to-the-point
To The Point
Episode 4

Simple Steps for Diagnosing Dry Eye

You've committed to treating patients with dry eye, but in order to treat them, you have to diagnose them. In this episode, Leslie and Jackie talk about establishing a dry eye protocol, what equipment is necessary, testing, and more.

Leslie O’Dell (00:06): Ocular surface disease. It's complex, chronic, and progressive, but rife with opportunity for the enterprising optometrist.

Jackie Garlich (00:14): The mission of this podcast is to make this condition more understandable and accessible to those interested in specializing in it. So, let's get to the point.

Auto Message (00:25): The following discussion was recorded prior to the COVID-19 outbreak, which has led to wide-spread interruption of eyecare practices and patient care. Despite the immediate challenges facing optometry, the principles of expanding and optimizing your practice will become even more imperative.

Jackie Garlich (00:42): Welcome to another episode of To the Point podcast, a podcast dedicated to helping doctors that want to start and grow their dry eye practice. My name is Jackie Garlich, I'm an optometrist practicing in Boston, and I'm joined by my cohost: Leslie O’Dell (00:58):Leslie O’Dell, from York, Pennsylvania.

Jackie Garlich (01:01): So, today we're gonna focus on diagnosis of dry eye, which seems like an easy enough thing, but, let's say that you've committed, that you really want to... You know you want to grow your dry eye practice. For me, when I sort of really know that I wanted to do that, I also then feel like, "Okay, what equipment do I need to buy, I want to buy this, I want to buy a meibographer, I want to do this", but I got a really good piece of advice form Damen Dierker actually. I asked him, I said: "Okay, so, now that I'm like all the way in, I definitely want to, you know, commit to growing my dry eye practice, what is your recommendation? What do you think I should buy as my first piece of equipment", and you know what he said? Did I tell you this story?

Leslie O’Dell (01:47): No.

Jackie Garlich (01:48): He said, "You shouldn't buy anything", and I was like, "Oh", he's like, "You gotta figure out what your protocol is gonna be, how that would fit in your office, as you're talking more about it and treating more", like, "What does that look like in your office, and then you'll kind of see what you do need, or what you feel like would be a valuable thing", that was, like, a really good piece of advice.

Leslie O’Dell (02:08): Mm-hmm (affirmative)

Jackie Garlich (02:08): Because I was all like, "I need this, I need that, I need this", and honestly, I feel like that was really helpful, because then I... This was like at academy in Orlando. And then I went back to the office and sort of really thought about this, talked about- patients about thermotherapy, etc., and I really did kinda find like, "Oh, this is actually, I think, something that I would feel valuable, purchasing this piece of equipment".

Leslie O’Dell (02:29): Mm-hmm (affirmative)

Jackie Garlich (02:29): So, I think that's actually a really excellent piece of advice, is just, don't but anything first, just, like, figure out what you're doing, implement small, and then get bigger. You don't need all the equipment to begin treating dry eye, which I think is one of the thought processes I had in the beginning, I said, "I need to buy this because I don't have anything to really treat them with, other than drops or something".

Leslie O’Dell (02:50): Well, and all the new technology's fun and exciting, and yeah.

Jackie Garlich (02:51): It's cool, it looks awesome, like, "Your glands are totally atrophied, this is amazing", not really. But you know, it's like, really cool to see that. And I feel like it resonates well with patients, but you don't have to invest a ton of money in the beginning, you can sort of figure out how you're gonna tackle all of this.

Jackie Garlich (03:07): So, that's the point of this episode, is to talk about just the diagnosis, and how to kind of start there, and start with something simple, like implementing questionnaires. I'm hoping, Leslie, you can talk about TFOS, what that is. I think, historically, I felt that that's complicated, like, DEWS II, I'm like, "God, I don't really know what they're talking about with DEWS II", so let's like break that down to like make it an easy, sort of digestible thing.

Leslie O’Dell (03:35): Well, I mean, everybody seems to want to recreate the wheel, I feel like when I talk to people they're always saying, "I want to figure out what the protocol's going to be", and I understand what he's saying and agree 100% that you don't need to go all in and buy things to start, you want grow your practice first, invest in, you know, the patients, and then you'll have the money to spend on the technology that is going to make your job a little bit easier, but I do sometimes disagree with people trying to recreate their own protocol, much like you using your own dry eye survey, you know, why use your own dry eye survey if there are validated surveys that can be reproducible, and we know through research that they actually can help us understand if symptoms are improving, you know?

Jackie Garlich (04:19): Yeah, yeah.

Leslie O’Dell (04:20): So, you know, maybe don't make it so complicated.

Jackie Garlich (04:23): Exactly, yeah.

Leslie O’Dell (04:23): People sometimes will, people don't know who TFOS is; so TFOS is a nonprofit organization that's dedicated to dry eye disease, so they're, the Tear Film and Ocular Surface Society. I reached out to them, I mean, wow, probably when my passion for dry eye first started, which was, 2007 or 4, or something, probably around the time of the first report.

Leslie O’Dell (04:46): So, in my case, I was working in a surgical practice, I was treating a lot of post cataract dry eye, I was trying to learn as much as I could, and they were the best resource, because they were the house of all of the research, right?

Jackie Garlich (04:59): Mm-hmm (affirmative)

Leslie O’Dell (04:59): And so, their first report in 2007 brought together worldwide leaders, whether you were an ophthalmologist, an optometrist, a researcher, industry, somebody that maybe just had an interest in dry eye. I met the woman that has the dry eye website, Rebecca Petris. So, you know, it's everybody that's got an interest in dry eye.

Leslie O’Dell (05:22): And so that has grown over the past 10 years, so now in 2017 they released the dry eye workshop part two, TFOS DEWS II.

Jackie Garlich (05:30): Mm-hmm (affirmative)

Leslie O’Dell (05:30): Which you have heard of.

Jackie Garlich (05:31): Yes, mm-hmm (affirmative).

Leslie O’Dell (05:33): You know, and a lot of times people say, "Oh, this is so overwhelming". But anyway, what that did was condense 10 more years of research, I think it was like 20,000 papers that they had to take, figure out what was important, and then find a way to streamline it so that you and I can use it in private practice or wherever we work. You know, in an academic setting, wherever.

