dews dry eye is not just a disease, it's a complex, multi- factorial

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The Greatest Ocular Surface Disease Course: Ever

Dr Jack Schaeffer Dr Whitney Hauser

Dr Jack L. Schaeffer

financial disclosure form

AlconAllerganAMO / AbbottBausch and LombCiba VisionCooper VisionEssilorHoyaInspireOptosOptovueZeis Vision

DEWS

Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.

Underlying Causes of Dry Eye -Disease

Lipid Deficiency

Neurological

Sjögren’s SyndromeInflammation

Pemphigoid

Ocular Surface Disease

LupusStevens-Johnson

Aqueous Deficiency

Mucin Deficiency

CombinationDeficiencies

Dry eye is not just a disease,

it’s a complex, multi-factorial disorder.

Prause JU, Norn M. Relation Between Blink Frequency and Break-Up Time. Acta Ophthalmol. 1983; 61: 108-116.Cho P, Cheung P, Leung K, Ma V, Lee V. Effect of Reading on Non-Invasive Tear Break-Up Time and Inter-Blink Interval. Clin. Exp. Optom. 1997; 80: 62-8.Tsubota K, Seiichiro H, Okusawa Y, Egami F, Ohtsuki T, Nakamori K. Quantitative Videographic Analysis of Blinking in Normal Subjects and Patients with Dry Eye. Arch. Ophthalmol. 1996; 114(6): 715-720.Nally L, Ousler GW, Abelson MB. Ocular discomfort and tear film break-up time in dry eye patients: a correlation. IOVS 2000; 41(4): 1436. Collins M, Seeto R, Campbell L, Ross M. Blinking and Corneal Sensitivity. Acta Ophthalmologica 1989; 67(5): 525-531.Abelson MB, Holly FJ. A tentative mechanism for inferior punctate keratopathy. Am. J. Ophthalmol. 1977; 83: 866-869.Doane MG. Dynamics of the Human Blink. Ber. Disch. Ophthalmol. Ges. 1980; 77: 13-17.Kaneko K, Sakamoto K. Spontaneous Blinks as a Criterion of Visual Fatigue During Prolonged Work on Visual Display Terminals. Perceptual and Motor Skills 2001; 92(1): 234-250.

Factors Influencing Dry Eye Age Gender Arthritis Osteoporosis Gout Lens Surgery Contact Lens Wear Blink Disorders Lid Disease Nutritional Problems Rheumatoid Arthritis Thyroid Problems

LASIK Surgery Cosmetic Surgery Mechanical Disturbances Exposure Keratitis Entropion Ectropion Symblepheron Formation Large Lid Notches Lagophthalmos Incomplete Blinking Dellen Formation Illumination Systemic Medications

Time of Day Temperature Humidity Air Movement Allergies Change in

Environment Reading Preservatives in

Topical Eye Medications

Watching Movies Sleep

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Sjogrens Non-Sjogrens

Auto-antibodies

Tear Deficient

Evaporative

Lacrimal Deficiency

Lacrimal Obstruction

Reflex

Oil Def. Lid Related Surface Change

Contact Lens

Dry Eye Etiology

NEI Workshop - Classification of Dry Eye (1995)

Tear Film Instability

Note that a patient may have one or more of these deficiencies—they are not mutually exclusive

Aqueous Deficiency Cause: insufficient tear production by

accessory and primary lacrimal glands Sign: low Schirmer (tear volume/flow) score,

tear meniscus height (better measurement)

Tear Film Instability (cont)

Mucin Deficiency Cause: insufficient or unhealthy mucin

production Sign: rapid tear film break-up time (TFBUT)

Lipid Deficiency Cause: meibomian gland dysfunction (MGD)

causing insufficient or unhealthy lipid production

Sign: irregular meibomian gland expression, fast TFBUT

DRUGS ASSOCIATED WITH DECREASED TEAR PRODUCTION

-Adrenergic-blocking, Anti-anginals and Anti-hypertensives

(e.g. Atenolol, Practolol, Propranolol)

Tricyclic Anti-depressants(e.g. Amittriptyline, Doxepin)

Oral Anti-histamines(e.g. Loratadine, Clemastine, Hydroxyzine, Ceterizine, Fexofenidine)

Alkylating Immunosuppressives(e.g. Busulfan, Cyclophosphamide)

Diuretics( T i t )

Role Of Inflammation

Inflammation present in SS-KCS and non-SS KCS

Inflammation present in lacrimal glands, conjunctiva and meibomian glands

Mediated by proinflammatory cytokines in tears

Delayed tear clearance accentuates effect Inflammation adversely affects neural

transmission

PHYSIOLOGY OF THE DRY EYE

PathologicCollagen vascular diseases or

Autoimmune diseases Rheumatoid Arthritis Lupus Erythematosis Sjogren’s Syndrome

0.4 % incidence 95-98% women

Fibromyalgia

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PHYSIOLOGY OF THEDRY EYE

Marginal Contact lens wear--spk Keratoconus Associated with GPC and/or blepharitis Meibomian gland dysfunction(mgd) EBMD (map-dot dystrophy) Acne Rosacea (involves mgd, blepharitis,

dry eye and leads to rosacea keratitis)


MEDICATION INDUCEDAntihistaminesDiureticsDermatologic--i.e. Accutane SSRI’S (Selective Serotonin Reuptake

Inhibitors--i.e. Prozac, Paxil, Zoloft, Lexapro, (Welbutrin- to a lesser degree)

SSRI/NorEpi RI Combination—ie. Cymbalta


HRT INDUCED Women on estrogen therapy (HRT) had a 69%

greater risk of dry eye syndrome Women on estrogen plus progesterone/progestin

had a 29% greater risk of dry eye syndrome Risk of dry eye increased 15% for every three

year interval on HRT 38% of Postmenopausal women in the U.S. use

HRT--translates into millions of women

Brigham and Woman’s Hosp. study—Nov. 2001, JAMA

Dry Eye Evaluation

Vision care Exam

CONVERSION

Medical Exam

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Examination

Adnexa

Lids / Lid Margins

Tears

Conjunctiva

Cornea

EXAMINATION

ADNEXA Dermatological Inflammation

Dermatochalasis

Rosacea

LIDS/ LID MARGINS Infectious

Inflammatory

Allergic

Physiologic( Lagophthalmos)

