Robert Latkany

Meibomian gland (MG) dysfunction (MGD) is a multifactorial, chronic condition of the eyelids, leading to eye irritation, inflammation and ocular surface disease. Initial conservative therapy often includes a combination of warm compresses in addition to baby shampoo or eyelid wipes. The practice of lid hygiene dates back to the 1950s, when selenium sulfide-based shampoo was first used to treat seborrhoeic dermatitis of the eyelids. Today, tear-free baby shampoo has replaced dandruff shampoo for MGD treatment and offers symptom relief in selected patients. However, many will not achieve significant improvement on this therapy alone; some may even develop an allergy to the added dyes and fragrances in these products. Other manual and mechanical techniques to treat MGD include MG expression and massage, MG probing and LipiFlow^®. While potentially effective in patients with moderate MGD, these procedures are more invasive and may be cost prohibitive. Pharmacological treatments are another course of action. Supplements rich in omega-3 fatty acids have been shown to improve both MGD and dry eye symptoms. Tea tree oil, specifically the terpenin-4-ol component, is especially effective in treating MGD associated with Demodex mites. Topical antibiotics, such as azithromycin, or systemic antibiotics, such as doxycycline or azithromycin, can improve MGD symptoms both by altering the ocular flora and through anti-inflammatory mechanisms. Addressing and treating concurrent ocular allergy is integral to symptom management. Topical N-acetylcysteine and topical cyclosporine can both be effective therapeutic adjuncts in patients with concurrent dry eye. A short course of topical steroid may be used in some severe cases, with monitoring for steroid-induced glaucoma and cataracts. While the standard method to treat MGD is simply warm compresses and baby shampoo, a more tailored approach to address the multiple aetiologies of the disease is suggested.

Diagnosis of dry eye disease and emerging technologies Dry eye is one of the most commonly encountered problems in ophthalmology. Signs can include punctate epithelial erosions, hyperemia, low tear lakes, rapid tear break-up time, and meibomian gland disease. Current methods of diagnosis include a slit-lamp examination with and without different stains, including fluorescein, rose bengal, and lissamine green. Other methods are the Schirmer test, tear function index, tear break-up time, and functional visual acuity. Emerging technologies include meniscometry, optical coherence tomography, tear film stability analysis, interferometry, tear osmolarity, the tear film normalization test, ocular surface thermography, and tear biomarkers. Patient-specific considerations involve relevant history of au-toimmune disease, refractive surgery or use of oral medications, and allergies or rosacea. Other patient con-siderations include clinical examination for lid margin disease and presence of lagophthalmos or blink abnormalities. Given a complex presentation and a variety of signs and symptoms, it would be beneficial if there was an inexpensive, readily available, and reproducible diagnostic test for dry eye.Keywords: cornea, dry eye, tear film, stain

Peer reviewed article authored by (Nguyen T, Latkany R). Read article or submit your manuscript for publishing.

Purpose: To evaluate the retention rate of silicone punctal plugs placed in patients with dry eye in a general clinic setting by ophthalmology residents. Methods: A cohort study reviewing charts of 88 patients who underwent punctal plug placement in the resident clinic at The New York Eye and Ear Infirmary from January 2007 to November 2008. Information recorded included age and sex of the patients, date of insertion, initial versus replacement plug, type and size of plug, location of insertion, and retention versus spontaneous extrusion versus removal of plugs at follow-up visits. Follow-up data were recorded at 30 and 60 days. Results: Follow-up data for 106 plug placements were available at 30 days. A total of 71.7% were retained, 23.6% were lost, and 4.7% were removed. At 60 days, data were available for 96 plug placements. A total of 50.0% were retained, 47.9% were lost, 5.2% had been removed prior to 60 days, and 2.1% had been replaced prior to 60 days. Conclusion: Spontaneous extrusion is a common complication in punctal plug insertion, and the retention rate in a general clinic setting with ophthalmology residents is low. This may suggest that attention should be placed on improved instruction in placement techniques and sizing, better patient education on avoidance of rubbing, and importance of follow-up. It may also support the need for better designed plugs or considering alternatives to the silicone plugs, or the placement of such plugs in a dedicated punctal plug clinic under supervision of an experienced attending physician.