Jackie Garlich (05:52): Yeah.

Leslie O’Dell (05:52): Condense it.

Jackie Garlich (05:52): Yeah.

Leslie O’Dell (05:53): But then I... You know, but that document is a little bit overwhelming, but I still would say if you're interested in dry eye, that's your thing, I would read it, I mean-

Jackie Garlich (06:00): Yeah.

Leslie O’Dell (06:01): -even if it is 400 and some pages, it's worth it, I mean, you- if you want to get into nitty-gritty details, I mean, even when you're talking about thermal treatments, where I started there was the meibomian gland workshop that TFOS put out. And yes, you know, some of it might be a little bit too scientific for you or me, but if you want to really understand how the meibomian glands perform, that is like the, you know, the encyclopedia of that, yep.

Jackie Garlich (06:25): Yeah.

Leslie O’Dell (06:26): So, I mean, what a great resource. But what they did really well is make an executive summary, which is downloadable, TFOS.org.

Jackie Garlich (06:33): No, no.

Leslie O’Dell (06:34): or TearFilm.org?

Jackie Garlich (06:35): Yeah, yeah.

Leslie O’Dell (06:35): Yep, TearFilm.org, sorry.

Jackie Garlich (06:35): Mm-hmm (affirmative)

Leslie O’Dell (06:37): And they have an app on your phone, so if you're just looking for like, something quick, you can look there as well.

Jackie Garlich (06:43): And so, for that actual, that summary, you can find that, we just pulled it up here, it's TearFilm.org, and then you go to Reports.

Leslie O’Dell (06:50): Okay.

Jackie Garlich (06:51): And then that's where it is.

Leslie O’Dell (06:51): Yeah.

Leslie O’Dell (06:52): And, so, now, this one is a little bit longer, this one might be like a few pages, but they have a two-sided one that you could have.

Jackie Garlich (07:00): Okay.

Leslie O’Dell (07:00): You know, sometimes it's nice to have that.

Leslie O’Dell (07:01): But anyway, the gist of this is you actually don't really need any high science to make the diagnosis of dry eye.

Jackie Garlich (07:09): Right.

Leslie O’Dell (07:09): So, if you look at their rep... um, if you look at their treatment algorithm, the staging of the disease, figuring out if you really, truly, have dry eye.

Leslie O’Dell (07:17): One thing is, what you're already doing, assessing risks, right?

Jackie Garlich (07:20): Mm-hmm (affirmative)

Leslie O’Dell (07:20): So... Now, that might be on your history form that you have for patients, like, "Are they smokers?", "What kind of medicines are they taking?", "What's their age and gender",

Jackie Garlich (07:27): Mm-hmm (affirmative)

Leslie O’Dell (07:28): "Are they a contact lens wearer", I mean, you know the risk, and we might need to talk about risk factors, but the risk factors, you know, for dry eye, digital device use,

Jackie Garlich (07:37): Right.

Leslie O’Dell (07:37): You know, throwing in things now like, how much preservative are they getting exposed to, whether it's through glaucoma medications, or facial products that they might be using with, cosmetics and things like that.

Jackie Garlich (07:48): Mm-hmm (affirmative), yeah.

Leslie O’Dell (07:48):But then, to make a diagnosis of dry eye, you only need two things. Only two.

Jackie Garlich (07:53): Lay it on me.

Leslie O’Dell (07:54): Doesn't sound hard, right?

Jackie Garlich (07:55): (laughing)

Leslie O’Dell (07:55): No. So, one is a questionnaire, you need to have symptoms.

Jackie Garlich (07:59): Mm-hmm (affirmative)

Leslie O’Dell (08:00): And it's recommended that you use, actually, TFOS DEWS II recommends either the dry eye questionnaire five.

Jackie Garlich (08:07): Mm-hmm (affirmative) DEQ-5.

Leslie O’Dell (08:07): DEQ-5, yep.

Jackie Garlich (08:08): Mm-hmm (affirmative).

Leslie O’Dell (08:08): Or the OSDI.

Jackie Garlich (08:10): Mm-hmm (affirmative)

Leslie O’Dell (08:11): So, the Ocular Surface Disease Index. It talks about SPEED, and we've talked about SPEED, and,-

Jackie Garlich (08:17): Right.

Leslie O’Dell (08:17): You know, still, it is a validated questionnaire, and so even though it might not be in their highlight box, I still know, you know, a lot of doctors and myself use SPEED.

Jackie Garlich (08:26): SPEED, yeah.

Leslie O’Dell (08:26): So, but the key of all of those are their validated questionnaires, which means they're repeatable, which is important.

Jackie Garlich (08:33): Yeah, yeah.

Jackie Garlich (08:35): Okay, all right, so, questionnaire, what's the second thing?

Leslie O’Dell (08:38): So, the second thing is just your fluorescein and lissamine green.

Leslie O’Dell (08:42): So, one thing you might not have is lissamine green, so-

Jackie Garlich (08:45): Mm-hmm (affirmative)

Leslie O’Dell (08:46): -the first buy, I would say, is lissamine green strips.

Jackie Garlich (08:49): Yeah.

Leslie O’Dell (08:49): Do you have them yet in?

Jackie Garlich (08:51): I do, yeah, so perfect.

Leslie O’Dell (08:52): Mm-hmm (affirmative), yeah.

Leslie O’Dell (08:52): So you already have all you need.

Jackie Garlich (08:53): Yeah, appar... I'm set.

Leslie O’Dell (08:54): (laughing) You're set.

Jackie Garlich (08:55): (laughing)

Leslie O’Dell (08:56): What you need from your fluorescein and lissamine green strips is just a positive staining on the cornea or conjunctiva, so, not even an and, cornea or conjunctiva.

Jackie Garlich (09:06): Yeah.

Leslie O’Dell (09:07): So you don't need corneal staining to find dry eye.

Jackie Garlich (09:09): Right.

Leslie O’Dell (09:09): Which I think a lot of times people are waiting for that.

Jackie Garlich (09:12): Oh, yeah, yeah.

Leslie O’Dell (09:13): But, you know, that is way downstream-

Jackie Garlich (09:15): Mm-hmm (affirmative)

Leslie O’Dell (09:16): -in the whole inflammatory process, so if you're treating based on corneal keratitis you want to move the needle up, right?

