As we all know that India is on the brink of a dry eye disease epidemic, this interview with the maestros in this field will help us to streamline our approach in managing the increasing number of dry eye patients. The availability of innumerable diagnostic tests always baffles us about how to use what in which time. The need for an integrated scheme in assessing and prognosticating dry eye cases is of utmost importance for a successful treatment outcome. Some of the very basic but most important areas are discussed by the unparallels in their field to clear the doubts of young ophthalmologists.
Dr. Srinivas K. Rao DO, DNB, FRCSEd has worked as a Senior Consultant at Sankara Nethralaya for 15 years before joining as Professor in the Chinese University of Hong Kong from September 2004 till August 2006. Since October 2006 he is Director of Darshan Eye Care and Darshan Surgical Centre, Chennai. He is also Visiting Professor, Sri Ramachandra Medical University, Cornea Head at Sankara Hospital, Pammal, and Sunetra Eye Care, Kolkata, and Ophthalmic Consultant to Madras Medical Mission, Chennai. He is Visiting Professor, Chinese University of Hong Kong, and Honorary Professor at the Shantou Medical University in China. He has published extensively in these areas and is much sought after as a speaker and teacher. He has authored multiple books in the areas of Cataract, refractive surgery, and Corneal diseases. He is actively involved in efforts to promote knowledge in the management of Corneal Diseases, and Mentors Fellows in his CORNEA Fellowship program. He has produced a Module called HOST (Handbook of Ocular Surface Treatment) which will serve as a comprehensive resource for the diagnosis and management of problems of the Ocular Surface. He is also currently the President of the Cornea Society of India.
Dr. Geetha Iyer FRCS(Glasgow), FRCS(Ed), FRCOphth, completed her training in Ophthalmology and Fellowship in Cornea and External Disease from Sankara Nethralaya, Chennai, India in 2003. She has done a short term observership in Ocular Surface Disorders with Dr Scheffer C G Tseng, Miami, USA in Oct 2006 and in Boston Type 1 keratoprosthesis with Dr Claes H Dohlman in Nov 2006. She was trained by Prof Giancarlo Falcinelli in performing the MOOKP procedure. She has so far done more than 200 keratoprosthesis surgeries (MOOKP, Boston Type 1, and 2 Kpro and osteo Kpro). She is actively involved in the management of ocular surface disorders and is currently working as a Senior Consultant at the Ocular Surface Clinic and the Cornea Services, Sankara Nethralaya. As a founding member of the Cornea Society of India, she is currently the Secretary of the Society. Her work in the management of chronic ocular sequelae of Stevens-Johnson syndrome has been extensive with an aim of preventing the occurrence/deterioration of the sequelae as well as understanding better the immunopathology of the ocular disease. Her other areas of interest include pediatric penetrating keratoplasty, ocular surface tumors, ocular surface disorders including chemical injuries, stem cell transplants, and keratoprosthesis.
Dr. Sayan Basu is the Director, Prof. Brien Holden Eye Research Centre, Prof D Balasubramanian Chair of Eye Research, Director, Centre for Ocular Regeneration (CORE) & Virender Sangwan Chair of Regenerative Ophthalmology, LVPEI, Adjunct Associate Professor of Ophthalmology, School of Medicine and Dentistry, University of Rochester, New York, USA. Dr Basu has received the Achievement Award from the American Academy of Ophthalmology and serves on the editorial board for the British Journal of Ophthalmology, Current Eye Research and Indian Journal of Ophthalmology. He has published numerous highly cited papers and is held in high regard as a researcher by the ophthalmology and visual sciences community. He is currently developing a state-of-the-art dry eye clinic, producing 3-D printed corneas and developing novel stem cell therapies with renowned national and international collaborators
eOphtha: Three leading questions that you always ask in your patients with dry eye
Dr.S.K.Rao:
- Is there a diurnal variation in symptomatology
- What treatment has been used and it’s benefits
- Any systemic conditions or symptoms
Dr. Geetha Iyer
- Presence of diurnal variation
- To rule out Systemic associations
- Frequency of topical lubricant usage, if already using
Dr. Sayan Basu
- What are your symptoms?Some patients will say they have dry eyes because they have been told they have dry eyes.That’s not a symptom and you can get misled.Typical symptoms will be irritation, FB sensation, difficulty in opening eyes after waking up, struggling to work long hours on the system, exacerbation of symptoms when working late, travelling by air, attending a conference, feeling like rubbing the eyes ( but this is different from itching)
- What other diseases or health issues do you have? Dry mouth? Joint pains? Mouth ulcers? Nose bleeds?
- What topical and systemic medications are you on? Particularly look for anti-glaucoma medications, sleeping pills, anxiolytics, antidepressants, antipsychotics
eOphtha: The symptom that worries you the most while assessing a dry eye patient
Dr. S. K. Rao: Vision decrease
Dr. Geetha Iyer:
In the presence of signs, if patient asymptomatic
In the absence of signs, if patient photophobic
Dr. Sayan Basu
If the patient says he/she has progressively worsening disease or poor vision that usually points towards aqueous deficiency.
eOphtha: The most important sign you will look first in a patient of dry eye
Dr. S. K Rao: Corneal lustre and surface quality
Dr. Geetha Iyer: Any e/o cicatrisation – helps you to subcategorise and proceed appropriately
Dr. Sayan Basu : Most important is corneal staining.Always look at the staining pattern, immediately tells you whether there is a problem and how bad it is.Then Shirmer without any anaesthesia and lateral canthus to examine the lacrimal gland.
eOphtha: List 3 most pertinent systemic investigations you will regularly write for your dry eye patients
Dr. S. K Rao: Rheumatoid factor, SSA and SSB antibody, ESR
Dr. Geetha Iyer: - antiRo/RA,ACPA/ANA for diagnosis - ESR ,CRP for activity and monitoring
Dr. Sayan Basu: Only for those with aqueous deficiency
- Hb, TC, DC (you will be surprised how many patients have chronic anaemia and get better just with improvement in Hb levels)
- ANA profile (includes SSO SSB, anti dsDNA, anti CCP)
- HLA typing
eOphtha: The most important tips in lifestyle modification you generally give to your dry eye patients
Dr. S.K. Rao: Avoid dessication of eyes, Blink frequently during visual tasks, drink 6 to 8 glasses of water daily
Dr. Geetha Iyer: Understand and accept chronicity – activities to improve QOL
- Creating awareness of factors that worsen symptoms and adjust accordingly (protective glasses, airconditioned environment, working with visual display monitors)
- Ensure compliance and follow up – most importantly to avoid initiating or stopping medications against medical advice
Dr. Sayan Basu: Anyone on a normal Indian diet is fine, those who are not may need micronutrients.Other than that I do recommend a healthy lifestyle, some patients may need counseling for depression.
eOphtha: What is the most important prognostic factor in a case of dry eye
Dr. S. K Rao: Extent of ocular surface staining
Dr. Geetha Iyer: SPK’s
Dr. Sayan Basu: Easily chronicity