Wednesday, February 17, 2010


So this bug I'd been battling for a week and thought was gone... is back in force. Maybe because I stayed up so late trying to get a bulletin out, like an idiot. Which also set my left eye back into a new freefall. Blech. Next week will be better. :-)

Abstract: Tearlab osmolarity test and three tears

(not to be confused with cheers)

Sorry, I don't buy it. I mean, I buy the part that any artificial tear will make things at least slightly better clinically. But I don't buy that Blink is better than Systane and Refresh Plus, symptomatically if not clinically, because I don't think any of those three has good results in signs or symptoms.

If Blink were better symptomatically, we'd be hearing it on DryEyeTalk. And honestly? If I were going to use an HLA drop myself, it would be Oasis Tears Plus, on the principle that if you're going to do it at all, get the molecular weight and suchlike details right please!

Tear osmolarity measurement using the TearLab Osmolarity System in the assessment of dry eye treatment effectiveness.
Cont Lens Anterior Eye. 2010 Feb 11. [Epub ahead of print]
Benelli U, Nardi M, Posarelli C, Albert TG.
Department of Neurosciences Section of Ophthalmology, University of Pisa, Via Roma 67, 56126 Pisa (Pi), Italy.

PURPOSE: To evaluate the efficacy of three commercially available lubricant eye drops for the treatment of mild, dry, irritated eyes.

METHODS: Randomized, investigator-masked evaluation of 60 patients in which 20 patients used carboxymethylcellulose sodium (CMC), 0.5% (Cellufresh((R)), Allergan Inc., Irvine, CA) (group 1); 20 patients used a drop containing polyethylene glycol 400, 2.5% and sodium hyaluronate (Blink((R)) Intensive Tears, Abbott Medical Optics Inc., Santa Ana, CA) (group 2); and 20 patients used HP Guar 0.18% (Systane((R)), Alcon Laboratories Inc., Ft. Worth, TX) (group 3). Study visits were at baseline and 1 month. Tests performed at both visits included Schirmer, tear-film break-up time (TBUT), visual acuity, fluorescein staining, tear osmolarity and wavefront aberrometry. Osmolarity testing was performed prior to instillation of the lubricant eye drops and then a final time 5min after instillation of the drop at both day 1 and day 30. Tear osmolarity was performed only in the right eye and only one time before and after instillation of lubricant eye drops.

RESULTS: At day 1 the mean reduction in osmolarity 5min after instillation of the lubricant eye drop was, -5.0+/-1.9 in group 1, -9.0+/-4.2 in group 2 and -5.0+/-2.2 in group 3. At day 30 the mean reduction in osmolarity 5min after instillation of the lubricant eye drop was, -5.6+/-2.3mOsm/L in group 1; -9.9+/-2.8mOsm/L in group 2 and -4.5+/-1.8mOsm/L in group 3. The differences were statistically significant between groups 1 and 2, and 2 and 3. There was a reduction of osmolarity from day 1 to day 30 but the differences were not statistically significant. We feel that after a 30-day treatment with the lubricant eye drops, the lower osmolarity values could indicate that the tear film is progressing towards a more normal osmolarity value. A future study could examine the tear osmolarity value after 60 or 90 days of usage. LogMAR best-corrected visual acuity (BCVA) results showed an improvement in group 2 compared with baseline with no change in BCVA in groups 1 and 3. There was no statistically significant change from day 1 to 1 month in TBUT, while the Schirmer test showed an improvement in all groups at 1 month.

CONCLUSIONS: Assessment of tear osmolarity provides the most objective, measurable test for determining improvement in dry eye patients. The instillation of any artificial tear or lubricant eye drop should decrease the tear-film osmolarity. The results found that polyethylene glycol 400, 0.25% and sodium hyaluronate (Blink((R)) Intensive Tears) significantly improved tear osmolarity compared with carboxymethylcellulose sodium (CMC), 0.5% (Cellufresh((R))) and HP Guar 0.18% (Systane((R))) after instillation.

Abstract: Which patients does Restasis help?