Jackie Garlich (09:22): Yeah.

Leslie O’Dell (09:22): So, like, I think we might have talked about that before, it's like treating the patient with a 0.7 cup, 0.8 cup, you know, you rather would start that glaucoma patient when their 0.5, right?

Jackie Garlich (09:32): Right.

Leslie O’Dell (09:32): Now, to get a little bit... So, what you need is positive staining-

Jackie Garlich (09:38): Mm-hmm (affirmative)

Leslie O’Dell (09:38): -or, same thing from your fluorescein, you can do a tear breakup time, so you need that tear breakup time to be less than 10.

Leslie O’Dell (09:44): The third thing...

Jackie Garlich (09:45): Which I feel like it's everyone.

Leslie O’Dell (09:46): Right. Yeah.

Leslie O’Dell (09:46): I know, I mean, and once you start looking, it is for everyone.

Jackie Garlich (09:47): I mean, everyone, yeah.

Leslie O’Dell (09:50): Especially your population of-

Jackie Garlich (09:52): Oh yeah.

Leslie O’Dell (09:53): Of patients, you are working with everybody who is working, right?

Jackie Garlich (09:56): Yes.

Leslie O’Dell (09:56): Digital device, heavy use,-

Jackie Garlich (09:57): Yeah.

Leslie O’Dell (09:57): That kind of thing.

Leslie O’Dell (09:58): The last test, that they include in the diagnosis, but remember it's an "Or", so you only need to have symptoms-

Jackie Garlich (10:04): Mm-hmm (affirmative)

Leslie O’Dell (10:05): And one of these tests is tear film osmolarity, which we talked about with the point-of-care testing. But you don't need that to get started necessarily, you can start building your practice, and finding your dry eye patients with your fluorescein and lissamine green, which most practices already have.

Jackie Garlich (10:21): Yeah. So, a word... You use SPEED, right? The questionnaire, SPEED.

Leslie O’Dell (10:24): Mm-hmm (affirmative).

Jackie Garlich (10:24): So, what is your... what are your cutoffs for SPEED, because I feel like that's a...

Leslie O’Dell (10:29): Yeah, so, this is sometimes the tricky part about SPEED.

Jackie Garlich (10:31): Mm-hmm (affirmative)

Leslie O’Dell (10:31): You know, I've actually talked to Don Korb who's behind that questionnaire-

Jackie Garlich (10:36): Mm-hmm (affirmative)

Leslie O’Dell (10:36): -and he felt if the patient was answering more than one, that you should be looking for dry eye and meibomian gland disfunction.

Leslie O’Dell (10:44): Um, I've heard six, I've heard eight ...

Jackie Garlich (10:46): I saw a scale that was, I think, five to seven was moderate.

Leslie O’Dell (10:51): Mild.

Leslie O’Dell (10:51): Oh, oh, moderate?

Jackie Garlich (10:52): I think it was zero to four was mild.

Leslie O’Dell (10:54): Okay.

Jackie Garlich (10:55): Five to seven moderate, and then eight or more is severe.

Leslie O’Dell (10:59): Yeah, and that, you know, kind of goes back to what I was saying with Dr. Korb.

Jackie Garlich (11:02): Yeah.

Leslie O’Dell (11:03): So that, you know, that's important.

Jackie Garlich (11:04): And the OSDI, that has, the second page of the OSDI actually has your scoring information on it.

Leslie O’Dell (11:11): Yeah, I mean, and so, sometimes it's a little bit daunting, but there is an app, I think, that you can use for that as well now that calculates it for you, so you don't have to spend the time, or you don't have to teach your tech how to do that-

Jackie Garlich (11:19): Yeah.

Leslie O’Dell (11:20): -and make sure that it's calculated the right way. And it's pretty easy to use if you have an iPad in your office you can just implement that, and, yeah.

Jackie Garlich (11:26): Yeah.

Jackie Garlich (11:26): So, during your comprehensive exam, you’re, let's say... Now, can you remind me, do you do a questionnaire on all of your patients? Or just...

Leslie O’Dell (11:36): Well, I'm doing it for all my dry eye patients, and so that's where the transition to the dry eye exam, you know, that might be more of where the complications are, like, identifying the patient during another type of an exam, and having them return.

Jackie Garlich (11:50): Right.

Leslie O’Dell (11:51): And some practices do screen all their patients. We use a questionnaire at the time of the dry eye evaluation and any dry eye follow-up.

Jackie Garlich (11:59): Yeah. I think that’s useful, to like, have your baseline, and to see for yourself and for your patient,-

Leslie O’Dell (12:04): Yeah.

Jackie Garlich (12:04): Like how the improvements are happening.

Leslie O’Dell (12:05): Oh, for sure.

Jackie Garlich (12:06): Alright, so you're seeing them for their comprehensive, you're having them back.

Jackie Garlich (12:12): Let's say that you discover something, they have a symptom, or you see something in your exam of which you're doing fluorescein-

Leslie O’Dell (12:18): Mm-hmm (affirmative)

Jackie Garlich (12:18): -staining on every comprehensive exam, right? So you'll pick up whatever. And then you'll have them back, and do what else? On your... that's when you're doing, you're implementing the SPEED.

Leslie O’Dell (12:28): Right, so that's where... So, those two things I'm telling you, symptoms and signs.

Jackie Garlich (12:32): Mm-hmm (affirmative)

Leslie O’Dell (12:32): That tells you, "Okay, I'm least I'm dealing with dry eye disease and not something else".

Jackie Garlich (12:37): Okay.

Leslie O’Dell (12:37): Like, maybe contact lens intolerance, that's not really lead to dry eye disease, maybe map that dystrophy,-

Jackie Garlich (12:43): Mm-hmm (affirmative)

Leslie O’Dell (12:44): -maybe, you know, over a current erosion or some- you know, something else like that.

Leslie O’Dell (12:48): So now you know that you're dealing with dry eye, but remember that we have, you know, aqueous deficient dry eye, and we have evaporative dry eye.

Jackie Garlich (12:55): Mm-hmm (affirmative)

Leslie O’Dell (12:55): And so that's where the technologies that we have really start to step in and help us to sub-type.