Lid Disease

Blepharitis

Lid Wiper Epitheliopathy LWE

Meibomian Gland Disease MGD

GPC

To be covered later in presentation

DIAGNOSTIC TESTS EXTERNAL EXAMINATION THE CRANIAL NERVE FUNCTION

For a 7th nerve palsy w/incomplete blink on one side Leads to asymmetric dry eye or exposure

keratitis

THE HANDS For typical arthritic changes suggestive of

Rheumatoid or Osteoarthritis Heberden’s Nodes--Nodular Swelling of

Distal Joints

EXAMINATION

CONJUNCTIVA Goblet Cell function (ekc/post-op)

Staining

Mechanical abnormalities

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EXAMINATION

CORNEA Staining

Topographical

Hypoxia

Secondary Infectious/Inflammatory

Dystrophy

The Economics of Dry Eye Disease

*figures based on one year

Type of Exam Average Revenue

Eyeglasses examination $125‐200

Contact lens examination $150‐200

Dry Eye care $300‐800


Medical Office Visit: OSD Evaluation

99212 $48.00 99213 $64.93 99214 $98.65

Medical Office Visit: Follow-up

99212 $48.00 99213 $64.93If you anticipate three follow-up visits during the year, here’s what the revenue would look like:

Follow-up Revenue per Year

99212(x3) $144.0099213(x3) $194.79


Level of Condition Annual Direct Costs

Mild Dry Eye $678

Moderate Dry Eye $771

Severe Dry Eye $1276


Level of Dry Eye Disease Cost of Lost Productivity

Mild Dry Eye $12,686

Moderate Dry Eye $12,569

Severe Dry Eye $18,168

DIAGNOSTIC TESTS

TEAR EVALUATION Tear Meniscus TFBUTOsmolarity Evidence of Fluorescein Staining Tear Consistency-i.e. thickness,

debris, evidence of meibomiangland oil and sebaceous secretions

Shirmers

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DIAGNOSTIC TESTS Schirmer--w/ or w/o anesthetic Phenol Red Thread Test Zone Quick-represents fluid present in

the conjunctival sac

Fluorescein Staining Rose Bengal Staining Lissamine Green Staining Tear Osmolarity Collagen Plugs

Zone‐QuickRed cotton thread treated with phenolsulfonphthalein

◦ Yellow (acidic) = water absorption indicator

◦ Red (basic) = tear volume indicator

Schaeffer Shirmer

Always do this as the last test

Place strip in any part of the eye

Count to three

remove

Tear Osmolarity

TearLabOcular Surface

DiseaseUPDATE 2011

Osmolarity Provides Improved Standard of Care

• Tear osmolarity is the most accurate diagnostic test for dry eye disease

• Elevated osmolarity is the central mechanism causing ocular surface damage

• Allows a physician to rapidly diagnose & classify patients with a global assessment

– In combination with a slit lamp exam, physicians can select therapies based on mechanism of disease and severity

• Modulate therapy using a quantitative endpoint

Tomlinson A, IOVS 2006. DEWS Ocular Surf 2007

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Meibomian Gland Evaluator (MGE™)

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The number of FUNCTIONAL Meibomian Glands correlates with dry eye symptoms

With Symptoms1 (n=133)Asymptomatic healthy eyes2

(n = 24 glands)Severe Symptoms

Moderate Symptoms

Minimal Symptoms

Symptom Score, SPEED (0-28)

≥10(14.4 ± 0.7)

6–9(7.3 ± 0.2)

≤5(2.3 ± 0.2)

0

Number of functional MGs for lower eyelid

4.1 ± 0.6 5.1 ± 0.4 6.3 ± 0.4 10.6 ± 2.6

≤ 4, treatment necessary, (if glands present)5-6, intervention highly advised7-9, preventive treatment (PRN)

Notes: 1. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008;27(10):1142-1147.2. Blackie CA, Korb DR. Recovery time of an optimally secreting meibomian gland. Cornea. 2009;28(3):293-297.

DRY NOT DRY

0 - 4 5 6 7 8 9 10+

FUNCTIONAL MGs in the Lower Lid

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OCULUS TF-Scan - Tear meniscus height measurement

New measurement options of the Keratograph 5M

• Overview of the curvature along the lid

• Digital measuring of the height and automatic documentation

• Automatic calibrated and digital measuring of the TMH

The NIKTMH measurement can be performed under infrared light conditions now → no influences on the tear film conditions!!

B.Sc. Florian Winzig

Lipiview◦ Uses interferometry to measure lipid layer thickness between blinks

◦ Quantitative assessment in interferometric color units (ICU)

Lipiview

InflammaDry

RPS Technologies

Dry Eye Disease Cycle of Inflammation1

Dry eye is often hidden until patients have progressed and experienced symptoms

Dry eye symptoms overlap with other ocular surface diseases, complicating diagnosis

Numerous clinical diagnostics exist, with no single method preferred

Most ECPs use one or multiple tests, symptom assessment and patient history to diagnose[1] Definition and Classification of Dry Eye. Report of the Diagnosis and Classification Subcommittee of the Dry Eye Work Shop (DEWS). Ocular Surface 2007;5:75‐92.

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Dry Eye Disease and MMP‐9

Matrix metalloproteinases (MMP) are proteolyticenzymes that are produced by stressed epithelial cells on the ocular surface1

MMP‐9 in Tears

Non‐specific inflammatory marker

Normal range between 3‐41 ng/ml

More sensitive diagnostic marker than clinical signs1

Correlates with clinical exam findings1

Ocular surface disease (dry eye) demonstrates elevated levels of MMP‐9 in tears1

[1] Chotiakavanich S, de Paiva CS, Li de Quan, et al. Invest Ophthalmol Vis Sci 2009; 50(7): 3203‐3209.

Dry Eye Disease and MMP‐9

Increased concentrations of MMP‐9 can be found in other diseases or conditions, including:

Ocular rosacea

Meibomian gland disease

Sjögren’s syndrome

Corneal ulcers

Corneal erosions

InflammaDry® Limit of Detection

Normal levels of MMP‐9 in human tears ranges from 3‐41 ng/ml

NEGATIVE TEST RESULTMMP‐9 < 40 ng/ml

POSITIVE TEST RESULTMMP‐9 ≥ 40 ng/ml

InflammaDry 4‐Step Process

* Release the lid after every 2‐3 dabs. Allow the sampling fleece to rest along the conjunctiva for 5 seconds.

