Ocular Surface Disease
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A COVID Long Hauler Struggles with Dry Eye

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Kambiz Silani, OD

I recently treated a 73-year-old retired female patient who had been hospitalized for several months with COVID-19 and continued to experience “long COVID” symptoms long after her May 2021, discharge from the hospital.

Her medical and ocular history included cataract surgery in 2000 and diagnoses of Crohn’s disease, hypercholesterolemia, hypertension, and thyroid disease (controlled with medications). Ocular surface disease ran in the family; she recalled watching both her grandmother and her mother (who had recently died from COVID) struggle with dry eye, and she worried this would be her fate, as well.

The patient’s mild to moderate dry eye symptoms had previously been managed reasonably well on cyclosporine topical eyedrops, but her symptoms had worsened considerably during the pandemic and her long hospital stay. When she came to see us, she was distraught because her symptoms were making it challenging to enjoy her favorite pastime, reading.  She had already visited four other eye care professionals who did the same basic intake and eye exam and offered nothing else beyond continuing to use her drops. She was beginning to lose hope.

At our advanced dry eye center, we first evaluated the patient with a thorough history and wide range of diagnostic tools. We conducted her diagnostic workup on February 24, 2022. Both eyes had excessive tear meniscus height (Figure 1) and moderately reduced noninvasive tear break-up time (Figure 2).  Her tear osmolarity scores (312 OD and 319 OS) were abnormal. She also had mild structural meibomian gland changes (Figure 3) in both lower eyelids, and significant lid thickening and lid telangiectasia (Figure 4) in all four eyelids. Fluorescein staining was normal but lissamine green staining was abnormal in both eyes and eyelids. Her SPEED score was 28, the maximum score possible, indicating severe dry eye symptoms. With diagnostic manual expression, there were many meibomian glands obstructed and not releasing oil. She also had signs of ocular rosacea, but no visible Demodex mites or much anterior debris or plaque.

Based on the diagnostic findings, I outlined a comprehensive treatment protocol that may include multiple office-based procedures, as well as a home-care regimen.  Punctal occlusion is typically only offered later in the treatment process, and only if aqueous deficiency is a major component of the patient’s ocular surface problems.  For most patients who are on topical drops like cyclosporine or lifitegrast, my goal is to get them off the chronic medication and focus on addressing underlying causes with office-based procedures and natural supportive therapies at home. Patients are given the option to either proceed with same-day treatment immediately following their consult or to reschedule for a near future date.

This patient was ready to take the next step right away, so we performed a TearScience LipiFlow vectored thermal pulsation procedure (Johnson & Johnson Vision) to simultaneously heat and evacuate the inspissated glands, as well as the first in a planned series of four OptiLight IPL treatments (Lumenis) to address her inflammation and rosacea (Fig 5).  While IPL also heats the meibum, I explain to patients that it is only sufficient to treat MGD in very mild cases, where the contents of the glands are nearly liquid, anyway. When there is full obstruction, a longer and more consistent level of heat to the inner surface of the lid, combined with the pulsation to clear the glands that we can achieve with TearScience LipiFlow, is needed. I find that TearScience LipiFlow and IPL work very synergistically in patients with multifactorial dry eye, like the one described here.

At the completion of this patient’s 3-hour visit, she asked for a hug and told me how grateful she was for our time and kindness. She reminded me of how important it is to be a humble provider as well as a compassionate practitioner.

At her second visit in mid-March, although we would not really expect significant improvement at that stage, she had an improved SPEED score of 24 (from her initial score of 28). We will continue to follow this patient as she undergoes additional treatments over the next several months.

Dr. Silani is Chief Clinical Director of Beverly Hills Optometry, a specialty practice with an advanced dry eye center in Beverly Hills, CA. He is a consultant for Johnson & Johnson Vision, Alcon, SightSciences, Lumenis, and NuLids. Visit his website at bheyeguy.com or contact him at [email protected].