Leslie O’Dell (13:01): So that's where, you know, meibography and, well, not so much nonevasive tear breakup time, because that's still part of the diagnosis, but the imaging that we have, measuring things like tear meniscus height, that really can help us be accurate.

Jackie Garlich (13:16): Yeah. But that's something you can do in your slit lamp, like, you don't need technology to measure-

Leslie O’Dell (13:20): Exactly.

Jackie Garlich (13:20): -tear meniscus height.

Leslie O’Dell (13:20): Right.

Jackie Garlich (13:22): So, how exactly do you do that?

Leslie O’Dell (13:26): Well, I mean, you can do that with your slit lamp beam.

Jackie Garlich (13:27): Yeah, just like your beam, yeah.

Leslie O’Dell (13:29): And so you're looking at 2 mm, okay? So, 2 mm would be considered mild, 0.22 mm, sorry; and 0.1 mm would be considered moderate; and then zero, like, you're not seeing anything in a tear lake that would be considered severe.

Leslie O’Dell (13:45): So, you can start to look at that...

Jackie Garlich (13:48): And your tear lakes, sorry to interrupt, your tear lake is talking about your aqueous deficient patients, right? Okay.

Leslie O’Dell (13:53): Right. And so that helps you to subtype into that aqueous deficient. You can still lean on things like a Schirmer, which not many of us are doing, but maybe as you're starting to kinda eyeball this tear meniscus height, you want to check yourself with a Schirmer every once in a while, to see like, "Okay, do I really see nothing?".

Jackie Garlich (14:08): Mm-hmm (affirmative)

Leslie O’Dell (14:08): And then-

Jackie Garlich (14:08): Right.

Leslie O’Dell (14:09): -see what the Schirmer compares. I mean, just a thought in the early, you know, early time of doing it.

Jackie Garlich (14:14): Yeah, yeah.

Leslie O’Dell (14:14): Same is true with the evaporative side; how do you determine the evaporative side is you want to figure out what the glands are doing.

Jackie Garlich (14:21): Right.

Leslie O’Dell (14:21): And so... Remember that when you're looking at the glands it's structure function, so, you were saying we can do that with, you know, we were talking about transillumination ...

Leslie O’Dell (14:30): So, I don't... I like to have meibography.

Jackie Garlich (14:33): Right.

Leslie O’Dell (14:33): When I have meibography I can teach the patient what I'm seeing.

Jackie Garlich (14:37): Yes.

Leslie O’Dell (14:37): But I started with some... I actually started and there was no meibography.

Jackie Garlich (14:41): (laughing)

Leslie O’Dell (14:41): Not to make me sound like a dinosaur, but...

Jackie Garlich (14:44): (laughing)

Leslie O’Dell (14:44): So, I had to grow up without technology-

Jackie Garlich (14:46): How old are you Leslie? (laughing)

Leslie O’Dell (14:47): -and that's probably how I learned without, you know, things, and grow into them.

Jackie Garlich (14:51): Yeah, yeah.

Leslie O’Dell (14:51): So it's kind of funny to think about it.

Jackie Garlich (14:52): Yeah.

Leslie O’Dell (14:52): I mean, much like glaucoma, we didn't always have-

Jackie Garlich (14:55): Yeah.

Leslie O’Dell (14:55): -the OCT technologies that we have right now, that's looking at ganglion cell loss and, you know, I actually, in my residency, Dr. Tony Litwak taught us how to use the red green filter and stare at the nerve and measure nerve ending loss.

Leslie O’Dell (15:09): Like, which is basically what the OCT and HRT technologies started to do.

Jackie Garlich (15:14): Yeah.

Leslie O’Dell (15:14): But we... That's what we were doing.

Jackie Garlich (15:16): Yeah.

Leslie O’Dell (15:17): I mean, so, it is...

Jackie Garlich (15:18): No, but that makes you a better doctor, [crosstalk 00:15:20] relying too much on instrumentation, absolutely.

Leslie O’Dell (15:22): Do you want to rely too much, but, -

Jackie Garlich (15:23): Yeah.

Leslie O’Dell (15:23): In the case of meibography, it's nice because now you can tell the patient instead of saying, "This is what I'm seeing".

Jackie Garlich (15:28): Yeah.

Leslie O’Dell (15:29): And, like, having to describe it. You can show them, and, to them, that's a powerful message, so-

Jackie Garlich (15:33): Yeah.

Leslie O’Dell (15:33): -I do think that that's not first line type of buy, but something that would be; when I have that little bit of money to invest, one of the first things that I would want.

Jackie Garlich (15:44): For sure.

Leslie O’Dell (15:44): Right.

Leslie O’Dell (15:44): But so, anyway, getting back to that, when we started using thermal treatments, our first... The only treatment that was available was, 2012, was thermal pulsation with LipiFlow. We had the LipiView version 1, which only measured lipid layer thickness and partial blinks, okay?

Jackie Garlich (16:00): Okay.

Leslie O’Dell (16:00): So, we didn't even have meibography, and actually, our practice was one of the first ones to have meibography to kind of experiment with, it was on two different machines, so, you know,-

Jackie Garlich (16:10): Wow.

Leslie O’Dell (16:10): -we're talking about small footprint, not taking up too much room, it wasn't like that back then.

Jackie Garlich (16:14): Mm-hmm (affirmative)

Leslie O’Dell (16:14): But what I did before that was I just used my transilluminator, and honestly, until I was trained properly, I was doing it outside of the slit lamp, so I would use my finger with the transilluminator under the lid margin in a dark room, and I would look for, like, shadows of the glands.

Leslie O’Dell (16:30): So, when you do that, the whole entire lid kind of glows orange, but you're looking for the dark shadows that are the lines of the meibomian glands-

Jackie Garlich (16:38): Mm-hmm (affirmative)

Leslie O’Dell (16:38): -so they'll look like dark lines.

Leslie O’Dell (16:40): But then some genius just came into my office to train me on how to properly diagnose meibomian gland dysfunction, and...

Jackie Garlich (16:49): Do you want to give a shout-out to that genius?

Leslie O’Dell (16:51): Yes! Dr. Sam Kim.

Jackie Garlich (16:51): Oh, okay. (laughing)

Leslie O’Dell (16:52): I haven't seen him in a long time, but... (laughing)

Jackie Garlich (16:53): (laughing) Okay.

