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Subspecialties Cornea / Ocular Surface

The Process Is the Product

At a Glance

  • The CEDARS algorithm was created as a response to great numbers of patients being treated for ocular surface disease and dry eye
  • Testing is used to get a diagnosis and develop a treatment plan, based on the diagnosis rather than severity
  • Cryopreserved amniotic membrane tissue can be used to treat common corneal pathologies associated with OSD.

Years before the now ubiquitous “dry eye center of excellence” emerged as a pervasive practice model, I was treating large numbers of ocular surface disease (OSD) and dry eye disease (DED) patients and, like so many, recognized how complex this issue is. Treating these patients inspired the creation of the Cornea, External Disease, and Refractive Society (CEDARS) Dysfunctional Tear Syndrome Algorithm, which I developed along with my colleagues Kenneth Beckman and Jodi Luchs on behalf of the CEDARS Dysfunctional Tear Syndrome Panel.

The foundation of the CEDARS algorithm is that we base treatment on diagnosis rather than severity. The CEDARS algorithm separates dysfunctional tear syndrome into diagnostic categories (aqueous deficiency, blepharitis, and so), which then guide treatment. We use testing to arrive at a diagnosis and the diagnosis to guide our treatment plan, keeping in mind that the patient may have more than one diagnosis. Finally, we treat the coexisting pathologies with a logical, step-wise approach (1). The formula goes hand-and-hand with what I have learned from these challenging patients for more than two decades: i) OSD is a multifactorial disease that often requires multiple forms of treatment; and ii) patients typically get some relief with a first-line treatment, but it’s usually the second or even third intervention that achieves our treatment goals. 

My success with cryopreserved amniotic membrane (CAM) tissue has led to its inclusion in the CEDARS algorithm. Throughout the years, I have seen CAM tissue evolve from a last-ditch initiative reserved for only the most recalcitrant OSD and DED patients – in other words, a treatment based solely on severity – to a quick and simple in-office procedure that is frequently relied upon to augment other therapies for patients at various stages of disease severity. CAM tissue is a staple in my practice; I use it to treat common corneal pathologies associated with OSD, such as superficial punctate keratitis, filamentary keratitis, recurrent corneal erosion, corneal ulcers, neurotrophic keratitis, neurotrophic ulcers (Figure 1), exposure keratitis, and Sjogren’s syndrome. In my hands, CAM provides these patients with relief for many months.

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About the Author

Mark Milner

Mark S. Milner, MD, is associate clinical professor at Yale University Medical School, Department of Ophthalmology, and cofounder and co-medical director of Precision LASIK Group, Cheshire, CT, USA.


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