Milton Hom, O.D., F.A.A.O.: Sometimes, we encounter cases of unsolvable dry eye. One theory is that binocular imbalances can cause dry eye symptoms. I have heard of many cases in which the dry eye remains symptomatic despite conventional treatments. Often as a last-ditch effort, we finally look at binocular dysfunction, and it is found to be the cause of the symptoms.

Lynn Lowell, O.D., F.A.A.O., F.C.O.V.D., and I have done research that corroborated these findings. We found that patients who have acquired brain injury and binocular dysfunction suffer from severe dry eye symptoms. Measured with the validated questionnaire, the Ocular Surface Disease Index, scores average about 45 (severe dry eye is classified as anything above 33).¹

Ben Gaddie, O.D., F.A.A.O.: The conundrum of the lack of correlation between signs and symptoms of dry eye continues. Binocular vision problems can certainly mimic dry eye symptoms. I have been enjoying some new technology called Opt-Align to assist me in identifying patients suffering from fixation disparity issues resulting in dry eye symptoms. I typically see horizontal disparities causing dry eye and vertical disparities resulting in chronic, debilitating headaches. Simple optometric therapy of prism (vertical or base out) has yielded phenomenal results for my patients. Talk about word of mouth referrals.

I know some of my colleagues can make these measurements with traditional equipment, but I love the Opt-Align, which was licensed to Stereo Optical by Jeff Krall, O.D., because it makes the diagnosis so easy. Thanks to Dr. Krall for taking his passion for helping patients to market this great device.

M.H.: Lately, there has been a revisiting of meibomian gland dysfunction (MGD) with the thought that it may be much more prevalent than we previously expected. The Meibomian Gland Evaluator (MGE), from TearScience, is a handheld instrument that applies repeatable pressure to express the lids. The pressure applied is considered to be gentle, mimicking the pressure exerted by the lids when blinking. For those who express glands, we know the pressure applied can be variable. My guess is the gentle pressure of the MGE is a lot less than the pressure applied to express the glands (at least in my case). So, if I were to use less pressure, I would diagnose MGD more often. Therefore, MGD prevalence numbers may actually be too low.

B.G.: Maybe it’s where I practice, but my main challenge is trying to decide which patients to treat with MGD since I feel that I could literally treat 75% of my patient population. MGD Is everywhere, and my biggest subset population is rosacea-related MGD. In addition, I have noticed that most of my glaucoma patients treated with prostaglandin analogues (PGAs) also develop a MGD-type disorder that includes thickening of the lower eyelid, redness, telengectasia of the vasculature and outright inflammation of the glands — not surprising since PGAs are inflammatory in nature. At times, I feel like I could treat every patient who walks through the door due to MGD. For now, the low-hanging fruit seems to be the symptomatic patients. OM