Leslie O’Dell (16:55): But, he sat me down at the slit lamp and said, like: "Do that here", and so now I do it at the slit lamp, which, you know, was kind of like, "Why didn't I do that before?", I can have magnification and see so much better.

Jackie Garlich (17:04): Yeah, right.

Leslie O’Dell (17:05): So, you just kind of bend the lid over the light. Now, I can do it all with one hand, but I can tell you that it's a little bit awkward, and-

Jackie Garlich (17:14): Mm-hmm (affirmative)

Leslie O’Dell (17:14): -it takes some practice, so, just getting in the routine of doing it, and making sure you're doing it with your nondominant hand as well, it's not painful to the patient, I mean, it's over and done within a couple seconds, really what you're looking to see is like, "Okay, are there glands present or not", that's how I kind of think about that.

Jackie Garlich (17:29): Yeah.

Jackie Garlich (17:30): So, um, you're like, everting the lower lid-

Leslie O’Dell (17:34): Yep, over top of them. [crosstalk 00:17:34]

Jackie Garlich (17:34): -to [crosstalk 00:17:34] let's say you're looking at their left eye, okay, so you have this transilluminator in your right hand, you're putting that up to the lower lid, and somehow pulling?

Leslie O’Dell (17:44): Like, right underneath the lashes.

Jackie Garlich (17:44): Mm-hmm (affirmative)

Leslie O’Dell (17:44): And, so, right underneath the lashes,-

Jackie Garlich (17:45): Yes.

Leslie O’Dell (17:45): And it kind of will bend the tarsal plate overtop of them.

Jackie Garlich (17:50): Oh, okay, all right.

Leslie O’Dell (17:51): Yep.

Jackie Garlich (17:51): All right.

Jackie Garlich (17:52): So then you're looking...

Leslie O’Dell (17:53): So like, kind of an inverted eversion, you know, if you think about how you could do, like, flip the lid on the top,-

Jackie Garlich (17:59): Yeah, yeah (laughing).

Leslie O’Dell (17:59): -it's sort of- you're using the transilluminator instead of a cotton [crosstalk 00:18:03]

Jackie Garlich (18:03): Yeah, got it, okay.

Leslie O’Dell (18:04): Yep.

Jackie Garlich (18:04): And then, so, for that, you are, you know, documenting severe loss? Like, are you more specific about it?

Leslie O’Dell (18:10): I might just be very general. Like, so, in a case like you, I would just chart, you know, atrophy. It's gonna be hard for you to grade that atrophy.

Jackie Garlich (18:19): Mm-hmm (affirmative)

Leslie O’Dell (18:19): So you could just say, like plus or minus atrophy for now.

Leslie O’Dell (18:23): Once you start getting to the point where you have meibography in your practice, that is a whole other beast.

Jackie Garlich (18:29): Yeah, yeah. Yeah.

Leslie O’Dell (18:30): Um, and that requires a lot of education that we're working on, actually, some research that I've been able to do over the past years, looking at, you know, inner observer grading of meibography, and how we need a training. We actually, even experts need training.

Leslie O’Dell (18:46): So, I'm working alongside some doctors to try to develop that tool so you're not just grading atrophy, we also look at bending of the glands, tortuosity.

Jackie Garlich (18:55): Oh, okay.

Leslie O’Dell (18:57): And we're also looking at, like, segmentation, or like, splitting of the glands.

Leslie O’Dell (19:00): So there's a lot, I think, that meibography is going to give us.

Jackie Garlich (19:04): Yeah.

Leslie O’Dell (19:04): And it's growing. But, so that's just your structure, so, again, yes you can do that without any technology. The next thing though, is you want to see the function, right?

Jackie Garlich (19:13): Mm-hmm (affirmative)

Leslie O’Dell (19:14): Ideally, you want to have a standard pressure, because you're gonna push against the lid different than I'm gonna push against the lid, and that doesn't tell you anything about what your patient's doing in a normal day when they're blinking their eyes.

Jackie Garlich (19:26): Mm-hmm (affirmative)

Leslie O’Dell (19:26): Right? So, there is one tool that I would probably encourage you to look at, which is called "Meibomian gland evaluator".

Jackie Garlich (19:34): Mm-hmm (affirmative)

Leslie O’Dell (19:34): And that is a... It is looking at the... you kind of section the bottom lid into-

Jackie Garlich (19:40): Three.

Leslie O’Dell (19:40): -three sections,-

Jackie Garlich (19:41): Mm-hmm (affirmative)

Leslie O’Dell (19:42): -and you're looking at about five glands each time you're pressing, so you're grading 15 glands, and then you're looking at what kind of secretion is coming out. Is it clear oil?

Jackie Garlich (19:50): Mm-hmm (affirmative)

Leslie O’Dell (19:51): Is it turbid oil? Is it really thick oil? Or is nothing?

Jackie Garlich (19:56): Nothing.

Leslie O’Dell (19:56): Yeah.

Jackie Garlich (19:56): Mm-hmm (affirmative)

Leslie O’Dell (19:57): And so you kind of... What I do is called meibomian, I call it MGYLS in my chart, MGYLS; "Meibomian glands yielding liquid secretion", and then I just give myself account.

Jackie Garlich (20:12): Is that your thing? Or - [crosstalk 00:20:13]

Leslie O’Dell (20:13): No, no, that's Dr. Korb.

Jackie Garlich (20:14): Oh, okay.

Leslie O’Dell (20:14): Yeah, that's Dr. Korb. Definitely I am not the meibomian queen. He is the meibomian master.

Jackie Garlich (20:18): (laughing).

Leslie O’Dell (20:19): So Dr. Korb's grading scale, that's one of them.

Leslie O’Dell (20:23): So, then you would maybe section in your chart, like, nasal two, central one, temporal none or, you know, zero. And the you would use that too when you're going back after treatments to see, "Okay, am I triggering any more of these glands to becoming clear secretions".

Jackie Garlich (20:40): Yeah. Okay.

Leslie O’Dell (20:40): So, in that case, you know, you're... That helps you stage your evaporative side mild, moderate, to severe as well.

Jackie Garlich (20:47): Mm-hmm (affirmative), okay.

Jackie Garlich (20:48): If we back up on the transilluminator thing.

Leslie O’Dell (20:50): Yeah.

