advancing the treatment of dry eye disease

Supplement to March 2016

Advancing the Treatment of

Dry Eye DiseaseDerek Cunningham, OD

Art Epstein, OD

Kelly Nichols, OD, MPH, PhD

Walt Whitley, OD, MBA

COPE CE ACTIVITY

AOCAdvanced Ocular Care

This continuing education activity is supported through

an unrestricted educational grant from Shire Pharmaceuticals.

Release Date: March 1, 2016; Expiration Date: March 1, 2019

This course is COPE approved for 2 hours of CE credit for optometrists.

COPE Course ID: 48410-AS

COPE Event ID: 110843Administrator Sponsored by

Advancing the Treatment of Dry Eye Disease

2 SUPPLEMENT TO ADVANCED OCULAR CARE MARCH 2016

FACULTY• Derek Cunningham, OD• Art Epstein, OD• Kelly Nichols, OD, MPH, PhD• Walt Whitley, OD, MBA

LEARNING METHODThis educational activity consists of a supplement and 20

study questions. To obtain credit, the participant should read the learning objectives contained at the beginning of this activity, read the material, answer all questions in the post test, and complete the activity evaluation Form. This educational activity should take a maximum of 2.0 hours to complete. Please follow the instructions provided below in the section entitled.

CONTENT SOURCEThis continuing education activity captures content from

a CE-accredited symposium held on Tuesday, October 6, 2015, in New Orleans, LA.

ACTIVITY DESCRIPTIONIt is estimated that 25 million Americans suffer from

dry eye disease (DED) and that $3.8 billion is spent on DED symptom relief annually in the United States.1 DED results in ocular discomfort, visual disturbances, contact lens dropout, and may lead to ocular surface damage. Meibomian gland dysfunction is a leading cause of evapo-rative DED2 and is frequently found in aqueous-deficient DED,3 making it one of the most common diseases observed in eye care clinics. However, it remains one of the most underdiagnosed.4,5

In order to reduce patient discomfort and improve ocu-lar surface health, it is critical that practitioners address the various underlying causes of what is broadly known as DED. In the last few years, numerous studies have demonstrated that the health of the ocular surface is a significant factor to success with any anterior segment patient, and much work has been done to establish the risk factors, symp-toms, causes, and treatment options for DED. However, the methodology preferences for evaluating and treating ocular surface disease remain disperse.

1. O’Brien PD, Collum LM. Dry eye: diagnosis and current treatment strategies. Curr Allergy Asthma Rep. 2004;4:314–319.2. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunc-tion: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011;52(4):1930–1937.3. Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive

summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922–1929.4. Bron AJ, Tiffany JM. The contribution of meibomian disease to dry eye. Ocul Surf. 2004;2(2):149–165.5. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop. Ocul Surf. 2007;5(2):75–92.

TARGET AUDIENCEThe target audience for this CE Activity is optometrists.

LEARNING OBJECTIVESAfter successfully completing this activity, optometrists will have improved their ability to:• Understand the latest estimates on the prevalence of dry

eye disease• Understand the importance of a thorough examination

of the ocular surface and adnexia• Identify the type of evaluations that will allow a definitive

diagnosis• Understand new evidence regarding the inflammatory

pathway• Apply new treatment strategies meant to increase effi-

cacy of dry eye treatments• Understand the importance of early symptom relief for

dry eye treatments • Apply evidence-based medicine in selecting a course of

treatment

ACCREDITATION DESIGNATION STATEMENTThis course is COPE approved for 2.0 hour of CE credit

for optometrists.

DISCLOSURESDerek Cunningham, OD, had a financial relationship dur-

ing the past year with the following commercial interests in the form of Consultant: Abbott Medical Optics Inc.; Advanced Tear Diagnostics; Alcon; Allergan, Inc.; ArticDx Inc.; Bausch + Lomb; Bio-Tissue; Glasses Off; TearLab Corporation. Grant/Research Support: Abbott Medical Optics Inc.; Alcon; Lumenis; Marco Ophthalmic Inc; and Optovue, Inc.

Art Epstein, OD had a financial relationship during the past year with the following commercial interests in the form of Consultant/Speaker’s Bureau: Alcon; BioD LLC; Bio-Tissue; NovaBay Pharmaceuticals, Inc.; PRN Pharmaceutical Research Network LLC; Oculus, Inc.; TearLab Corporation; and TearScience. Grant/Research Support: Alcon; NovaBay Pharmaceuticals, Inc.

Kelly Nichols, OD, MPH, PhD, had a financial relation-ship during the past year with the following commercial

Release Date: March 2016Expiration Date: March 2019

COPE Course ID: 48410-ASCOPE Event ID: 110843


interests in the form of Consultant: Eleven Biotherapeutics; Insight Pharmaceuticals; Kala Pharmaceuticals; Parion Sciences Inc.; Shire Pharmaceuticals; and Sun Pharmaceutical Industries Ltd. Grant/Research Support: Eleven Biotherapeutics; Kala Pharmaceuticals; and Shire Pharmaceuticals.

Walt Whitley, OD, MBA, had a financial relationship during the past year with the following commercial inter-ests in the form of Consultant/Speaker’s Bureau: Alcon; Bausch + Lomb.

DISCLOSURE ATTESTATION Each of the contributing physicians listed above has

attested to the following: (1) that the relationships/affilia-tions noted will not bias or otherwise influence his or her involvement in this activity; (2) that practice recommenda-tions given relevant to the companies with whom he or she has relationships/affiliations will be supported by the best available evidence or, absent evidence, will be consistent

with generally accepted medical practice; and (3) that all reasonable clinical alternatives will be discussed when mak-ing practice recommendations.

PRODUCT USAGE IN ACCORDANCE WITH LABELINGPlease refer to the official product information for each

product for discussion of approved indications, contraindi-cations, and warnings.

GRANTOR STATEMENTThis COPE CE Activity is supported through an unre-

stricted educational grant from Shire Pharmaceuticals.

DISCLAIMERThe views and opinions expressed in this educational

activity are those of the faculty and do not necessarily represent the views of The State University of New York College of Optometry, Evolve Medical Education LLC, Shire Pharmaceuticals, or Advanced Ocular Care. n

MARCH 2016 SUPPLEMENT TO ADVANCED OCULAR CARE 3




MOST IMPORTANT SYMPTOM OF DEDDr. Cunningham: What do you think is the most important over-

all symptom seen in patients with DED? What are they concerned about the most? Is it: ocular discomfort, eye redness, fluctuating vision, or inability to continue near-vision tasks.

