Contemporary concepts in the diagnosis and management of dry Eye

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#OptoWest
101
Taming the Desert…Contemporary
Concepts in the Diagnosis and
Management of Dry Eye Disease
S. Barry Eiden, OD, FAAO
Room: Crystal C
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101 – Taming the Desert…Contemporary Concepts in the Diagnosis
and Management of Dry Eye Disease
S. Barry Eiden, OD, FAAO
This course material and information was developed
independently of any assistance.
I have the following financial relationships to disclose:
•Alcon /CIBA Vision – Honorarium/Consulting, lecturing, research
•Alden – Consulting, research
•Bausch + Lomb – Honorarium/Consulting, lecturing, research
•Cooper Vision – Honorarium/Consulting, lecturing, research
•Merck - Consulting
•Oculus - Honorarium/Consulting, lecturing, research
•Special Eyes – Honorarium/Consulting, lecturing, research
•SynergEyes - Consulting, lecturing, research
•Visionary Optics - Honorarium/Consulting, lecturing, research
•Vistakon - Honorarium/Consulting, lecturing, research
S. Barry Eiden, OD, FAAO
North Suburban Vision Consultants, Ltd.
EyeVis Eye and Vision Technologies and Research Institute
National Keratoconus and Dry Eye Institutes
Assistant Clinical Professor University of Illinois Medical Center,
Department of Ophthalmology, Cornea and Contact Lens Service
Adjunct Faculty at the Indiana, Illinois, PCO @ Salus, and UMSL
Colleges of Optometry
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100 million cases world wide /
40 million USA
>30% of patients report some dry eye
symptoms
>50% of CL wearers report dry eye
symptoms (ocular dryness is the #1
most common complication of CL wear)
Common complaint S/P
LASIK/Refractive S.
Impacts optical outcomes of Cataract
Surgery

Quality of life
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DED hampers lives and, in some cases, severely limit
activities such as reading, operating a computer,
working, driving, and watching television.3
Comorbidities

Significantly higher prevalence of medical
comorbidities in patients with dry eye disease*:
 ischaemic heart disease, hyperlipidaemia, cardiac arrhythmias,
peripheral vascular disorder, stroke, migraines, myasthenia gravis,
RA, systemic lupus erythematosus, asthma, pulmonary circulation
disorders, diabetes with complications, hypothyroidism, liver
diseases, peptic ulcers, hepatitis B, deficiency anaemias, depression,
psychoses and solid tumors without metastasis.
*Wang TJ, Wang IJ, Hu CC, Lin HC. Comorbidities of dry eye disease: a nationwide population-based study. Acta Ophthalmol 2010;Aug 31

Dry Eye Definition:
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“A multifactorial disease of the
tears and ocular surface that
results in symptoms of discomfort,
visual disturbances, and tear film
instability with potential damage to
the ocular surface”
Accompanied by tear film
hyper-osmolarity and inflammation
of the ocular surface.
(Ocular Surface, 2007,5:75-92)
Dry eye disease is caused by
conditions that either increase
evaporation of the tear film or
decrease tear production.
The resulting increase in tear film
osmolarity (hyperosmolarity) leads to
ocular surface inflammation,
damage, and symptoms
Geerling G, Schaumberg DA, Optometry Times
March, 2009.
Ocular Surface Disease Update 2010, Lonsberry BB, CL Spectrum, July 2010

Various diseases that can
destabilize the tear film and result
in dryness of the ocular surface:
Aqueous deficient dry eye
 Evaporative dry eye
 Anterior blepharitis
 Meibomian gland dysfunction
(MGD/posterior blepharitis)
 Allergic conjunctivitis
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History
Biomicroscopy
Vital Staining
TBUT / IBI
Tear production / quality
Tear Film Osmolarity
Symptoms
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Descriptive Sx’s
Time of day Sx’s are worse
Associations
(activities, cycles, environments, etc.)

