What’s the deal with all these tests?

Jerry Robben, O.D.
Chief Optometric Physician-Bowden Eye & Associates
Dry Eye University

How things have changed! If you were to look back on the way we diagnosed and treated dry eye disease in the past compared to today, you would think that we were treating a totally different condition from to two time periods. In the past, a patient’s Schirmer’s test and conjunctival and corneal staining along with their positive symptomology would be the main driving force for the diagnosis and treatment of dry eye disease. Today we have so much more to go on, but is it all really needed? Let’s take a brief look at the diagnostic tests that we use at Bowden Eye & Associates and discuss in detail at Dry Eye University to make a little more sense out of all the dry eye tests that have hit the market as of late.

At Bowden Eye & Associates we have always payed attention to the ocular surface of our patients. As I mentioned above we utilized Schirmer’s test and staining with Fluorescein, Lissamine Green and Rose Bengal (when needed) regularly. We still use the various stating of the surface with the appropriate dye nearly every visit, but Schirmer’s test is rarely used these days in our clinic. That is because of the amazing breakthroughs seen in dry eye disease diagnostics. In my opinion, the Schirmer’s test has become obsolete. It is time consuming and difficult to keep standardized. We find that these new diagnostics are better at repeatability and consistency and also offer more clinical information than we have ever had access to.

The first diagnostic that we added at Bowden Eye was the LipiView (TearScience). This was years before the release of the LipiView II with the DMI Meibography technology. The LipiView I had the Lipid Layer Thickness (LLT) measurement and the partial blink analysis. With this technology alone we had to learn what it was telling us and how it applied to patient care. It was an amazing amount of new information and started a revolution in our clinics with how we approached dry eye disease.

The next diagnostic test we added, shortly after LipiView, was the Tear Osmolarity (Tear Lab) test. I can remember thinking to myself, “why do we need this test if we already have the LipiView?” I didn’t understand it and therefore I didn’t see the value. Today I can’t imaging not having the Tear Lab test availalbe.

Soon after Tear Osmolarity was added, we also added the MMP-9 testing with the Inflammadry test (RPS). At that point we were starting to make connections with the first two diagnostics and this test made perfect sense to me! It also surprised us all, as we started to get positive MMP-9 results on patient who we would have never suspected to be positive. This test has also revolutionized our treatments in our clinic.

Shortly after the MMP-9 testing addition we found two test that were looking for more systemic disease correlation to dry eye disease. We added environmental allergy testing with the Dr.’s Rx Formula Allergy testing and the Sjo test. Both of which have been so successful that they each have been recently acquired by Baush & Lomb.

Light microscopy made its way into our diagnostic flow with the increased awareness about Demodex infestations. We found ourselves plucking eyelashes and finding the little mites via light microscopy and a wet mount slide. We have even been able to readily photograph the mites to show the patients, in real time, the presence of and, therefore; the need to treat for Demodex. It is an easy case to make!

The next addition was when Tear Science added their DMI Meibography technology to the LipiView platform, spawning the LipiView II. In my opinion this additional technology has made as massive contribution to our clinics as the original LipiView did first off. To be able to make an anatomical correlation to the other tests and show the patient this in such detail has proven to be priceless! So much so that we have also added the LipiScan (Tear Science) technology in our satellite offices, while keeping a LipiView II in each of our main locations.

At the time of me writing this, the latest diagnostic that we have added is The HD Analyzer (Visiometrics) OSI Scatter evaluator which is the latest type of Optical Quality Analysis System (OQAS). This novel piece of equipment analyzes the quality of image that the ocular surface is producing vs the lens to determine if either interface is effecting the patient’s visual quality and quantifying it. This is very helpful in demonstrating if a patient is ready for cataract surgery or if the patient’s complaints of blur are more ocular surface related. It allows us to actually show the patient how much either or both conditions is effecting the patients reduced visual clarity.

There are other diagnostics available that I haven’t mentioned that may be utilized by other practices. We have tried to implement others that are not listed above as well. The above list shows the diagnostics that have proven effective and relevant in our clinic. As you all know, Bowden Eye does not endorse products or treatments that we do not use ourselves. There are new tests that we are looking at all of the time, some may make the grade; others won’t.

The above list has taken years to develop with some trial and error. For a practice that is just entering the dry eye arena, these diagnostics can be confusing and seeing the variety can be intimidating. We feel that all of these tests listed are needed in order to fully address our patient’s dry eye disease, but we acknowledge that it is very difficult to add them all at the same time. We would recommend a multi-phase roll out, adding one or two diagnostics at a time. This allows you and your staff to focus on what is new, learn to use it, learn to educated patients about it and learn to apply the information it is giving you. Then add more as you go. Do your research and try to think outside of the box. Remember that I was caught being closed minded about the tear osmolarity test, I was very wrong. These tests have revolutionized our understanding, diagnosis and treatments of dry eye disease, and they are becoming the standard of care.