*

Ocular Surface DiseaseSecondary to Systemic Disease

Patient /Busy Doctor 64 YOM History of Dry eye with all signs and

symptoms Restasis UNG PM PP PFAT Signs / symptoms vary at each visit over a

year

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Systemic Disease Diabetes Rheumatoid Arthritis Sjogren’s syndrome

Thyroid Eye Disease Rosacea Sleep Apnea Graft Vs Host DiseaseMany others

VITAL STAINS

Sodium Fluorescein Epithelial defects Accumulates intracell. space

Rose Bengal Premier dye of conjunctiva Stains devitalized cells on

cornea and conjunctiva Stains mucin strands Stains unprotected tissue Phototoxic, sting is dose

dependent, antiviral?

Lissamine Green Same purpose as RB Less stinging

Fluramene

Causes of Clinical Dry Eye

Mucin deficiency Goblet cell dysfunction

Epithelial surface disease

Aqueous deficiency Lacrimal gland dysfunction

Keratoconjunctivitis sicca

Meibum deficiency Meibomian gland disease

Evaporative dry eye

Developing a Specialty Ocular Surface Disease

Practice

Lid Disease

Lid Disease

We cannot treat the dry eye until we understand and treat

LWEMGDBlepharitisEpihora

IT IS ALL ABOUT THE LIDS

Case #252 year old, white female

Occupation: Web designer

Hobbies: Pinterest on her iPad, reading, yoga

Ocular history: Dry Eye Disease, mild cataracts

Medical history: Occasional migraine headaches, mild hypertension

Meds: Lorazepam, Cymbalta, flax seed oil

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Case #2

Complaint Dry symptoms worsening, “OTC’s don’t work,”

Associated symptoms

Eye fatigue, discomfort, worsening in the evening, often matted

Effect to ADL’s Effects work, limits reading

Medications for DED Similasan “Dry Eye Relief” (has used “all” artificial tears), warm compresses, cold packs

Case #2

cc DVA 20/20 OD 20/20 OS

EOMs FROM OU

Pupils ERRL(‐)APD

SPEED 14/28

OSDI 54/100

Inflammadry

Negative

NIKBUT (initial)

4.72 OD 4.33 OS

Osm 294 OD 277 OS

Case #2Visit 3:◦ Patient reports significant improvement and relief

◦ ADL’s not effected at the end of the day

◦ Continuing Cliradex qhs OU and Systane Balance QID OU

◦ Switching to Avenova BID OU in 2 weeks

Microscopy

Demodex visible at slit lamp◦ Cylindrical dandruff

◦ Base of lashes

Microscopy for patient education

MicroscopyEpilation maneuver

Rotation is key

MicroscopyPlate to slide

Observe under lower magnification

Increase magnification

Photograph

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Demodex• Ubiquitous obligatory ectoparasites of

man

• Two forms: D. brevis and D. folliculorum

• Lifecycle of 14.5 days

• Negatively phototaxic

• Move in dark environment, stop with bright ones

Lacey N et al. Demodex Mites – Commensals, Parasites or Mutualistic Organisms? Dermatology 2011;222:128–130 62

Demodex• 84% of patients at 60, 100% over 70

• Increased incidence with:

• Age

• Immunocompromised

• Skin disorders (Rosacea)

• Eye environment- increased pH and amino acids

Lacey N et al. Demodex Mites – Commensals, Parasites or Mutualistic Organisms? Dermatology 2011;222:128–130

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Demodex

• Blepharitis secondary to demodexconsuming epithelial cells

• Micro-abrasions causes reactive hyper-keratinization which leads to cylindrical dandruff

Liu J et al. Pathogenic role of Demodex mites in blepharitis Curr Opin Allergy Clin Immunol. Oct 2010; 10(5): 505 510

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Demodex Treatment

• 50% TTO in-office weekly, 10% TTO wipes bid OU

• 5% TTO ointment massage

Gao YY et al. Treatment of Ocular Itching Associated With Ocular Demodicosis by 5% Tea Tree Oil Ointment. Cornea. Jan 2012: 31(1), 14-17

Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in Demodex Blepharitis J Korean Med Sci. Dec 2012 27(12), 1574-9.

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Demodex Treatment

• Commercially available:

• Cliradex- 25% TTO wipe

• OcuSoft Demodex kit (for in-office)

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OcuSoft Tea Tree Kit

• Contains Tea Tree Oil + Buckthorn seed oil

• Ung QHS

• OcuSoft Cleansers

67 68

BlephEx Treatment

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Lid Hygiene – Surgical ConsiderationsTypes of Blepharitis:◦ Anterior

◦ Staphylococcal

◦ Seborrheic

◦ Demodex

◦ Angular

◦ Posterior

◦ Meibomian Gland Dysfunction (MGD)

Baby Shampoo…..really a myth

It is the traditional method taught in school but is has disadvantages which include:

• Requires Mixing and Diluting (Convenience?)

• Poor Patient Compliance (actually is irritating to eye)

• Long Term Use Will Make the Skin Dry• More Professional Treatments are Available

Case #184 year old, white, female

(+) severe dry eye for 1 year

Oral Medications: ◦Metformin ◦ Lisinopril◦ Glyburide◦ Lovastatin◦ Sertraline◦ ASA◦ Glucosamine

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Case #1

Complaint Chronic dryness, increasing for 1 year

Associated symptoms

Fluctuating vision, photophobia

Effect to ADL’s Unable to read, cannot go outside comfortably

Medicationsfor DED

Restasis BID, Non‐preserved Systane, doxycycline 100mg BID, Omega 3FA

Case #1

cc DVA 20/100 OD 20/200 OS

EOMs FROM OU

CFV FTFC OD, OS

Pupils ERRL(‐)APD

SPEED 22

OSDI 75

Osm 301 OD 321 OS

Inflammadry

Negative

Case #1 Case #1Diagnosed with glaucoma in 1970’s

Instilling 2 glaucoma medications◦ Latanoprost qhs OU

◦ Brimonidine BID OU

Case #1Treatment:◦ Lipiflow treatment – begin Acuvail bid for 2 weeks, then qd for 2 weeks

◦ Lid hygiene – Cliradexwipes bid x 10 days then qhs for 20 days

◦ RTC 4‐6 weeks

Case #1Follow up examination◦ “Good days and bad days”

◦ Dryness less of a problem since treatment and vision is improving

◦ Able to read the newspaper

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Case #1

cc DVA 20/60 OD (PH: 20/30) 20/100 (PHNI)

EOMs FROM OU

CFV FTFC OD, OS

PUPILS ERRL(‐)APD

SPEED 14

OSDI 62.5

Osm 308 OD 308 OS

Case #1Patient returned for PROKERA® at follow‐up visit. S/p removal of amneotic membrane results:

cc DVA 20/60 OD (PH: 20/30) 20/50 (PH: 20/30)

