Evaluation and Management of Ocular Surface Disease in an Academic Setting

Thinking “outside the box” to advance dry eye science and bring patients hope

Victor L. Perez, MD The Ocular Surface Center Bascom Palmer Eye Institute

Victor L. Perez, MD
The Ocular Surface Center
Bascom Palmer Eye Institute

At The Ocular Surface Center, part of the University of Miami’s Bascom Palmer Eye Institute, we consider ourselves to be in the business of providing hope to the patients who come to us for care. By the time patients come through our door, typically they’ve seen several other doctors. They need someone to take a fresh look at their dry eye and identify appropriate therapies. As an academic center, we’re uniquely equipped to do that.

We’re fortunate to have new technologies for expanding our understanding of dry eye that aren’t yet available in private practices. This allows us to “think outside the box” and provide care for these patients that they wouldn’t receive elsewhere. And while all Dry Eye Centers of Excellence rely on a team effort, our team has a somewhat different make-up. We have three ophthalmologists, an optometrist, three technicians, a clinical coordinator, an executive administrator and a clinical research team.

The fellows on the research team and the clinical coordinator have very important roles. The fellows generate new ideas about what patient data we should be collecting and evaluating, and the clinical coordinator helps us to manage and work with that real-time data, which enables our center to be part of groundbreaking research. We have the ability to conduct non-sponsored clinical research into areas such as the exploration of what the relationship is between tear osmolarity and levels of MMP-9. We can also take part in clinical trials with industry, creating a bridge between the laboratory and the clinic, which gives our patients access to cutting-edge technologies and treatments. Through clinical trials, we’re contributing to the field and bringing much-needed hope to our patients.

Standardized Data Collection Enhances Patient Care

Because of our work in clinical trials, we’re keenly focused on standardized patient data collection and grading degrees of disease severity. However, examining and testing patients in a standardized manner is beneficial for any dry eye practitioner. Doing so ensures the quality of the information gathered, guides therapy and enables precise evaluation of the state of patients’ ocular surface health from visit to visit. The dry eye workup should be similar to a glaucoma workup. With glaucoma patients, we perform corneal pachymetry, IOPs, OCT optic nerve evaluation, fundus photography and visual fields. The same comprehensive approach should be applied to dry eye (Figure 1). Each part of the workup should be done in a standardized way. In our clinic, we use precise, pipette-delivered microvolumes of fluorescein or lissamine green for corneal/conjunctival staining and we score patients using the National Eye Institute scale. We’re also careful to accurately time the tear break-up test. Even the Schirmer’s test, which some doctors want to eliminate, when done in a standardized way, yields useful diagnostic information. Certainly, an extremely low Schirmer’s result is usually confirmation that tear insufficiency is a patient’s primary problem. Other grading scales we use include the Meiboscale for gland dropout developed by Dr. Heiko Pult (www.dry-eye-tool-box.com).

Figure 1. A dry eye patient workup should include all diagnostic tests that can inform treatment decision-making.

Finding New Ways to Make a Difference

The following are some of the components of The Ocular Surface Center and some treatments we provide that may differ from what is commonly seen in private practice.

■ Ocular Imaging Center. Ophthalmology is one of the few medical specialties with direct access to its target organ, so we should take full advantage of that. In our Ocular Imaging Center, in collaboration with Dr. Jianhua (Jay) Wang, we’re working to adapt ultra-high resolution OCT for imaging the ocular surface at a microscopic level. The aim is to develop new diagnostic techniques that could serve to provide doctors with information such as earlier endpoints of ocular surface damage. We’re envisioning a day when OCT can be performed at the slit lamp and deliver 3-micron-resolution images of the cornea that could be used, for example, to quantify the thickness of the epithelium, intricately evaluate the tear meniscus, visualize the vascular biology of conjunctival blood vessels or assess the velocity of cells as they fluctuate on the ocular surface.

■ Lid Margin Clinic. As I tell our fellows, an exam is incomplete if the meibomian glands aren’t evaluated and manually expressed. We’ve established a Lid Margin Clinic so we’re giving the glands and lid margin the attention they deserve as contributors to ocular surface disease. We perform a very careful lid margin evaluation and once we diagnose meibomian gland disease, we recommend aggressive, mechanical therapy. For the purposes of patient education, we equate this with dentistry. Patients can floss and brush every day, but at some point, they still need to go to the dentist for a deeper cleaning. So, in our Lid Margin Clinic, we provide thermal pulsation, digital massage, palate massage and scraping. We use the LipiFlow (TearScience) thermal pulsation device as baseline therapy and we teach patients how to properly care for the lid margin.

■ Autologous serum tears. At our center, we draw patients’ blood, separate the serum and divide it with preservative-free saline in bottles from 20% to 50% concentration. We store it in the freezer and dispense to patients who thaw it for use 4 to 6 times a day. The hypothesis is that the serum contains various growth factors that are beneficial for the ocular surface.

■ Prosthetic replacement of the ocular surface ecosystem (PROSE). The PROSE device was developed by the Boston Foundation for Sight. It’s a special scleral contact lens designed for the treatment of severe dry eye and cicatrizing disorders and the pain and neuropathy associated with them. PROSE consists of a transparent dome made from highly gas-permeable plastic. It fits under the eyelids, creating a space between the device and the eye that is filled with sterile saline. The liquid remains in the reservoir, providing constant lubrication by bathing the eye in a pool of artificial tears. Patients wear PROSE during waking hours and are trained in daily application, removal and cleaning as part of the treatment process. Because the device is essentially a contact lens, we can use it for refractive correction, too. The optometrist on our team is in charge of our PROSE service.

Beyond helping our patients in any way we can, our ultimate goal at The Ocular Surface Center is to continue contributing to the development of new diagnostic tools and treatments so all ophthalmologists can enhance the care they provide for their ocular surface disease patients. ■