MEDICAL MODEL
ocular surface disease

OSD: a Gumshoe’s Guide

Effectively manage these patients through detective work.

JILL AUTRY, O.D., R.PH., HOUSTON, TEXAS

Ocular surface disease (OSD) impacts our patients and our practices on a daily basis. Yet, some of us fail to actively identify and manage these patients. This is a huge mistake. The reason: Diagnosing and effectively treating this multifaceted condition increases practice revenue (e.g. diagnostic testing/follow-up appointments), patient loyalty, due to the alleviation of symptoms, and patient referrals, as a result of patient appreciation for our eyecare expertise.

To build a case, detectives seek information and evidence via the following three steps. To identify OSD, you, as the optometrist, must follow suit.

1 Ask specific questions.

Just as getting suspects to volunteer information without specific questioning is slim, patients aren’t always forthcoming regarding symptomatology without direct questioning either. (They often think their symptoms are a normal part of aging, or they confuse various causes of OSD, such as allergy, dry eye syndrome [DES], blepharitis, etc.)

Therefore, to identify OSD suspects, provide a patient questionnaire, or have your technician or yourself personally ask questions, such as “Do your eyes burn? Water? Itch? Feel gritty?” and “Does your vision fluctuate?” (I find patients are more forthcoming when a technician or doctor asks these questions.) Once you have these answers, you can ask follow-up questions whose answers will refine the description of the patient’s symptoms. This, in turn, will aid you toward determining the type of OSD that may be present. Examples of such follow-up questions:

▸ Are symptoms worse at the end of day?

▸ Are symptoms worse around wind or ceiling fans?

▸ Are symptoms worse in the fall or the spring?

▸ Do you have seasonal allergies? Pet allergies?

▸ Does your vision clear with blinking?

▸ What makes your symptoms better; what makes them worse?

▸ Is tearing intermittent or constant?

▸ Are the symptoms equal between eyes, or is one eye worse than the other?

▸ Do your eye(s) burn and water more, or do they itch and water more?

2 Conduct a background check.

When looking at a suspect, detectives assess their recent and personal histories to weigh their likelihood of involvement in a case. As an optometrist, you must examine the OSD suspect’s medical history to determine the prospect of their symptoms having systemic associations — another answer that will help you toward finding out the OSD type the patient may have. To acquire medical history, ask personally or via patient questionnaire:

▸ Do you have thyroid disease?

▸ Do you have dry mouth?

▸ Do you have arthritis?

▸ Do you have autoimmune conditions, such as lupus, sarcoidosis or rosacea?

▸ Have you had chemotherapy or radiation treatments?

▸ Do you smoke?

▸ Do you wear contact lenses, or have you been unable to wear them in the past?

▸ How much of your day is spent on the computer?

▸ Are you a frequent flier?

▸ Have you had LASIK or any other ocular surgery?

Next, scan the patient’s medication profile to look for oral agents, such as decongestants, antihistamines, hormone replacement therapy, antihypertensives (e.g. diuretics and beta-blockers), antidepressants, acne products and thyroid medications, that can cause OSD symptoms. Glaucoma patients, for example, are at increased risk for DES, due to chronic medicamentosa.

Finally, don’t forget to ask patients to list any over-the-counter products they are currently using, including any eye products that contain naphazoline, pheniramine and tetrahydrozoline, and their frequency/duration of use.

3 Acquire hard evidence.

A black eye, a rap sheet rife with arrests for brawling, a poor alibi and knowing the victim can make one a suspect in a murder, but doesn’t automatically make them the murderer. The reason: None of these characteristics fall under the category of hard evidence.

Similarly, although OSD symptoms and a strong medical history can lead you to a definitive diagnosis, nothing is confirmed without a problem-focused exam and diagnostic testing.

Looking for OSD should start before you touch the slit lamp. A refraction that varies between blinks can signal poor tear quality and poor corneal wetting. Facial pustules and telangiectasia point toward possible meibomian gland dysfunction and ocular rosacea. In addition, arthritic hands can indicate inflammatory ocular surface disorders, such as Sjögren’s syndrome. And, a butterfly patterned facial rash is classic for systemic lupus erythematosus.

