to-the-point
To The Point
Episode 8

How to Handle Dry Eye Masqueraders

Knowing what to do when confronted with a dry eye masquerader can go a long way to ensuring better patient outcomes. Working their way in from the outside of the eye, starting with the lid and ending with the cornea, hosts Leslie and Jackie discuss how to identify and manage conditions that can masquerade or contribute to dry eye and complicate a patient's treatment plan.

Leslie O'Dell (00:06):

Ocular surface disease: it's complex, chronic, and progressive, but ripe 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.

Jackie Garlich (00:26):

Welcome to another episode of To the Point podcast, where we are covering all topics dry eye and how to start building your dry eye clinic. Today, we're going to be talking about all of those masqueraders in dry eye.

Jackie Garlich (00:40):

So, you're treating for someone for dry eye and they don't seem like they're responding to the treatment. And today, we're going to be talking about all those little things that can masquerade as dry eye that we should really tackle and be sure what we are looking for when we're examining a patient. So, today I'm joined by my cohost, Leslie O'Dell. How are you doing, Leslie?

Leslie O'Dell (01:00):

I'm doing great. I think these are really important, um, areas just because it can sometimes complicate your dry eye, um, treatment plan, and how you expect a patient to respond to the treatments that you have laid out.

Leslie O'Dell (01:13):

So, sometimes these masquerade conditions, um, don't necessarily mean that dry eye is not present as well. But, identifying them and being able to treat them in conjunction with dry eye is important. And if there is not true dry eye, then, you know, treating the masquerade syndrome is going to really help your outcomes with the patients that you're, you're dealing with.

Jackie Garlich (01:42):

Yeah, exactly. So, what we're going to cover today is, um, we're gonna kind of work our way in from the outside of the eye. So, we're going to talk about lid issues, we're going to move to conjunctival issues, and then we're going to finish up on the cornea.

Jackie Garlich (01:56):

So, let's start with, um, lid problems that can masquerade or contribute to dry eye.

Leslie O'Dell (02:02):

Yeah. So a lot of these I think I've learned kind of by trial and error, and a lot of them have come to me through referrals, you know, from other doctors that were sending patients to me that did fail on topical therapies or even treatments that they were performing in the office.

Leslie O'Dell (02:17):

And so, the, you know, the doctor grew frustrated and then sends on to the expert, if you will. But, um, when I evaluate any new patient, especially one that has been to multiple providers ahead of me, I, I do kind of break things down into the, the lid, the conj, and the cornea just to see if I can weed out anything that might have been overlooked.

Leslie O'Dell (02:40):

When I'm looking at the eyelid, I, again always start my slit-lamp exam with closed eyes. So then, I can really evaluate the upper lid, the lash margin, and get a feel for things like blepharitis, um, thinning of lashes, irregular contour, you know, which could indicate, um, Demodex.

Leslie O'Dell (03:02):

So, I know we did a deep dive into Demodex blepharitis, but really what you want to make sure when you're looking at that superior lid on your slit-lamp exam is that you don't see the present of, presence of the collarette, or that waxy cuff at the base of the eyelash.

Leslie O'Dell (03:18):

If that's what you're dealing with, yes, it's promoting inflammation that you're gonna then see downstream on your corneal exam or when you're looking at the conjunctival tissue, but it might not respond, you know, to the traditional medications, um, as it would. So, looking for the collarette at the base of the lash would be my number one thing.

Leslie O'Dell (03:41):

The other things I do when I'm looking at the lid is actually perform a very easy snap test. And so, that is done now open-eyed, and actually I might even do this ahead of the slit-lamp because it's done outside of your slip-lamp. And so, I approach the patient, you can use a cotton tip, you can use a clean finger, and you just gently pull down the bottom lid and watch to see how quickly does it snapback, um, to the globe. And, it helps to show your, you know, lid to globe congruity.