Jackie Garlich (20:51): So, because I recently had meibography done on myself, and I knew that I had...

Leslie O’Dell (20:57): Eye doctors are the worst patients.

Jackie Garlich (20:58): Oh, I knew that I had dry eye, but when I actually saw the images I was like: "Oh my gosh, this is really a lot worse than I thought".

Leslie O’Dell (21:06): Yeah, yeah.

Jackie Garlich (21:07): And so that experience taught me that the images really speak a lot,-

Leslie O’Dell (21:12): Yeah.

Jackie Garlich (21:13): -especially for like, patient [inaudible 00:21:14], especially if you're gonna be talking about LipiFlow or some other sort of treatment. Is there, and I know I asked you about his before, but have you ever tried to photograph your transilluminator findings in the slit lamp?

Leslie O’Dell (21:27): Yeah, and you probably would be better at this.

Jackie Garlich (21:28): I... (laughing)

Leslie O’Dell (21:29): You're more tech-savvy than I am.

Jackie Garlich (21:29): Well, no, but I do have a camera on my slit lamp-

Leslie O’Dell (21:32): Oh yeah.

Jackie Garlich (21:32): -and so, this made me think like, "Oh, I wonder if I could actually photograph this", I mean, it's not as beautiful as, like, what it is in the other machines.

Leslie O’Dell (21:37): Yeah, you just have to play around with the ...

Jackie Garlich (21:40): Just a thought.

Leslie O’Dell (21:40): I have tried, I have taken some photos, you have to play around with the- how bright you have your-

Leslie O’Dell (21:44): -transilluminator, so you maybe-

Jackie Garlich (21:46): Oh, oh, yeah, okay.

Leslie O’Dell (21:46): -don't want to have it at its full setting.

Jackie Garlich (21:48): Mm-hmm (affirmative)

Leslie O’Dell (21:48): So, you might want to turn it down, you have to turn it down a little bit. You wouldn't have your slit lamp on, as far as that light goes. And then, you know, is that gonna be hard to get a good photo? I mean, if you have a slit lamp camera, I think you'd get it.

Jackie Garlich (22:00): Maybe.

Jackie Garlich (22:01): I'm gonna try it and then I'll let you know.

Leslie O’Dell (22:02): Yeah, let us know.

Jackie Garlich (22:02): Yeah. (laughing)

Leslie O’Dell (22:04): But there are pictures, I mean, actually

Jackie Garlich (22:05): Yeah.

Leslie O’Dell (22:06): I think Drs. Korb and Caroline Blackie have some research that actually talks about transillumination, and they have some decent photos that they've taken, so it's doable.

Jackie Garlich (22:14): Yeah.

Leslie O’Dell (22:15): Yeah.

Jackie Garlich (22:15): Okay.

Leslie O’Dell (22:15): It still would be hard to use that as a patient education piece, I think.

Jackie Garlich (22:19): You think so? Yeah.

Leslie O’Dell (22:19): Mm-hmm (affirmative)

Jackie Garlich (22:19): Okay.

Leslie O’Dell (22:19): Yeah.

Jackie Garlich (22:20): Yeah.

Jackie Garlich (22:22): All right, so, where did we leave off?

Leslie O’Dell (22:24): So, when you talk to the patients, if you don't have meibography, you would have maybe three images; mild, moderate, severe. And you would say, "This is what I'm seeing, here's where you fall on the scale".

Jackie Garlich (22:35): Mm-hmm (affirmative)

Leslie O’Dell (22:35): You know, until you could move into the part of getting that technology.

Jackie Garlich (22:39): Yeah.

Leslie O’Dell (22:39): Yep.

Leslie O’Dell (22:40): So then, I think that a lot of times too, maybe what we do wrong, and again, I didn't know this, I learned as I went for a long time. (laughing)

Jackie Garlich (22:48): (laughing)

Leslie O’Dell (22:48): Was how to properly stain the patient, so fluorescein is not going to be giving you... fluores rather, is not gonna be giving you your best, you know.

Jackie Garlich (22:59): Right.

Leslie O’Dell (23:00): Right, and then I'd even be creating other problems, right? Because of the anesthetic and things like that.

Jackie Garlich (23:05): Yeah.

Leslie O’Dell (23:05): So, you want to be using the strips.

Jackie Garlich (23:10): Yes.

Leslie O’Dell (23:10): Lissamine and fluorescein.

Jackie Garlich (23:13): Yeah.

Leslie O’Dell (23:13): You want to use an artificial tear to moisten the top, maybe put one drop on each of the top of you strip, and then, actually Dr. McGee has recommended to... she read this somewhere I'm sure, but, Dr. Selina McGee says like, "Wait actually a couple seconds, maybe 30 seconds of that drop saturating your strip before you even go to the eye".

Jackie Garlich (23:38): Oh really, okay.

Leslie O’Dell (23:39): So... Yep. So I usually do that over in my trash can in my office.

Jackie Garlich (23:42): Mm-hmm (affirmative)

Leslie O’Dell (23:42): You know, I put one drop on there and kind of, I'm talking to the patient about something while I'm just waiting for that to saturate. And then you want to... Now she does it simultaneously, she'll put the fluorescein and the lissamine in at the same time.

Jackie Garlich (23:56): Mm-hmm (affirmative)

Leslie O’Dell (23:57): You can do it one at a time, but you can put them in at the same time.

Jackie Garlich (24:00): Mm-hmm (affirmative)

Leslie O’Dell (24:02): And that's okay.

Jackie Garlich (24:03): Yeah.

Leslie O’Dell (24:03): Or you can just do your fluorescein first and then come back and do your lissamine,-

Jackie Garlich (24:05): Mm-hmm (affirmative)

Leslie O’Dell (24:05): -you know, whatever's gonna be comfortable. I'm sure it's- you know, a time saver, right? If you do them together?

Jackie Garlich (24:11): Yeah.

Leslie O’Dell (24:12): So, you do have to look right away because you want to grade your breakup time, right?

Jackie Garlich (24:16): Mm-hmm (affirmative)

Leslie O’Dell (24:16): You need to look right away for breakup time.

Jackie Garlich (24:18): Mm-hmm (affirmative)

Leslie O’Dell (24:19): So, you would immediately put the patient at the slit lamp to look at that, you know, and have them blink three times is what I usually say, and then I have then stare. And I'm kind of counting in my head.

