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    Testing at point of care for improved patient satisfaction, re-treatment rates

    Preoperative testing identifies both symptomatic and asymptomatic ocular surface disease

     

    A valuable series of tests

    Dry eye testing begins subjectively. When patients check in at the practice, they fill out a questionnaire about their ocular symptoms. In response to the question, “What is your most bothersome symptom?” many patients offer answers that indicate dry eye.

    Even patients who do not have symptoms can acquire dry eye after any surgery. However, if we do not detect, explain and treat the problem, the surgeon will be blamed.

    Thus, my staff performs point-of-care testing for all patients. Test results determine whether the patient will have measurements for surgery that day or begin dry eye treatment and be measured later.

    The first point-of-care clinical test we perform is a measurement of tear osmolarity (TearLab Osmolarity System, TearLab). It is important to do this test first because the effects of other tests on the ocular surface can influence the measurement.

    Next, we test for the inflammatory marker MMP-9 (InflammaDry, Quidel) to determine if the disease has an inflammatory component. Thirdly, we measure changes in visual quality caused by an unstable tear film (HD Analyzer, Visiometrics).

    The questionnaire and primary testing give a sense of what is happening on the ocular surface. For example, high scores on the dry eye questionnaire (Figure 1) and tear osmolarity above 308 mOsm/L or with an inter-eye difference above 8 mOsm/L indicate that the patient may have dry eye disease.

    If meibomian gland dysfunction (MGD) is suspected, we can extend the workup to include meibography (LipiScan, TearScience). A noninvasive tear breakup time test with my three-dimensional Scheimpflug camera (Sirius, CSO) is also illuminating.

    If the schedule does not build in time for meibography or other additional testing, we can reschedule a patient for further testing at a later time.

    When the tests reveal dry eye, we are meticulous about improving the patient’s ocular surface before surgery. I prescribe anti-inflammatory eye drops, recommend omega-3 supplements and sometimes use punctal plugs to lower the outflow of tears from the eye.

    When meibography shows significant atrophy or dilation of the glands, I start treatment with thermal pulsation gland expression (LipiFlow, TearScience) and/or intense pulsed light (IPL) treatment for inflammation (E-eye, E-Swin), as well as standard dry eye treatments, before measurements or surgery.

    We perform dry eye testing at follow-up visits after surgery; patients continue dry eye treatment for six months.

    Dr Erik L. Mertens

    Erik L. Mertens, MD, FEBO is Director and Ophthalmic Surgeon at the Antwerp Eye Centre in Belgium. He may be reached by E-mail: ...

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