Leslie O'Dell (04:12):

Sometimes I have done this and the only thing that resets that is the blink. So, they have very poor, um, muscle tone there. I mean, and obviously if that's happening, it's gonna be pretty difficult for your blink reflex to help distribute tears throughout a day.

Leslie O'Dell (04:28):

So, that helps me identify things like floppy lids, is a big one, um, or even just like an inferior dermatochalasis that might need repaired with the blephar- um, blepharoplasty. And then also with that being said, I pull out, again, ahead of my slip-lamp exam my transilluminator and darken the room and I'm looking for inadequate nocturnal lid seal, which is not lagophthalmos. It's not nocturnal lagophthalmos, um, but it's actually just, you know, an inability of the lid to form a tight seal when the eye is closed.

Leslie O'Dell (05:03):

M- I, I kind of use the analogy of the refrigerator door to my patients. The refrigerator door has that nice seal. When it shuts, it's supposed to make a nice seal. But if you have an old refrigerator and you start losing that seal, it starts to kind of get that wiggle to it. When that refrigerator door closes you have less, you're more likely to not create a good seal.

Leslie O'Dell (05:24):

So, sometimes in patients who have floppy lids, um, you're gonna notice, or even just aging, um, because that thin, that, because that skin is so thin around the eye, you're gonna notice that that lid starts to sag downward. And so a lid that may be used to close might not close as fully.

Leslie O'Dell (05:43):

And, uh, and how I identified that is the darkened room, the transilluminator, um, have the patient close their eyes, and then I place the transilluminator, usually I start temporally, centrally, and then nasally. And, I'm evaluating the lid margin where the lashes are to see if there's any light spill onto the cheeks.

Leslie O'Dell (06:03):

So when that lid is tightly shut, you're not gonna see a glow coming out where the lashes are. When the lid is not tightly shut, you're gonna get this glow at the lid margin, a- at the lash base.

Leslie O'Dell (06:17):

Um, the other thing about that, though, is your transilluminator is a little heavy, so it takes a little bit of practice. You don't wanna kind of, you know, just plop it down on their eyelid because you can sort of fold the lid outward a little, creating a lid seal, inadequate lid seal yourself.

Leslie O'Dell (06:32):

So, it's sort of more like a gentle placement of the transilluminator. Um, and once you do a few of them, you kind of get the feel just of that weight in your hand and how easy it is to perform.

Jackie Garlich (06:43):

When you're examining for lid seal, where exactly are you placing the transilluminator on this patient's lid? Are you closer to the, you know, eyelid margin or are you higher up?

Leslie O'Dell (06:53):

Great question. I use the lid crease as my guide. So, probably a little bit higher up than the lash margin, for sure. I, um, am using that lid crease as the guide and placing the transilluminator kind of right along that, um, line, if you will.

Jackie Garlich (07:09):

Okay, and this is referred to as the Korb-Blackie light test, right?

Leslie O'Dell (07:12):

Blackie, yep. Korb-Blackie light test. And really, one of the posters that they presented at ARVO was kind of shocking to me. They took, um, dry eye patients in one bucket and then they took patients without dry eye in another. And what they, what they showed was patients who had dry eye that were kind of resistant to traditional therapies, 80% of the time had some degree of an inadequate lid seal.

Jackie Garlich (07:39):

Wow.

Leslie O'Dell (07:40):

That's a lot.

Jackie Garlich (07:40):

That is a lot.

Leslie O'Dell (07:40):

(laughs) Um, and then, the same group, uh, or the same findings in the group for the non-dry eye patients, um, 80% of them did not have a lid closure issue.

Jackie Garlich (07:51):

Interesting.

Leslie O'Dell (07:52):

So, it is a significant, um, m- you know, I don't even know if I would call it a masquerader. It's more of a, um, a challenge when you're trying to treat dry eye if you don't identify that ahead of time. And, that's because now that patient is going to be having their eye open, for however many hours they're fortunate enough to be sleeping, and they don't have that tear film replenishing, you know, with the blink. The closed eye tear are far different than the open eye tear, and it's a big risk for evaporative stress, which then can trigger that meibomian gland, shutdown in obstruction that we know is so challenging to, to treat.