EOMs FROM OU

CFV FTFC OD, OS

PUPILS ERRL(‐)APD

SPEED 8

OSDI 30

Osm 312 OD 306 OS

Sutureless Amniotic Membrane

ProKera – Amniotic Membrane for wound healing Cryopreserved

Bio Optix Dry Membrane

Biological Scaffolding

Helps initiate an active healing process by providing proteoglycans and growth factors

Collagens, fibronectin and lamillin Cryopreserved membrane contains heavy-

chain hyaluronic acid Inhibits proinflammatory cells Suppress T Cells

Persistent Corneal Defect Recurrent Cornea Erosion Corneal Ulcer Pterygium Graft Bullous Keratopathy Band Keratopathy

Sutureless Amniotic Membrane

ProKera – Amniotic Membrane for wound healing Corneal Ulcer Bullous Keratopathy Folds in Descemet’s Chemical Burns Mechanical Complications 2ary to graft Disruption of surgical wound Non-healing surgical wound

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• The amniotic membrane is the innermost lining of the placenta (amnion)

• Amniotic membrane shares the same cell origin as the fetus• Stem cell behavior

• Structural similarity to all human tissue

The Amniotic Membrane

Ocular Surface Disease

Corneal Inflammation

Keratitis

Conjunctival Inflammation

Conjunctivitis

Eyelid Inflammation

Blepharitis

Inflammation is the Hallmark of All Ocular Surface Diseases

Inflammation’s Effect on Healing

Inflammation: the first sign of wound healing & is also the hallmark symptom of all ocular surface diseases

Uncontrolled inflammation leads to: Chronic pain and discomfort/irritation Delayed healing, more tissue damage Vision-threatening complication, e.g., scar/haze

Effective control of inflammation is an important strategy to promote healing and minimize the risk of scar/haze

Non-Resolved Inflammation

Tissue Damage

Controlling Inflammation is Key to Preventing Tissue Damage!Controlling Inflammation is Key to Preventing Tissue Damage!

PROKERA® utilizes the proprietary CryoTek™ cryopreservation process that maintains the active extracellular matrix of the amniotic membrane which uniquely allows for regenerative healing.

PROKERA® is the only FDA-cleared therapeutic device that both reduces inflammation and promotes scar less healing

PROKERA® can be used for a wide number of ocular surface diseases with severity ranging from mild, moderate, to severe

PROKERA®: BIOLOGIC CORNEAL

BANDAGE

Insertion of Pro-Kera

Remove from inner pouch Rinse with saline (prevents stinging from

preservation media Apply topical anesthesia Hold upper lid and have patient look down Insert into superior fornix Slide under lower eyelid Check for centration

Devries Amniotic MembraneVEE 2016

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BRUDER Dry Heat Glass Bead Sanitizer

Suitable for all metal instruments including the Bruder Meibomian Gland Expression Instruments

Fast acting and easy to use:

• Chamber size: : 1 5/8" Diameter x 2 1/2" Deep.

• Chamber with glass beads heats to 250 °C in approximately 30 minutes

• Sanitizes in 30 seconds

• Electrical

NOTE: Glass Beads Sanitizers are not FDA approved as sterilizers. Glass Bead sanitizers are a quick, easy and accurate alternative to traditional methods of sterilization and sanitizing.

Item #98200 Sanitizer with 1 bag of glass beads.

Item #98201Replacement Beads. Contain 2 refills.

Bruder Instrument Trays

Autoclavable instrument trays are ideal for instrument storage or transport.

Available in two convenient sizes.

Item #98301Instrument Tray Large ‐ 4”

4" x 6 1/2" x 3/4"

Item #98300Instrument Tray Small – 2 1/2”

2 1/2" x 6" x 3/4"

Item #98610 COLLINS Expressor ForcepsGERMAN STAINLESSFor mild to aggressive expression of Meibomian gland. 95mm Forceps with closed paddles

Item #98620 LIVENGOOD Expressor Paddle ‐ AngledGERMAN STAINLESSFor mild or gentle expression of the Meibomian gland. 75mm oval blades with 12 degree angle. Non‐slip knurled handle.

Item #98630 LIVENGOOD Expressor Paddle – StraightGERMAN STAINLESSFor mild or gentle expression of the Meibomian gland. 75mm flat oval blades. Non‐slip knurled handle.

Meibomian Gland Expression Offering

COLLINS Forceps

LIVENGOOD Forceps can be used together or in tandem.

Sold separately.

BRUDER Surgical Instrument Line


Item #98650 BRUDER Epilation ForcepsThese forceps feature non‐slip jaws/tips and an easy‐grip, no slip handle for precise eyelash removal. German stainless.

Item #98651 KARPECKI Punctal Plug ForcepsThis instrument has a groove on the inside tip to hold the plug solidly in place during the procedure. Also if necessary the instrument can be turned 90 degrees to a flat side to push the plug into place. German stainless.

Item #98652 KARPECKI Bandage Lens ForcepsThis instrument has a narrow, but rounded tip. The application of a special coating instead of serration assures the bandage will not slip when being removed. Slide the forceps under the edge of the bandage lens and easily pick it off the eye. German stainless.

Item # 98653 KARPECKI Debrider The instrument has a slightly curved tip with a “crisp” edge on both sides. The edge is just right to remove the keratin easily by sliding the instrument, curve forward, along the eyelid in a single direction. German stainless.

Specialty Instrument Offering


Item #98703 BRUDER Jeweler Forceps 3




Bruder Surgical Instruments ship in storage cases.

Popular Jeweler Forceps

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Sjogren’s syndrome leads to:Corneal abrasions and other Keratopathies

Blepharitis

Uveitis

Other ocular infections

Dental caries

Other infections of the mouth

Systemic involvement in Sjogren’s syndrome may lead to:

Respiratory dysfunction

Renal dysfunction

Lymphoma

Sjö Testing - Research

26% of DED patient have autoimmune disease

11% have Sjögren’ssyndrome

Average delay of 10 years in receiving an accurate diagnosis

Common Complaints:

Dry eye

Dry mouth

Fatigue

Joint pain

Akpek EK, Klimava A, Thorne JE, et al. Evaluation of patients with dry eye for presence of underlying SjögrenSyndrome. Cornea. 2009 Jun;28(5):493-7

Sjö Testing - Research

Cataract Surgery risks:

SPK

Filamentary keratitis

Conjunctivitis

Infectious keratitis

Recurrent epithelial defects

Stromal keratolysis

Corneal ulceration

Lasik surgery risks: Severe and difficult-to-

treat dry eyes

Refractive regression

*Some case reports note good safety and refractive stability

Aggravated dry eye after laser in situ keratomileusis in patients with Sjögrensyndrome.Liang L, Zhang M, Zou W, Liu ZCornea. 2008 Jan; 27(1):120-3.

