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Diagnostic systems launch new era in dry eye care


New diagnostic platforms for dry eye disease can help in determining the underlying cause and severity, which is useful for guiding treatment decisions.



New diagnostic platforms for dry eye disease can help in determining the underlying cause and severity, which is useful for guiding treatment decisions.


Dr. Starr

By Cheryl Guttman Krader; Reviewed by Christopher E. Starr, MD

New York-Recent technological advances are improving the diagnosis of dry eye disease and should enable more timely intervention that will help to reduce the morbidity of this common condition, according to Christopher E. Starr, MD.

“New diagnostic tests for dry eye not only are increasing [ophthalmologists’] ability to identify affected patients correctly, but also our ability to offer appropriate treatment,” explained Dr. Starr, associate professor of ophthalmology, Weill Cornell Medical College, New York.

“Using sensitive and specific objective testing takes the guesswork out of dry eye diagnosis-allowing clinicians to identify patients with significant disease who might otherwise have gone unnoticed or not treated aggressively enough,” he added.

The value of some new dry eye diagnostic platforms relates to their ability to identify two features of the disease:

> Hyperosmolarity, which is a core mechanism.

> Inflammation, which is a result of hyperosmolarity and a defining characteristic of dry eye disease.

The currently available point-of-care device for measuring tear film osmolarity now plays a central role in his practice as a screening and follow-up tool, Dr. Starr said.

Patients are first seen by a technician who asks a series of questions to elicit any symptoms potentially associated with dry eye disease.

Patients with any of the following symptoms will then undergo tear osmolarity testing before the eyes are exposed to any drops or lights.

> Grittiness on awakening

> Foreign body sensation

> Redness

> Tearing

> Burning

> Intermittent blurred vision

> Fluctuating vision

“Validated standardized questionnaires, such as the Ocular Surface Disease Index, are useful for research studies, but a bit too time-consuming to be practical for daily patient care,” Dr. Starr said. “We have developed a more streamlined approach to patient screening. Because we exclusively use an EMR for charting, a verbal, technician-driven, questionnaire is much faster and easier than scanning in the OSDI 45 times a day.”

Dr. Starr added that bilateral measurement of  film osmolarity takes about 1 or 2 minutes, making it a lot faster than the Schirmer test.

In addition, unlike the Schirmer test, testing tear film osmolarity is reimbursable.

Dr. Starr noted that the Schirmer test as well as tear film breakup time (TBUT) and ocular surface staining still have a valuable role in patient evaluation as they can help to further determine the etiology of dry eye disease (aqueous tear deficiency versus evaporative).

However, having the symptom and osmolarity information available from the technician’s initial workup enables a directed, more efficient examination by the ophthalmologist and saves decision making time as well.

Tear osmolarity not only makes a diagnosis of dry eye, it also helps in assessing its severity.

Dr. Starr considers any patient with a hyperosmolar tear film or significant tear instability to be a candidate for immunomodulatory therapy with topical cyclosporine A 0.05% emulsion (Restasis, Allergan).

“Hyperosmolarity leads to ocular surface inflammation and the vicious progressive cycle of damage as outlined in the DEWS report,” he said. “My aim is to inhibit that process by therapeutic intervention, and cyclosporine is the only FDA-approved anti-inflammatory medication for treating dry eye.

“Even if patients have minimal symptoms but significant signs, such as hyperosmolarity or staining, proper therapy with cyclosporine should be initiated,” Dr. Starr added. “Similarly, anti-inflammatory treatment should be instituted in early stages of dry eye disease to prevent progression and potential ocular surface damage.”

Dr. Starr said he also likes to utilize a short tapering course of loteprednol etabonatel 0.5% gel (Lotemax gel, Bausch + Lomb) in conjunction with topical cyclosporine in patients with significant inflammation.

He also considers off-label use of topical azithromycin 1% (Azasite, Merck) for patients with dry eye disease associated with meibomian gland dysfunction or other forms of blepharitis because of the macrolide antibiotic’s anti-inflammatory activity.

Other considerations

Artificial tears also have a role in the management of all patients with dry eye disease, and Dr. Starr said he monitors frequency of their instillation along with changes in tear film osmolarity to determine treatment response.

A system for ocular surface interferometry that characterizes the tear film’s lipid layer (LipiView, TearScience) is also available in the United States for use in diagnosing dry eye. Though Dr. Starr does not have access to that technology yet, he hopes to have it soon. He believes it to be helpful for differentiating patients who have evaporative dry eye disease and for identifying patients who would benefit from treatment with the new thermal pulsation system for clearing meibomian gland obstruction (LipiFlow, TearScience).

Another platform that measures the level of matrix metalloproteinase-9 (MMP-9) in the tear film (InflammaDry, Rapid Pathogen Screening) is CE-marked and undergoing FDA review.

Dr. Starr said he intends to use it for diagnosis and follow-up when it becomes available, as studies show detection of elevated MMP-9 levels has very high sensitivity and specificity for diagnosing dry eye disease.


Christopher E. Starr, MD

e: cestarr@med.cornell.edu

Dr. Starr is a consultant for Alcon Laboratories, Allergan, Bausch + Lomb, Merck, Nicox, Rapid Pathogen Screening, and TearLab.



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