Kelly Nichols, OD, MPH, PhD: In my practice, the most common problem that patients report in the symptom-based surveys is ocular discomfort and/or dryness. But, that is not always what your patients say is bothering them when they are trying to function and work. I hear a lot of complaints regarding “fluctuating or changing vision.” More and more, we are starting to ask questions about doing near work, including using handheld devices, and how that is affecting patients’ vision. Patients are using handheld devices like smartphones and tablets all the time, they are having trouble seeing, and they report blinking to clear the image.

Art Epstein, OD: We are seeing a younger population, and they tend to be much more visually aware than the more traditional older population. I hear more complaints about visual variability.

Walt Whitley, OD, MBA: When it comes to fluctuating vision, we have to be careful when we are talking to our patients because if you ask them, “Does your vision fluctuate?” they may have no idea what that means. But if you ask them, “Does your vision change through-out the day? Is it clear, and does it become blurry and clear again?” they will have a better understanding of my question. I changed my phrasing from the information I learned at the Dry Eye Summit. I also changed how I talk to patients about their vision.

BOSS STUDY Dr. Cunningham: The Beaver Dam Offspring Study (BOSS),1 pub-

lished in 2014, was probably the most pivotal study we have seen so far in DED (Figure 1). The researchers in the BOSS found that the prevalence of DED is dramatically higher than we originally thought. The most surprising thing I learned from this study was that the

split between men and women did not happen until women were perimenopausal. In 20-year-olds, those in their early 30s, and even individuals in their teens, there is the exact same amount of DED. Statistically, DED did not vary between men and women, which was really remarkable. We all think of DED as being more prevalent in women, so that was one of the key points I took away. If we are look-ing at 14% of the US population, it is a huge number. That puts DED at anywhere between 30 and 50 million people.1

Dr. Whitley: In the BOSS, it is important to take a look at the patients between 21 and 49 years of age: 14.1% of patients had DED.1 These are patients that we have overlooked because when we think of ocular surface disease and DED, postmenopausal women and aging often come to mind. We need to remember the younger patients and be more aggressive in asking the right questions and providing the appropriate treatment.

Dr. Cunningham: Let us look at the size of the United States market (Figure 2). There are approximately 30 million to 50 million patients with DED in the United States.1 There are only 2 million

This live roundtable used an app that allowed the audience to actively participate during the meeting and share discussions with other users of the app, regardless of their locations.

In conceptualizing Advancing the Treatment of Dry Eye Disease, we wanted to come up with the same type of candid conversations that we have with each other away from the podium. We wanted this roundtable to be a glimpse of what we truly think about some of the procedures used to treat dry eye disease (DED), because frankly, the options can be overwhelming.

In 2014, this faculty participated in the first-ever Dry Eye Summit in Dallas. We brought together about 30 of the top DED experts in North America. From this summit, we realized that we have a large brain trust, but even the experts are on different pages. The Dry Eye Summit was quite chaotic with many diverse opinions, and we all learned many new pearls. We all do things very, very differently. With the management of DED, optometry has an opportunity to own a disease state and truly help patients—not only by improving their comfort but the quality of their vision as well. This, after all, is how we are often judged by our patients.

—Derek Cunningham, OD

Figure 1. Prevalence of and risk factors for DED in BOSS.1



suspected glaucoma patients in the United States.2 If we are looking at where our resources should be put on a day-to-day basis in clinic or how to best serve the public, these are sobering numbers. Also, according to IMS Health data from 2014, the artificial tears market in the United States is about a $530 million market. Restasis (cyclospo-rine; Allergan), the only prescription medication indicated for kerato-conjunctivitis sicca in the United States, has sales around $1.4 billion.

Dr. Epstein: From an epidemiologic point of view, we are looking at an extremely dynamic situation. We are seeing rapid shifts that the studies are not even keeping up with. My experi-ence is obviously anecdotal, but I am seeing younger and younger patients. I have some weeks when I am seeing preteens with DED. Likewise, from the dry eye products market, we are seeing the tip of the iceberg. This is quite an opportunity for optometry to reach additional patients.

ARTIFICIAL TEARS MARKETDr. Cunningham: According to IMS Health, there are 17.7 million

US households that bought DED products last year. In a 52-week period, the average household buys 3.1 units of artificial tears. How are these individuals using artificial tears if they are only buying three bottles a year?

Dr. Epstein: Very sparingly. This is going to sound crazy, but my goal is to have patients not use artificial tears. Patients with healthy eyes do not use artificial tears. In my scheme of managing patients, I suddenly started to notice that more and more patients were com-ing back feeling better, and less and less patients were using tears that I had prescribed. I realized I was on the right track. Artificial tears are an old standby that we have been accustomed to rely on.

Dr. Cunningham: I think your point clearly shows that people are simply reacting when their DED becomes out of control or they use artificial tears until they forget about them. Then, they wait until their DED spirals out of control again before continuing with the drops.

Dr. Whitley: We tell our patients, “You have DED, you need an artificial tear, here is a sample, use it four times a day.” We need to emphasize to patients that compliance is key. This is an opportunity for us to educate our patients on their condition. They need to use this drop, whether it is an over-the-counter artificial tear or whether

it is a prescription product. We need to educate our staff on how to help us to improve patient compliance.

Dr. Cunningham: Does our recommendation really matter in the artificial tears market?

Dr. Nichols: It probably does. Market data has reported that a high percentage of artificial tear buyers have not been formally diagnosed with DED by an eye care provider.

Dr. Cunningham: Those patients are driving more sales than the rest.

Dr. Nichols: They are the seekers.

Dr. Cunningham: Of that endless sea of artificial tears in the phar-macy, there is one tiny bottle that outsells everything else—the red eye reliever (Figure 3). What does that tell us about what patients want? We need to stop thinking about what we think patients want, and start listening to what patients actually want. Nothing tells us more than what patients want than the market. Red eye relief is far more important than we give credit for. Why does everyone buy red eye relievers? It works quickly every time and takes the red out of patients’ eyes. If you think you see a lot of patients with DED, how many of them are buying red eye relievers? These are the people we need to identify.

Dr. Epstein: We have a tremendous opportunity to treat patients with DED. Obviously, they do not want to look tired or like they were out all night. For example, these people may be afraid that their boss is going to say something about their appearance. Our practice created a webpage specifically to educate these individuals about red eye, which has actually drawn a fair number of patients.

Dr. Nichols: Eye redness may be an useful indicator in DED, and I believe that we need to pay more attention to patient reports of redness.

Figure 2. Estimated number of DED patients and market size for

artificial tears and cyclosporine.