Very interesting - thank you! At last something breaking down results by dry eye severity level. This one seems to say, the mild-to-moderate dry eye patients are much more likely to benefit from cyclosporine 0.05% than the severe ones.

Evaluation of the effect of topical cyclosporine A with impression cytology in dry eye patients.
Eur J Ophthalmol. 2010 Feb 1. [Epub ahead of print]
YĆ¼ksel B, Bozdag B, Acar M, Topaloglu E.
Eye Bank and Cornea Section, Izmir Bozyaka Teaching and Research Hospital, Bozyaka-Izmir - Turkey.

Purpose. This study evaluated the efficacy of topical cyclosporine A 0.05% treatment with impression cytology in dry eye patients.

Methods. Forty eyes of 40 patients with dry eye were included. Schirmer, tear break-up time, and Ocular Surface Disease Index (OSDI) scores and goblet cell densities were noted before and after 6 months of topical cyclosporine A treatment. Patients were graded clinically and biomicroscopically as follows: grade 1, 12 patients; grade 2, 18; and grade 3, 10 patients.

Results. Mean age was 57.1 plusmn;11.8 (23.0 ndash;80.0) years. A total of 36 (90%) of the patients were female and 4 (10%) were male. Mean Schirmer test value was 3.2 plusmn;1.6 (0.0 ndash;8.0) mm in the beginning and was 8.4 plusmn;4.3 (1.0 ndash;19.0) mm after 6 months of cyclosporine A topical treatment (p=0.00). At the first visit, mean tear break-up time was 4.4 plusmn;1.8 (2.0 ndash;8.0) seconds. It increased to 11.8 plusmn;4.8 (2.0 ndash;20.0) seconds at the end of the sixth month (p=0.00). Mean clinical grading was 1.9 plusmn;0.8 (1.0 ndash;3.0) and this value regressed to 0.8 plusmn;1.2 (0.0 ndash;3.0) after the treatment (p=0.00). Mean OSDI score was 30.0 plusmn;11.7 (9.0 ndash;50.0) before the treatment and 21.3 plusmn;11.0 (4.0 ndash;47.0) after the treatment (p=0.00). Mean goblet cell density of all cases was 12.3 plusmn;8.7 before the treatment (2.0 ndash;28.0). It increased to 33.0 plusmn;25.4 (6 ndash;70) after the treatment (p=0.04).

Conclusions. Topical cyclosporine A treatment is effective in grade 1 and grade 2 dry eye patients but results are poor in grade 3 patients.

Abstract: Augmentin Duo for childhood blepharoconjunctivitis

Augmentin Duo in the Treatment of Childhood Blepharokeratoconjunctivitis.
J Pediatr Ophthalmol Strabismus. 2010 Feb 8:1-5. doi: 10.3928/01913913-20100118-01. [Epub ahead of print]
Cehajic-Kapetanovic J, Kwartz J.

PURPOSE:To report the use of Augmentin Duo 400/57 (GlaxoSmithKline, Middlesex, UK) in the treatment of childhood blepharokeratoconjunctivitis (BKC).

METHODS:This is a retrospective interventional case series. The case notes of 7 consecutive patients treated with Augmentin Duo 400/57 for BKC during 18 months were reviewed. Diagnostic criteria for BKC were blepharitis including recurrent chalazia and meibomian gland dysfunction, eyelid margin telangiectasia and facial rosacea, recurrent episodes of chronic red eye, photophobia, watering, punctate superficial keratopathy, corneal neovascularization, and corneal ulcers.

RESULTS:Seven children (age range: 6 to 14 years) were diagnosed as having BKC. All children received systemic Augmentin Duo 400/57 and showed considerable improvement within the first month of therapy. Six children had no recurrences during a mean follow-up of 6 months. No patients experienced any side effects from this treatment.

CONCLUSIONS:Augmentin Duo 400/57 has not previously been reported in the treatment of BKC in children. In this case series, Augmentin Duo 400/57 proved to be at least as effective as current treatments with systemic erythromycin or doxycycline with the advantage of a twice-daily dosage and a superior side-effect profile. Copyright 2010, SLACK Incorporated.