Onset / Duration

Systemic Health:

Systemic Medications:
osteoporosis, diabetes,
Sjorgen’s Syndrome, lupus, rheumatoid arthritis, acne
rosacea, pregnancy/lactation, menstruation,
postmenopausal, asthma, Scleroderma, thyroid
disease
beta blockers,
antihistamines, decongestants, anti-hypertensives,
diuretics, oral contraceptives, antidepressants,
hormone replacement therapy, tranquilizers, blood
pressure medications, antibiotics, anti-diarrheals,
ulcer medications
Archives of Ophthalmology/Vol.18, Sep 2000; Survey of Ophthalmology/Vol45 Supplement, Mar 2001.
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Rapid assessment of Sx’s of ocular
irritation consistent w/DED & its
impact on vision related functions
12 items relating to Sx’s past 1 wk.
Scale 0 to 100 (higher greater severity)
Good correlation to DED physical
findings*
Good test/retest reliability*
Ability to discriminate mild, mod, severe
DED*
*Shiffman, Arch Ophthal 5/2000
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Anterior Blepharitis
Posterior Blepharitis (MGD)
Mixed Blepharitis
Lid Wiper *
Lid Closure / Blink Quality and Frequency
Conjunctiva (Chalasis, injection patterns)
Tear Quality and Meniscus
Corneal Surface
(EBMD, irregularity, staining, etc.)
Anterior blepharitis
Clinical Findings:
•Scurf
/ Collarettes
•Anterior marginal telangiactasia
•Tylosis
•Maderosis
Etiologies:
•Bacterial
overpopulation
(staph)
•Seborrhea
(yeast – Malassezia?)
•
D. folliculorum
•Cylindrical
lash roots
D. brevis
debris at
ndary:
• 2
MGD, Papillary Conj., Maderosis,
Hordeola, Chalazia, Phlyctenules,
& Dry Eye
 TX:
Tea Tree Oil
50% scrubs - kills mites
5% cream – prevents mating &
reinfestation
Posterior Blepharitis / MGD
Posterior
Telangiactasia
Meibum “alterations”
•(color / composition)
Photos courtesy of Richard Yee, MD , Don Korb, MD and Justin Kwan, MD.
Obstruction and “capping”of
meibomian gland orifices
Gland drop out
Short TBUT
“Meibomian gland dysfunction (MGD) may well
be the leading cause of dry eye disease
throughout the world.”1
—The International Workshop on Meibomian Gland Dysfunction:
Executive Summary
1. Nichols KK, et al. The international workshop on meibomian gland dysfunction: executive summary.
Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929.
2. Lemp MA, Nichols KK. Blepharitis in the United States 2009: a survey-based perspective on prevalence and
treatment. Ocul Surf. 2009;7(2 suppl):S1-S14.
26
Decrease in lipid secretions and LLT
Evaporation increases (4x to 16x)
Decrease in aqueous layer thickness
Unstable tear film
SYMPTOMS START
27
LLT indicates lipid layer thickness.
• MGD may be present without obvious signs
(non-obvious MGD [NOMGD])
• NOMGD may be a precursor to obvious MGD,
highly prevalent, and under diagnosed
Two possibilities with NOMGD: forceful expression
may or may not yield secretion
NOMGD with no overt inflammation or
pathology but neither oil nor any secretion
upon max force manual expression
NOMGD yielding white filamentary
secretions upon max force manual expression
1. Blackie CA, Korb DR. Prevalence of non-obvious meibomian gland dysfunction (NOMGD) in a dry eye study.
28
In press.
28
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937 subjects (mean age (SD):
63.4 (14.5) years, range: 40–96).
Prevalence: asymptomatic MGD was 21.9%.
Prevalence increased with aging
Prevalence: symptomatic MGD was 8.6%.
Abnormal TBUT and NaFl staining were higher
among asymptomatic subjects (vs Nl)
Asymptomatic MGD was associated with
diabetes and cardiovascular disease
Viso E, Rodríguez +. Invest Ophthalmol Vis Sci. 2012 Mar 16
•
Trans-illumination of the lids to clearly
view the entire length of the MGs
 The MGs are assessed
by IR-Diodes:
The use of IR light to
trans-illuminate the lid
upper and lower eyelid

