Need Advice Regarding Testing

[LNgraphics]

I recently went to see Dr. Azman in Baltimore. He is recommending some expensive testing that is not covered by insurance:

1) Osmolarity Test

2) Pictures of the front and back of the cornea (Endothelium)

And depending on the above results, he might need to do:

3) Higher Order Aberrations (HOAs)

Once the testing is complete (hundreds of dollars later!) he will determine my course of action for treatment. The first priority will be to get my Blepharitis and MGD under control.

In the past 4 years since I have had dry eyes I have seen MANY eye doctors and have tried many failed treatments. I am impressed with Dr. Azman and have a feeling that he is different than the other doctors I've seen. But I am a skeptical person and want to make sure I'm not spending money needlessly. I actually found Dr. Azman in this forum so he apparently has been able to help some patients. Is anyone familiar with these tests and the benefits of taking them? While he does not claim to be able to cure dry eyes he does say that he can treat it and make it much more manageable. He claims to have a 98% success rate with his patients.

Thank you for taking the time to read my post!

[Rebecca Petris]

I would say #1 makes good sense to me but I personally would not shell out one dime out of pocket for #2 and #3 without more information.

Do you have something going on with your eyes other than dry eye?

By "pictures" of the front & back of the cornea what kind of scan do you mean specifically?

By "higher order aberrations" I'm assuming that's wavefront aberrometry.

What's the stated purpose of #2 and #3, and how will the answers help with treatment decisions?

Osmolarity (#1) is directly connected to dry eye and is increasingly used to test for severity. (What it's used for clinically other than to assess you at regular intervals I don't really know.)

Aberrometry and other scans are not tests frequently done for dry eye in routine clinical practice. Usually related to other vision or disease issues. HOAs for example can help determine the proper course for some vision treatments such as for people who've had a poor outcome from a laser eye surgery. I see wavefront scans mentioned now and then in the dry eye medical literature but other than for research purposes I'm not familiar with a reason to test that in clinic. I'm not saying there isn't a reason, mind you, just that I don't know it.

Personally before paying out of pocket for any testing I would want to know the reason, i.e. what kinds of things they're looking for

[indrep]

My experience tells me that that anterior segment photography of an ocular surface stained with lissamine green is a great diagnostic and disease management tool. The osmolarity device being used today by most clinics has too many variables for me. The lissamine green stained surface shows where the epithelium cells (outside layer of cornea) is compromised. This sometimes correlates with a patients symptoms and sometimes not. Start a therapy program and come back in 90 days for another photo. If the therapy is working the new photo shows less corneal damage than the previous one. At this point a new therapy can be added and tried for 90 more days.

My reasoning for this is a patient can sometimes not feel differently even though healing is taking place. It is a shame to stop treatment when the cornea is healing based on how it feels. It may take several months for nerves to get back to "normal" after the cornea heals. Anterior segment photos can show progress or lack there of of corneal healing.

The posterior cornea pictures and HOA testing can wait until the front of the cornea is improved. My theory on this is if the endothelium cells are less than ideal there is nothing really to do to improve that.

On the flip side, I can understand the doctor wanting as much information as possible to set the expectation of what "best possible vision" might be if everything that is correctable is corrected.

[Rebecca Petris]

My experience tells me that that anterior segment photography of an ocular surface stained with lissamine green is a great diagnostic and disease management tool. The osmolarity device being used today by most clinics has too many variables for me. The lissamine green stained surface shows where the epithelium cells (outside layer of cornea) is compromised. This sometimes correlates with a patients symptoms and sometimes not. Start a therapy program and come back in 90 days for another photo. If the therapy is working the new photo shows less corneal damage than the previous one. At this point a new therapy can be added and tried for 90 more days.

My reasoning for this is a patient can sometimes not feel differently even though healing is taking place.

Wow that's really helpful - thanks IndRep.

[LNgraphics]

Thank you, Rebecca! Other than dry eye I also have Lagophthalmos and Rosacea. I'm not having any vision problems, if that's what you're asking. Dr. Azman also mentioned wanting to test for Demodex.

One possible treatment he mentioned is using bandage contact lenses, which he thought might help with the Lagophthalmos, especially at night.