Abstract: What's going on behind the scenes in evaporative dry eye

Tear proteomics in evaporative dry eye disease.
Eye (Lond). 2010 Feb 12. [Epub ahead of print]
Versura P, Nanni P, Bavelloni A, Blalock WL, Piazzi M, Roda A, Campos EC.

Ophthalmology Unit, University of Bologna, Bologna, Italy.
Purpose:To analyze tear protein variations in patients suffering from dry eye symptoms in the presence of tear film instability but without epithelial defects.

Methods:Five microlitres of non-stimulated tears from 60 patients, suffering from evaporative dry eye (EDE) with a break-up time (BUT) <10 s, and from 30 healthy subjects as control (no symptoms, BUT >10 s) were collected. Tear proteins were separated by mono and bi-dimensional SDS-PAGE electrophoresis and characterized by immunoblotting and enzymatic digestion. Digested peptides were analyzed by liquid chromatography coupled to electrospray ionization quadrupole-time of flight mass spectrometry followed by comparative data analysis into Swiss-Prot human protein database using Mascot. Statistical analysis were performed by applying a t-test for independent data and a Mann-Whitney test for unpaired data (P<0.05).

Results:In EDE patients vscontrols, a significant decrease in levels of lactoferrin (data in %+/-SD): 20.15+/-2.64 vs24.56+/-3.46 (P=0.001), lipocalin-1: 14.98+/-2.70 vs17.73+/-2.96 (P=0.0001), and lipophilin A-C: 2.89+/-1.06 vs3.63+/-1.37 (P=0.006) was revealed, while a significant increase was observed for serum albumin: 9.45+/-1.87 vs3.46+/-1.87 (P=0.0001). No changes for lysozyme and zinc alpha-2 glycoprotein (P=0.07 and 0.7, respectively) were shown. Proteomic analysis showed a downregulation of lipophilin A and C and lipocalin-1 in patients, which is suggested to be associated with post-translational modifications.

Conclusions:Data show that tear protein changes anticipate the onset of more extensive clinical signs in early stage dry eye disease.Eye advance online publication, 12 February 2010;

Abstract: DA-6034

All ya gotta do these days is google it. S'long as you don't mind getting 96,000 or so results. I don't really care about its effects as a treatment for inflammatory bowel disease is mice, but improvement of dry eye in bunnies, well, who knows what that might lead to.

The Therapeutic Effect of DA-6034 on Ocular Inflammation via Suppression of MMP-9 and Inflammatory Cytokines and Activation of the MAPK Signaling Pathway in an Experimental Dry Eye Model.
Curr Eye Res. 2010 Feb;35(2):165-75.
Seo MJ, Kim JM, Lee MJ, Sohn YS, Kang KK, Yoo M.

Research Institutes, Dong-A Pharmaceutical Company, Yongin, Kyunggi, Korea.
Purpose: To investigate the effect of DA-6034, 7-carboxymethyloxy-3',4',5-trimethoxy flavone, in experimentally-induced inflammatory dry eye in rabbit. In addition, to elucidate the mechanism of DA-6034, we evaluated the mitogen-activated protein kinase (MAPK) signaling pathway and transcriptional factor-kappa B (NF-kB) in corneal epithelial cells.

Methods: Rabbit lacrimal glands were injected with the T-cell mitogen concanavalin A (Con A). DA-6034 was then administered topically four times a day for six days starting 24 hr after Con A injection. Tear volume, tear function, MMP-9 and inflammatory cytokine levels in the lacrimal glands, and histological evaluation were subsequently assessed. In in vitro study, phosphorylated MAPKs (c-Jun NH2-terminal kinase (JNK) and p38 MAPK) and NF-kB were detected by enzyme-linked immunosorbent assay (ELISA) using human corneal epithelial cells.

