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A: Assess the condition(s) present for signs of ocular surface disease.
B: Begin treatment.
C: Continue and modify your treatment plan based on the findings and degree of resolution of the patient’s condition during the follow-up exam.
This month, I will discuss the assessment portion of my ABCs.
First and foremost, determine what you are dealing with: Is it dry eye disease, corneal dystrophy, blepharitis, a mechanical lid abnormality or a combination of etiologies that are impacting your patient’s quality of vision and causing other symptoms? My assessment is straightforward and starts with a question: "How do your eyes feel when you wake up in the morning or if you wake during the night?” This question is crucial to determining whether the patient’s symptoms are driven or exacerbated by inadequate lid seal (ILS). If the answer to this question is anything other than “my eyes feel great when I wake up,” ILS is going to need to be addressed to get the most from the treatments you apply. It is important to realize that ILS and the corresponding inflammation will drive so many subsequent anatomical changes in ocular surface disease.
Next, look at the lids and lid margins. Is there ocular rosacea and erythema on the lids or scalloped lid margins? Have the patient look down, while you look closely at the base of their lashes for the presence of collarettes and the degree of any damage to the lids and lashes. Missing, sparse, thin, brittle or misdirected lashes all indicate stress on the lash follicles. Collarettes will point you in the direction of Demodex because they are pathognomonic of Demodex blepharitis. If no collarettes are present, consider a bacterial component. Push on the central meibomian glands and look at the oil that is expressed. If the meibum is anything other than easily expressed, clear and colorless, the patient has meibomian gland dysfunction.
Before instilling NaFl, look at the tear meniscus to determine whether the patient has a component of aqueous deficiency. Then put in a small amount of NaFl, wait at least 60 seconds and look for tear break-up areas and time. I’ve found that tear break-up patterns are helpful in detecting subclinical epithelial basement membrane dystrophy that can masquerade as dry eye disease. Evaluate both the cornea and conjunctiva for staining, including small areas of micropunctate staining. Look at the inferior cornea and the inferior limbus if the patient has reported symptoms upon waking because the staining typically starts with these areas when they are exposed by ILS.
I often talk about point-of-care testing, such as osmolarity and inflammation testing, but this assessment is done with only the equipment that everyone has in their offices–a slit lamp and NaFl strips. This simple process allows you to accurately assess and treat most ocular surface disease patients.
