There are many similarities between eye care and dentistry. Why am I bringing up dentistry in an optometry magazine? Preventing ocular surface disease (OSD) is imperative to keeping our patients’ eyes healthy, just as preventing gum disease is imperative to keeping mouths healthy. Does this mean a preventative model for OSD is possible?
ODs and Dentists: The Parallel
Beginning with diagnostics, dentists use mirrors and magnifiers to closely observe the mouth, but especially the gingiva or gums. Likewise, we need to spend more time not just observing the cornea and internal eye, but truly scrutinizing the eyelids.
Dentists use X-rays, and we can use imaging ranging from meibography (LipiScan, Oculus) to slit lamp cameras (Haag-Streit BQ900) to advanced diagnostics such as tear film imaging (AdOM) and dry eye analysis (Oculus). Dentists have eye whitening options and ODs can consider eye whiteners that don’t constrict arteries, like Lumify (Bausch + Lomb). Finally, dental patients with morning symptoms typically have bruxism (teeth grinding) and eyecare patients with morning symptoms have inadequate lid closure.
Examining the Eyelids
To effectively manage OSD, shift your focus from the ocular surface to the eyelid. The reason is that 86% of dry eye disease (DED) involves meibomian gland dysfunction (MGD).1 Some clinical signs to observe include a frothy tear film, a sheen on the lids indicative of biofilm, collarettes or a volcano sign where debris is present at the base of the lashes indicating Demodex or staphylococcal blepharitis. Capped glands, posteriorly placed meibomian glands and thickened or scalloped eyelid margins are all key signs.
Next, have the patient look down, increase magnification and scan the upper eyelid margin. Finally, express the meibomian glands. Not doing this is akin to saying you want to manage glaucoma but don’t want to observe the optic nerve or manage macular degeneration without looking at the macula.
Plaque and Biofilm
In the world of dentistry, the term for biofilm is plaque. Dentists or hygienists spend the majority of their time removing biofilm because it leads to diseases like gingivitis and eventually loss of teeth. We should do the same by focusing on microblepharoexfoliation (BlephEx) and debridement (Bruder), which may prevent meibomian gland loss or atrophy. Dentists recommend patients continue to work on preventing plaque through brushing and flossing, and we can recommend lid scrubs from (Ocusoft) and Bruder mask hydrating compresses.
Morning Symptom Treatments
Dental patients who have morning symptoms are often diagnosed with bruxism, and the solution is an overnight bite guard. In eye care, patients with morning symptoms almost always have inadequate lid seal issues, and the treatment involves overnight lid seals (SleepTite).
Prevention and Pre-scheduling
An area where optometrists and dentists diverge is in disease prevention. Dentists treat plaque every six months to prevent loss of tissue and teeth. Perhaps we should consider this to prevent meibomian gland atrophy and chronic DED. While it might be a stretch for us to treat patients without signs or symptoms, start treatment when signs are first evident, including MGD-based on expression or froth in the tear film, blepharitis or biofilm, with signs including a sheen, collarettes or debris on the lashes, or inadequate lid closure.
The second thing we can learn from dentistry is to preappoint patients. Dentist offices know how essential it is to reschedule a patient every six months. In our case, we need to make the decision based on the level of disease, such as DED vs. MGD, but it’s important to schedule that patient for a follow-up exam so we can avoid the progression of OSD.
It’s important to take all of the steps necessary to prevent ocular surface disease or at least manage it properly, even if it means taking a different approach and shifting your focus. So, maybe it is possible to follow this model and have not just happy patients, but happy optometrists!
Dr. Karpecki is the director of Cornea and External Disease for Kentucky Eye Institute, associate professor at KYCO and medical director for the Dry Eye Institutes of Kentucky and Indiana. He is the Chief Clinical Editor for Review of Optometry and chair of the New Technologies & Treatments conferences. A fixture in optometric clinical education, he consults for a wide array of ophthalmic clients, including ones discussed in this article. Dr. Karpecki's full list of disclosures can be found here.
|1. Lemp MA, Crews LA, Bron AJ et al. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: A retrospective study. Cornea. 2012;31(5):472-8. 1.|