Leslie O'Dell (08:33):

Um, so this one, honestly, easy to identify once you just get that transilluminator in hand and start doing it, and relatively easy to treat. So when you identify this one, your treatment plan's going to look like, you know, the traditional things that you do for lagophthalmos, gels, ointments.

Leslie O'Dell (08:51):

Um, but what I have seen really, really beneficial is, um, using some kind of sleep mask that really traps moisture and provides this, like, humanity environment hu- Um, for the patient, they actually wake up to moist eyes, and, and they haven't had that, you know, in a long time ahead of you. And, that's what they'll say, "I wake up and my eyes don't feel dry to start the day."

Leslie O'Dell (09:14):

Um, there's not a lot in that space right now. The one that I, is kind of my go-to is, um, created by Eye Eco and it's called the EyeSeal 4.0. Uh, a tem- you know, kind of like the airplane mask or the beauty mask that people sleep in isn't gonna give you a good enough seal, uh, but I also wouldn't be, you know, worried about telling patients about sleeping with a mask.

Leslie O'Dell (09:38):

One of my patients that kind of always stands out was this older gentleman that, you know, I looked at him thinking, "There's no chance that I'm going to get this guy to sleep with a mask on." He, I don't know, in my mind he just didn't look like the person that would ever, (laughs) ever do that, you know?

Jackie Garlich (09:51):

(laughs)

Leslie O'Dell (09:52):

And, I, it made the biggest impact on him. He was coming back in the office, like, super excited, telling me his eyes never felt better, and he sleeps with a mask every night. So, you do have to kind of get out of your own, you know, however you put your patients into these categories, you know, you just got to tell them what they need and let them help you make what decision, you know, is gonna be best.

Jackie Garlich (10:13):

Okay good, yeah. All right. So, um, bleph, Demodex, lid seal, MGD lid issues. S-

Leslie O'Dell (10:22):

Yeah, definitely. And, you know MGD, right?

Jackie Garlich (10:24):

Yeah. (laughs)

Leslie O'Dell (10:24):

So, there's the obvious kind, and then there's the non-obvious kind. What do you think, you know, do you think are some tips when you're looking for non-obvious? What do you do?

Jackie Garlich (10:35):

I mean, for in any dry eye exam, in any exam, really, I'm always giving a little push on the glands just to see. I think sometimes it can give the ap- if you're not actually pushing on those glands to see what's happening and what's coming out of them, you can miss it if they really don't look inflamed and they just kind of look, you know, anatomically like a normal gland.

Jackie Garlich (10:57):

So, that's one thing I, I'm always doing, you know, in the exam, And then, obviously, the vital dye staining I think is really helpful for that lid wiper issue that you're seeing next to the glands there.

Leslie O'Dell (11:08):

Yeah, I would, I would definitely agree, especially when you don't have that Telangiectasia. If you don't push, you're completely missing. Um, and sometimes when you do push, it's not the toothpaste that you expect to see. It's sometimes nothing.

Jackie Garlich (11:22):

Right, it, right. Exactly, yep.

Leslie O'Dell (11:23):

Right?

Jackie Garlich (11:24):

All right, anything else on lids we wanna cover for masqueraders?

Leslie O'Dell (11:27):

Um, you know, just, just that floppy lid, which again, is easy to identify using that snap test, then I usually parlay that into, you know, do you already know you have sleep apnea or do you have any risk factors for sleep apnea? Because, that can make a big difference for patients as well.

Jackie Garlich (11:44):

(laughs) Yeah. Yep.

Leslie O'Dell (11:45):

Understanding, you know, just the whole body approach.