Development of the Oculus Meibo-Scan in cooperation with the
Jenvis Research Institute (Germany), University of Applied
Sciences Jena (Germany) and University of Waterloo (Canada)
“Meibography of the upper lid”
Authors:
Dr Sruthi Srinivasan, Kara Menzies, Luigina Sorbara, and Professor Lyndon Jones
are based at the Centre for Contact Lens Research, School of Optometry,
University of Waterloo, Canada.
Professor Wolfgang Sickenberger is based at the University of Applied Sciences,
Jena, Germany
Puplished:
www.opticianonline.net 09/2011
 Photo of the MGs of the upper and lower eyelid
 Calculated three-dimensional representation of the MGs
Staining of the lid
wiper
portion of the
palpebral conjunctiva
Staining of Marx line
of the lid margin
(normal finding)
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88% of symptomatic dry eye
patients had + LWE
Only 16% of asymptomatic patients
had + LWE
+ LWE was more severe in
symptomatic vs. asymptomatic
subjects
Korb, D.R., et al., Lid-wiper epitheliopathy and
dry-eye symptoms in contact lens wearers.
CLAO Journal, 2002. 28(4): p. 211-6.
Korb, D.R.e.a., Prevalence of Lid Wiper
Epitheliopathy in Subjects with Dry Eyes
Signs and Symptoms, in ARVO. May 2009:
Fort Lauderdale.
NIBUT- Normal
Basics
Score
Grade 0
Grade 1
Grade 2
NIBUT:
>24s
Grade 0
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Osmolarity is a measure of the
concentration of active particles in a
solution
Integral in the contemporary definition
of dry eye
+LJK·SRVLWLYHSUHGLFWLYHYDOXHZL
dry eye
*Disease severity is calculated as an unbiased, normalized composite of seven clinical signs & symptoms
•
Pharmacokinetics
– TOBRADEX® ST Suspension is
bioequivalent to
TOBRADEX® Suspension
– TOBRADEX® ST Suspension contains
one-half (0.05%) the concentration
of dexamethasone present in
TOBRADEX® Suspension (0.1%)
– TOBRADEX® ST Suspension is on
the ocular surface, there is a
80-fold difference in viscosity
when compared to TOBRADEX®
Suspension
Mastrota
Meibomian Paddle
MG Expressor
Gulden, inc.
Lid heating w/ EyeGiene
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Serum = fluid component of full
blood which remains after clotting
Use first described in 1984 by Fox
– Currently NOT FDA APPROVED
Unpreserved, non-antigenic
Biomechanical and biochemical
properties similar to natural tears
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Blood serum contains critical
elements found in healthy tears for
epithelial health:
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EGF (epidermal growth factor)
Vitamin A
TGF beta
Elements missing or highly reduced
in severe dry eye
(SS, SJS, etc.)
Critical elements NOT found in AT’s
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pH = 7.4
Osmolality = 298
EGF (ng/ml) = 0.2 – 3.0
TGF-b (ng/ml) = 2 – 10
Vitamin A (mg/ml) =
0.02
Lysozyme (mg/ml) =
1.4
SIgA (ug/ml) = 1190
Fibronectin (ug/ml) =
21
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pH = 7.4
Osmolality = 296
EGF (ng/ml) = 0.5
TGF-b (ng/ml) = 6 – 33
Vitamin A (mg/ml) = 46
Lysozyme (mg/ml) = 6
SIgA (ug/ml) = 2
Fibronectin (ug/ml) =
205
Hepatocyte GF, NGF, IGF-1,
Substance P, Complement,
Fibroblast GF, cGRP, other
Ig, etc.
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Lab draw 30cc blood
Spin 4000 RPM 20 min.
15ml sterile eye drop bottle
Mix: 5ml Serum, 10ml sterile water,
+ 5 drops of Zymar
Freeze one bottle, refrigerate other
(frozen lasts 3mo, refrig. use w/in 2 wks.)

Use drops q 2 hrs
“Eiden’s OTC Agents”
 Blink
Tears line:
low to high viscocity
(tears, tearsPF, gel tears), contains “HA” but
low MW.

Soothe XP Emolliant: Restoryl®
mineral oil-based emulsion,
re-establishes the lipid layer and
decreases evaporation
 No longer available!
“Eiden’s OTC Agents”
 Oasis
Tears / Tears Plus
(Stabilizes the Tear Film)
 Patient
Pay Out of Pocket
(procedures without CPT codes):
 Probing/Expression of MG
 LipiFlow (ave. $1,200 -$2,000)
Thank You!
S. Barry Eiden, OD, FAAO
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