Glaucoma and dry eye

Patients with dry eye disease need to be screened for glaucoma. It is not uncommon for steroids to be used in dry eye disease and is often used in a “pulsed” type fashion. As a result, while the pressure may be measured as “normal” in the office, the intra-ocular pressure could have been elevated during the previous steroid pulse and cause optic nerve damage. Even with mild steroids such as Lotemax. Alrex, or 0.1% FML, pressure elevations can occur especially in patients who are steroid responders. At Fishmanvision, we always include OCT optic nerve analysis as part of our new patient dry eye work-up. At risk patients should have a visual field and the below video snippet is visual field testing as seen from the doctor’s side.

Blue Sclera

The below video snippet is a case of blue sclera. Blue sclera isn’t really blue but can be from either thinning of the sclera which causes a bluish hue on examination or pigmentation deposits that can also appear to give a bluish hue to the sclera.



Blue sclera can be a sign of systemic disease such as collagen synthesis disease (Ehlers-Danlos syndrome, osteogenesis imperfecta and, occasionally, Marfan’s syndrom).  Collagen synthesis diseases cause congenital defects in collagen synthesis that results in thinning of the sclera.  However, blue sclera can also be from pigmentation deposits associated with systemic diseases including Alkaptonuria, Primary adrenal insufficiency (Addison’s disease) , or by autoimmune destruction of the adrenal glands.

Systemic medicines such as minocycline can also cause blue sclera as is the answer in this case.  Other medicines that can cause this include amiodarone, phenothiazines, antimalarial agents, and long-term use of prednisone. Finally, topical medications such as epinephrine-containing eye drops can lead to pigmented deposits and exposure to soluble silver compounds (argyrosis).

Death by Ipl

Fishman comments: Our paper is the first to show direct evidence of “Demodex Death by IPL” using live video microscopy.   Honored to collaborate on this important work with Dr. Periman (aka @dryeyemaster) and Dr. Shah (@sfgotox). Click the below download button for the full PDF of the paper.


Real-Time Video Microscopy of In Vitro Demodex Death by Intense Pulsed Light. Fishman HA, Periman, LM, Shah, AA.