11702; email: asn516lu@gmail.com.
Medical management
Skilled treatment of the patient with ocular surface disease takes four simple steps:
- ask the questions (OSDI, SPEED, VAS questionnaires);
- assess the risk factors (age, medical history, surgical history, medications, review of systems, lifestyle, screen use);
- perform diagnostics (osmolarity, matrix metalloproteinase-9, meibography, fluorescein and lissamine green staining, tear breakup time); and
- categorize and treat (identify contributing factors and treat the root cause as well as the consequences).
Corneal topography can be helpful as well and provide some important clues as to the location, severity and source of visual disturbances.
I cast a broad net when I first encounter each patient. In my mind, ocular surface disease is a metaphorical big tent with 30-plus different circus animals running amok with the lights off. Who did it? What is involved here? Ask the questions, assess the risk factors, do your diagnostics, categorize and treat. It is the same simple steps every time. If a patient is not responding as expected, repeat the four steps and cast another broad net. Identifying the contributing factors is key to selecting the best treatments
A complete exam includes the face, lids and lashes for conditions such as rosacea, incomplete lid seal, lid malposition, excess laxity (eg, floppy eyelid syndrome, which is highly correlative with obstructive sleep apnea) and incomplete blinking. Foundational-level intervention includes discussion of the Whole30 (or autoimmune protocol in autoimmune cases) and nutraceutical omega-3 fatty acid supplementation. I almost never use oral antibiotics because the published literature does not convincingly demonstrate benefit for the patient with ocular surface disease/meibomian gland dysfunction. Additionally, in the case of patients with rosacea, there is already reduced gut biodiversity, and throwing an oral antibiotic on top of their underlying pathophysiology has never made sense to me. Furthermore, in my clinical experience, about 10% of women on oral doxycycline will report experiencing yeast vaginitis when asked. I have a case series of men with rosacea/meibomian gland dysfunction on oral doxycycline for years who developed chronic dacryocystitis requiring dacryocystorhinostomy. Oral antibiotics are not a benign treatment strategy. More effective treatment strategies include topical immunomodulators, dietary changes, nutritional supplementation, intense pulsed light (IPL) therapy and skin care, as well as identifying and treating Demodex (60% of patients presenting with dry eye complaints have eyelash collarettes, the pathognomonic sign of Demodex blepharitis).
With respect to recurrent corneal erosion syndrome or anterior basement membrane dystrophy, I am on the hunt for sources of inflammation and strategies to improve goblet cell density (topical immunomodulators). A corneal abrasion in the context of inflammation may re-epithelialize; however, those inflammatory mediators make the basement membrane dysfunctional, and the new epithelium does not adhere strongly to it. I have had some clinical successes in reducing recurrent corneal erosion frequency with IPL and maximum medical strategies (inflammation control, goblet cell density improvements). If these measures at managing the underlying drivers are not sufficient, of course surgical/interventional treatments are offered.
OptiLight (OPT-IPL, Lumenis) is my workhorse for drug-free, in-office reduction of the inflammation load and is now FDA approved to treat dry eye disease associated with meibomian gland dysfunction. OPT-IPL is also effective in treating styes and chalazia in a medication-free, injection-free, incision-free way. Patient satisfaction is excellent.
- For more information:
- Laura M. Periman, MD, can be reached at Periman Eye Institute, 320 W. Galer St., Seattle, WA 98119; email: dryeyemaster@gmail.com.
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