One could write a several hundred page book on the topic of ocular surface disease, and my comments are limited to a few paragraphs, so many topics are left out. The focus is on the horses, not the zebras.
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In regard to symptom screening by my technicians, the symptom most frequently missed is fluctuating vision, which is quite common in meibomian gland dysfunction MGD with evaporative dry eye. I find tear film osmolarity useful in diagnosis and treatment, but the osmolarity numbers that I consider to be consistent with dry eye are different from those taught by many. In my patients who are screened for corneal refractive surgery with no symptoms, no MGD and no corneal staining, the tear film osmolarity is always under , actually usually around , and symmetrical within 2 milliosmoles to 3 milliosmoles.
So for me, with the TearLab device, a reading higher than milliosmoles and asymmetry of 4 milliosmoles or more is significant. If osmolarity is higher than or asymmetric at the 8 milliosmole level, the patient has significant dry eye syndrome. In regard to MGD or squamous blepharitis, which is my best ICD code, I find it is pretty much present at least to a minor extent in everyone older than the age of 50 years.
In these cases, I note it in the chart but do not treat unless I elicit symptoms of fluctuating vision or ocular fatigue associated with computer use or the like. An irregularly irregular topography is also common and a useful sign. In these patients, treatment of their dry eye is critical before surgery, especially if corneal refractive surgery or a premium IOL is planned or errors in spherical and toric power will be made and patient satisfaction reduced.
There are, of course, a lot of other findings to note, and the most common I observed in the last 2 weeks were lid laxity, nocturnal lagophthalmos, conjunctivochalasis, nasal ectropion, punctal atresia, anterior basement membrane dystrophy, pingueculae, pterygium and floppy lids associated with obesity, to mention a few. Now on to a few comments on treatment.
Ocular Surface Disease
In my practice, most, if not all, patients have an evaporative component to their dry eye. I therefore prescribe a lot of omega-3 supplements and find them very effective. Many patients are on ineffective OTC omega-3s that are not well absorbed, and many are using a sub-therapeutic dose. I recommend 2, mg per day. In addition, I find many patients cannot swallow the larger capsules and prefer the liquid omega-3 in a bottle as a preferred alternative.
In regard to tear supplements, I am a fan of those containing sodium hyaluronate, which is increasingly supported in the literature. If a patient is taking a topical lubricant more than four times a day or is on other preserved drops such as preserved generic glaucoma medications, I recommend non-preserved tears.
Involve the patient
FAQ Policy. About this Textbook Ocular Surface Disease: Medical and Surgical Management is the only comprehensive and definitive text on the medical and surgical management of the diseases of the ocular surface. Show all. Mark J.
Mannis Dr. Edward J. Holland Dr. Barry Lee. Pages Dry Eye Pflugfelder, Stephen C.
Ocular surface disease: One physician’s approach to treatment
Pterygium Tan, Donald T. A Dry Eye specialist will determine if LipiFlow is right for you based on a complete eye exam. Lipiflow treatment is quick with a duration of 12 minutes and minimal discomfort. Our ocular surface experts use surgical therapies to successfully treat these conditions.
Procedures include limbal stem cells and cornea transplants to rehabilitate the surface of damaged scarred tissue. In severe, end-stage cases of blindness-causing scarring, Bascom Palmer surgeons also use artificial corneas Boston keratoprosthesis type I. This treatment involves the custom-designing of a prosthetic device made for patients with ocular surface diseases, to help protect and heal the ocular surface.
The device can also correct for refractive errors. In fact, Bascom Palmer performed the first autologous transplant of limbal stem cells from the fellow eye of a patient with stem cell deficiency.
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