Complications occur more commonly with ECCE than phacoemulsification

Sjö Testing - Clinical

Combines 4 traditional biomarkers with 3 novel, propriety biomarkers

Helps detect Sjögren’ssyndrome early in its disease course

Offers significantly higher sensitivity and specificity than previous screening methods

101CONFIDENTIAL

Advanced Recalcitrant PEK

Autologous Serum Amniotic Membrane

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Autologous Serum

Contains Epithelial Growth Factor (EGF) Transforming Growth Factor 8 (TGF8) Fibronectin Vitamin A Other Cytokines

Autologous Serum

Blood Draw at Lab Spin down to plasma @4000 rpm for 20

minutes Deliver to Compounding Pharmacy 2:1 Filtered Compounding with BSS 8 Bottles Frozen until used

Autologous Serum

1 gtt q2h from morning until bedtime Keep Vial Refrigerated Keep Additional Vials Frozen Until Use 8 Straight Weeks Evaluate After 6-8 Weeks Possible Additional Course

Autologous Serum Cost

Lab Draw $30 Compounding Pharmacy $120 $150 for 8 Vials

IF Patient delivers Serum to Pharmacy

Autologous Serum Cost

Lab Draw $30 Compounding Pharmacy $120 Virology Testing $210 Freeze and Shipment To/From

Compounding Pharmacy Approximately $450 to $550 for 8 Vials

SCLERAL LENSES

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Punctal / Lacrimal Occlusion

Rationale for occlusion therapy: Diminishes tear drainage from the ocular surface Enhances contact time between tears & ocular surface Utilizes “normal tears” Natural complement of proteins, enzymes, buffers, etc.

Multiple modalities, manufacturers, products Collagen, silicone, acrylic polymers Intracanalicular vs. punctal occlusion

LACRISERT®

(hydroxypropyl cellulose ophthalmic insert)

A Novel Approach to Treating

Dry Eye Syndrome

Please see full Prescribing Information.

LACRISERT(hydroxypropyl cellulose ophthalmic insert)

Lacrisert [package insert]. Aton Pharma, Inc.: Lawrenceville, NJ; 2007.

Indicated in patients with moderate to severe dry eye syndrome (DES), including keratoconjunctivitis sicca.

Indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions.

Indicated for patients with exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions.

Case #368 year old, white male

Hospital‐based medical researcher

Ocular history◦ (+) Dry Eye – irritated, red, gritty OU

◦ (+) POAG OU

◦ (+) Retinitis pigmentosa OU

Medical history◦ Rosacea

◦ High cholestrol

◦ Osteoarthritis

Case #3

cc DVA 20/60 OD 20/70 OS

EOMs FROM OU

Pupils ERRL *corectopia OS

SPEED 28/28

OSDI 100/100

Inflammadry Negative

NIKBUT (initial)

6.33 OD 5.41 OS

Osm 311 OD 290 OS

M G D

Meibomian Gland Dysfunction

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Level one Treatment: Available to all Doctors Medical : In office and home Procedures

Level two Treatment: Specialized equipment needed


1 Manual Expression

2 Miboflow

3 Lipiflow

M G D

Meibomian Gland Disease Meibomian Gland Dysfunction and Management

Kelly K. Nichols, OD, MPH, PhD

FERV ProfessorUniversity of Houston College of Optometry

Chair, TFOS International Meibomian Gland Workshop

©KNichols 2012


• The TFOS Report of the International Meibomian Gland Dysfunction Workshop– Etiologies

– Definition/ Classification

– Epidemiology

– Clinical characteristics

– Diagnosis/ Management

– Contact lenses, surgical implications

©KNichols 2012

Current Dry Eye Definition “Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.”

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©KNichols 2012

DEWS—Classification of Dry Eye

80%20% 5% 65% 35%

©KNichols 2012

TFOS International MGD Workshop

• Over 65 International clinicians, scientists, and industry participants

• 2+ year process

• Published in March 2011, IOVS

• #1 Most downloaded IOVS article for the last 12 months

• Downloaded over 5500 times

• All MGD workshop reports are in the “top 10”

• Translation into 12 languages

• www.tearfilm.org

©KNichols 2012

Lecture Descriptionwww.tearfilm.org

©KNichols 2012

Anatomy, Physiology and Pathophysiology of the

Meibomian Gland

Erich Knop, M.D., Ph.D. (Chair)Nadja Knop, M.D., Ph.D.Thomas J. Millar, Ph.D.Hiroto Obata, M.D.

David A. Sullivan, Ph.D.

©KNichols 2012

• Large sebaceous glands

• No direct contact to hair follicles

• Located in the tarsal plates

• Upper and lower eye lids

Meibomian Gland ‐ ANATOMY

Modified and colored from Krstic H. Human microscopic anatomy. Springer Medizin Verlag 1991, (reproduced from Knop N & Knop E Ophthalmologe 2009; 106:872–883)

©KNichols 2012

• Length

• Follows the tarsus

• Number• More in upper lid (30‐40)• Less in lower lid (20‐30)

• Volume• Higher in upper lid (26µl vs. 13µl)

• Relative functional contribution (upper vs. lower) to the tear film lipid layer is unknown

Meibomian Gland ‐ ANATOMY

Modified from Sobotta Atlas der Anatomie des Menschen. Urban & Schwarzenberg Verlag 1982, (reproduced from Knop N & Knop E. Ophthalmologe 2009; 106:872–883)

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©KNichols 2012

Meibomian Gland – PATHOLOGY• Obstructive MGD leads to a progressive ductal DILATATION and acinar ATROPHY

Fom Knop E & Knop N. Meibom-Drüsen Teil IV. Funktionelle Interaktionen in der Pathogenese der Dysfunktion (MGD). Ophthalmologe.2009;106:980–987

©KNichols 2012

Meibomian Gland DysfunctionDefinition & Classification

J. Daniel Nelson, M.D. (Co‐Chair)

Jun Shimazaki, M.D., Ph.D. (Co‐Chair)

Jose M. Benitez‐del‐Castillo, M.D., Ph.D.

Jennifer Craig, Ph.D., MCOptom

James P. McCulley, M.D.