Results: A single injection of Con A into the lacrimal glands induced a pronounced inflammatory response, caused elevated levels of MMP-9 and cytokines IL-8 and TGF-beta(1), and induced a decrease in tear volume and shortening of tear breakup time (TBUT). In this inflammation model of dry eye, DA-6034 clearly showed therapeutic efficacy by restoring tear function and inhibiting inflammatory responses after topical ocular application. Furthermore, DA-6034 attenuated the phosphorylation of JNK and p38 MAPK and inhibited NF-kB activation in a concentration-dependent manner in corneal epithelial cells.

Conclusions: These results suggest that DA-6034 has the therapeutic effect in rabbit lacrimal gland inflammation model of dry eye and might be a potential treatment option for acute dry eye syndrome.

Abstract: Fourier-domain OCT tear meniscus measurements (with real or fake eyeball)

Tear Measurement in Prosthetic Eye Users with Fourier-Domain Optical Coherence Tomography.
Am J Ophthalmol. 2010 Feb 5. [Epub ahead of print]
Kim SE, Yoon JS, Lee SY.
Department of Ophthalmology, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea.

PURPOSE: To investigate whether Fourier-domain (FD) optical coherence tomography (OCT) can measure the tear meniscus of anophthalmic patients using prosthetic eyes and to compare the characteristics of normal and artificial eyes.

DESIGN: Prospective, nonrandomized, observational case series.

METHODS: Thirty-one patients who had undergone anophthalmic surgery in 1 eye and had been wearing artificial eyes for more than 6 months were included. Subjects with socket inflammation, contracted sockets, or other known lid disorders were excluded. Patients were asked to complete a questionnaire regarding their demographic status and dry eye symptoms before treatment, and FD OCT scanning and the Schirmer test were performed. Three images were obtained by FD OCT on each normal and anophthalmic eye, and the tear meniscus height, tear meniscus depth, and tear meniscus angle were measured with computer calipers.

RESULTS: FD OCT was able to visualize the tear meniscus of both normal and artificial eyes. The mean tear meniscus height of artificial eyes was significantly lower than that of normal eyes (200.59 +/- 79.68 mum vs 261.24 +/- 86.17 mum; P < .001). Mean tear meniscus depth, tear meniscus area, and tear meniscus volume also were significantly lower in artificial eyes than in normal eyes. The dry eye symptom score showed significantly negative correlation with tear meniscus height. The Schirmer test results correlated with tear meniscus parameters in normal eyes, but not in artificial eyes.

CONCLUSIONS: FD OCT is a valuable clinical tool in the evaluation of tear meniscus height in normal and artificial eyes. In addition, tear meniscus height can be a useful clinical parameter that estimates symptoms of ocular dryness and discomfort in both normal and artificial eyes.

Abstract: GVHD: conjunctiva in trouble

Differential chemokine expression in chronic GVHD of the conjunctiva.
Bone Marrow Transplant. 2010 Feb 8. [Epub ahead of print]
Westekemper H, Meller S, Citak S, Schulte C, Steuhl KP, Homey B, Meller D.
Department of Ophthalmology, University of Duisburg-Essen, Essen, Germany.

In chronic GVHD after BMT, the conjunctiva represents a target organ. GVHD can lead to severe inflammation and dry-eye syndrome (sicca syndrome). The molecular mechanisms are largely unknown. We examined the expression of chemokines in the conjunctiva in cases of chronic GVHD. In this study, we included 10 patients with chronic GVHD and 10 healthy controls. Clinical data were collected and tear film analysis and conjunctival cytology were carried out. Conjunctival biopsies were taken from all participants. Gene expression profiles of chemokines and their corresponding receptors were evaluated by means of quantitative real-time PCR. Chemokine protein expression was analysed by immunohistochemical analyses. Expressions of the Th1-associated chemokines, chemokine (C-X-C motif) ligand (CXCL) 9 (Mig), CXCL10 (IP-10), and their receptor chemokine (C-X-C motif) receptor 3 (CXCR3) were significantly increased in GVHD patients. Immunohistochemical analysis confirmed marked expression of the inflammatory CXCR3 ligands. A total of six patients had a moderate or severe sicca syndrome. Impression cytology revealed a mild keratinisation, moderate keratinisation or severe squamous metaplasia in three patients, respectively. Chronic GVHD of the conjunctiva is characterised by the expression of Th1-associated chemokines. Taken together, our results confirm that the conjunctiva is a target organ in this T cell-mediated process and add to molecular understanding of conjunctival GVHD.Bone Marrow Transplantation advance online publication, 8 February 2010; doi:10.1038/bmt.2009.346.