Once at the biomicroscope, check lid and lash health first. Is there eyelid telangiectasia, clogged or atrophied meibomian glands, anterior blepharitis or inflamed caruncles? Also, look for entropion, ectropion, a small or absent punctum, lagophthalmos and incomplete blink.

Next, quickly press on the meibomian glands to evaluate meibum consistency, and perform a snap-back test on the lower eyelid. As the conjunctiva can also contribute to OSD and associated symptoms, note any conjunctival chalasis or inflamed pinguecula.

At the cornea, look for punctate keratopathy, and note the location and amount in each eye. Observe any corneal dystrophies or degenerations, which can cause or exacerbate OSD.

Ultimately, DES and ocular allergy are the most common OSD disorders. Although the conditions have symptom overlap and may occur simultaneously, they are distinct in their pathologic basis and treatment.

Ocular allergy is bilateral, with itching usually concentrated in the inner canthus. It generally comes in a seasonal pattern and is often accompanied by a runny nose, sneezing, inner ear itching or throat itching. DES is more chronic and causes burning, intermittent epiphora, worsened by wind or certain tasks, such as frequent and extended computer use, and often feels like sand in the eye. Also, the condition is more common in females older than age 40, due to menopausal hormonal changes.

Posterior lid disease is diagnosed through meibomian gland and eyelid margin inspection. A diagnosis of chronic epiphora, due to eyelid malposition or punctal abnormalities, is also made via inspection and/or dilation and irrigation.

Underlying systemic conditions may be diagnosed after selective blood work is performed based on history and examination. For example, blood work is often ordered for Sjögren’s syndrome, sarcoidosis and lupus. Also, a thyroid panel may be ordered.

Making the arrest

Now, that you’ve discovered the smoking gun for OSD, you’re ready to make your arrest (cease symptoms through treatment). Episodic DES symptoms that have minimal ocular signs are alleviated by b.i.d. to q.i.d. artificial tear use PRN. Patients who already use artificial tears but have continued DES signs and symptoms after six months should be moved to medical therapy (discussed below).

For moderate to severe DES cases, prescribe a combination of steroids b.i.d. to q.i.d. and cyclosporine emulsion (Restasis, Allergan), and follow-up with the patient in one month. Also, discuss environmental factor management, such as avoiding car vents and ceiling fans, and consider omega-3 supplements.

Have the DES patient discontinue any vasoconstrictors, as they can cause rebound hyperemia, and allergy drops, as they don’t treat DES.

For DES patients who desire contact lenses, prescribe daily disposable lenses. Extended wear increases infection risk, secondary to a poor epithelial barrier.

For glaucoma patients with DES, consider referring them for SLT, so they can eliminate or decrease the need for medicamentosa-causing drops.

When dealing with allergic conjunctivitis patients, recommend an antihistamine/mast-cell stabilizer, artificial tears and avoidance of known antigens. In patients who don’t achieve relief via a topical antihistamine/mast cell stabilizer, prescribe an oral version.

For posterior blepharitis, prescribe hot compresses, topical azithromycin and oral doxycycline, q.d. to b.i.d., depending on the severity. Hot compresses are generally the chronic mainstay of therapy, with the others used for several months until symptom control, although all can be chronic.

Many types of OSD require surgery: Pterygium removal, superficial keratectomy for severe epithelial basement membrane dystrophy or Salzmann’s nodules, punctoplasty for punctal stenosis, dacryocystorhinostomy for nasolacrimal duct obstruction, entropion or ectropion correction and excess conjunctiva removal with conjunctival chalasis.

Case closed

This three-step gumshoe guide benefits your patients and your practice. So, grab a fedora and trench coat, solve some cases and make arrests. OM

Dr. Autry received her pharmacy degree from the University of North Carolina at Chapel Hill and her optometry degree from the University of Houston. Today, she is a partner at the Eye Center of Texas ophthalmology center. She lectures internationally on several pharmaceutical and ocular disease topics and is a prolific author on these topics. E-mail her at jill_autry@hotmail.com, or send comments to optometricmanagement@gmail.com.