A delightful and intelligent 87-year-old woman was referred to me with a lengthy history of severe dry eye. This nice lady had traveled more than two hours each way to get to our office and as you can see below, after years of poor management, her eyes had been devastated. She shared that she often had agonizing pain, and I couldn’t help but think that after a long and productive life she didn’t deserve this. Then again, who does?

I’ve found that sometimes the obvious remains obscure up until it hits you like a smack in the face. At her first visit I was perplexed by the four different glaucoma medications she was on, but at that moment my focus was on her ocular surface. I explained that I was concerned about the number of drops she was using, but that we would address her glaucoma management later, after we stabilized her dry eye. I prescribed an aggressive treatment regimen and saw her again several weeks later.

There are moments when you sit across from a patient and are moved by their suffering. You look into their eyes realizing you've tried nearly everything, but nothing seems to be working. Panic sets in. What do I do now? In that instant you realize you are it, and you have no choice but to do something. And you look again, and you think.

Then, I suddenly recognized what I was really seeing. Beyond her dry eye, the combination of preserved drops she was taking multiple times a day was too much for her fragile cornea, and it was driving her severe surface disease. We modified her treatment using non-preserved medications and expect significant improvement.

For a moment, I was angry with myself for not realizing what was happening sooner, and equally annoyed at the glaucoma specialist who prescribed so many toxic drops in the first place. As I thought about it, I realized how easy it is to be blinded by too narrow a focus. At a time when dry eye is epidemic and glaucoma is being diagnosed and treated earlier, medicamentosa must be considered a likely contributing factor in ocular surface disease.

Editor’s Note: Yet another optometric luminary has passed this year. I am very saddened to report the passing of my friend and mentor Jerry Lieblein, OD, a successful and well-known California OD. Jerry was well ahead of his time and at the forefront of the profession for his entire career. An unceasing bundle of ideas, positive energy and humor, Jerry showed how much he cared about our profession and patients with his diverse involvement in education and professional advocacy. As one example, he co-founded OD Excellence, a still growing alliance group that I belong to. It’s hard to imagine Jerry gone. The man was so alive when I last saw him. His passing leaves behind a significant and important legacy and many notable accomplishments. Jerry will long be remembered and dearly missed.

Arthur B. Epstein, OD, FAAO Chief Medical Editor artepstein@optometricphysician.com