Company news: Restasis sales burgeoning

Allergan Delivers Strong 4Q

While aesthetic new products such as Latisse and Juvederm should help goose growth in 2010, we're even more enthusiastic about Restasis for dry eyes. The product saw a 40% increase in sales during the fourth quarter, which seems to be driven by ongoing detailing efforts to let practitioners know of how widespread dry eye is and its chronic nature.

Translation: Restasis sales dudes and dudettes are making hay while the sun shines. They know they ain't gonna be the only FDA approved dry eye drug foreva.

Company news: New head of AVR

Advanced Vision Research (the Theratears company) has named Neil Donnelfeld as CEO to replace founder Dr. Jeff Gilbard who died tragically last year.

Neil Donnenfeld named CEO of Advanced Vision Research

Swampscott —
Neil D. Donnenfeld of Swampscott has been named chief executive officer of Advanced Vision Research of Woburn, makers of the TheraTears and MacuTrition brands for dry eye and macular degeneration. He was also named as a director of the company.

Donnenfeld has extensive experience with Advanced Vision Research and has been instrumental in its growth. He most recently served as the company’s senior vice president of global sales and marketing, a position he held since 2005.

Donnenfeld, 48, joined AVR in May 1998, shortly after Advanced Vision Research was originally formed as an over-the-counter eye care company to market and distribute TheraTears products.

Advanced Vision Research continues to rebound after the sudden loss of Jeffrey P. Gilbard, MD, the company’s founder, CEO and chief scientific officer last August.

Noted Donnenfeld, “I’m honored to have been chosen as the new CEO of Advanced Vision Research where we are dedicated to continuing the path blazed by Dr. Gilbard. We are eager to introduce revolutionary new products that are already in the pipeline, and look forward to the development of new advances in eye care treatment that improve patients’ lives.”

Donnenfeld has been involved in most aspects of building Advanced Vision Research and its brand portfolio and has maintained close connections with the professional community that forms the base of TheraTears and MacuTrition’s loyal advocates, including optometrists and ophthalmologists.

Tuesday, February 16, 2010

Abstract: How dryness changes corneal tissue

Desiccating Stress Promotes Th17 Differentiation by Ocular Surface Tissues through a Dendritic Cell-Mediated Pathway.
Invest Ophthalmol Vis Sci. 2010 Feb 3. [Epub ahead of print]
Zheng X, de Paiva CS, Li DQ, Farley WJ, Pflugfelder SC.

Ophthalmology, Baylor College of Medicine, Houston, United States.
Purpose. To explore a phenomenon that corneal and conjunctival tissues subjected to desiccating stress promote Th17 differentiation by stimulated production of Th17 inducing cytokines through a dendritic cell (DC) mediated pathway.

Methods. Experimental dry eye was created by subjecting C57BL/6 mice to desiccating environmental stress. Corneal and conjunctival explants from dry eye or control mice were co-cultured with DCs for 24 hours, prior to adding CD4+ T cells for an additional 4 7 days. Expression of Th-17 associated genes in the cornea, conjunctiva, DCs and CD4+ T cells was evaluated by real-time PCR. Cytokine concentrations in co-culture supernatants were measured by Luminex immunobead assay. IL-17 producing T cells were identified by ELISPOT bioassay.