Figure 3. Millions of units sold each year of artificial tears in the United

States.



Dr. Whitley: I think you are all missing the boat. I acknowledge that there is a market for red eye relievers; however, we need to identify the underlying cause. We need to figure out why our patients’ eyes are red. Using these products is like putting a bandage on the problem. I do not disagree that there is a market for artificial tears, but what are you going to do about the underlying cause?

Dr. Nichols: It should trigger your exam.

Dr. Cunningham: Because we capitalize on the market, we know that there is an off-label concoction that many of us will use for getting the red out (Figure 4). Even some of the ESPN anchors use this. For years, when we were treating glaucoma patients with brimonidine, we realized that, although there is a fair bit of an allergic reaction, most patients have with blanched, white eyes. We diluted the solution with Optive Refresh (Allergan). The ratio is five drops of a sample bottle of brimonidine, which is free, into five drops of a sample bottle of Optive, which is also free. Does anyone here do this?

Dr. Epstein: Yes, I use six drops, which seems to work well with my patient population.

Dr. Cunningham: The reason we use Optive is because the nipple on the cap snaps off. If you use a cap, you can aseptically snap off the nipple. You do not have to touch it, you can put the drops inside the bottle, and screw the cap back on. It is not totally sterile, but you have an untouched concoction that you can give to a patient. You cannot sell this mixture because that would be compounding and then selling it. Bausch + Lomb hopes to come to market this year with a version of this.

Dr. Epstein: I call them “magic drops” and the patients want them. To address Dr. Whitley’s comment, this is a good strategy for dealing with redness, but there are underlying causes such as mei-

bomian gland dysfunction (MGD) or overpopulation of bacterial lid commensals. There are additional ways of managing DED that can reduce a lot of the inflammation and redness.

MEIBOMIAN GLAND DYSFUNCTIONDr. Nichols: There are not much data on the prevalence of MGD,

because it has not been studied on a population basis until fairly recently. There has been a lot more work in Asia, because doctors have been looking at MGD a bit more closely for a number of years (Figure 5). If you talk about the US study, there is 14.5% prevalence.1

In Asia, there is more than 60% prevalence of MGD.3

Dr. Cunningham: Is that the general population with MGD? Sixty percent?

Dr. Nichols: Yes, and you have to take that figure into consider-ation. The first study is of the general population. The second one is a clinic-based study. The third one is a Japanese study.3 The studies were not necessarily designed to evaluate MGD, but taken together, these studies represent the best data we have. This information is from the MGD report,4 which came out a couple years ago. There have been a few more studies that have been done since, but they tell the same story. We are either looking more carefully for MGD or the prevalence is very high in other parts of the world. Perhaps we are not reflecting that here, because we are not measuring it appro-priately, or maybe there is something different about the population.

Dr. Cunningham: Is there a definitive US study on MGD preva-lence? There is a huge number difference there.

Dr. Nichols: No, not across the population. There is a wide range of MGD prevalence sited in various places, anywhere from 4% to 70%. It depends on how you are categorizing it and whether you are classifying it just on the quality of the secretions. If we look in clinics, of course, we would expect a higher prevalence. But those numbers

Figure 4. An off-label concoction of brimonidine and lubricant eye

drops is used by many to relieve red eye. Figure 5. Worldwide prevalence of MGD.

Graph created by Debra Schaumberg, OD, and presented by Kelly Nichols, OD.



should be staggering to you. That means if you look at patients, you are going to find DED every day in your patients, and we need to look more.

Dr. Cunningham: What is staggering to me is the error bars: 4% to 70%?

Dr. Epstein: This is my experience, exactly what Dr. Nichols is saying. I have a subset of patients coming into my office because they have DED. And the vast majority—probably 90%—have MGD, so it is a self-selecting sample, but MGD is just about everywhere for me.

Dr. Nichols: Most of my work has been treating DED in post-menopausal women (Figure 6). I think it is interesting to compare this—a group of women older than 52 years of age—to the BOSS.1 We classified them in a number of ways: (1) aqueous-deficient DED, (2) mixed, which is a combination of some sort of aqueous deficien-cy and MGD, or (3) just evaporative DED, or (4) mixed. If you add up those with MGD, you have 90% of those older than 60 years of age who had DED—some form of MGD.5 So we should be looking for MGD in all of our postmenopausal women. I am always startled by your data in the younger folks, Dr. Epstein. You are going to find it if you look there, too. It is a growing segment.

Dr. Epstein: Most of these patients are symptomatic. The vast majority come in complaining, which is really disturbing.

Dr. Nichols: You do notice some trends if you look closely at evaporative DED; the younger age groups are more likely to have it. If you look at younger patients, you would still find more DED.

Dr. Cunningham: Who here expresses meibomian glands?

Dr. Epstein: Yes. Always.

Dr. Whitley: Every time.

Dr. Cunningham: Therapeutically or diagnostically?

Dr. Epstein: Both.

Dr. Whitley: Both. We teach all of our residents and students that you do not know what is normal until you keep expressing the meibomian glands and examine the secretions. What kind of secre-tions, if any, are coming out of the eye? Is it a clear oil? Is it cloudy secretion? Inspissated or totally blocked? This is something that all of us have often overlooked.

Dr. Cunningham: That is diagnostically expressing them, though. Will you routinely take a patient with DED who you knew had stagnant meibomian glands and therapeutically manually express his or her glands every time?

Dr. Whitley: I did it today.

Dr. Nichols: No, not every time.

Dr. Cunningham: Right, because you run the risk of crushing the lumen of the gland. Do you agree?

Dr. Nichols: I agree. I think that we need to be cautious about how much and the technique we use to express the meibomian gland.

Dr. Epstein: Yes, do not confuse diagnostic and therapeutic, especially from the audience’s perspective. To me, diagnostic expression is a great test of function. You are not applying a ton of force. Use the same force that would be exerted by a blink. If you see significant lipid coming out of the gland orifices, it is telling you that at least some of the glands are functioning and producing lip-ids, which is very important. I have seen some people use paddles, and they will really give it a strong push, which does not tell you very much because it is not what typically happens during normal eye function.

Dr. Cunningham: I think that meibomian glands need to be evacuated, especially if they are stagnant because that is the only way that they are going to start to work again. My fear is that those who routinely manually express meibomian glands with a lot of pressure is that it will eventually start to crush the lumen of the gland. The gland is a very delicate tissue, and if you are using too much pressure in trying to evacuate it (especially if you do not heat it adequately first), you are trying to push out stagnant and solidi-fied meibum that will not flow. By doing that, and trying to put too much pressure in that area, you are probably slowly killing the meibomian glands faster than they would otherwise die.