Seika Den, M.D., Ph.D.

Gary N. Foulks, M.D.

Evaluation, Diagnosis and Grading of Severity of


Alan Tomlinson, MCOpt, Ph.D. (Chair) E. Ian Pearce, Ph.D. Anthony J. Bron, F.R.C.S. Richard Yee, M.D.Donald R. Korb, O.D. Norihiko Yokoi, M.D., Ph.D.Shiro Amano, M.D., Ph.D. Reiko Arita, M.D., Ph.D. Jerry R. Paugh, O.D. Murat Dogru, M.D.

©KNichols 2012

Management and Therapy of Meibomian Gland

Dysfunction

Gerd Geerling, M.D. (Chair) Terrence O’Brien, M.D. Joseph Tauber, M.D. Maurizio Rolando, M.D.Christophe Baudouin, M.D., Ph.D. Kazuo Tsubota, M.D.Eiki Goto, M.D. Kelly K. Nichols, O.D., M.P.H., Ph.D.Yukihiro Matsumoto, M.D.

Under-Treated Meibomian Gland Dysfunction

How treating MGD improves your practice

040215

MGD ExposedA new look at an old problem

132

1. Foulks GN1, Nichols KK, Bron AJ, Holland EJ, et al. Improving awareness, identification, and management of meibomian gland dysfunction. Ophthalmology. 2012 Oct;119(10 Suppl):S1-12.2. Murakami DK, Blackie CA and Korb DR. The Prevalence of Meibomian Gland Dysfunction in a Caucasian Clinical Population. ARVO abstract 20153. Blackie et al. Nonobvious MGD. Cornea. 2010 Dec;29(12):1333-45.4. Mudgil P. Antimicrobial role of human meibomian lipids at the ocular surface. Invest Ophthalmol Vis Sci. 2014 Oct 14;55(11):7272-7.5. Napoli PE, Coronella F, Satta GM, et al. Evaluation of the adhesive properties of the cornea by means of optical coherence tomography in patients with meibomian gland dysfunction and lacrimal tear deficiency., PLoS One. 2014 Dec 23;9(12):e115762. 6. Jackson et al. Evaluation of Thermal Pulsation Treatment for Meibomian Gland Dysfunction in Cataract Surgery Patients ASCRS 20157. Suhalim JL, Parfitt GJ, Xie Y, et al. Effect of desiccating stress on mouse meibomian gland function. Ocul Surf. 2014 Jan;12(1):59-68. 8. Holland et al. Patient Characteristics Associated with Improved Meibomian Gland Function after Thermal Pulsation Treatment for Meibomian Gland Dysfunction. ASCRS 20159. Grenon, Liddle and Grenon et al. A Novel Meibographer with Dual Mode Standard Noncontact Surface Infrared Illumination and Infrared Transillumination. ARVO 2014

The prevalence of MGD is as high as 60-70%1,2

MGD is frequently nonobvious and therefore missed3

Meibomian lipids are critical for innate tear film host defense4

MGD decreases corneal adhesiveness5

Pretreatment optimizes post-cataract surgery ocular comfort6

Evaporative stress causes MGD7 (Modern lifestyle, Contact lens wear and Chronic use of topical medications all induce evaporative stress)

MGD is progressive: Early intervention optimizes outcomes8

Identify early compromise to MG function and structure with the MGE and DMI9

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Lipids Essential to Stable Tear Film

Unstable Tear Film

Lipid

Aqueous

Mucin

Tear Clearance & Spread

Evaporation

Anatomical Anatomical

Sensory MotorSensory Motor

MeibomianGlands

MeibomianGlands

Lacrimal GlandLacrimal Gland

Goblet CellsGoblet Cells

Lid BlinkingLid Blinking

Lid ClosureLid Closure

133

1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478.

86% of dry eye patients have MGD1 causing instability

An Unstable Tear Film Negatively Impacts Premium Quality Vision Care

Fluctuating Vision Ocular Discomfort

Compromised Barrier to Infection1

63%+ of Cataract Patients (PHACO study results)

Contact Lens Intolerance and LASIK Candidates

Glaucoma and Retinal Patients

134

1Antimicrobial role of human meibomian lipids at the ocular surface. Mudgil P. Invest Ophthalmol Vis Sci. 2014 Oct 14;55(11):7272-7.

Focus on the Gland

“Meibomian Gland Dysfunction (MGD) is a chronic, diffuse abnormality of the Meibomian Glands, commonly characterized by terminal

duct obstruction and/or qualitative/quantitative changes in the

glandular secretion.”

135

Notes: The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Geerling G, Tauber J, Baudouin C, et al. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):2050-64

Function Structure

Normal Function Normal Structure

Meibomian Gland Function

136

Notes: Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for Meibomian gland dysfunction. Finis D, Pischel N, Schrader S, Geerling G. Cornea. 2013 Dec;32(12):1549-53.Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Korb DR, Blackie CA. Cornea. 2008 Dec;27(10):1142-7.

DRY NOT DRY

0 - 4 5 6 7 8 9 10+

FUNCTIONAL MGs in the Lower Lid≤ 4, treatment necessary, (if glands present)5-6, intervention highly advised7-9, preventive treatment (PRN)

• A functional Meibomian Gland is a gland that releases its liquid contents during a deliberate blink.

• The number of functional MGs along the lower eyelid can be used to diagnose MGD and to direct therapeutic intervention

When the total number of functional glands is 10 or higher, but there is evidence of compromise to gland function and/or structure, therapy should still be considered.

MGD is ProgressiveExamples of Compromised Function and Structure

Function

Structure

Normal Function Nonobvious MGD Obvious MGD Obvious MGD

Normal Structure Gland Duct Dilation& Drop Out

Gland Truncation & Drop Out

Gland Duct Dilation, Truncation & Drop Out

137

Notes: Siak JJ, et al. Prevalence and risk factors of meibomian gland dysfunction: the Singapore Malay Eye Study. Cornea. 2012;31(11):1223-1228. Viso E, et al. Prevalence of asymptomatic and symptomatic meibomian gland dysfunction in the general population of Spain. Invest Ophthalmol Vis Sci. 2012;53(6):2601-2606. Hom MM, et al. Prevalence of meibomian gland dysfunction. Optom Vis Sci. 1990;67(9):710-712.