Jackie Garlich (11:47):

So if you're, if you're thinking of like, okay. So, I've had s- many patients with floppy eyelids, um, that, you know, some are and some are not symptomatic for dry eye. But, are you, is your treatment plan for that patient, um, where in the treatment plan is the, is the referral to ophthalmology to maybe tighten that lid?

Leslie O'Dell (12:08):

You know, it, that's another great question. Um, and I've had a few patients that I worked really hard to... One of the problems with floppy lids, at least from my experience, is, um, meibomian gland dysfunction because there's just not that mechanical force to push the meibom out.

Leslie O'Dell (12:25):

So, I have done some gland treatments on patients, you know, they've gotten symptomatic relief, we've, we've made some improvements on the meibom secretion but, you know, 8 months later, we're right back where we started. Um, you know, and ahead is that, even ahead of my first meibomian gland clearing treatment, we had the talk.

Leslie O'Dell (12:46):

For me in my area, sometimes the trick that I run into is that, um, the surgeons that I'm referring to don't always do what I think that, that they should. (laughs)

Jackie Garlich (12:57):

(laughs) Right.

Leslie O'Dell (12:58):

Um, at the time that they should. So, so, you know, really, it's a conversation to have with your referring surgeons. You know, what's their comfort level? You know, sometimes it's a coverage issue. You know, they can't get coverage for certain surgeries. It's getting harder for the oculoplastics I know, at least in my area, to get certain things covered, even with photo documentation.

Leslie O'Dell (13:18):

So, just really sitting down and kind of figuring out with your referring f- um, oculoplastics, you know, what are they looking for? Because to me, you know, if I can tighten that bottom lid, it makes a world of difference.

Leslie O'Dell (13:29):

A patient that really sticks out in my mind about floppy lids, I performed that snap test that we spoke of earlier and the lid just hung down. (laughs) It didn't want to snap back at all. The only thing that reset it in his case was the blink. He had been on and off, you know, corticosteroids, on and off other anti-inflammatory treatments. He had been through meibomian gland treatments over the course of, probably I was working with him for two or three years, and finally I, you, you know. And actually not finally, he had been to a few oculoplastics over the way, um, as well, but we, you know, really pushed hard for him to have surgery to tighten the bottom lid, and it was life-changing.

Jackie Garlich (14:09):

Oh, wow. Yeah.

Leslie O'Dell (14:12):

It was kind of like, you know, as soon as he healed from that, he had, it was so much easier to control his symptoms. So, sometimes you just have to really, you know, talk to the referring doctors that you're working with, get a feel for their comfort level. If they aren't doing certain procedures that you want, try to find someone else in your area that is. Um, I've had that, you know, be the case a couple of times as well.

Jackie Garlich (14:33):

Is that something that is typically covered by insurance? I actually don't know that, like if they, if they want that repair.

Leslie O'Dell (14:39):

Um, in this case, I know it was covered by his Medicare insurance, but I think, um, it's just sometimes laborious, like, to get the paperwork, to prove it, um, and I think just some of the insurance, it might not be Medicare, but it could be some of the more commercial payers that are a little bit more strict on the guidance. And, a lot of that comes from, you know, the anti-aging, the cosmetic push, right?

Jackie Garlich (15:03):

Sure.

Leslie O'Dell (15:04):

So because this a- this area of the yo- of the skin is so thin, obviously it's the first to age. So, you know, they wanna make sure that they're paying for medically needed things, not the cosmetic, um, side of it.

Jackie Garlich (15:18):

Yeah.

Leslie O'Dell (15:18):

You were speaking to the vital dyes, and I think that's a great way to transition to how I do the exam to find another thing, which is, you know, kind of grouped into this mechanical dry eye or conjunctivochalasis. A lot of these things myself personally I kind of learned by getting burned. (laughs)

Jackie Garlich (15:36):

(laughs)

Leslie O'Dell (15:36):

Uh, you know, I was treating something and thinking, "Why is this not getting better?" And then, I would learn about a new, you know, not even new but new to me, problem. And, that's also how conjunctivochalasis was for me, but this is the root of chronic inflammation. So, you know, there's always the debate, "Oh, can I manage dry eye with tears?"