Results. Higher levels of IL-17A, TGF-beta1, -beta2, IL-6, IL-23 and IL-1beta mRNA transcripts and TGF-beta1, IL-6 and IL-1beta protein were observed in corneal epithelium and conjunctiva from dry eye mice. DCs co-cultured with the epithelial explants from dry eye mice for 2 days produced higher levels of TGF-beta1, IL-6, IL-23 and IL-1beta mRNA transcripts and TGF-beta1, IL-6 and IL-1beta protein. CD4+ T cells co-cultured with DCs and epithelial explants from dry eye mice, expressed increased levels of IL-17A, IL-17F, IL-22, CCL-20 and retinoic-acid-receptor-related orphan receptor-gammat (RORgammat) mRNA transcripts and increased IL-17A protein and number of IL-17-producing T cells (Th17 cells).

Conclusions. These findings demonstrate that desiccating stress creates an environment on the ocular surface that stimulates production of Th-17 inducing cytokines by corneal and conjunctival epithelia that promote Th17 differentiation through a dendritic cell mediated pathway.

Abstract: Lacrisert

Hydroxypropyl cellulose ophthalmic inserts (lacrisert) reduce the signs and symptoms of dry eye syndrome and improve patient quality of life.
Trans Am Ophthalmol Soc. 2009 Dec;107:214-21.
McDonald M, D'Aversa G, Perry HD, Wittpenn JR, Donnenfeld ED, Nelinson DS.

Ophthalmic Consultants of Long Island, Long Island, New York, USA.
PURPOSE: A multicenter, 2-visit, open-label, 4-week study was conducted to determine the acceptability of hydroxypropyl cellulose ophthalmic inserts in adult patients with a history of dry eye syndrome (DES).

METHODS: At visit 1, patients (N = 520) were evaluated, screened by slit-lamp biomicroscopy, and completed the Ocular Surface Disease Index (OSDI), a validated measure of quality of life. Patients were trained in the proper placement and use of hydroxypropyl cellulose ophthalmic inserts and were contacted by telephone on day 3 of the study. At week 4, patients were given a clinical evaluation and completed a second questionnaire. Answers determined changes in symptoms and quality of life. Adverse events were monitored throughout the study.

RESULTS: Four hundred eighteen patients completed the study and reported significant improvements in discomfort, burning, dryness, grittiness, stinging, and light sensitivity (P = .05) after 4 weeks use of hydroxypropyl cellulose ophthalmic inserts. Significant improvements in clinical signs (keratitis, conjunctival staining, and tear volume) were reported. Contact lens wearers reported significant improvements similar to nonwearers, with a strong trend toward improvement in light sensitivity. Mean OSDI total scores, measuring quality of life, significantly improved by 21.3% (from 41.8 +/- 22.38 to 32.9 +/- 21.97, P < or = .0215). The most commonly reported adverse event leading to discontinuation was blurred vision, observed in 8.7% of patients (n = 45). Compliance during the study was good; 41.5% of subjects were fully compliant. Of the 58.5% of subjects who missed doses, the majority (69.4%) missed only one to five.

CONCLUSIONS: Hydroxypropyl cellulose ophthalmic inserts significantly reduced symptoms and clinical signs of moderate to severe DES. They also significantly improved DES in patients wearing contact lenses. Patients experienced a statistically significant improvement in quality of life, as measured by the OSDI, of 21.3%.

Abstract: They get it

...In some degree, anyway. Doctors know that current dry eye treatments aren't necessarily cutting it. My only comment on this is to question whether these doctors are employing exclusively therapeutic pharmaceutical agents or are employing additional lifestyle modifications and consumer products to manage dry eye.

At the end of the day, what helps people most?

The drugs? (Restasis, steroids, azasite, doxy)

The drops & goop? (artificial tears, ointments, the few lubricants that actually work)

The gear? (moisture goggles, moisture chambers during day)

The lid treatments? (compresses, lid scrubs)

Dietary change?

Lifestyle change?

Bits and pieces of all of the above?

Ophthalmologist perceptions regarding treatment of moderate to severe dry eye: results of a physician survey.
Trans Am Ophthalmol Soc. 2009 Dec;107:205-10.
Asbell PA, Spiegel S.