The Cycle of Inflammation

Sym

pto

ms

Incr

ease

Potential Long-term DamageInflammationInflammation

Stasis, inspissation and obstruction of the Meibomian Glands

Meibomian Gland Dysfunction (MGD)

Tissue ChangesTissue Changes

Decrease in Meibomian secretions

Decrease in tear film stability, increased aqueous tearing1

Increase in evaporative stress

Ocular surface exposure (between blinks) & Micro-trauma (during blinking)

138

1. Arita R, et al. Increased Tear Fluid Production as a Compensatory Response to Meibomian Gland Loss: A Multicenter Cross-sectional Study. Ophthalmology. 2015 Jan 24. pii: S0161-6420(14)01195-6. doi: 10.1016/j.ophtha.2014.12.018. [Epub ahead of print]

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• Wait for the onset of sequelae: The patient tells you there is a problem

• Measure and manage dry eye sequelae• Lead with palliative artificial tears • Gradually advance treatment as sequelae

increase in severity1,2

A Change in Philosophy – MGD First

Dry Eye Approach MGD First/Root Cause Approach

• Evaluate everyone for MGD: Identify MGD at its earliest stages

• Educate patients about the front line of defense of the tear film – the lipid layer

• Offer the most efficacious MGD treatment as early as possible

• Rehabilitate the ocular surface and manage sequelae with adjunctive therapy

Goal: Restore and optimize gland function/intervene in progression

• Root cause is not identified: Promotes confusion, and patient despair

• Promotes patient and physician confidence in MGD management.

139

Notes: 1. Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop. Geerling G et al. Ocular Surface. 2007 Apr;5(2) 163-178,2. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Geerling G, Tauber J, Baudouin C, et al. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):2050-64

Goal: Treat Sequelae (primarily symptoms)

MGD First: If the etiology is not treated, the Dry Eye will not resolve

MGD First does not mean that the sequelae of dry eye should be ignored.

140

SYMPTOMS

VISION

TEAR INSTABILITY

OCULAR SURFACE DAMAGE

HYPEROSMOLARITY

INFLAMMATION

Compromised Lacrimal Function

MGDLipiFlow/ Manual Expression,

Warm Compress, lid hygiene, Blinking, Lipid Drops Topical & Systemic

Medications

MEASURE AND MANAGE DRY EYE SEQUELAE

IDENTIFY AND TREAT THE CAUSE

MOST COMMON

Allergy, Autoimmune Treat Accordingly

TREATMENT

Treat Accordingly

+

Non-Obvious MGD (NOMGD)• MGD may be nonobvious without

inflammation and without other obvious signs (NOMGD)

• NOMGD may be precursor to obvious MGD

• Highly prevalent and under-diagnosed – may be most common cause of evaporative eye disease

• In a recent dry eye study of the 52 subjects that had MGD, 48% of them had NOMGD. 141

MGDMedical treatment

142

Mild/Acute• Hot compresses• Lid hygiene• Lipid based tears-mild/moderate• Osmolarity lowering drops in

moderate/severe

144

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Moderate/Acute

• Tobradex ST • Zylet• AzaSite• Tobradex generic

Long Term

• Pulse dose medications periodically• Restasis bid• Essential fatty acids

– EPA– DHA– GLA

Moderate/severe or not improving

• Add PO tetracycline• Recommendation:• Doxycycline 50mg bid x 4-8 weeks

then taper to qd• Periostat (20 mg doxycycline) bid• OcuSoft: ALODOX – generic 20 mg

Tetracyclines

• Antibiotics inhibit bacterial protein synthesis by binding 30S ribosome

• Anti-inflammatory properties

– decreases IL-1, TNF-– decreases NO production

– decreases HLA Class II antigen expression

– decreases metalloproteinase production and activation

• Decrease symptoms and joint destruction in RA

Contraindications

• Pregnant or child bearing age• Children

Cautions• Photosensitivity• Chelates with dairy products,

antacids etc.• Minocycline may cause

vestibular toxicity• Number one drop-out reason?• GI problems

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How to Minimize Stomach Problems with Tetracycline

1. Do not take the second pill (bid) before going to bed

2. Do not take pills with acidic beverages

3. Take pills with food (except a high dairy meal)

4. Prescribe the lowest dose available

MGDMedical-Instrument

Treatment

152

Treatment of MGD/NOMGD

In-Office Therapy Manual Expression Off-Label Pharmacotherapy

Oral tetracycline/doxycycline Topical Antibiotics – erythromycin, tobramycin Topical Steroids – dexamethasone

153

At Home Therapy– Warm compresses– Eyelid Scrubs

– Self expression

Collins Expressor Forceps (Item 98610)For aggressive expression of the Meibomian gland.

Livengood Expressor PaddlesAngled (Item 98620) & Flat (Item 98630)

For mild or gentle expression of the Meibomian gland.

New! Ophthalmic Surgical Instruments

Maskin Expressor

$ 575

Rhein Medical

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WARNING

Hot compresses can change the corneal tissues and structure

Possible Link to Keratoconus

Evidence Based Medicine

Meibomina Gland Expression

Schaeffer Eye Protocol1) OSD Evaluation

1) Includes test expression2) All staining

2) RTC expression1) At home heat with eye medibeads2) 15-20 minutes in waiting room with Bruden’sheat pack ( or rear wait) 3) Expression 1 of 34) RTC 2 weeks

Meibomian Gland Expression

Fees: $289 / $25

Out of pocket: ABN

Covers 3 Office visits

$68.00 Per visit after initial three visits

99213 / 99212

Dry eye progress check before expression

MGD

Maskin Expressor

Maskin Probe

1)$ 158 box ( 10)

2) 1,2,4,6 MM intraductals

3) Aluminum Handle $104

Maskin Tube

Meibomian gland Drug delivery system

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Maskin Probe

Leiter Pharmacy8% lidocaine with 25% Jojoba in

ung base

OBSTRUCTIVE MGDWarm Compress Treatment

Increase in LLT Following Treatment with Warm Compresses in Patients with MGD

Olson, Korb, Greiner, Eye & CL, 2003

Baseline LLT = 60 nm5 minutes = 105 nm15 minutes = 117 nm30 minutes = 122 nm

Not published: 1 to 2 mins – minimal or no improvement

Warming devices : Goto et al., 2002; Mori et al., 2003; Nagymihalyi et al., 2004;Mitra et al., 2005; Di Pascuale et al., 2005; Spiteri et al., 2007

Warm Compresses: Olson et al., 2003: Matsumoto et al., 2006

Standard Patient Evaluation of Eye Dryness (SPEED) Questionnaire

• Evaluates the frequency and severity of symptoms

• Developed as an easy to use fast screening tool for dry eye disease

• SPEED questionnaire is one of the tools used to identify candidates for LipiView®

Meibomian Gland Evaluator™ (MGE)

• The TearScience® Meibomian Gland Evaluator– Applies consistent, moderate pressure

• Between 0.8 g/mm2 and 1.2 g/mm2

– Allows evaluation of secretions from Meibomian gland orifices through a slit lamp biomicroscope

166

Grade Secretion Characteristics

3 Clear liquid oil

2 Colored/cloudy liquid

1 Inspissated (toothpaste consistency)

0 No secretion (includes capped orifices)

Indications for Use

Meibomian Gland EvaluatorTM

• Intended for use by a clinician to evaluate meibomian gland secretions. Used to apply consistent light pressure to the outer eyelid skin of a patient while visualizing secretions from meibomian gland orifices through a slit lamp biomicroscope.

