Recently, I saw a patient who was on three topical anti-inflammatory medications (lifitegrast, cyclosporine and an ester-based steroid), two oral treatments (antibiotic and omega fatty acid), an artificial tear and gel, lid scrubs, a Bruder mask and he had Lipiflow done two months ago. He also walked into the lane carrying a small plastic bag that contained a set of scleral lenses. Talk about a shotgun approach to therapy! This poor gentleman could get no relief despite toting around nearly every remedy his doctors could provide.

He informed me he’d had dry eye symptoms since his LASIK surgery one year ago. He was being managed by the dry eye center at the surgical practice and he didn’t want them to know he was seeking a second opinion before purchasing the sclerals. He estimated he had spent over $10,000 between the surgery, procedures, treatment options and now the cost of the scleral lenses. 

A Fresh Start

Where do you even start with this patient? The first test I ran was osmolarity (TearLab). It measured 291mOsmol/L and 290mOsmol/L. When it’s between 280mOsmol/L and 295mOsmol/L and both eyes are within 5mOsmol/L of each other, I estimate that there is only about a 2% to 3% chance a patient has dry eye disease (DED)—provided they didn’t instill drops within the last hour or the tech caused reflex tearing when taking the measurement. 

Next, I expressed the meibomian glands, which were mildly turbid but had good expressibility and at least five glands yielding liquid secretion in the lower nasal to central lower lid. Meibography showed minor truncation of about three glands in each eye, and he had trace inferior corneal staining with NaFl dye.  

Based on these findings, it was time to go back to the basics. New theories suggest that patients with subtle binocular fusion issues can overstimulate the trigeminal nerve, and the resultant saccadic and pursuit eye movements can, over time, cause headaches and even dry eye symptoms.1-5

 So, I asked him about headaches, and he mentioned they had begun at about the same time as the eye dryness after LASIK. They were frontal in location and occurred as the day progressed or when using a computer. He also noticed his eyes were much dryer when using a computer than he recalled prior to LASIK, and he spent most of his eight-hour workday on digital devices. He said he had worn glasses for about 4.50D of myopia prior to surgery.  

Next, a cover test showed exophoria at distance and slight left hypertropia. Von Graefe confirmed the findings, including convergence insufficiency. 

I prescribed prism to a new pair of glasses, and his headaches went away almost immediately, as did his dry eye symptoms. He also set up an appointment with the local vision therapy expert and has reported no further headaches, eye pain or dryness. 

Optometry at its Core

What does this case tell us? While advances in medical eye care and new diagnostic technologies were crucial, the most important step was remembering the core strengths that set optometrists apart from other professions; in this case, looking for and measuring subtle eye misalignment issues changed the diagnosis—and the patient’s life. 

Many articles in this month’s issue get back to the basics of optometry, including testing for accommodative and convergence disorders, when to use prism vs. vision therapy in amblyopia treatment, a better understanding of meibography and its application to DED management, nutrition and the eye and, harkening back to the example above, differentiating diseases that mimic dry eye.

It’s important that we advance our knowledge in medical eye care, invest in new diagnostic technologies and focus on patient education, but never lose sight of the core strengths we have in this profession—that’s what truly differentiates us. 

1. Teitlebaum B, Pang Y, Krall J. Effectiveness of base in prism for presbyopes with convergence insufficiency. Optom Vis Sci, 2009;86 (2):153-6.
2. Krauzlis RJ. Recasting the smooth pursuit eye movement system. J Neurophysiology. 2014;91(2):591-603.
3. Weir CR. Proprioception in extraocular muscles. J Neuro-Ophthalmol. 2006;26:123-7. 
4.  Yang M, Rendas-Baum R, Varon AJ, Kosinski M. Validation of the headache impact test (HIT-6) across episodic and chronic migraine. Cephalalgia. 2011;31(3):357-67.
5. Godlove DC. Execution and evaluation of eye movements: from muscles to medial frontal cortex. Dissertation for Doctor of Philosophy in Neuroscience. Vanderbilt University, December 2013.