I just received a Facebook message from an OD who shared with apparent glee that he had kept a young ophthalmologist, new to town, in his waiting room for two hours, only to give him a minute of his time. I winced when I read the note, feeling the discomfort and perhaps humiliation of the young MD, whom I assume came just to introduce himself and perhaps to ask for help in establishing his new practice.

I responded that while I understood where this OD was coming from, I make it a practice to try and treat others as I would like to be treated. I suggested that he imagine how he would have felt had the roles been reversed.

Let's face it, optometry and ophthalmology have had issues for as far back as most of us can remember. With this long-standing animosity, it's easy to justify treating “them” the same way they treat us – condescendingly, if not dismissively. But where has than gotten us – or them over the last century?

I can't help but feel that if this miserable cycle of disdain and distrust is to ever be broken, it will be done one relationship at a time. And maybe – just maybe – by treating that young MD who sits in your waiting room, hat in hand, nervously waiting to introduce himself, with the same kindness and courtesy you would hope for, we can eventually break this futile cycle.

Arthur B. Epstein, OD, FAAO Chief Medical Editor [email protected]

 

 

The recently published seminal dry eye workshop proceedings defined Lissamine Green (LG), an organic dye, as a gold standard for demonstrating ocular surface staining. The purpose of the current study was to determine the optimal parameters of 1% LG instillation for the ocular surface examination in dry eye patients. A quality improvement study evaluated 16 eyes from eight dry eye patients with different levels of severity. LG (1%), in three volumes (5, 10, and 20 µl) was instilled into the conjunctival cul-de-sac, and four masked observers with different levels of clinical expertise examined the patients with and without red filter. The staining pattern of the conjunctiva and cornea was documented with the Oxford scale within 4 min of LG instillation. Optimal volume and inter-observer reliability were assessed.

All dye volumes were tolerated well by all patients. Experienced observers preferred 10 µl volume because of the ease of examination and accuracy. Although instillation of 20 µl yielded similar scores as 10 µl, it resulted in overflow of the lid and facial skin staining. The use of red filter significantly improved reading scores. Inter-observer reliability was higher for conjunctival scores than for corneal scores for all patients. The highest reliability was demonstrated with 10 µl volume and increased with greater experience of the observer.

Ocular surface examination with instillation of 10 µl 1% LG has good inter-observer reliability and is well tolerated. Observation through a red filter facilitates the examination.

This 3-month, double-masked, parallel-group, controlled study was conducted in nine centers to determine whether oral supplementation with omega-3 and omega-6 fatty acids can reduce conjunctival epithelium expression of the inflammatory marker human leucocyte antigen-DR (HLA-DR) in patients with dry eye syndrome (DES). Eligible adult patients with mild to moderate DES were randomized to receive a placebo containing medium-chain triglycerides or treatment supplement containing omega-3 and omega-6 fatty acids, vitamins and zinc. Treatment regimen was three capsules daily. Impression cytology (IC) was performed at baseline and at month 3 to assess the percentage of cells expressing HLA-DR and to evaluate fluorescence intensity, an alternate measure of HLA-DR. Dry eye symptoms and objective signs were also evaluated.

In total, 138 patients were randomized; 121 patients with available IC were included in the FAS, and of these, 106 patients had no major protocol deviations (PPS). In the PPS, there was a significant reduction in the percentage of HLA-DR-positive cells in the fatty acids group (p = 0.021). Expression of HLA-DR as measured by fluorescence intensity quantification was also significantly reduced in the fatty acids group. No significant difference was found for the signs and symptoms, but there was a tendency for improvement in patients receiving the fatty acids treatment.

This study demonstrates that supplementation with omega-3 and omega-6 fatty acids can reduce expression of HLA-DR conjunctival inflammatory marker and may help improve DES symptoms.

The lower tear meniscus of 16 consecutive patients with dry eyes was imaged by a Fourier-domain optical coherence tomography (FD-OCT) system to study the effect of artificial tears on the tear meniscus in patients with dry eyes. Baseline and five serial pairs of measurements were taken after the instillation of artificial tears at 1, 2, 5, 10 and 15 minutes. The lower meniscus height, depth, and area were measured with a computer caliper.

Baseline meniscus measurements were 235.5 ± 150.0 µm, 138.1 ± 78.7 µm and 0.020 ± 0.022 mm² for height, depth, and area, respectively. After instillation of artificial tears, all lower tear meniscus parameters remained significantly elevated for 5 minutes and returned to baseline by 10 minutes.

FD-OCT is able to quantify a dramatic initial increase in tear meniscus, followed by a decay back to baseline values after approximately 5 minutes. FD-OCT may be useful in objectively quantifying the dynamic efficacy of dry eye treatments.