• NO KNOWN CONTRADICTIONS

LipiView® Ocular Surface Interferometer

• An ophthalmic imaging device intended for use in adult patients by a clinician to capture, archive, manipulate and store digital images of specular (interferometric) observations of the tear film, which can be visually monitored and photographically documented.

• NO KNOWN CONTRADICTIONS

167

Tear Conservation

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Therapeutic Approaches Stabilize the tear film

(subjective)

Increase lubricity -decrease coefficient of friction

Increase aqueous production

Decrease inflammation

Create a more normal tear film environment for epithelial healing

Categories of Lubricant Eye Drops

Cellulose Derivative Products

Glycerin Containing Products

Lipid Based Emulsion Products

Polyethylene Glycol and Propylene Glycol Products

Tear Conservation- Therapeutics

Artificial tears

Ointments

Steroids

Cyclosporine

Doxycycline

Lacriserts

Lid disease therapy

Glasses

Sunglasses

Tear Conservation: Surgical Intervention

Punctal occlusion

Lateral tarsorrhaphy

Other procedures Ectropion correction

Lifestyle Adaptations:

Increase humidity

Wear eye shield or goggles

Avoid: wind, air conditioning, dry heat, high altitudes

smog, exhaust, smoke

prolonged computer use

contact lens wear

medications that contribute to KCS

Sunglasses

Restasis™

Ophthalmic emulsion of cyclosporine 0.05% Unique emulsion technology provides effective drug

delivery to ocular tissue at low cyclosporine concentrations

Cyclosporine is a complex molecule with antiinflammatory and immunomodulatory properties. Inhibits T-cell mediated inflammation and cytokine

driven inflammatory cell chemotaxis

In the eye: Restasis™ increases production of natural tears

increases goblet cell density

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Restasis™ Dosing: BIDRecommended Restasis™ regimen: 1 drop in

each eye every 12 hours Inform patients: do not use “as needed” like

traditional drops

Concomitant therapy Clinical study showed Artificial tears excellent

adjunct Additional emulsion may be poorly tolerated

Contact lens users Remove lenses, administer Restasis, replace

lenses after 15 minutes

How Does Restasis Work?

Restasis™ prevents T-cell activation(Kunert et al, Arch Ophthalmol. 2000;118:1489)

Activated T cells produce inflammatory cytokines that result in: Recruitment of more T cells (Stern et al, IOVS. 2002;43:2609)

More cytokine production (Pflugfelder et al, Curr Eye Res.1999;19:201)

1

Steroids and Dry EyeSymptomatic improvement in irritation symptoms in 83% and objective improvement ( redness, dye staining and tarsal papillae, FTC) in 80% of 70 patients treated for 2 weeks with non-preserved methylprednisolone

Prabhasawat & Tseng BJO 1998

DOXYCYCLINE

SIDE EFFECTSNVD, anorexia, dysphagia, severe photosensitivity, superinfection (fungus, vaginal candidiasis) benign IC-HTN, hepatoxicity, pancreatitis

WARNINGSdrink fluids to prevent esophagitis, use sun block, simultaneous ingestion of food OK.

Link to Breast CA?

ALTERNATIVES Tetracycline qid Minocycline $$ ALODOX

Alodox

20 mg Doxycyline Hyclate

Sub-antimicrobial dosage (<50mg)

Enzyme modulation of inflammation

By OCuSOFT

Kit comes with lid scrub foam

Claims to be a more potent

collagenase inhibitor than

minocycline and therefore less SE

Long term use

ONCE DAILY DOXYCYCLINE

Great for long term usage once controlled

Blepharitis, dry eye, rosacea

Brand Name Oracea® 40mg

Long term –cycline therapy associated with pseudotumor cerebri TCN, Doxycycline, Minocycline

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Contraindications

Pregnant or child bearing age

Children

Cautions

PhotosensitivityChelates with dairy products,

antacids etc.Minocycline may cause

vestibular toxicity

How to Minimize Stomach Problems with Tetracycline

1. Do not take the second pill (bid) before going to bed

2. Do not take pills with acidic beverages

3. Take pills with food (except a high dairy meal)

4. Prescribe the lowest dose available

Omega-3s and Omega-6s:Essential Fatty Acids

Essential fatty acids Optimum Omega-6:Omega-3 ratio for good health

varies from 3:1 up to 1:1: Ratio in current American Diet is about 1:10 American diet too high in Omega-6s from dairy

products, beef, vegetable oils, shortening American diet too low in Omega-3’s from salmon,

cold-water fish, krill oil, flaxseed, walnuts, dark green leafy vegetable, beans

Omega-3 Essential Fatty Acids

Omega-3’s American diet has undergone a 6-fold reduction in

Omega-3’s since 1850

Increases “good” prostaglandins

Inhibits “bad” prostaglandins

Omega 6’s US consumption of this fatty acid has doubled

from what it was in 1940.

Excess intake can increase water retention, raise blood pressure and increase blood clotting.

L W E

Lid Wiper Epitheliopathy

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Width = .4 to .6 mm

That aspect of the marginal conjunctiva of the upper eyelidthat wipes the ocular surfacesduring blinking

Ocular surface

Korb et al., 2002-2005

THE LID WIPER DEFINED

LID WIPER

© LID WIPER & AUTOMOBILE WINDSHIELD WIPER

Windshield Wiper

Windshield WiperClearance Space

Kessing’s Space

OcularSurface

16 M

LID WIPER EPITHELIOPATHY DEFINED

LWE is any compromise

of the squamous epithelial cells

or the protective coatings

of the Lid Wiper

A cascade of sequelae will follow

16 M

dews dry eye is not just a disease, it's a complex, multi- factorial

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