Department of Ophthalmology, Mount Sinai School of Medicine, New York, New York, USA.
PURPOSE: To understand ophthalmologists' current perceptions and treatment of patients with moderate to severe dry eye syndrome (DED).

METHODS: An online survey was distributed to 7,882 ophthalmologists, including 51 corneal specialists, throughout the United States from October 9 to 21, 2008. The response rate was 3.1% (n = 245), typical for this type of survey. Those who treated 4 or more patients with moderate to severe DED per month (235 of 245 [96%]) were asked to complete the survey.

RESULTS: Ninety-four percent of respondents agreed that more treatment options are needed for moderate to severe DED. Corneal specialists were more likely to strongly agree (63%) than general ophthalmologists (54%). Only 33% overall felt that current therapies were extremely or very effective for moderate DED, and only 5% for severe disease. Ninety-two percent agreed that multiple therapeutic agents are needed to manage moderate to severe DED. The respondents reported prescribing, recommending, or suggesting a mean of 3.2 different treatment approaches over the course of a year for patients with moderate DED and 4.9 for patients with severe DED. The most highly ranked goals in treatment of moderate to severe DED were maintaining and protecting the ocular surface (ranked 1 or 2 by 74%) and lubricating and hydrating the ocular surface (ranked 1 or 2 by 67%). Corneal specialists ranked maintaining and protecting the ocular surface even higher (ranked 1 or 2 by 82%).

CONCLUSIONS: Results reflected the difficulty of treating more serious moderate to severe cases, the importance of using multiple treatment approaches, the limitations of current treatment options, and the need for additional treatment options.

Abstract: Blepharoplasty complications: blah blah blah DRY EYE blah blah blah


Dear oculoplastic surgeon:

I understand and accept that medical professionals and medical journals necessarily have their own special vernacular. It is with the greatest respect that I would like to gently encourage you to employ that vernacular in its proper context and exercise vigilence to prevent it from creeping into communications during clinic with evidently distressed ocular surface disease patients - such as your recent bleph patient whose lids through no fault of yours unfortunately ended up a bit on the short side. Such patients have quite a different vocabulary and may not understand yours.

Some post blepharoplasty dry eye syndrome patients experience extreme surface pain with resulting disruptions to certain incidental life activities, such as sleeping, working, reading and driving. These patients may or may not have dramatic ocular surface signs, but they have symptoms in spades. In such cases, employing phrases like "minor complication" could interfere with your ability to maintain an excellent (or perhaps any) relationship with this patient. Naturally, these patients understand that blindness is worse, but, strange to say, it may not be a comfort to them when you say so.

Trust me, I know. I'm the one they call when they get desperate and go scouring the internet for the help you are not offering them.

Speaking of which, if all you can do is tell them to use drops and ointments, please don't be offended when I ask what rock you are living under? There are a ton of excellent products out there to help these patients. It is astonishing to me how frequently I get calls from patients who in the very best case may have been hesitantly told that Saran Wrap might help if the Refresh PM didn't cut it on its own. If you don't have time to learn about products for night eye protection, does the corneal specialist in your practice? If not, give them a nudge. Something will help this patient - perhaps a Tranquileyes moisture goggle, a bandage contact lens for night use, a sleep mask, a skin-friendly tape, Dwelle, Genteal Gel, an Onyix shield, even a post LASIK style goggle - something will help.

A significant number of these patients will end up severely clinically depressed for the first time in their lives - all due to unremitting corneal pain poorly understood and inadequately addressed. Please, step in and prevent this escalation: do a little homework on what might help. You can't expect every company to show up on your doorstep with a solution to every problem. If you're new to this and don't know where to start, I'm here - call me.



Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show.
Plast Reconstr Surg. 2010 Feb;125(2):709-18.
Pacella SJ, Codner MA.
Division of Plastic Surgery, Scripps Clinic and Research Institute, and Paces Plastic Surgery, La Jolla, Calif, USA.