Jackie Garlich (24:28): Mm-hmm (affirmative)

Leslie O’Dell (24:29): Unless I'm doing some kind of research where I have a stopwatch, I'm not usually doing that in day to day.

Jackie Garlich (24:33): Mm-hmm (affirmative)

Leslie O’Dell (24:34): So, I'm usually like, "One one thousand, two one thousand", I mean, honestly, it's rare that I'm getting about five.

Jackie Garlich (24:38): Yeah.

Leslie O’Dell (24:38): (laughing)

Leslie O’Dell (24:39): And that sounds like-

Jackie Garlich (24:39): Yeah, yeah.

Jackie Garlich (24:40): Same with me too, yes.

Leslie O’Dell (24:41): So then, while you're doing that, you really want to give that dye about 90 seconds on the surface of the eye, and this is where I think sometimes people don't do it. If you actually load the eye with that dye and look right away, the cornea almost will look beautiful, right?

Jackie Garlich (24:55): Yes it does, I found that also, likely it's staining.

Leslie O’Dell (24:57): Yeah.

Jackie Garlich (24:57): Yeah.

Leslie O’Dell (24:57): So you have to kind of just, again, maybe have more of a conversation with your patient and then go back and look at... yeah.

Jackie Garlich (25:02): Yeah, that's what I do, yeah.

Leslie O’Dell (25:03): And then don't forget to lift up the lid and lower the bottom lid, especially with your lissamine stain to look for that band of staining with the lid wiper epitheliopathy that you'll find under, kind of hiding, underneath the lid.

Jackie Garlich (25:16): Yeah. So, I don't remember actually... When did that lid wiper epitheli- that was like relatively new-

Leslie O’Dell (25:23): I know, yeah.

Jackie Garlich (25:24): -where that came out, because I don't remember learning about that I school, and I remember reading a paper, thinking like, "What is this LWE they're talking about?", like, I don't-

Leslie O’Dell (25:31): I know!

Jackie Garlich (25:31): -even know what this is. But that is what it is, it's... Which makes sense, okay? It's like this area of stain, like, if you pull down, as you said, on the lower lid. It's like closer to the globe, so it's like right on the eyeball, you know, and you'll see this sort of fluorescein just kind of have this line of fluorescein on there.

Leslie O’Dell (25:49): Yeah.

Jackie Garlich (25:49): And, you can correct me if I'm wrong, but, my- what I- there wasn't a ton of information about this either, right?

Jackie Garlich (25:55): Am I right that this is newer? Or I just wasn't paying attention?

Leslie O’Dell (25:58): Well, no, I feel like everything with dry eye is new, which-

Jackie Garlich (26:00): Yeah, I guess.

Leslie O’Dell (26:01): Yes, so it is... it could [inaudible 00:26:04] back, but I- I definitely feel like in the past maybe 7 or 8 years, is when I started to see that.

Jackie Garlich (26:10): Yeah.

Leslie O’Dell (26:10): You know?

Jackie Garlich (26:10): Yeah.

Leslie O’Dell (26:11): Um, and that was because of research that we were doing, right? So actually, we were privy to doing some early research using LipiFlow, that Don Korb wrote the protocol.

Jackie Garlich (26:21): Mm-hmm (affirmative)

Leslie O’Dell (26:22): Which was huge for me because when you read the protocol of somebody like Don Korb, you see all the things you were doing wrong.

Leslie O’Dell (26:28): Mm-hmm (affirmative).

Jackie Garlich (26:28): (laughing).

Leslie O’Dell (26:28): Yeah, yeah.

Jackie Garlich (26:29): I'm like, "Oh"...

Leslie O’Dell (26:29): That's where I learned about dye placement, waiting, I mean, I was never waiting 90 seconds before I saw his protocol-

Jackie Garlich (26:36): Yeah.

Leslie O’Dell (26:36): -and that’s where I learned about grading, um, the lid wiper epitheliopathy. So, don't... I mean, it is…

Jackie Garlich (26:44): Yeah.

Jackie Garlich (26:44): The only reason I knew about that waiting to look at the cornea is because I remember as I was a resident, I stained the cornea and I was like: "Nope, looks great", and then I'd go out to report to my attending, and they came back in and they're like, "The cornea, do you see this? Like, there's all this extra"...

Jackie Garlich (26:59): And I was like, this… okay, yes, I know, they're like, "What is wrong with you".

Leslie O’Dell (27:03): Yeah, this is called punctate keratitis.

Jackie Garlich (27:03): So, I do, I learned my lesson that day.

Leslie O’Dell (27:07): Yeah.

Jackie Garlich (27:07): Just lovely. Okay…

Leslie O’Dell (27:08): But sometimes you have to learn the hard way, the trouble is once we get out into practice, when you're not exposed to people, you know, doctors again... I mean, it's nice that we do live in the world of digital devices, because videos are out there that we can watch. But it's hard to learn as, you know, especially as you're running a business, you know?

Jackie Garlich (27:26): Yeah, yeah.

Leslie O’Dell (27:27): How do you find the time to work on always making yourself better?

Leslie O’Dell (27:30): So, once you get out into practice, you don't the opportunity to learn and have someone correct you, right?

Jackie Garlich (27:36): Right.

Leslie O’Dell (27:36): So, it's nice, I mean, that's where it's nice to have organizations like, even like TFOS, like, that's why I started to get involved with them, it's because I wanted to learn as much as I could about dry eye, or reaching out to anybody that you know that's, you know, doing research in that area, or has a dry eye clinic, they want to share, you know?

Jackie Garlich (27:52): Mm-hmm (affirmative)

Leslie O’Dell (27:52): They don't want you to feel like you're on an island all by yourself.

Jackie Garlich (27:57): Yeah.

Leslie O’Dell (27:57): So I would say finding doctors like... You know, just like what we're doing here, you know, we are all willing to share-

Jackie Garlich (28:03): Yeah.

Leslie O’Dell (28:03): -to make everybody better.

Jackie Garlich (28:05): Yeah.

Leslie O’Dell (28:05): To help the patients better, all of that.

Jackie Garlich (28:07): The last thing I just want to ask about is this lid wiper.

