For the last four years, I’ve had the privilege of using this column as a platform to share insights and advice on ocular surface disease. It has been an eye-opening experience; one that has allowed me to connect with colleagues. Before I pass the torch to the new columnist, I’d like to use my last column to reinforce what I consider the most impactful action steps.

Have patients look down
Having patients look down when examining the upper lashes can reveal collarettes, signaling Demodex, that might otherwise be missed due to redundant, overhanging lid tissue.

Grade the expression
Apply gentle pressure to the meibomian glands to grade the expression (quantity and quality). This aids in diagnosing meibomian gland dysfunction (MGD).

Consider meibography
This imaging technique provides a precise evaluation of the meibomian glands and allows us to identify MGD earlier, providing a quantitative measurement that can guide treatment.

Utilize in-office treatments
In-office dry eye disease (DED) treatments are underutilized but highly effective (i.e. amniotic membranes, autologous serum tears, intense pulsed light, microblepharoexfoliation, ophthalmic inserts, punctal occlusion, and thermal procedures) in addressing both the signs and symptoms of ocular surface diseases.

Pro tips. Don’t have in-office treatments in your office? That’s ok! Laterally refer the patient to another OD in your community who does. Also, educate patients they can keep their autologous serum eye drops cold while out and about by using a travel mug with a freezer pack inside of it.

Mitigate progression
Several strategies can help mitigate DED progression:
• Always assess the patient’s eyes with vital dyes, even if they don’t report symptoms — being proactive is key.
• Prescribe treatments based on clinical findings, and don’t hesitate to switch up contact lens storage solutions or even refit contact lenses if allergies or corneal sensitivities are suspected.
• Consider referring for surgical interventions, such as punctal cautery, tarsorrhaphy, or a conjunctival flap, to protect the cornea.

Use the education approach
Over the years, I’ve found that a three-step approach to patient communication works wonders:
1. Provide visual evidence (“seeing is believing”).
2. Educate on the consequences. Explain the significance of the condition.
3. Discuss treatment options. Outline what each treatment addresses. Doing so improves patient understanding, which enhances compliance with prescribed treatments.

Stay current on diagnostics
These tools will provide deeper insights into our patients’ conditions and help us craft the most effective treatment plans. At the very least, ensure every patient receives a slit-lamp exam with vital dyes — it’s a simple step that yields invaluable information. And, as always, don’t forget the lids — look, lift, push, and pull.¹

A heartfelt thanks
Thank you for allowing me to be a part of your DED management journey. I look forward to seeing where the next chapter takes us! OM

Reference:

1. Starr CE, Gupta PK, Farid M, et al. ASCRS An algorithm for the preoperative diagnosis and treatment of ocular surface disorders. J Cataract Refract Surg. 2019;45(5):669-684. doi: 10.1016/j.jcrs.2019.03.023.

Cecelia Koetting, OD, FAAO, is an associate professor at the University of Colorado School of Medicine. She is a fellow of the American Academy of Optometry, diplomate of the American Board of Optometry, an active American Optometric Association member, and she consults for multiple companies. Email her at Dr.CeceliaKoetting@gmail.com.