Until recently, the cause of dry eye syndrome was uncertain and the treatment was palliative. Since discovering that dry eyes are caused by inflammation, there has been an abundance of research focusing on anti-inflammatory therapies, other contributing causes, and better diagnostic testing. This review summarizes some of the interesting published research on ocular surface disease over the past year. The definition of dry eye now highlights the omnipresent symptom of blurry vision. The re-evaluation of ocular surface staining, tear meniscus height, and visual change will allow for a better diagnosis and understanding of dry eyes. Punctal plugs, and oral and topical anti-inflammatory use will strengthen our arsenal against ocular surface disease. Major progress has occurred in the past few years in gaining a better understanding of the etiology of dry eye syndrome, which will inevitably lead to more effective therapeutic options.

Purpose: To evaluate outcome after refractive surgery in cataract patients for whom intraocular lens (IOL) selection was based on the use of a myopic regression formula. Methods: This prospective case series included 20 eyes of 14 patients who had previous uncomplicated myopic refractive surgery, followed by uncomplicated cataract extraction with IOL implantation. Calculation of IOL was based on flattest keratometry readings, spherical equivalent refraction before refractive surgery, and an adjustment factor derived from the regression formula: −(0.47 x + 0.85). Following cataract extraction, refractive error was compared against refractive aim. The power of IOL obtained by the regression formula (IOL _RF ) was compared to those obtained using the clinical history method at the spectacle plane (IOLHisKs) and the Double-K formula (IOL _DoubleK ). The results acquired with each technique were compared with those achieved using an IOL back-calculated for emmetropia (IOL _exact ). Results: Using the regression formula, IOL calculations produced postoperative cataract extraction refractions within 1.00 diopter (D) (range: −1.00 to 0.78 D) of the intended outcome. Mean spherical equivalent refraction after cataract extraction was −0.31±0.56 D. Twelve of 20 eyes had sufficient data to evaluate the statistical relationships among the three formulas compared with IOL _exact . Paired t test results revealed IOL _RF ( P =.0932) and IOL _HisKs ( P =.9955) were not statistically different from IOL _exact whereas IOL _DoubleK was statistically different from IOL _exact ( P =.0008). Conclusions: The myopic regression formula is recommended for postoperative myopic LASIK IOL selection to provide a simple, accurate, and consistent method of predicting IOL calculation that is not statistically different from IOL _exact . [ J Refract Surg . 2008;24:33–38.]

To evaluate the normalization of the tear film (tear film normalization test [TNT]) as a diagnostic test for dry eye syndrome. The uncorrected distance vision of 20 patients with dry eyes (40 eyes) and 20 normals (40 eyes) before and after instillation of carboxymethyl cellulose 0.5% (CMC; Refresh Plus; Allergan, Irvine, CA) was recorded. We used study early treatment diabetic retinopathy (ETDRS) vision charts to test vision in each eye. Tear film breakup time (TBUT), presence or absence of superficial punctate erosions (SPE), tear film meniscus height, meibomian gland function, and ocular surface disease index (OSDI) questionnaire scores were evaluated. CMC improved visual acuity in the dry eye group (P < 0.0001). Response operator's curve (ROC) analysis showed that vision improvement of 2 lines or more after tear normalization was associated with an 82.5% (95% CI: 66.6%-92.1%) sensitivity and 100% (95% CI: 89.1%-100%) specificity for dry eye. There was a significant correlation between vision improvement and OSDI score in the dry eye group (P = 0.003). The TNT is a highly sensitive and specific test for dry eyes and is available in every eye care professional's office. The more symptomatic the dry eye, the greater the improvement.