An estimated 3.2 million women and 1.68 million men age 50 and over are affected by Dry Eye Disease, and the demographics are growing rapidly among Baby Boomers who work on computers all day. Dry Eye can be quite uncomfortable for patients and tends to get worse if left untreated, leading to pain, scarring, and in many cases fluctuating vision, which may cause intermittent loss of vision.
All of these symptoms can be frustrating, especially for the patient, as well as the doctor. Making the diagnosis is the key to effective treatment. Communicating effectively with the symptomatic individual is also critical.
CCh, clearly a disease of the Tenon’s fascia, is often overlooked as patients typically present with symptoms similar to Dry Eye. The three key characteristics of CCh include: dissolved and degenerated Tenon’s which appears to be related to elevated matrix metalloproteinase (MMPs) activity; excess, loose conjunctiva in the inferior fornix; and prolapsed fat into the inferior cul-de-sac. This results in obliteration of the tear reservoir within the recess of the inferior fornix and an obstructed tear meniscus along the inferior eyelid margin.
Unlike aqueous tear-deficient (ATD) Dry Eye, the symptoms of CCh tend to be the same throughout the day versus worse as the day progresses with ATD, and CCh is worsened by increased blinking/tightening lid and punctual occlusion, and in down gaze when reading. CCh is best detected with fluorescein staining and cobalt blue light, identifying the redundant folds that occupy the normal position of the inferior tear meniscus, and measuring the recovery of the tear meniscus after maximum depletion. Although patients are initially treated medically, surgery is often indicated for those individuals that do not obtain adequate relief from the non-surgical treatments.
At the American Society of Cataract and Refractive Surgery (ASCRS) meeting, Bio-Tissue announced a new procedure for CCh, the Reservoir Restoration Procedure, which I am very excited about as it is the only procedure to truly address the Tenon’s fascia. The Reservoir Restoration Procedure restores the tear reservoir by reforming the inferior cul-de-sac and the tear meniscus to their natural states. The use of cryopreserved amniotic membrane inhibits MMP activity.
This straight-forward surgical procedure restores the function of the anatomical tear reservoir (inferior fornix) by removing deteriorated Tenon’s Capsule, rearranging conjunctiva and trimming a small amount of conjunctiva if necessary, deepening the fornix, and using multiple-layers of cryopreserved amniotic membrane to replace the Tenon’s and conjunctiva. There are two versions of the technique, one with sutures and the other without sutures that removes the unhealthy Tenon’s and accomplishes restoration of a more normal anatomy in the inferior fornix and along the inferior lid margin.
The cryopreserved amniotic membrane (Bio-Tissue AmnioGraft) expedites the patient’s recovery by:
• Reducing Inflammation
• Promoting regenerative healing
• Minimizing pain associated with inflammation
• Achieving superior cosmetic results.
This procedure is very effective for Dry Eye patients who are suffering, and allows them to recover quickly and get back to their active lifestyles. Additionally, it is truly a practice builder. If we can make these frustrated patients into happy patients and improve their outcomes, we will see them less frequently, making room for more patients who are suffering with Dry Eye that we can make happy by improving their symptoms. We would rather see happy patients less often with better outcomes than have unhappy patients filling the schedule. We all know that happy patients help to build our practice through word of mouth referrals, which is more effective than the biggest billboard