Dr. Nichols: It is thought that obstruction of that duct causes the stagnation to occur inside. We are trying to understand what causes that duct to be blocked—what is going on with the keratins and the skin layer? We know there are some irregularities that can be seen clinically. There is a lot more work to be done before we fully understand MGD. Although the processes in DED are com-plex, tear film instability is a hallmark that we see clinically. Right

Figure 6. Prevalence of DED in postmenopausal women.



now, most of the drug companies are focusing on the sequelae of DED, the inflammatory components, or in stabilizing the tear film.

Dr. Epstein: Blinking is a way of expressing meibomian glands and is also a way of debriding the lids. When you have partial blink-ers, not only do you have stagnation of meibomian gland produc-tion, but you also have significant buildup that can interfere with the meibum getting into the tear film, and it can also interfere with meibomian gland secretion.

Dr. Nichols: If you scrape that off, patients sometimes can become asymptomatic.

MAXIMIZING RESOURCES AND DIAGNOSTIC TESTSDr. Whitley: Before we talk about diagnostic testing, how do you

use your staff to help you address ocular surface disease?

Dr. Epstein: On one hand, the government is pushing us away from fee-for-service reimbursement, toward a capitation model and toward metrics for determining quality of care. At the same time, you have decreased reimbursements, and you have insurance companies that do not want to pay—they seem to want to place the burden on patients. So you have angry, aggravated patients who certainly are not going to look at your care as high quality. The only defense we have is by empowering technicians and engaging them to actually help us in providing higher quality care. Just as we were taught in school, we should interpret test results and then make decisions. I have a technician who works almost exclusively with me, and she is phenomenal. She does at least 50% to 60% of the workup.

Dr. Whitley: Let us look at the commonly used tests (Figure 7). What is your favorite?

Dr. Nichols: Meibography and a symptom survey like the Ocular Surface Disease Index (OSDI) or the Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire.

Dr. Whitley: Meibomian gland evaluation with Lipiview II (TearScience) and tear osmolarity.

Dr. Epstein: The questionnaire for sure and meibomian gland testing as well.

Dr. Cunningham: I do not use questionnaires. I just ask patients questions. I find that my patients do not have time to fill out a questionnaire. So, I simply ask them if their eyes are dry.

Dr. Epstein: We use tear meniscus height instead of a Schirmer strip.

Dr. Cunningham: Diagnostically, I usually use staining tests, but as far as managing patients, I use tear film osmolarity testing.

Dr. Nichols: Do you do tear film osmolarity testing on all your patients?

Dr. Cunningham: Yes, on all the patients once they are diagnosed.

Dr. Epstein: If part of the workup, tear osmolarity testing can be done by a technician. Tear meniscus testing can be done if you have the right instrumentation. The technicians can test for the blink rate, matrix metallopeptidase-9 levels, and tear interferometry. Staining is something you really need to do yourself. You also need to evalu-ate meibomian gland function, whether you are using a meibomian gland evaluator or if you are using your fingertip (Figure 8). You need to see for yourself what is going on.

Dr. Nichols: Are you doing those two tests, yourself?

Dr. Epstein: Yes, and the other tests are done by my technicians.

Dr. Nichols: What about you, Dr. Whitley?

Dr. Whitley: In our practice, we have a protocol that our tech-nicians know about. We talked about using our resources. We do numerous meibomian gland treatments. We have a DED counselor, just like we have a cataract counselor or a contact lens counselor. When it comes to the DED diagnostic testing, if it is a new patient or existing patient, our staff knows that when he or she checks in, that the patient will need to first use the SPEED screening questionnaire.

Figure 7. Tests used to diagnose DED.

Figure 8. Meibomian gland evaluation using a fingertip or a gland

evaluator.



If a patient comes to our office specifically for DED, we have a complete diagnostic protocol. We may or may not do all of the test-ing that is available, but it is important that your staff is on board and knows exactly what tests to perform. Additionally, we have a process in place to identify our DED patients in multispecialty clinics (retina, glaucoma, etc.). For instance, our retina specialist is not going to address the DED. But within the protocol for any of his patients (diabetes, macular degeneration, etc.), the patient fills out a SPEED questionnaire, and if patients have DED symptoms, we will perform tear osmolarity testing, which is our preferred point-of-care test. If the patient has a symptom and high tear osmolarity levels, then he or she will be referred to our DED clinic for an appropriate evaluation.

Dr. Cunningham: Dr. Epstein, are you using these DED questionnaires?

Dr. Epstein: We do.

Dr. Cunningham: So these are readily available questionnaires?

Dr. Epstein: And they are free. We use the OSDI.

Dr. Cunningham: We use the SPEED questionnaire for an ocular surface disease exam, but we do not screen all of our patients with a questionnaire.

Dr. Nichols: In our DED clinic, we usually do the OSDI to obtain a baseline in the clinic when a patient is referred to our office. We have tried using the SPEED test.

Dr. Epstein: When using the SPEED test, I like that you can treat the patients and follow them by repeating the test to get an objec-tive measure of how the patient is doing. However, I agree that talk-ing to the patient is much more important.

Dr. Whitley: We use the SPEED questionnaire in our practice. It lets the patients think about how severe their condition is and how frequently it affects them. It gives a score of their subjective symp-toms. The score helps us and helps the patient understand that per-haps he or she is improving.

UNDERSTANDING OSMOLARITYDr. Whitley: We know that a hyperosmolar state can lead to a

cascade of inflammatory events.

Dr. Cunningham: The main point about osmolarity is that 90% of the osmolarity units in the United States are in ophthalmology offices rather than optometry offices (data on file with TearLab Corporation).

Dr. Whitley: The most important issue when it comes to tear osmolarity is understanding the test (Figure 9). We know DED is a variable condition and that you are going to have some fluctuations in results, especially in patients with more severe conditions.

Dr. Nichols: I think that tear osmolarity testing got a bad reputa-tion early on because clinicians would see the difference between the two eyes, and patients would not understand what that meant. Is this eye “right” or is that eye “wrong”? If you see a difference between the two eyes, that means something. You see that variability reduce as you start to manage these patients. If you look at patients with healthy eyes, they are really consistent over time between the eyes. If you look at patients with DED, they can be all over the map.

Dr. Cunningham: Think about osmolarity this way. When you use a glucometer, if you see blood sugar readings that vary greatly, do you say the glucometer is broken? Or do you say the patient has diabetes? It is the same situation with osmolarity. If you are getting osmolarity readings that are over the place, it would mean dysregula-tion of homeostasis. You cannot maintain a baseline.

