Ocular surface disease (OSD) is a multifaceted clinical disorder that is encountered by most eyecare professionals daily. It represents the most common reason for office visits. Patients frequently describe ocular discomfort and foreign-body awareness, as well as a variety of visual disturbances resulting from the loss of tear film homeostasis. OSD may adversely impact contact lens adherence, as well as ocular surgical outcomes. In general, it may affect patient satisfaction with all aspects of eyecare services.

Patient Symptom Severity and Clinical Manifestations

There is often poor correlation of patient symptom severity and the clinical manifestations of OSD. It is not uncommon to see significant clinical pathology in patients with few or no symptoms. These patients often have symptoms of visual fluctuation, ocular fatigue, tearing and blurred vision, which they have attributed to other causes such as sleep deprivation, allergies, and the need for new glasses. A detailed ocular history involving lifestyle, occupation, systemic disease, and medications may provide insights necessary to effectively engage the asymptomatic or skeptical OSD patient.

Tools for Detecting OSD

Clinicians and surgeons have benefitted from an improved understanding of the pathophysiology, immunopathology, and homeostatic mechanisms of the tear film and ocular surface structures provided by international expert collaborations and TFOS-DEWII (2017), as well as MGD workshop.^1,2 These workshops have provided a wealth of clinical information which has enabled improved disease awareness and management strategies.

In addition, several diagnostic technologies have been developed for effective detection of the loss of homeostasis of the tear film and ocular surface injury. The detection of tear film hyperosmolarity, matrix metalloproteinase-9 levels, and lipid layer thickness may be facilitated by convenient point-of-service tests in the office. Meibomian gland imaging and corneal sensitivity testing provide important metrics as well. These tests further complement clinical examination methods which include ocular surface vital staining, meibomian gland expression, meibomian grading, corneal topography, and slit lamp biomicroscopy with photography. In aggregate, these diagnostic tools provide an evidence based approach to ocular surface management. They also provide effective patient education tools and reference guides.

The international workshops in dry eye and MGD have further advocated an etiology-based approach for therapeutic intervention. Medical therapy is guided by measures to improve tear volume, restore tear composition, and reduce evaporation stress. Office procedures have been developed to restore meibomian gland function, halt gland atrophy, and reduce ocular surface inflammation. These measures complement established corneal, conjunctival, and lid procedures which address structural pathology contributing to tear film disruption, ocular exposure, and surface injury.

It is important that patients understand that quality vision requires a healthy ocular surface. Effective patient education with an evidence- based approach to clinical management may result in improved patient acceptance and compliance with treatment recommendations.

OSD Disorders

Dry eye disease is the most prevalent disorder encountered among OSD patients, including epithelial basement membrane dystrophy (EBMD), Salzmann’s degeneration, recurrent corneal erosion, neurotrophic keratitis, and filamentary keratitis. Conjunctival disorders with similar symptoms include pterygium, superior limbic keratoconjunctivitis, and conjunctivochalasis. Lid malpositions, which cause ocular surface exposure or mechanical trauma, may include floppy iris syndrome, entropion, ectropion, lid retraction, and eyelid scarring. Lid margin disorders may cause inflammatory ocular surface symptoms. These include meibomian gland dysfunction, Demodex blepharitis, ocular rosacea, seborrheic blepharitis, and microbial blepharitis. Effective OSD management requires a systematic diagnostic approach and a targeted therapeutic approach.

Recognize Ocular Surface Compromise Prior to Surgery

OSD patients preparing for ocular surgery are particularly vulnerable to exacerbation of their symptoms. Those with minimal disease awareness may become symptomatic, blaming their discomfort on the surgeon. Ocular surgery exposes the patient to a variety of factors that disrupt tear film stability with ocular surface injury. These insults to the surface include topical anesthetics and antiseptics, irrigation, desiccation, corneal denervation with incisions, and preservative toxicity.

It is important to recognize ocular surface compromise prior to surgery to make efforts to stabilize the surface and mitigate insults. This approach has been advocated by the ASCRS Cornea Clinical Committee in the familiar OSD algorithm for cataract and refractive surgery in 2017.² The surgeon is obliged to share with the patient the potential postoperative consequences of untreated OSD. This discussion and recommendations should be memorialized in the office record and the surgical consent, as there is usually poor recollection postoperatively when postop expectations are not met or when symptoms worsen.

The essential elements of ocular surface optimization include the following measures:

1. Restore tear film composition with MGD treatments:

1. Blepharoexfoliation
2. Meibomian gland probing
3. Thermopulsation

2. Restore tear volume

1. Punctal occlusion
2. Neurostimulation
3. Preservative-free lubricants
4. Tear reservoir restoration
5. Cyclosporine therapy

3. Reduce ocular surface inflammation

1. Steroids
2. Cyclosporine
3. Lifitegrast ophthalmic solution 5% (Xiidra; Bausch + Lomb)
4. Macrolide antibiotics
5. Tetracycline derivatives
6. Amniotic membrane products
7. Systemic immunosuppression
8. Photo facial therapy

4. Restore a smooth corneal surface

1. Superficial keratectomy
2. Excimer phototherapeutic keratectomy

5. Reduce tear evaporation

1. Perfluorohexyloctane ophthalmic solution (Miebo; Bausch + Lomb)

6. Address ocular surface exposure

1. Lid malposition repair
2. Tarsorrhaphy
3. Part-time patch occlusions
4. Mindful blinking
5. Moisture chamber eyewear
6. Side panel eyewear

7. Address neurotrophic keratitis

1. Autologous serum tears
2. Cenegermin-bkbj (Oxervate; Dompé)
3. Ocular insult avoidance
4. Side-panel eyewear

8. Address mechanical trauma to the ocular surface

1. Epilation
2. Bandage contact lens
3. Scleral contact lens
4. Lid malposition repair

Conclusion

The recognition of OSD has become a necessary skillset for all eyecare providers. Early recognition may enable timely intervention with medications, procedures, and homecare practices. These measures may limit ocular surface damage and reduce patient symptom severity. It is important to identify those corneal specialists and dry eye specialists providing comprehensive management to facilitate timely referral for these OSD patients. OP

References

1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283. doi:10.1016/j.jtos.2017.05.008

2. 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. Published 2011 Mar 30. doi:10.1167/iovs.10-6997a

FRANK W. BOWDEN III, MD, FACS, a distinguished ophthalmologist with deep roots in Tennessee, is proud of his continued dedication to providing exceptional eye care through his practice, Bowden Eye & Associates (Eye Health America), which has been serving the Jacksonville community since 2001. With a robust background that includes military service and extensive training, Dr. Bowden is a leading authority in the treatment of corneal and external diseases, refractive surgery, cataract surgery and dry eye care, making him a vital resource for patients in the southeast region.