There are many effective dry eye treatment options available—but what should you do if, despite all of your attempts to combat dry eye in a patient, they don’t seem to be responsive?
This is the exact conundrum that Jerry Robben, OD—Chief Optometrist at Bowden Eye & Associates in Jacksonville, Florida—faced in the case he shares with Damon Dierker, OD, FAAO, during today’s Dry Eye Fireside Chat.
Conjunctivochalasis as a co-conspirator in dry eye
The case in question involved a long-established patient of the practice who, despite being given a range of both traditional and more aggressive modalities for treating dry eye disease (DED)—including several immunomodulators, MIEBO (perfluorohexyloctane ophthalmic solution, Bausch+Lomb), steroids, supportive therapies, and even both LipiFlow (TearScience, Johnson & Johnson) and microblepharoexfoliation—had eyes that remained unresponsive.
When a variety of symptoms are being experienced, both Drs. Dieker and Robben find it most effective to ask their patients for a one- or two-word summary of the primary symptom they are facing. This allows them to focus on which key issue should first be addressed. For example, this patient’s main symptom was excessive tear production.
Identifying concomitant ocular surface disease
The persistence of this symptom amidst the numerous treatment attempts, alongside having a concrete knowledge of the patient’s long-term history, indicated to Dr. Robben that there was another problem acting as a co-conspirator to the DED the patient was also experiencing: conjunctivochalasis (CCH).
In Dr. Robben’s experience, if you don’t first deal with the co-conspirator—be it CCH or another issue such as Demodex blepharitis or rosacea—as a distinct and separate issue, you’ll find yourself butting your head against the wall when attempting to quell the patient’s symptoms.
Alongside increased tearing/watering and persistent dry eye unresponsive to treatment, foreign body sensation and scratching/burning sensation are additional signs indicative of potential CCH.
Treatment options for conjunctivochalasis
So, what are the effective ways for treating CCH? As Dr. Robben explains, it’s an area that’s seen a lot of advancements recently.
Before the latest innovations, surgery was the only option and was only offered to those with moderate-to-severe CCH—Bowden Eye & Associates specifically employed an ocular surface reconstruction approach, whereby CCH patients underwent conjunctival resection with amniotic membrane and tissue glue.
LUMIFY eye drops
Now, there are two new approaches available to patients, including those with milder CCH cases. The first is LUMIFY eye drops, which, when started alongside dry eye treatment, can act as a “pacifier” for the chronic inflammation that can arise.
However, it isn’t able to address CCH-induced structural changes (including the physical change to Tenon’s capsule, the adhesion to the conjunctiva, and the conjunctiva’s laxity). As such, LUMIFY alone may not be enough to spur long-lasting change within patients.
Plasma pen conjunctivoplasty
This is where the second modality, an in-office plasma pen conjunctivoplasty, may be able to help. Although the plasma pen conjunctivoplasty isn’t able to address any damage to Tenon’s capsule, by tightening the conjunctiva, it is able to tackle some of the structural changes that a CCH patient may experience.
And, as a minimally invasive, in-office procedure that can be redone if needed, it’s an option that has been well-received by Dr. Robben’s patients. For the team, it served as a successful interventional stopgap, reducing the number of ocular surface reconstruction surgeries required.
Top tips for patient education on CCH
But how do you go about educating patients on why their eyes aren’t responding to dry eye treatments and the need to bring in a new treatment modality?
Here are Dr. Robben’s top tips on how you can make talking to your patients about CCH easier:
- Show them imagery of their own eyes: Taking a high-resolution image of the affected area in question can be a quick and easy way to make patients aware that they have bunching of the tissue at the bottom of their eyelids.
- Break down the mechanics. Alongside imagery, highlighting the underlying mechanics in a patient-friendly way can help them to understand why they’re experiencing the symptoms they are.
- Dr. Robben does this by explaining that the tissue at the bottom of a patient’s eyelids is taking up the space that their tears usually reside in. This helps them to understand both why they’re experiencing excessive tear production and the perpetuation of their dry eye—caused by the lack of a proper reservoir.
- “I explain to patients that that’s the missing link that we need to address by tightening things up in order to make strides with their dry eye care, both to improve their symptoms and the disease state because it’s a chronic progressive disease,” he says.
- Use your hands: For patients who may benefit from a more tactile aid, you can use the hands and the differing levels of elasticity between the front and back to demonstrate the difference that modalities such as the plasma pen conjunctivoplasty can make in tightening the elasticity of the target tissue and reducing symptoms.
Conclusions
So, what should you take away from this chat? First, if, despite trying a number of treatment modalities, a patient appears to be unresponsive and persists in their dry eye, it may be a sign that there is a dry eye co-conspirator that needs to be addressed first before the dry eye can be resolved.
Second, like many other areas of eyecare, there is a lot of innovation taking place in CCH treatment—modalities such as LUMIFY and the plasma pen conjunctivoplasty offer less invasive options for CCH management that patients can access earlier on in the disease process and many times in-office.
Finally, showing high-resolution imagery, breaking down ocular mechanics, and using the hands as an explanatory aid are three ways to make the process of educating your patients on CCH easier for both you and them.