Dr. Epstein: I look at this situation as an ocular surface health index. When you have someone who is in the range of 350 mOsm/L and above, this is a very strong indication that his or her ocular surface is in serious need of help.

DIAGNOSTIC DEVICESDr. Whitley: The Keratograph 5M (Oculus) is a popular diagnostic

tool in the evaluation of DED (Figure 10). I have used it in our clinical research protocols and was impressed. Dr. Epstein, tell us how you use this in the clinic and its benefits.

Dr. Epstein: I love this device. In fact, it was a real surprise when we first started using it in Phoenix about 2.5 years ago. What is helpful about this device is that we needed topography in the office for fitting specialty lenses and evaluating the cornea, and we also knew that it had the capability of doing meibography, tear meniscus height measurement, and non-invasive tear breakup time.

Dr. Cunningham: Do you use all of that on every patient?

Dr. Epstein: No.

Dr. Nichols: Have any of you used the report function?

Figure 9. Understanding and interpreting tear osmolarity testing.



Dr. Epstein: We have used the report function. I think it is not quite ready for prime time. What is great about this report is that it incor-porates results from many of the instrument’s tests and other tests as well. You can give the report with the test results to the patient after-ward. The patient now has documentation to take home and discuss with his or her family. Most of the time I spend with my patients is discussing their test results and their disease, listening to their symp-toms, and talking about a treatment plan. So, I am doing relatively little testing myself. This device frees me up tremendously. To me, the most important test is probably meibography. We have other companies that have introduced more advanced forms. In fact, we are looking at the LipiView II (TearScience) (Figure 11), which has higher resolution dynamic meibomian imaging (DMI). I do like the Keratograph’s non-invasive breakup time. I describe it to patients as a measurement of tear structure. Basically, we are looking at tear stability. I image every DED patient.

Dr. Whitley: I also image every DED patient.

Dr. Cunningham: To tell you the truth, we go further. Every patient that comes in our clinic does not undergo a full LipiView II test, but he or she does get the DMI. For every single person that comes in our clinic, whether it is for aesthetics, cataract, LASIK, dis-ease, we look at their meibomian glands. This test takes less than a minute. We are not looking at lipid layer on all patients. We do DMI because I want to see the meibomian glands on all patients. It is that pivotal in our practice now.

Dr. Epstein: The vast majority of the patients I am seeing are patients with DED who have self-identified as having the disease. So yes, I am performing meibography on my DED patients.

Dr. Nichols: We do meibography on all of our DED patients, but I am curious, do you think there is a difference between upper and lower meibomian glands?

Dr. Epstein: I think there is a significant difference. Sometimes, you will see glands totally wiped out superiorly, and you will see

viable glands with reasonably normal structure inferiorly or vice versa. You will see a lot more tortuosity, and you see a lot more duct dilation as a sign of gland obstruction.

Dr. Cunningham: We had the Keratograph 5M 3 years ago—right when it first came out—and I thought it was phenomenal. It is a remarkable machine.

Dr. Epstein: The educational value is extraordinary.

Dr. Whitley: The LipiView II definitely helps increase patient com-pliance by showing patients their eyelids/glands and why we need to address their glands. Other reasons why I utilize the LipiView II is the interferometry and the partial blink ratio. The interferometer allows for a quantification of the lipid layer of the tears. I look at the patient’s partial blink; this is something the Lipiview II measures during the test—how many times the patient does a full blink. If they do not do a full blink, then that leads to exacerbation of their symptoms. We know that each time the patient blinks, the Riolan’s muscle does express some of the meibum. We can prescribe blinking exercises to help patients address this issue.

THE SJÖGREN TEST Dr. Whitley: This is a condition that is definitely underdiag-

nosed. DED is one of the most common eye diseases in the United States, affecting nearly 29 million American adults.6,7

In the United States, Sjögren syndrome is estimated to be the sec-ond most common rheumatologic disorder, behind systemic lupus erythematosus. Sjögren syndrome affects 0.1 to 4% of the population.8 It is estimated that one out of 10 patients likely has Sjögren syndrome.9 This is an opportunity for us to identify patients and diagnose and treat them accordingly.

Dr. Cunningham: I am curious to see how many people use the Sjögren syndrome test (Sjö; Nicox).

Dr. Nichols: I am curious about the panelists, too. With all of our students, we had trouble finding consistency in students being able

Figure 10. The Keratograph 5M is a popular diagnostic tool in the

evaluation of DED.

Figure 11. LipiView II images in 3 modes—DMI, adaptive

transillumination, and dual-mode.



to perform this test, as it seems like you need a technician who is doing it all the time. We are now referring these patients to the hos-pital lab at University of Alabama at Birmingham.

Dr. Cunningham: We do not do this.

Dr. Whitley: We send our patients to a specific lab to have the test performed.

Dr. Epstein: We send it to the lab.

Dr. Cunningham: LabCorp now has a national contract for this test. You can do this in the office, and if you do not have read-ily accessible labs in and around your area, I suggest you look into doing it. The test consists of a finger prick. It just takes a lot more time because you have to certify staff to be able to perform the test, and there are infectious disease protocols that must be followed. Or, you can send someone to the lab to get it done, in which case you will not be paid for doing this in your clinic. I suggest sending your patients to the lab where they can get their blood drawn, and you can suggest any other tests you think are necessary. I order the Sjö about twice a week.

Dr. Whitley: Many times, patients want to know why their eyes are dry. Sjö test can give them an answer. This newer panel has sev-eral novel proprietary markers (salivary protein-1, carbonic anydrase, parotid secretary protein) in which the specificity and sensitivity is much, much higher. When it comes to Sjögren syndrome, we are used to hearing about dry eyes and dry mouth, but those are just some of the early symptoms of other cardiovascular problems as well as kidney and liver function, so we play a huge role in helping these patients (Figure 12).

Dr. Nichols: There is also a high prevalence of lymphoma in patients with Sjögren syndrome.

ALLERGIES AND DEDDr. Whitley: Dr. Cunningham, can you tell us why you do allergy

testing in your practice?

Dr. Cunningham: Skin testing is awesome. It tests for the

60 known environmental allergens (not food allergens) in the patient’s geographical area. It is a skin prick test in which 60 spots are tested on the patient’s arms, and the patient is billed per spot. Most importantly, the test reveals the patient’s allergies. In our DED clinic, skin testing has really helped us be more defini-tive in treating DED, identifying true DED, and getting rid of the allergy component (Figure 13). We absolutely love this test and probably do three or four per day.