Leslie O'Dell (15:56):

You know, and, and no, it is an inflammatory condition. And if you are just managing it with artificial tears and you're not implementing some kind of anti-inflammatory treatment along the, you know, the path of that patient, here's where your downstream is.

Leslie O'Dell (16:11):

Now, you have these, you know, significant changes to the conjunctival tissue, um, where it becomes boggy, it disrupts the natural tear flow, it creates a problem sometimes even with the drainage. Meaning, that that tissue can bog up over on top of the punctum and really create, like, epiphora for the patient.

Leslie O'Dell (16:33):

Um, so, it, it really obliterates the normal tear reservoir, um, and the tear meniscus. And so, if you can treat and treat aggressively early in the disease process, we wouldn't be at the point, you know, of this mechanical dry eye, um, further downstream from many of our patients.

Jackie Garlich (16:52):

Yeah. I think that's a good point. I think it's really, when you're looking at a dry eye patient, it's really easy to be like, "Okay, lid's clean. Like, do they have MGD? All right, let's see what the cornea's doing," and, like, blow right past the conjunctiva. (laughs) So, I think the dyes actually really help highlight that, um, that issue. But even just in a resting position you can see where that conjunctiva is just heaped up on that lower lid.

Leslie O'Dell (17:13):

Yeah. And sometimes, though, even easy to miss. And, um, I will look at the patient at the slit-lamp and have them take a few blinks. You know, you're doing that anyway because you're, you're looking at their tear breakup time, but you really kind of monitor that to see, is it coming up over the cornea?

Leslie O'Dell (17:29):

A lot of times, that tissue is so boggy, when they blink it comes up over the inferior cornea. So if you're seeing lot of inferior staining and they don't have inadequate lid seal or lagophthalmos, um, or MGD, another thing to really pay attention to is, is there this conjunctivochalasis that's creating a problem with how the inferior cornea's wetting or even, you know, dragging across the inferior cornea?

Jackie Garlich (17:54):

Mm-hmm (affirmative).

Leslie O'Dell (17:54):

Uh, it can be managed, you know, a few different ways, and it can worsen with cataract surgery. That's something that I learned kind of the hard way. So, my mother-in-law, um, had cataract surgery. But ahead of that, she suffered a lot with dry ey- dry eye and allergies and she was a big eye rubber. And, that's one of the things that you don't wanna be doing throughout your life because it's going to help loosen the conjunctival tissue.

Leslie O'Dell (18:17):

But, you know, I often would just see her kind of, you know, doing the eye rubbing, especially late summer, um, thr- you know, throughout our visits. She had cataract surgery, beautiful cataract surgery, 20/20 vision, and she could not get rid of this epiphora.

Leslie O'Dell (18:34):

What was happening in her case was the conjunctiv- the conjunctivochalasis worsened temporarily, you know, because inflammation worsens temporarily after cataract surgery as well, um, and it blocked her punctum. So, tears were just dripping from the center of her eye, (laughs) um, and, you know, she was making her miserable.

Leslie O'Dell (18:54):

In her case, we really worked hard, uh, on everything that was anti-inflammatory through medications. We worked on things like environment, trying to keep humidity at a certain level to try to help with any overnight dryness that could be occurring. She even did things as far as, um, decreasing her salt intake, because those things, um, were guidance from an oculoplastics surgeon in my area to try to do all these lifestyle modifications ahead of the referral to him for surgery.

Leslie O'Dell (19:23):

It, he was saying it's kind of, in his practice, now this isn't for everybody, but he was saying like 50/50. Sometimes he can modify it just by hitting it hard, drops, environment, lifestyle. And then, 50% of the time he does have to take the next step, which is, you know, performing a treatment that reduces that tissue by cautery. Um, and then a lot of times, they'll play amniotic tissue there to help with, um, healing and in- inflammation.

