dry eye

Get on the “Stick”

What sticks with you may make a difference in patient care.

KELLY NICHOLS, O.D., M.P.H., PH.D.

Sometimes, you hear or see something that just “sticks” with you. You find yourself continuously thinking about it, as if it were a problem begging to be solved. You just can’t shake it, for better or worse.

As you read this month’s OM, something might “stick” with you about managing your staff, integrating new equipment or committing to beefing up the medical side of your practice. These are all topics I planned to write about this month, with a dry eye disease slant, of course: staff teamwork to streamline the ocular surface exam, new equipment to aid in efficiency and providing “cool” results to reinforce you provide medical eye care. But, something else “stuck” with me: a scientific presentation I attended in November.

The fluorescein drop

At this year’s annual American Academy of Optometry meeting, Donald R. Korb, O.D., F.A.A.O.*, gave a presentation on lipid behavior.

Specifically, Dr. Korb showed a video in which a drop of fluorescein the size of a meibomian gland orifice is placed between two meibomian glands on the lower lid margin. The patient, meanwhile, proceeds to blink normally.

So, what was so fascinating about this video? Despite blink after normal blink, the fluorescein dot does not integrate into the tear film at all. Only a forced blink mixes the fluorescein.

Clinical implications

In translating the video to clinical practice, the lipid from the meibomian glands probably just sits on the lid margin, never moving. I think we get our bolus of lipid in the morning or just after a shower, and that may be all the “fresh” lipid we get for the day.

So, if our lipid is abnormal in quality or quantity, the end of the day might be a bad time for our tear film, thus causing the discomfort and visual issues that many of our meibomian gland disease (MGD) patients experience.

If the morning is “the time” we get our best lipid, should we be telling our patients to perform lid hygiene and warm compress therapy in the morning rather than in the evening? Are we getting the timing all wrong? I want to find out.

In practice

For the next month, I am going to focus on “morning management” for my MGD patients. I am going to get my staff on board, as they are critical in providing patient education. The big challenge will be the patients: It is hard enough to convince them that warm compress therapy, in the time that it takes, is beneficial. I suspect those patients who comply with this regimen perform compress therapy in the evening when they have a little more free time. Can patients (and doctors) commit to morning therapy? Will it make a difference? Join me in this experiment. Perhaps, it will “stick” with you and your patients. OM

*For those of you who have not had the delight of spending time with Dr. Korb, track him down at a meeting, and introduce yourself. Having known him for years, I am always amazed by his inquisitive observations.

DR. NICHOLS IS A FOUNDATION FOR EDUCATION AND RESEARCH IN VISION (FERV) PROFESSOR AT THE UNIVERSITY OF HOUSTON COLLEGE OF OPTOMETRY. SHE LECTURES AND WRITES EXTENSIVELY ON OCULAR SURFACE DISEASE AND HAS INDUSTRY AND NIH FUNDING TO STUDY DRY EYE. SHE IS ON THE GOVERNING BOARDS OF THE TEAR FILM AND OCULAR SURFACE SOCIETY AND THE OCULAR SURFACE SOCIETY OF OPTOMETRY AND IS A PAID CONSULTANT TO ALCON, ALLERGAN, INSPIRE AND PFIZER. DR. NICHOLS CAN BE CONTACTED AT KNICHOLS@OPTOMETRY.UH.EDU. TO COMMENT ON THIS ARTICLE, E-MAIL OPTOMETRICMANAGEMENT@GMAIL.COM.