Dr. Nichols: How does it work?

Dr. Cunningham: You have preformed allergens in welts that you buy from the company for your particular area of the United States. They come in a little tray with pointers on it that you stick on the patient’s skin. The test is a predetermined 60-grid pattern on the patient’s arms. Based on which welts form, you know what the patients are allergic to. The wait time is typically about 3 to 10 minutes. We have our technician administer this test. Some states will allow optometrists to bill for this testing, and others will only let an MD bill for this.

Although there has never been an anaphylactic reaction result-ing in death in the United States with this test, I feel that if you are testing at this level, a crash cart should be available on site. This is not required. You are only required to have an EpiPen (epineph-rine auto injector; Mylan).

Dr. Whitley: I have a classic example where point-of-care allergy testing comes into play. I had a patient who had nonspecific symp-toms of allergy and DED, and I educated her on why the skin test was important in the management of her condition. I said, “Mrs. Smith, you tested positive for allergies to red cedar.” This caught her by surprise. She mentioned that she had a large red cedar tree out-side of her bedroom window. We know that avoidance is the No. 1 treatment for allergy. So I said, “Close your window, take a shower at night before you go to bed to wash out all the pollen, and change your sheets more frequently.” Just by identifying what she was aller-gic to, we were able to manage her symptoms much better.

STEROIDSDr. Epstein: Does anybody use difluprednate (Durezol; Alcon) for

DED (Figure 14)?

Figure 12. Sjögren syndrome is about more than just DED. Figure 13. Who should be tested for environmental allergens?



Dr. Cunningham: Typically, loteprednol (Lotemax; Bausch + Lomb) would be my go-to for DED. We are using difluprednate more and more in a non-dry eye—and typically twice a day and even four times daily; we found some utility for it. Difluprednate is a fantastic drug. I think loteprednol is going to be our mainstay for years to come, and I am prescribing it more often. Anyone who is symptomatic to any degree will probably be prescribed a steroid in my clinic, and patients that have any amount of staining will probably be prescribed a steroid in my clinic. Not long term, but at least short term.

Dr. Nichols: Do you think difluprednate is too big of a gun to solve the problem when other choices are available?

Dr. Epstein: Well, I do not want to say I am steroid aversive, but I am steroid cautious. I have become much more steroid aggressive, but my mainstay is loteprednol at this point. I do think there is a role for prednisolone acetate (Pred Forte; Allergan). I think there may be a role for difluprednate, but this is not therapy to be used for a long period of time and very rarely with more than twice-daily dosing.

Dr. Whitley: I normally go with loteprednol, but it is an emulsion. If your patient ends up getting prednisolone acetate or any of the suspensions, he or she is getting a “diet steroid” and needs to shake the bottle 25 times to address settling issues. If it is an emulsion, instill the drops once per day to treat that inflammation.

Dr. Epstein: What do you think about using steroids long term? Obviously, I said that I do not.

Dr. Cunningham: It depends on the definition of long term. I feel completely comfortable with almost all patients using loteprednol for up to 3 months.

Dr. Epstein: Is there a safe steroid? I imagine that you are going to say that every steroid is safe.

Dr. Cunningham: We went to school to first learn how to make people feel better, and then we were educated enough to deal with

the side effects. Under no circumstances do you ever do anything that can possibly harm a patient. We were left to prescribe artificial tears to all DED patients until they found another doctor. Things change, and we realize now that when patients are symptomatic, you need to make them better yesterday. That is why we use a ste-roid. I am comfortable using loteprednol for up to 3 months. Yes, I do watch intraocular pressure. If I am using difluprednate, it is a much shorter duration and a much lower dosage—usually easily less than a month, maybe even just 2 weeks.

Dr. Epstein: I do not use steroids as much. I have to see signifi-cant inflammation and discomfort that is not resolving quickly.

IMMUNOMODULATORY AGENTSDr. Epstein: As you are probably well aware, we have cyclospo-

rine, which is a T-cell modulator; it has an immunomodulatory effect. There was recently a published clinical trial regarding tacroli-mus for allergy.10

Dr. Cunningham: Some people may not be familiar with lifitegrast (Shire). Shire is new to the ophthalmic space. It is a company that works with rare diseases, and it is hoping to come to market with a product that is an immunomodulator. This is different from cyclosporine. It is not yet approved, it is in phase 3 trials. Everyone here has some familiarity with it, so we can only speak to what is on public record. Dr. Whitley, your practice was a study site, correct?

Dr. Whitley: Yes, we were involved with the OPUS-1 and OPUS-2 trials.11,12

Dr. Cunningham: The trial investigators are studying signs and symptoms of DED. This drug could be on the market this year.

Dr. Epstein: What is exciting about lifitegrast is that it has a totally different mechanism, and it operates on the surface. If you think about it, surface disease is modulated at the surface, so it may be a significant addition.

Dr. Cunningham: The thought is to stop T-cell binding, which is the idea with intracellular adhesion molecule-1.

Dr. Epstein: If it works, it is going to be great. Let us hope it does for all of our sakes.

PUNCTAL OCCLUSIONDr. Epstein: Punctal occlusion is interesting. At one point, if you

walked into our office with DED, you got punctal plugs (Figure 15).

Dr. Cunningham: Why was that?

Dr. Epstein: Because we did not have much else to do, and we bought into the plug story. It was a procedure that made me feel like I was doing something, and most patients seemed to benefit.

Figure 14. Topical steroids used in the treatment of DED.



Dr. Cunningham: Reimbursement was quite high.

Dr. Nichols: The procedure might have generated a lot of money, but we had patients who did really well.

Dr. Epstein: There is no question that for some patients, punctal plugs worked well. Yet, I find myself very rarely using plugs these days. I am not sure if it is a change in philosophy, my sophistication with dealing with patients, or other available options. In fact, I am removing more than I am putting in.

Dr. Whitley: Punctal plugs are definitely underutilized. I think the rate is anywhere between 1% to 3% right now in the Medicare population.13 These are used for long-term conditions, and I tell patients that anything that we can do to increase the contact time of their tears and increase the contact time of their medication is only going to help them. I use punctal plugs frequently.

Dr. Cunningham: I use a ton of them. We are getting the dis-solvable plugs for use especially in patients with allergies. We like using those outside of allergy season.

Dr. Nichols: But not during allergy season?

Dr. Cunningham: Right. If you insert punctal plugs during aller-gy season, they just maintain allergens, and patients end up with worse allergies. It is important to treat the inflammation before inserting a plug. We used a lot of punctal plugs when reimburse-ment was high, we then fell out of love with them for a while, and for some reason, over the past several years, we are once again using a great number of punctal plugs in our clinic.