Leslie O'Dell (19:50):

Uh, and that's now called Res- uh, part of that's called Reservoir Restoration. So by reducing that conjunctival tissue, you're helping to create a better tear reservoir for the patients.

Jackie Garlich (20:01):

I'm actually kind of surprised that it's a 50/50. I would think that, um, getting that conjunctiva to shrink down with just drops and lifestyle modifications, I would think that wouldn't be so successful.

Leslie O'Dell (20:13):

You're, you know, and I actua- uh, you know, would totally agree but, again, I think that where I am in (laughs) Pennsylvania is just a little bit limited. Um, this was actually a two-hour away referral that I was speaking to.

Jackie Garlich (20:24):

Uh, yeah. (laughs)

Leslie O'Dell (20:24):

Um, I don't have a surgeon in my area yet that was doing conjunctivochalasis repair, um, but that doesn't mean that they aren't going to start soon. And, sometimes it's just saying, "Hey, I have a lot of these patients. I think it would bring value to our area, you know, and also to your practice if, if we could get that service done locally."

Leslie O'Dell (20:45):

Um, you know, I know in some areas that this is probably, you know, performed a lot more commonplace.

Jackie Garlich (20:52):

Yeah.

Leslie O'Dell (20:52):

So, I, I think it's more just where you are geographically, what kind surgeons you're working for, or with, alongside. Yeah.

Jackie Garlich (20:59):

Regional. (laughs) Yeah. Yeah. Okay, good. Um, let's move into the cornea and talk about the other masquerader, EBMD.

Leslie O'Dell (21:07):

Again, vital dyes, so important. And, and a lot of times, I mean, EBMD, easy to find when it's centrally located, when it's inferior, um, but I think what, you know, you can often overlook is the subtle EBMD when it's first beginning, and your fluorescein dye is so good at highlighting that for you.

Leslie O'Dell (21:26):

And so with this, I usually will put my fluorescein dye in. What I do, um, um, right after I place it, um, kind of in line with when I'm looking at the tear breakup time, is I lift up the upper lid just slightly away from the conjunctiva to reveal the superior cornea.

Leslie O'Dell (21:47):

So when you're looking at your slit-lamp, a little bit of the cornea is hiding underneath the upper lid. And if you don't do that p- you know, that simple thing of just lifting up the upper lid to look at this superior cornea, you can often find EBMD, um, that's kind of missing or hiding.

Leslie O'Dell (22:06):

When you lift the superior lid, you get to see some very early changes to, um, map-dot-dystrophy or EBMD. You know, and it, remember, it's that negative stain, kind of the fluorescein pools around the edge. You might just see almost like a comma instead of a circle when it's early in the formation. But, that disrupts a lot of the, the way that the tears kind of anchor throughout the day.

Leslie O'Dell (22:32):

So, it's going to accelerate things, like the evaporation, it's going to, you know, if you're not treating that, it's gonna also make it just challenging to get your patient fully, you know, feeling better. Sometimes it's the blurry vision complaint as well.

Leslie O'Dell (22:49):

With EBMD in that form, that super mild kind of hiding up underneath the upper lid, sometimes those patients will also present with some morning symptoms, where they feel like their lid is kind of stuck. So, it's not a recurrent erosion, um, but it's the beginning of the process that gets us to recurrent erosion.

Leslie O'Dell (23:08):

So, sometimes they will respond with lubricants at night. Um, I really like, you know, not to call out certain, you know, I really like some gel tears for those patients. I, I guess maybe, you know, GenTeal gel. If you can find GenTeal gel, that in the moderate-to-severe, seems to work well, uh, for those patients.

Leslie O'Dell (23:27):

Um, other things would be an ointment. Um, again, that, a, a mask that seals around their eye and helps create a humidity environment overnight can be beneficial. This is a great place for, for drops like, um, FreshKote as well. So, I have a lot of success using FreshKote tears for my early EBMD patients as well.

