Each issue, Dr. Mark Colip proposes a new topic to members of the ICO family. With the help of noted alumni, he puts a spotlight on important people at ICO and across the profession of optometry.
“The year 2020 is a symbolic and important time for optometry. As the profession looks toward the future, we see standards of care evolving for many eye conditions. In addition to glaucoma and myopia control, dry eye is a priority for the Illinois College of Optometry in 2020 and beyond. As ICO’s dry eye experts, what innovations do you see being made in its diagnosis and treatment?
Jennifer S. Harthan, OD ’06, FAAO
Professor Chief, Cornea Center for Clinical Excellence
“Dry eye disease (DED) is one of the most common eye diseases that we see in clinical practice. DED is a ‘hot topic’ right now as there is more public awareness with advertisements and new diagnostics and management options. Managing dry eye is critical for better outcomes with contact lenses, ocular and cataract surgery, and glaucoma management.
We are seeing increased reports of DED among all age groups including children, potentially indicating its association with digital device use.
The signs and symptoms of DED do not always correlate with the severity of disease, therefore, it is imperative to establish a protocol for examining patients in practice.
The curriculum at ICO has been updated to include ocular surface disease diagnosis and management in the second year of study along with a ‘hands-on’ lab where students are able to perform each test and procedure of the ocular surface disease evaluation. Within the Cornea Center for Clinical Excellence at the Illinois Eye Institute, residents and students can rotate through the Ocular Surface (dry eye) Center to integrate their didactic skills into clinical practice.”
Casey L. Hogan, OD’97, FAAO, FSLS, Dipl. AAO, Anterior Segment, Dipl. ABO
Advanced Eyecare Professionals
“Innovations in dry eye management are directly related to the updated definition and guidelines established by the Tear Film & Ocular Surface (TFOS) DEWS II® Report. This
subcommittee concluded that the core mechanism of DED is evaporation-induced tear film hyperosmolarity. This understanding has revolutionized the way we manage the dry eye patient, with the goal to manage and restore homeostasis.
Diagnosis should begin with proper triaging questions and risk factor analysis. A patient questionnaire should be completed such as the Dry Eye Questionnaire (DEQ-5) or the Ocular Surface Disease Index (OSDI). Diagnostic tests that assess homeostasis markers should include a non-invasive tear break up time, which can be obtained with the Oculus Keratograph or the Visiometrics HD analyzer (as examples) or substituted with the traditional fluorescein TBUT if not available. Tear film osmolarity testing should be performed, and traditional vital dye ocular staining of the cornea, conjunctiva, and lid margins is crucial. Any abnormality of these three key diagnostic tests would indicate a disruption in homeostasis and a diagnosis of DED.
Management can be challenging due to the multifactorial nature of DED. Step 1 includes education and modification of environment, diet, hygiene, and potential offending medications. Step 2 includes non-preserved lubricants punctal occlusion and in-office heat therapy (LipiFlow, TearCare, iLux, and MiBo Thermoflo). Intense pulsed light therapy (IPL) is an emerging therapy showing promising results. Topical prescription medications include shortpulsed corticosteroids, topical secretagogues, calcineuri inhibitors, or LFA-1 antagonists. The three current FDA approved dry eye medications are Restasis (Allergan), Xiidra (Novartis), and Cequa (Sun Ophthalmics). Step 3 includes oral secretagogues, autologous/allogenic serum, and therapeutic contact lenses. Scleral lenses have an increasingly growing presence in this space. Lastly, step 4 would include amniotic membrane grafts, permanent occlusion, and tarsorrhaphy or salivary gland transplantation.”
Golie Roshandel Keovan, OD ’02
Belmont Eye Care, Ashland Eye Care
“I believe that dry eye syndrome can benefit from an integrative medicine approach to treat the whole person alongside a functional medicine approach to treat the root cause.
In our clinics, we often first screen our patients with a BioPhotonic Scanner so we can understand their level of carotenoid antioxidants. Low antioxidant level cause increased oxidative stress, leading to
apoptosis or cell death. The desired result in the blue zone is close to 50,000 or higher. However, many of our chronic dry eye sufferers have baseline testing at levels between 10,000 and 30,000.
If their diet is poor, then a list of high carotenoid antioxidant fruits and vegetables is given to the patient. Additionally, we recommend eating smaller fish such as sardines, anchovies, salmon, as well as ground flax, ground chia, olive oil, avocado oil, and organic omega-3 eggs. Fish oil supplements are usually recommended to patients who have meibomian gland dysfunction.
If carotenoid antioxidant levels are low due to poor gut absorption, then it is suspected that pathological microorganisms and leaky gut are the root cause, and/or smoking and drinking. In these cases, we recommend the use of digestive enzymes, probiotic serum, bovine
immunoglobulin, gastrointestinal amino acids, and antioxidant support. If applicable, education is also given on the cessation or reduction of smoking and alcohol use.
As far as palliative eye drop recommendations, we prefer preservative-free hyaluronic acid drops as well as our line of Nurturing the Soul Organic Daytime and Evening Oil eye drops. We discourage the use of industrial oils such as mineral oil and petroleum oil found in many over the counter ointments.
This past year, our practices have incorporated radiofrequency treatments to stimulate meibomian gland secretions as well as intense pulsed light to help treat ocular rosacea. As more dry eye studies are being published, we feel there may be less need for overprescribing medications. We continue to perform meibomian gland expressions, punctal plug procedures, and scleral contact lens fittings as needed.
Last, a thorough discussion about ingredients in personal products and makeup occurs with every patient. This topic is one of my favorites, as the importance is often overlooked. Ocular surface offenders such as parabens, phthalates, formaldehyde, sodium lauryl sulfate, lead, triclosan, butylated compounds, fragrance, and more exist in many unregulated personal and makeup products. Education about safer, better recommendations are given to all patients.
In 2020, we should believe that the eyes are the windows to the soul and our health. If we can look at our patient as a whole entity and address factors that affect them daily, not only will ocular surface disease heal, but chances are, their entire body will. Here's to hoping more of us incorporate an East meets West approach in this new decade.”