Dr. Epstein: I am concerned about what I used to call “the cesspool effect,” which occurs when you are blocking all of these inflammatory mediators. The literature is quite equivocal. It says plug the lowers, the uppers increase drainage, plug the uppers the

lowers drain more, so I am not totally convinced of the effective-ness of plugs. But, as you can see, we all have different opinions.

AUTOLOGOUS SERUM AND LIPIFLOWDr. Epstein: How many of you are using autologous serum?

Dr. Cunningham: I used it quite a while ago, and I have not used it probably in a year or 2.

Dr. Whitley: Yes, we attempted to try it in our area, but I could not find a lab to prepare it for me.

Dr. Cunningham: I used it a lot when I was in medical school at Texas Tech, and it was because I had a lab downstairs. The lab technicians would charge me $60 to send the serum down, pull three vials, spin them for 10 minutes, pull up the serum, and make the drops. When it was that readily available, it was easy to do. But now it is approximately $600 to $1,000 per patient per draw to get it done. The cost is now excessive.

Dr. Epstein: One of the problems with autologous serum is that it has to be refrigerated, and then the patient has to carry it around, which is quite an inconvenience. So, we use LipiFlow (TearScience). From my perspective, if you are going to be a dry eye specialty prac-tice, this is essential equipment. It has been life-altering for many patients, but despite phenomenal results for some, I have also had some failures. It does not work on every single patient. But it has taken patients who have been in miserable shape, who have seen as many as eight other doctors, and we have been able to get these patients back on track. And in some cases, not using anything else.

We had a patient with Sjögren syndrome who came into our office wearing wraparound glasses. Her face was a mask of pain. She had been to countless doctors, and we ended up running out of options after a while. We used LipiFlow (Figure 16), and she came back a year later. I saw her in between that time, obviously, but she came back a year later, still pumping meibum with a light touch.

Figure 15. Punctal occlusion may help DED patients by increasing the

contact time of tears and medication.

Figure 16. A patient receives LipiFlow treatment.



She was totally asymptomatic, surprisingly not using any drops, and not wearing her glasses. She said, “God bless you,” and started tear-ing up. She said, “You literally changed my life.” I wish every single patient were like that. For some patients, LipiFlow really is game-changing technology.

Dr. Nichols: I do not think all of us would have LipiFlow in our practice if we did not think it had a benefit. The cost is coming down, and you can uncouple the instrumentation from the actual device. You really do see some benefits. Now, that does not mean you get to quit using anything else, either. I think that is the big mistake that patients and clinicians make. They tend to think, “I will do this, so I do not need to use anything else.” Maintenance therapy results in the best, most sustainable outcome.

Dr. Epstein: I agree. I think one of the original problems was that a lot of people saw this as the be-all and end-all, that this was the solution to everything. In truth, you need nutritional support like a decent triglyceride-based omega-3, and you need other things like topical hypochlorous acid to control lid flora and neutralize lipase that degrades tear lipids. We have a specific algorithm that combines an omega-3, hypochlorous acid, and several other adjuncts with LipiFlow that really make a tremendous difference and increase suc-cess. But with LipiFlow, the placement of the activators is critical. We had to learn how to ensure that they were properly positioned to make sure that they were going to work.

Dr. Whitley: The important issue is that we need to do some-thing. We are seeing patients who have MGD, we need to heat the glands, we need to consider doing the mechanical expression, and you mentioned the cost of LipiFlow. When it comes to cost, our job is to make a recommendation on what treatment a particular patient needs. It is up to the individual to determine whether or not he or she sees value in that. Regarding the SPEED score mentioned earlier, for the patients that we have treated, we have performed about 450 LipiFlow procedures. We use that SPEED score. For exam-ple, I have a patient who came in with very high scores on the sever-

ity of frequency, and after doing the treatment 6 weeks later, he was doing 50% better in his SPEED scores. These types of results resonate with patients because they understand the symptoms. Six-month data show that patients are still doing 50% better; 1-year data show patients are still doing better.14,15 But they still have to comply with treatment, whether it is nutraceuticals or drops.

Dr. Cunningham: We hope this roundtable has provided you with some valuable insight that spans the continuum of optometric practice. From research to private practice, you can see that we all share some very similar beliefs although none of us does anything the exact same way. We all work toward identifying more patients earlier in the disease state and treating them more effectively than we have in the past. n

1. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014;157(4):799-806.2. American Optometric Association. Glaucoma FAQS. www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/glaucoma/glaucoma-faqs?sso=y. Accessed January 15, 2016. 3. Chao W, Belmonte C, Benitez del Castillo J, et al. Report of the Inaugural Meeting of the TFOS i2 = initiating innovation Series: Targeting the Unmet Need for Dry Eye Treatment. theocularsurfacejournal.com. www.theocularsurfacejournal.com/article/S1542-0124(15)00205-0/abstract. Published January 16, 2016. Accessed January 29, 2016. 4. Schaumberg DA, Nichols JJ, Papas EB, et al. The international workshop on meibomian gland dysfunction: report of the subcom-mittee on the epidemiology of, and associated risk factors for, MGD. Invest Ophthalmol Vis Sci. 2011;52(4):1994-2005. 5. Jones-Jordan L, Nichols K. Prevalence of evaporative dry eye in postmenopausal women. Presented at: AAO. October 24, 2013, Seattle, Washington.6. Paulsen AJ, Cruickshanks KJ, Fischer ME, et al. Dry eye in the beaver dam offspring study: prevalence, risk factors, and health-related quality of life. Am J Ophthalmol. 2014;157(4):799-806. 7. US Census Bureau. Annual Estimates of the Resident Population for Selected Age Groups by Sex for the United States, States, Counties, and Puerto Rico Commonwealth and Municipios: April 1, 2010 to July 1, 2012. factfiner.census.gov. Published June 2013. Accessed June 4, 2015. 8. Miller Av, et al. Sjögren Syndrome Epidemiology. medscape.com. emedicine.medscape.com/article/332125-overview#a6. Updated on September 25, 2015. Accessed February 11, 2016. 9. Liew M, Zhang M, Kim E, Akpek EK. Prevalence and predictors of Sjögren’s syndrome in a prospective cohort of patients with aqueous-deficient dry eye. Br J Ophthalmol. 2012;96(12):1498-1503. 10. Fukushima A, Ohashi Y, Ebihara N, et. al. Therapeutic effects of 0.1% tacrolimus eye drops for refractory allergic ocular diseases with proliferative lesion or corneal involvement. Br J Ophthalmol. 2014;98(8):1023-1027. 11. Sheppard JD, et al. Lifitegrast ophthalmic solution 5.0% for treatment of dry eye disease: results of the OPUS-1 phase 3 study. Ophthalmology. 2014;121(2):475-483. 12. Tauber J, et al. Lifitegrast ophthalmic solution 5.0% versus placebo for treatment of dry eye disease: results of the randomized phase III OPUS-2 study. Ophthalmology. 2015;122(12):2423-2431.13. Apple, D, Corcoran, K. Utilization analysis. Presented at ASCRS. April 17-21, 2015, San Diego, California. ascrs15.expoplanner.com/handouts_asoa/000372_25100241_042115_UtilizationAnalysis_Handout.pdf. 14. Lane, et. al. A new system, the LipiFlow, for the treatment of meibomian gland dysfunction. Cornea. 2012;31(4):396-404.15. Greiner, JV. Long-term (12-month) improvement in meibomian gland function and reduced dry eye symptoms with a single thermal pulsation treatment. Clin Experiment Ophthalmol. 2013;41(6):524-530.

