Article

Guest Editorial

2017: An epic year for the ocular surface

I truly believe that that 2017 will be an epic year in the advancement of knowledge and treatment of ocular surface disorders and dry eye disease.

2017 is the year when the lingering “dry eye stigma” fades into oblivion, when DED/OSD/ DTS — whatever you want to call it — becomes sexy, fun and cool. The reason, in large part, is because of new treatments and procedures, particularly those for MGD and blepharitis, and high-tech objective diagnostic tools are on the market.

The full-court press is on to make sense of this disease, which is widespread, complicated to diagnose and difficult to manage. For those of you who are trying to absorb the avalanche of new information, have no fears. There are, and will continue to be, many sources to turn to, including ASCRS, the Tear Film and Ocular Society, the work of numerous researchers, and publications like this one.

LONG AWAITED, FINALLY HERE

The TFOS DEWS II report should be online very soon. Having served on a DEWS II subcommittee, I can tell you that my fellow participants, about 130 of us, worked long hours trying to get it all right. I referred to the first DEWS1 report, now 10 years old, as the “Bible of DED,” crediting it for stimulating my fascination in this field. I hope this new report does the same for other physicians.

And there is more new guidance. The Cornea, External Disease, and Refractive Society (CEDARS) in a new review article, offers new strategies for diagnosing and treating dysfunctional tear syndrome (DTS).2 Mark Milner, MD is the lead author; he has also written for this issue. (More on this issue’s articles, below.)

AND ASCRS TOO

When a subspecialty rapidly and seismically evolves and expands, as OSD/DED has, it can leave many practitioners feeling overwhelmed and excluded. Like other organizations, ASCRS wants to help narrow this widening educational gap. The ASCRS Cornea Clinical committee, on which I sit, is on track to publish its robust yet practical OSD/DED diagnostic and treatment algorithm. It’s a consensus-based interactive graphical protocol, incorporating all the available diagnostic tests and treatments, designed to guide the general practitioner through the increasingly complex decision tree for managing OSD/DED patients. Look out for it in JCRS later in 2017.

Just why ASCRS, a surgical society, is spearheading a major nonsurgical educational initiative, should be obvious. A HEALTHY ocular surface and tear film are vital to EXCELLENT surgical outcomes … period.

We agree. My research team will present study results at this year’s ASCRS and ARVO meetings in which we screened consecutive preoperative cataract surgery patients with a validated DED questionnaire, as well as tear osmolarity and MMP-9 testing.3

Our data — of 70 scheduled cataract patients, 81% had an abnormality on tear testing — shed more light on the strikingly high prevalence of OSD in this cataract surgical population. Even more striking, in our subset of patients with minimal to no OSD/DED symptoms (n=40), osmolarity was abnormal in 68%, MMP-9 abnormal in 88%, and both tests were abnormal in 55%.4

Because of this well-established disconnect between signs and symptoms of DED, I now perform point-of-care DED diagnostics on all of my patients undergoing premium cataract or refractive surgery regardless of symptomatology.

POINT OF CARE

In my practice, I have found point-of-care analytical tests to be indispensable in reducing the diagnostic confusion surrounding OSD by helping me to reliably rule in and rule out DED. My research team recently presented a study on the utility of normal osmolarity measurements in symptomatic patients.5 In 50 consecutive patients with symptoms suggestive of DED that prompted osmolarity testing, we found an alternate non-DED diagnosis to explain the symptoms in each case. The most common diagnoses included allergic conjunctivitis and anterior blepharitis (24%), epithelial basement membrane dystrophy (12%) and keratoneuralgia (12%).

Now, in addition to osmolarity, in symptomatic patients I also routinely test for the presence of tear MMP-9, providing a basket of diagnostic data that further refines the differential diagnosis and guides my treatment decisions. Although available for a few years now, 2017 seems to be the year that adoption of point-of-care diagnostic testing for OSD/DED finally goes mainstream.

IN THIS ISSUE

Alice Epitropolous, MD, reinforces the negative impact OSD can have on IOL selection and refractive outcomes. She provides strategies for identifying and reversing OSD in preoperative patients. She references the PHACO study that found 87% of patients scheduled for cataract surgery had DED and just a few had a prior DED diagnosis.6

Dr. Milner also has contributed to this issue, on the “co-conspirators” of DED, those pesky and all too common conditions that symptomatically masquerade as DED. I agree with Dr. Milner that these “co-conspirators” are in large part to blame for the traditional stigma surrounding DED. On the “co-conspiratorial” flip side, Kenneth Beckman, MD, another author of the CEDARS DTS paper, discusses DED masquerading as keratoconus, proving that ocular surface diagnostic conundrums can swing both ways.

It is shaping up to be a watershed year in the OSD/DED treatment pipeline. The FDA, roughly 13 years after approving cyclosporine, has approved lifitegrast, which has been making its first meaningful impressions on patients and doctors in 2017. In her article, Preeya Gupta, MD, discusses her initial impressions of lifitegrast and provides tips for integrating it into the practice.

In recent years, we have learned a great deal about the role of the corneal nerves in OSD/DED, keratoneuralgia, and neuropathic pain disorders. In this issue Perry Rosenthal, MD, Marguerite McDonald, MD, Herbert Kaufman, MD, and Lance Forstot, MD comprise a fascinating roundtable on this topic. And, speaking of nerves, 2017 may just be the year we’re introduced to a first-in-kind paradigm-shifting neuro-stimulation device for treating DED … only time will tell.

I often argue that the field of OSD/DED is so deep and sophisticated that it deserves to be a free-standing ophthalmic subspecialty like retina, glaucoma, pediatrics and cornea. In 2017, we are witnessing the proliferation of the Dry Eye Clinic. Laura Periman, MD discusses the all-important role of technicians and ancillary staff in the efficient day-to-day operations of these specialty DED-clinics.

I hope you get as much enjoyment from reading the articles in this issue as I did, and that your interest in and enthusiasm for managing OSD/DED patients grows in 2017 and beyond. OM

REFERENCES

  1. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf. 2007 Apr;5:75-92.
  2. Milner MS, Beckman KA, Luchs JI, et al. Dysfunctional tear syndrome: dry eye disease and associated tear film disorders - new strategies for diagnosis and treatment. Curr Opin Ophthalmol. 2017 Jan;27 Suppl 1:3-47.
  3. Drinkwater OJ, Brissette AR, Starr CE. Assessing the prevalence of abnormal tear testing in cataract surgery patients using two point-of-care diagnostic tests: a prospective observational study. Poster, ARVO Meeting, Baltimore, MD. May 2017.
  4. Brissette AR, Drinkwater OJ, Starr CE. The prevalence of abnormal tear testing in cataract surgery patients with minimal to no symptoms of ocular surface disease: a prospective observational study. Paper presentation, ASCRS Meeting, Los Angeles, CA. May 2017.
  5. Brissette AR, Bohm KJ, Starr CE. The utility of a normal tear osmolarity test in symptomatic patients. Poster presented at: The 8th International Conference on the Tear Film & Ocular Surface: Basic Science and Clinical Relevance; Montpellier, France. 2016 Sept 7-10.
  6. Trattler WB, Reilly CD, Goldberg DF et al, Cataract and Dry Eye: prospective health assessment of cataract patients’ ocular surface (PHACO). Poster, ASCRS, San Diego, CA, March 2011.