Dry eye tests using photography

Dry eye tests using photography

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Dry eye treatments

Meibum and microsphericles particles

Renewed attention is being given this area. Use this link for more information on meibomian examinations  

Direct observation of the tear film

PRE CORNEAL tear film
PRE CORNEAL tear film

Observe that by using retroflection you can see the actual PRECORNEAL TEAR FILM.  With careful high power observation you can see meibian particles, oil, globular mucus and even a sense of thickness. A video below shows the tear film rising after the blink. 

Click any photo to enlarge it

Other explanations beyond ‘tear film evaporation or defective tear films’

Note the lower corneal punctate stain and the lack of coating the lower 1/3. Tear film evaporation is less significant since it never got coated.

Advantages of photography

A photo is better than a word description to document your findings. It allows you to track changes with treatment and to engage the patient when you show your patients their own images.

1. Photos plus video will shows you the whole picture of tear film coating during the entire cycle. 


2. A specially advanced fluorescein slit lamp camera is now available and gives detail that you would miss with a normal slit lamp. 

 Below is a comparison of your slit lamp blue light to what the new system can visualize. It allows you to see subtle punctate stain as well as tear coating and dynamics. 

Tear film in motion

Static pictures are useful in DED, video shows you the complete picture of the tear coating during the blink.  Ex. If you recall the gallop of horses was painted incorrectly until movies. Note the actual gallop.

Over the counter treatments

These are appropriate for minor DED without punctate stain. They reduce the sensations by putting a temporary tear film  thickener like CMC. Another good product is Gycerol. My preferences is for Systane Relieva™️ with hyaluronic acid.  Believed to be best in non preserved multi dose bottles or single dose vials.  

Most anticipated new eye drop 

All currently available eye drops only offer temporary relief. The new drop Lubrizity is the first treatment. It is the only drop with bio available lubricating oil and lipidzomes to replicate normal tear components. Currently we are in the process of mass producing the product for widespread distribution. 

Immunomodulators

They theoretically work by stopping inflammation of the lacrimal glands. So far no evidence of how it would get into glands or biopsies showing decreased inflammation, there believed mode of action. They have an incredible psychological effect since they require a prescription, are expensive and highly endorsed on TV. My opinion is that steroids have more efficacy when inflammation is present. The draw backs are potential pressure elevation and cataracts. 

Antihistamines drops and tablets

These medicines not only block histamine which is a common inflammatory component but may also effect other inflammatory mediators. Not as powerful as steroids but very safe. The best maybe Olopatadine ™️. 

Punctual Plugs

When placed these are believed to decrease tear outflow from the eye. Mostly placed in the lower lid puncta while the uppers are left open. There are no studies to demonstrate actual tear retention. The tears provide an outlet for cleaning bacteria and particulate matter from the surface of the eye. Some practitioners find them helpful. 

Oiintments

These are petroleum gels. They allegedly are retained longer. The effect the tear film coating and spread by forming globs on the ocular surface. The nighttime use makes the vision blurry. They are useful when the eyes don’t close at night.  Their negative is that they interfere with tear film coating. 

Serum tears

The patients blood is drawn, plasma is spun down and diluted with artificial tears. It appears to be effective short term as in the Corchoran reviews and the hyperlink here. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855871/#:~:text=The%20overall%20success%20rate%20of,effective%2C%20safe%20and%20well%20tolerated. There is no proven method of action although there is speculation that there are tissue factors.

Various hypothesis exist about how it works  Briefly some doctors feel it is due to growth factors, other to platelets and some to proteins and lipids.  

The disadvantages include a blood draw, office mixing with sterility concerns and the expiration of the serum used. 

Lubrizity is an advanced treatment 

This is a complete formulation of the basic components in tears. This includes the aqueous, cmc,  non emulsified bioavailable oil and microsphericles. 

This has a higher retention rate because of the microsphericles and oil droplets do not wash out but persist. 

Additives:

Menthol. This has a cooling and soothing effect and maybe can disrupt the biofilm in the conjunctiva. It has been useful in sore eyes and neuropathic dry eyes. 

Hyaluronic acid.  Frequently used to hydrate the skin and now used on the cornea and conjunctiva. It appears to be a mucus substitute but had reduced friction compared to CMC. 

Mucus. Snail mucus is the only commercially available product. Multiple mucins  have been identified in the tears and conjunctival surfaces. The so called branching mucus coats the surface of the eye. Mucus provides a barrier to pathogens, smooths the surface and allows water to adhere to the conjunctiva.  This is an important area of research. 

Parasympthomimetics. are known to stimulate secretions of the glands. These are effective when the upper and lower tear prisms are depleted. This is commonly seen in lasik, chemotherapy and immunological disorders such as Sjogren’s disease. 


Photograph is Meibiography
Photograph is Meibiography

Warm compresses and lid squeezes

The meibomian glands are susceptible to clogging and when blocked infection. We use home treatment of hot compresses to heat the oil to decrease viscosity and increase flow. Our preferred method is with a heat retaining gel pack. It is applied to heat the glands for 45 seconds followed by squeezing (tight lid closures 5 times for 3 seconds) to force out the oil. We observe the glands before and after treatment with Meibiography. There are advanced equipment to do a more precise treatment with pressure and temperature control. There are studies which demonstrate efficacy. There are multiple office devices for improved expression. 

Dr. Clifford Terry