INSTRUCTIONS FOR CE CREDIT

1. What does the SPEED questionnaire evaluate?a. DED incidenceb. Inflammationc. Medication used. DED symptom severity

2. Diagnostic expression of the meibomian glands is important because:a. It reveals meibomian gland functionb. It clears the meibomian glandsc. It shows meibomian gland structured. It teaches the patient who is the boss

3. According to the literature, MGD is associated with what percentage of DED?a. 87%b. 2%c. 100%d. 25%

4. Restasis is an:a. Immunomodulatorb. Anti-infectivec. Anti-fungald. Lubricant

5. Meibography is:a. Removing meibomian gland blockageb. A way to probe meibomian glandsc. A way to visualize the meibomian glandsd. Can be performed with a fundus camera

6. Inflammation plays a role in which type of DED? a. Aqueous-deficient DEDb. Evaporative DEDc. Both A and Bd. DED is not inflammatory in nature

7. According to the Beaver Dam Offspring Study (BOSS), what is the overall prevalence of DED in 21 to 49 year olds?a. 6%b. 10%c. 14%d. 20%

8. According to the Dry Eye Workshop (DEWS) Report, abnormal levels of MMP-9 ___________ have been shown to correspond with moderate-to-severe DED.a. >20ng/mLb. <20ng/mLc. >40ng/mLd. <40ng/mL

9. In regards to tear osmolarity, all of the following confirms the diagnosis of DED except? a. Either eye >308 mOsm/Lb. Difference between 2 eyes >8 mOsm/Lc. Qualifies disease severityd. Either eye >40ng/mL

10. All of the following are novel, proprietary markers for Sjögren syndrome except?a. Salivary Protein-1b. Carbonic Anydrasec. Parotid Secretary Proteind. ACE

11. The Beaver Dam Offspring Study (BOSS) showed the prevalence of DED to be:a. About 5%b. About 15%c. About 50%d. About 80%

12. What is the most commonly purchased eye drop in the United States?a. Lipid containing tearsb. Hypo-osmotic tearsc. Refresh brand tearsd. Red eye relievers

13. What glaucoma medication has a common side effect of vascular blanching (eye whitening)?a. Brimonidine b. Latanoprostc. Timolold. Brinzolamide

To receive credit, you must complete the Post Test and Activity Evaluation and mail or fax to Evolve Medical Education; PO Box 358, Pine Brook,

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ADVANCING THE TREATMENT OF DRY EYE DISEASECE QUESTIONS

Cope Course ID: 48410-ASCOPE approved for 2 credits

Expiration Date: March 2019CE credit is available electronically via evolvemeded.com

14. Meibomian glands have been show to be critical in:a. Early stage DEDb. Late stage DEDc. Lipid deficient DEDd. All of the above

15. The SJÖ blood test for Sjögren syndrome:a. Can only be performed in officeb. Is available at blood testing facilities c. Can not be performed by optometrists d. Is not commonly available

16. What is the average length of time to a diagnosis of Sjogren syndrome? a. 4.7 yearsb. 2.5 yearsc. 7 yearsd. 1.8 years

17. The prevalence of MGD might be as high as ____% worldwide.a. 10b. 95c. 60d. 20

18. When should punctal occlusion not be used?a. In patients wearing contactsb. During allergy seasonc. Before LASIKd. Prior to ocular surgery like cataract surgery in a DED patient

19. Which is not a reason to perform meibography?a. Patient management is easier if the patients see their glandsb. Determination of amount of loss helps with designing treat-ment plansc. It may not be covered by insurance

20. ___% of patients older than 60 years that have some form of MGD.a. 60%b. 90%c. 14%d. 87%

Did the program meet the following educational objectives? Agree Neutral DisagreeUnderstand the latest estimates on the prevalence of DED _____ _____ _____ Understand the importance of a thorough examination of the ocular surface _____ _____ _____ and adnexiaIdentify the type of evaluations that will allow a definitive diagnosis _____ _____ _____ Understand new evidence regarding the inflammatory pathwayApply new treatment strategies meant to increase efficacy of DED treatments _____ _____ _____ Understand the importance of early symptom relief for DED treatments _____ _____ _____ Apply evidence-based medicine in selecting a course of treatment _____ _____ _____ _____________________________________________________________________________________________________________________

Your responses to the questions below will help us evaluate this CE activity. They will provide us with evidence that improvements were made in patient care as a result of this activity.

Do you feel the program was educationally sound and commercially balanced? ___ Yes ___ NoComments regarding commercial bias:_____________________________________________________________________________________________________________________

Rate your knowledge/skill level prior to participating in this course: 5 = High, 1 = Low __________Rate your knowledge/skill level after participating in this course: 5 = High, 1 = Low ____________Would you recommend this program to a colleague? ___Yes ___No Do you feel the information presented will improve/change your patient care? ____ Yes ____ No Please identify how you will improve/change:____ Change the management and/or treatment of patients. Please specify _______________________________________________________________________________________________________________________ Create/revise protocols, policies, and/or procedures. Please specify ___________________________________________________________________________________________________________________ Please identify any barriers to change. ____ Cost ____ Lack of consensus or professional guidelines ____ Lack of administrative support____ Lack of experience ____ Lack of time to assess/counsel patients ____ Lack of opportunity (patients)

____ Reimbursement/insurance issues ____ Lack of resources (equipment)____ Patient compliance issues____ Other. Please specify ____ No barriers

ACTIVITY EVALUATION

advancing the treatment of dry eye disease

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