An update on the dry eye doc with dry eye
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There is an old saying — it might even be true — that medical students who go into psychiatry do so to figure out what is wrong with them.
I confess that I have never had the guts to ask my psychiatric colleagues if this is accurate, but I can say for certain that a whole bunch of my orthopedic buddies are broken down ex-jocks who spent all kinds of time in the professional company of the team bone jockeys when they were younger. Heck, I was such a stereotypical jock when I arrived at the University of Vermont that everyone just assumed that I would end up being an orthopedic surgeon.
If you ever meet my saint of a wife, Beth, ask her about her med student boyfriend with the AstroTurf shoes.
Because I have had a bitter dry eye for going on 40 years now (I had a workup for multiple sclerosis because of my eye symptoms), many folks have quite naturally assumed that my interest in dry eye disease (DED) must stem from my own malady, just like my psychiatry friends. This is actually not the case, though. Back in my med school/residency/early practice years, our collective understanding of all things DED would barely coat the bottom of the proverbial thimble, let alone fill it. Indeed, pretty much everyone ascribed my dryness to rigid gas permeable contact lens wear (I was a –6 D with a couple bucks of cylinder), which was not an unreasonable call, to be honest. When I got corneal edema from my original PMMA lenses, I switched over to the RGPs, trading hypoxia for dryness.
Thankfully, my prescription was too high to have RK. Boy, would that have been a disaster once my primary DED kicked in. I was one of the first couple hundred laser vision correction surgeons in the U.S., one of the buccaneers like Michael Coleman and Vance Thompson who followed closely behind the original pioneers like Marguerite McDonald, Dick Lindstrom and Dan Durrie as we all figured out that new, thrilling landscape. Wearing those RGPs got to be so difficult that I naturally chose to have LASIK so that I could leave contacts behind. You know how that turned out; my DED got all kinds of worse. Maybe a 30+ on the Ocular Surface Disease Index, if we had such a thing back then. In 1999, we did not really have an understanding about the risk of dryness after LASIK.
But still, it was not my postop experience that prompted me to dive into all things dry eye. You see, my vision was fantastic. I mean, see through walls, count the freckles on a flea’s backside at 100 m fantastic. Dave Hardten hit a grand slam for me. What really got me interested in DED in laser refractive surgery was the observation that my associate and close friend Scott Schlegel, OD, made one Friday morning when we were seeing all kinds of LASIK postops with a prescription of plano and 20/20 or better vision, a few of whom were 20/20 unhappy: “You know, D, all of the folks who are complaining have some sort of dryness going on.”
And that, my friends, was the launching of Scott and Darrell’s excellent adventure and my career-long interest in all things dry eye.
What about my DED then? Well, just like we tell everyone who has LASIK, whether their flap is made with a fourth-generation keratome or a femtosecond laser, the increase in my dryness symptoms following LASIK slowly resolved over about 12 months, and I returned to my baseline. Probably an OSDI mostly in the teens with occasional flares in the 20s. Original Refresh (Allergan) three or four times a day was helpful. When I turned 40, I started taking fish oil to mitigate my family heart history and got a nice little improvement in my DED symptoms. But it was the approval of Restasis (cyclosporine ophthalmic emulsion 0.05%, Allergan) in 2003 or so that really made the difference. I like to tease that I was stalking Joe Bankovich, waiting for the first dropperettes to arrive in Cleveland.
So it went for the next 20 years. Restasis and the other immunomodulators (I have tried them all) have relieved 60% to 70% of my DED symptoms. Like everyone else, my symptoms have gotten a bit worse just from getting older. Sadly, the scourge of EMRs and “meaningless use” have also done their nastiness, adding the effects of the “digital lifestyle.” My meibomian glands are kinda ratty; I have taken advantage of LipiFlow thermal pulsation therapy (Johnson & Johnson Vision), which has brought additional relief. Come to think of it, my first treatment was probably around the time I wrote my original “Dry eye doc with dry eye” blog.
For years now, my exams have been fairly similar. Tear osmolarity has been low although occasionally asymmetric. Long days in the OR or the end of a full 8 hours in clinic would result in fluorescein staining, particularly of my conjunctiva. My tear breakup time was getting progressively shorter in general but for sure at the end of those OR and gut-busting clinic days. I found myself resorting to loteprednol several times each week. Pretty much the poster child for my buddy Mark Milner’s incomplete success from treatment. My inflammatory DED and associated symptoms have been well-treated, leaving me like so many others with residual symptoms from evaporative DED.
Then along came Miebo!
Honestly, it is nothing short of amazing how much better my eyes feel since I added Miebo (perfluorohexyloctane ophthalmic solution, Bausch + Lomb) to my regimen. Liquid silk is a most apt description of the sensation one gets when Miebo hits the eye. The only side effect for me is roughly 8 seconds of blurred vision, just enough to let me know that I successfully got one of those tiny 11 µL drops in. I no longer use any over-the-counter drops, and I have not found it necessary for a “rescue” with steroid drops. Even on Tuesdays when I start in the OR, do lasers and then finish with 4 hours in the clinic, 90% of my DED symptoms have been relieved. For the first time since I was a teenager, I have days when I simply do not notice my eyes at all.
My experience is nothing more than an n = 1 study, albeit a pretty savvy “1.” What I think it means is that what we have had at our disposal over the last 20-some years has been pretty darned good. I like to tell my patients that technology and progress almost always save the day, just not necessarily today. My long dry eye journey is an example of both phenomena.
Now I am hoping that I will live long enough to give a first-person report on the perioperative dry eye experience in cataract surgery!
- For more information:
- Darrell E. White, MD, of SkyVision Centers in Westlake, Ohio, can be reached at dwhite@healio.com.
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