I'll have to ask the doctor more questions regarding these tests before I commit to spending that kind of money.

[LNgraphics]

My experience tells me that that anterior segment photography of an ocular surface stained with lissamine green is a great diagnostic and disease management tool. The osmolarity device being used today by most clinics has too many variables for me. The lissamine green stained surface shows where the epithelium cells (outside layer of cornea) is compromised. This sometimes correlates with a patients symptoms and sometimes not. Start a therapy program and come back in 90 days for another photo. If the therapy is working the new photo shows less corneal damage than the previous one. At this point a new therapy can be added and tried for 90 more days.

My reasoning for this is a patient can sometimes not feel differently even though healing is taking place. It is a shame to stop treatment when the cornea is healing based on how it feels. It may take several months for nerves to get back to "normal" after the cornea heals. Anterior segment photos can show progress or lack there of of corneal healing.

The posterior cornea pictures and HOA testing can wait until the front of the cornea is improved. My theory on this is if the endothelium cells are less than ideal there is nothing really to do to improve that.

On the flip side, I can understand the doctor wanting as much information as possible to set the expectation of what "best possible vision" might be if everything that is correctable is corrected.

This is very encouraging. Thank you, IndRep.
Dr. Azman did mention that patients often don't notice any improvement even though he might see clinical improvement.

[Rebecca Petris]

IndRep... Going back to aberrometry again and at the risk of veering slightly off topic... I just read an interesting abstract on using serial aberrometry (anytime Baudouin is listed among co-authors it seems a little more worth reading) in assessing dry eye. Not for garden-variety dry eye practice I would imagine and I haven't seen the whole study so I don't know the details but I found it quite interesting that the progression of vision degradation the aberrometers captured was correlated with dry eye clinical findings.

[LNgraphics]

Thanks for the article, Rebecca. I have not been back to Dr. Azman for treatment but I'll probably go ahead with it soon.

[indrep]

Rebecca, I agree that this technology is beneficial in managing the therapy for dry eyes. Personally I think it is time for practices to invest in this type of technology. There is a new device trying to make its way to market that measures light scatter among many other tests. The vision degradation is equal to what I call the "stare test". Blink and look at an object with eyes constantly open, count the number of seconds till the object begins to blur. As the tear film evaporates and breaks up vision becomes distorted.

My desire is for a practice to be able to say to a patient, "We are going to manage this disease objectively with tests results from .... and your symptoms." This way when a flare up is happening an objective result can be looked at and a determination can be made that the therapy is providing progress in healing or anew treatment needs to be added to the regimen. This is a unique disease and needs to be treated as such.

[poppy]

Regarding whether the test is worthwhile, you have to ask yourself whether the test is likely to actually improve your outcome.

This is a question a lot of doctors are starting to ask (not just with dry eye) but whenever they order any test for a patient; will it change the patient's outcome?

I think it can be hard for a patient to understand when a doctor doesn't want to do a test, as they want the doctor to "try everything" but the longer I live with this and other chronic conditions the more I understand the doctor's point of view, even some of the doctors that I've despised and hated.

At the end of the day there are only so many treatments for dry eye, doing some expensive test isn't going to change that. Unless of course, the test might tell you that you don't in fact have "dry eye", but some other problem that is actually curable Now that might be worthwhile hoping for...

[LNgraphics]

I went back to Dr. Azman today. He performed two tests ... First was the Osmolarity test, which came back normal. Then he took pictures of the front and back of my cornea. The front of my cornea are fine but the back showed a significant loss of cells which he suspects might be Fuch's Dystrophy. He seemed very surprised that none of the doctors that I've seen over the last 4-1/2 years had ever considered this diagnosis or performed the appropriate tests. If they had, my cell loss might night be as advanced as it is today. His treatment includes using Muro 128 (5%) ointment at bedtime, and Blink Tears (6 to 8 times a day). He wants me to come back in about 6 weeks to see if the treatment is working, and will then refer me to a cornea specialist.

Needless to say, I'm very upset about these results. I'm wondering if it's not Fuch's Dystrophy what else might it be. I would appreciate any advice.