A targeted approach to treatment based on the findings of a thorough history, appropriate testing, and clinical exam can be successful for bringing relief to many patients with dry eye that is difficult to manage, said Deepinder K. Dhaliwal, MD.
Chicago-A targeted approach to treatment based on the findings of a thorough history, appropriate testing, and clinical exam can be successful for bringing relief to many patients with dry eye that is difficult to manage, said Deepinder K. Dhaliwal, MD.
However, when all else fails, ophthalmologists may want to consider referral for acupuncture, said Dr. Dhaliwal.
The treatment consists of two 45-minute sessions performed 1 day apart using a set of 12 needles placed in the ears and index fingers. According to the findings of a prospective randomized, sham-controlled study, acupuncture provided significant and fairly durable benefits, said Dr. Dhaliwal, associate professor of ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh.
“True acupuncture did not significantly improve the assessed objective measures of dry eye, which included Schirmer testing, tear film breakup time, and ocular surface staining,” she said. “However, it significantly improved patients’ subjective assessment of dry eye symptoms versus sham, was associated with significant reduction in use of artificial tears at 6 months, and its benefits lasted for 9 to 12 months.”
Dr. Dhaliwal also provided additional pearls for evaluation and management of the “problem” dry eye patient.
Questions to ask when taking the history should elicit if symptoms are worse in the morning than at night, if there is exposure to circulating air (e.g., fans, CPAP devices), any presence of mucus discharge, and if there is anything that brings even very temporary symptomatic relief.
“If the answer to the last question is ‘no,’ after the testing and exam is done, I first place a drop of artificial tears in the eye, and if that provides no relief, I put in topical anesthetic,” she said. “If there is still no relief, then the patient may have neuropathic pain and standard dry eye therapy is likely to be ineffective.”
For testing, Dr. Dhaliwal says she now uses the phenol red thread test instead of Schirmer test, and she recommended using a fluorescein strip instead of solution so as to avoid missing subtle pathology. She emphasized the importance of a thorough external examination at the slit lamp with attention to the meibomian glands, blinking, and identification of Demodex.
A range of treatments can then be considered based on the findings from the evaluation, but education and empathy are critical as well in managing these individuals who may have already been to many other physicians seeking a magic cure.
“Take a little time to talk to these patients,” Dr. Dhaliwal said.
“Be empathetic and give them hope they will get better,” she said. “However, let them know you are striving for a long-term solution because they have a chronic disease and that results will not occur overnight.”