Jackie Garlich (23:48):

Can you talk a little bit about FreshKote? I know that they're, a lot of, people really like that drop, but can you talk about why that's a good drop?

Leslie O'Dell (23:56):

So, FreshKote is, um, made by Eyevance. It's now a drop that's no longer... It kind of, it was an interesting, um, medica- or eye drop because it started out that you had to write a prescription for it, um, years ago. Then, patients could get it over-the-counter but they, at least again in my area, they would have to ask the pharmacist, sometimes the pharmacist would have to order it.

Leslie O'Dell (24:15):

Um, but now, it's actually available through Eyevance for retail in our clinics. And, it's different, it's a different tear because it's really helping all three layers of the tear film, and that's because of the components that make it up. Um, there's povidone 2%, which helps with the, uh, lipid layer of the tear film, helps with reducing evaporation, um, it helps with kind of, um, you know, spreadability, if you will, of the tears. There is a lacrophilic aqueous solution in here as well. That helps with both of lipid and the mucin layers. And then, there is a polymer blend that helps with the wettability of the tears.

Leslie O'Dell (24:59):

So, it's really a very scientific tear, which many tears, you know, are when you kind of break down the ingredients, but this one is definitely unique, um, and, and it gets a lot of good feedback from doctors around corneal things, such as, you know, EBMD, uh, for sure.

Jackie Garlich (25:16):

Yeah. I've, I've heard, um, a lot of doctors really talk, um, highly and speak highly of FreshKote, so it's good to know. Okay, good. All right, we covered a lot of masqueraders. Did we forget anything? Did we get them all?

Leslie O'Dell (25:28):

Well, we might have. (laughs)

Jackie Garlich (25:29):

We probably forgot something. (laughs)

Leslie O'Dell (25:29):

Yeah, there's probably one that I'm still waiting to learn about as well.

Jackie Garlich (25:32):

Right.

Leslie O'Dell (25:33):

Um, you know another, you know, another challenging patient that will teach me something else, but as long as we keep learning. Do you feel like there's anything that you have?

Jackie Garlich (25:43):

Right. No, I think we, I think we got them all. Yeah, these are good.

Leslie O'Dell (25:45):

And, do you think that, you know, when you have some of your challenging dry eye patients that some of these that we talked about have been your hang-up, um, you think, "Oh, I want to actually go back and look at Mr. Jones' chart to see maybe he does have one of these things"? Has it sparked any of that for you?

Jackie Garlich (26:01):

Well, I, I definitely had it an instance where I missed, I saw the conjunctivochalasis, but I just didn't think too much of it in this setting that, uh, of dry eye that this patient had.

Jackie Garlich (26:14):

So, um, this was when I was looking with my ophthalmology group, um, and my corneal surgeon ended up saying like, "Oh yeah, I just performed procedure to kind of shrink down that conjunctivochalasis," and I was like, "Oh. Yeah, I probably should've maybe paid a little more attention to it."

Jackie Garlich (26:31):

So, I think this is, like, a nice refresher to, you know, look at everything. I think it's really easy to be, like, very targeted in how you're looking at dry eye and you're look- wanna look at that cornea and see what that's doing. But, you can easily kind of forget some of these other things, so it's a good refresher to think about.

Leslie O'Dell (26:51):

And now for the To the Point wrap-up. When treating dry eye disease, it's important to identify things that can coexist and complicate your treatment, sometimes known as masquerade syndromes. When you're doing with the eyelid, these can be floppy lid syndrome or inadequate, nocturnal lid seal, even Demodex blepharitis.

Leslie O'Dell (27:14):

The conjunctiva can create some problem with conjunctivochalasis or mechanical dry eye. And then with the cornea, if you're not lifting and looking at the superior cornea in particular, you might miss early, subtle EBMD, or map-dot-dystrophy. Identifying them and developing treatment plans in conjunction with your dry eye treatment can go a long way to better outcomes.

8/21/2020 | 27:51