SUMMARY: Blepharoplasty remains one of the most popular operations in facial aesthetic surgery. Serious complications, which include blindness, retrobulbar hematoma, and ectropion, although relatively rare, are well reported in the literature. As techniques evolve in aesthetic eyelid surgery, minor complications continue to be very common. Nonetheless, management of these complications can be challenging and may require extended management or surgical revision. The authors discuss several of the most common minor complications, including hematoma, dry-eye syndrome, infections, atypical lesions, lid malposition, and scarring. In addition, preoperative assessment of risk factors, treatment, and management of these minor complications are presented.

Abstract: Dry eye and Omega 3 EFAs

Don't get excited. This is just one of those studies that studies other studies to let us know whether we know anything yet.

The answer seems to be that we know just about enough that you should keep taking your fish or flaxseed oil until we know enough to tell you whether it was worth it (that is, if you haven't noticed on your own).

Essential Fatty acids in the treatment of dry eye.
Ocul Surf. 2010 Jan;8(1):18-28.
Rosenberg ES, Asbell PA.

From the Department of Ophthalmology, Mount Sinai School of Medicine,New York, NY.
Essential fatty acids (EFAs) play many important roles in human biology, affecting organ systems and cellular and intracellular function. Omega-3 and omega-6 EFAs are the precursors of eicosanoids, locally acting hormones involved in mediating inflammatory processes. It is largely via the production of these eicosanoids that the essential fatty acids influence human health and disease. In general, the omega-3 derived eicosanoids are anti-inflammatory while the n-6 pathway eicosanoids promote inflammation. To date, EFAs have been primarily studied with regard to systemic diseases, particularly cardiovascular disease. Currently, no dietary recommendations of EFAs for the prevention or treatment of eye disease exist. The majority of studies concerning EFAs and eye disease have focused on diseases of the retina. This article provides an overview of the current literature regarding EFAs and dry eye disease (DED). Eight studies were identified, including six randomized controlled trials. All the studies preliminarily confirmed that there is a relationship between EFA supplementation and improvement in DED. However, strong conclusions cannot be made yet because of limitations in the research reported. The role of essential fatty acids is an important topic that would benefit from a large, multicenter, randomized clinical trial powered to reach a conclusion regarding the efficacy of essential fatty acids in the treatment of dry eye disease.

Abstract: What makes a Sjogrens dry eye different?

Rose bengal staining, according to this study!

Rose Bengal Staining of the Temporal Conjunctiva Differentiates Sjogren's Syndrome from Keratoconjunctivitis Sicca.
Invest Ophthalmol Vis Sci. 2010 Jan 27. [Epub ahead of print]
Caffery B, Simpson TL, Wang S, Bailey D, McComb J, Rutka J, Slomovic A, Bookman A.
School of Optometry, University of Waterloo, Waterloo, Canada.

Purpose: To compare the clinical presentation of 231 patients with primary Sjogren's syndrome (pSS) with 89 aqueous deficient dry eye patients (KCS), to determine those procedures that best differentiate these groups in the eye care clinic.

Methods: The records of all patients seen at the University Health Network Sjogren's Syndrome Clinic from October 1992 to July 2006 were reviewed and documented. Patients were diagnosed with pSS by the AECC criteria of 2002. KCS controls were non-SS patients with symptoms of dry eye and Schirmer scores of <= 10 mm in 5 minutes in at least one eye. There were 90 variables used in the analysis of the total database. Recursive partitioning was used to generate tree diagrams that demonstrate which characteristics best distinguished pSS from KCS.

Results: Recursive partitioning of the full database demonstrated that the serum immunoglobin Ro and the status of the salivary gland biopsy are most important in distinguishing pSS and KCS. The presence of rose bengal staining of the temporal conjunctiva was the most important noninvasive ocular variable to separate the groups. Total rose bengal staining also improved the sensitivity. Using non-invasive techniques only, staining of the temporal conjunctiva and severity of dry mouth symptoms proved to be the major factors in distinguishing pSS from KCS.

Conclusions: Rose bengal staining of the ocular surface is an important observation in the detection of SS and the differentiation of pSS and KCS.