Leslie O’Dell (28:10): Yeah.

Jackie Garlich (28:10): Because it was somewhat newer to me, so there may be other people that didn't know what that was. But, am I correct in saying that that staining sort of develops from a mechanical sort of friction?

Leslie O’Dell (28:20): Yeah.

Jackie Garlich (28:20): Of that lid sort of coming... So that's why that, that's correct, right.

Leslie O’Dell (28:23): Yeah, that's what's the thought is, and then that, it's like, the part of why it's called lid wiper epitheliopathy is because if you think about your windshield wiper, and how that travels over your windshield.

Jackie Garlich (28:35): Mm-hmm (affirmative)

Leslie O’Dell (28:36): If you don't have a good rubber whipper blade,-

Jackie Garlich (28:39): Mm-hmm (affirmative)

Leslie O’Dell (28:41): -then it's going to scrape against.

Jackie Garlich (28:42): Mm-hmm (affirmative)

Leslie O’Dell (28:43): And so, as the lid becomes inflamed, it actually will thicken, so now it's creating more friction over the surface of the eye, and then it just becomes a problem that until... I mean, it's a huge sign of inflammation, when I see that, I'm saying, like, there's a lot of inflammation here.

Jackie Garlich (29:00): Oh, really? Okay, yeah.

Leslie O’Dell (29:01): Uh, yep.

Jackie Garlich (29:02): I feel like I see that a lot.

Jackie Garlich (29:03): Okay, so this was really helpful, like this kind of, I think, solidifies the fact that you really don't need to buy a ton of equipment, and probably suggested not to buy a ton of equipment. So you're... Have kind of a plan on how you're implementing everything, and that you can do all of this stuff with things that you actually have in your office.

Jackie Garlich (29:21): And, you know, purchasing the small device like the...

Leslie O’Dell (29:25): MGE?

Jackie Garlich (29:25): MGE, yeah. And then lissamine green, these are like inexpensive things.

Jackie Garlich (29:30): And I think also, the important thing is to incorporate a questionnaire, which is inexpensive, obviously, just paper and a printer.

Leslie O’Dell (29:37): Yeah.

Jackie Garlich (29:37): Incorporating that into your workups. And looking at TFOS, I think it, historically, even, and I mean, to me it has seemed overly complicated, but really, when you look at it it's really- it's really not. And I think that should be a good guide...

Leslie O’Dell (29:53): I mean, it actually can be as complex as you want to make it, right? So-

Jackie Garlich (29:57): If you read all 400 pages. (laughing)

Leslie O’Dell (29:58): -for people who are in research, they use that as, you know, they're learning a lot about the proteins in the tears. We don't necessarily need that, that's their job, they'll tell us what's gonna be important, and then, you know, maybe we'll have a different test that we can look for different proteins in the tears.

Leslie O’Dell (30:13): So, it can be very, very scientific and very, very complex, and that's great, because it's meeting the needs of so many different types of people interested in dry eye, right?

Leslie O’Dell (30:24): For you and I, in a private practice setting, we don't necessarily need to be talking about all of these, you know, tear dynamics to our patients; we need to be able to diagnose it-

Jackie Garlich (30:35): Mm-hmm (affirmative)

Leslie O’Dell (30:36): -pretty quick and easy, and we need to then be able to subtype, and that's what we were talking about.

Leslie O’Dell (30:40): And then, that actually gets you to the next step. So once you have your staging, so, they give us these stages, right? One, two, three, four; it actually then guides you to treatment.

Leslie O’Dell (30:50): So that's the last part of this, I would say is you even don't have to, like, recreate your own, "Okay, this is what I'm gonna do now", you know that level one, which is, I mean, maybe you're gonna get mild ones, you know, if you have a younger patient population. But, so, level one, you're talking about things like diet, environmental modifications, there's always the mention of, like, moisture eye wear, those kinds of things. Oh, fish oil, omega-3's, that's where those things kind of play into role, maybe the- the GLAs type-

Jackie Garlich (31:20): Mm-hmm (affirmative)

Leslie O’Dell (31:21): -type of things.

Jackie Garlich (31:21): Yeah.

Leslie O’Dell (31:21): Um, level two is gonna be where you start to use all your antiinflammatories, so, your corticosteroids, your lifitegrast, your cyclosporines, but it's also where your thermal treatments come in.

Jackie Garlich (31:32): Mm-hmm (affirmative)

Leslie O’Dell (31:32): So that's the place for things like the thermal pulsation, the IPL, the tear care, the eye lux, it's actually level two.

Jackie Garlich (31:41): Mm-hmm (affirmative), yeah.

Leslie O’Dell (31:41): Level three then gets into things like otalgia serum, it gets into things like amniotic membranes.

Jackie Garlich (31:46): Amniotic membranes, yeah.

Leslie O’Dell (31:47): Level- level four now is like, things like tarsorrhaphy, I mean, we don't want to get there-

Jackie Garlich (31:51): Yeah.

Leslie O’Dell (31:51): -If we can avoid it. So, you want to have the easy things to diagnose because you want to start your treatment as early as possible.

Leslie O’Dell (31:58): It will make your life easier as the clinician, and it's gonna make a bigger impact for the patients, that, you know, treating early is gonna make everybody feel better, see better.

Leslie O’Dell (32:15): And now for the To the Point wrap up. Making the diagnosis of dry eye does not have to be hard or expensive. Utilizing the document from TFOS DEW II, we know that we need symptoms and sign of dry eye to make the diagnosis.

Leslie O’Dell (32:30): Symptoms come from a questionnaire, using a validated questionnaire like OSDI, dry eye questionnaire 5, or SPEED are great ways to start.

Leslie O’Dell (32:39): And for signs, looking for corneal and conjunctival staining, rapid tear breakup time, with your vital dyes fluorescein and lissamine, or if you have access to osmolarity, that's another great way to assess the tear film.

Leslie O’Dell (32:54): From there, you need to use technology for subtyping. This helps you decide if you have aqueous deficient dry eye or evaporative dry eye, or a combination.

Leslie O’Dell (33:05): TFOS DEWS II then goes on to show us about staging, and what treatments are part of that staging.

Leslie O’Dell (33:13): But remember, diagnosing and treating early is always in your best interest.

5/28/2020 | 33:35