understanding dry eye treatment and protocol · the definition and classification of dry eye...
TRANSCRIPT
Tim Trinh, O.D., F.A.A.O.Box Medical SolutionsDate: September 19th, [email protected]
UNDERSTANDING DRY EYE TREATMENT AND PROTOCOL
The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry E ye Work Shop (2 0 0 7) THE OCULAR SURFACE / APRIL 2007, VOL. 5, NO. 2
Hyperevaporativedisorders, mostly caused by dysfunction of the meibomian glands, and mixed hyperevaporative/aqueous-deficient forms account for more than 80% of cases
Increased Osmolarity
Cellular DeathInflammation
Tear Film Instability
Causes:• Eyelid dysfunctions, • Tear film instability• Allergies
Causes:• Direct trauma, • Friction• Exposure• Increased osmolarity
Increased EvaporationCauses:• Blepharitis • Meibomian Gland
Dysfunction• Chalasis
Causes:• Cellular damage • Systemic inflammatory
factors
Baudouin C, et al. Br J Ophthalmol 2016;100:300–306. doi:10.1136/bjophthalmol-2015-307415
Vicious Cycle of Dry Eyes
Nerve Stimulation
Cyt
okin
e Re
leas
eC
ell Dam
age
Increased Osmolarity
Cellular DamageInflammation
Tear Film Instability
1. Tear Lab2. Eyelid Assessment3. Blink Rate 4. Lagopthalmos Eval5. Tear Lake Assessment
1. Corneal Staining Assessment
2. Conjunctival staining Assessment
Increased Evaporation
What testing is necessary to do a dry eye evaluation?
1. Meibography2. Meibomian Gland
Quality3. Lid Assessment4. Tear Break Up Time
1. MMP-9 testing2. Health History3. Sjo Testing4. Autoimmune blood panel
Testing Procedures
Cell D
amage
Nerve Stimulation
Cyt
okin
e Re
leas
e
What is the best order of testing and evaluation?
History Survey Dry Eye Questionnaire
Observation Tear Meniscus Blink Rate Assessment Lid Position LIPCOF
Osmolarity/Inflammation
Structural Assessment
Tear Break Up* Time
Conjunctival Staining
Corneal Staining Marx Line
MMP-9*
Tear Film Stability
Least invasive to most invasive:
Tear Lab*
BlepharitisAssessment
Lid Margin Meibography
*Testing recommended on separate visit
SPEED TEST OSDI
Survey Scoring can help determine prevalence
DRY EYE SPECIFIC PATIENT QUESTIONNAIRE
TEAR MENISCUS
>0.2-0.4 mm Normal
<0.2 mm Hyposecretion –Think Aqueous Deficiency
>0.40 mm Hypersecretion
Normal Blink Rate: 15.5 +/- 13.7
blinks/minute
•“The most prevalent symptom associated with Computer Vision Syndrome was tired eyes, which was reported by 40% of subjects as occurring "at least half the time". 32% and 31% of subjects reported symptoms of dry eye and eye discomfort, respectively, with this same frequency”
•Mark Rosenfield; Yuliya Bababekova; Joan K. Portello Investigative Ophthalmology & Visual Science March 2012, Vol.53, 5459. doi: Prevalence Of Computer Vision Syndrome (CVS) And Dry Eye In Office Workers
Reading/Computer: 5.3 +/- 4.5
blinks/minute
BLINK RATE ASSESSMENT
Lagophthalmos
Floppy eyelid Syndrome• Velvety papillary
conjunctivitis• Swollen lids• Strong association with Sleep
Apnea
EYELID POSITION ASSESSMENT
TEMPORAL LID PARALLEL CONJUNCTIVAL FOLDS (LIPCOF’S)
Slit Lamp Evaluation Lid Parallel Conjunctival Folds:
Results from increased friction between the lids and conjunctiva.
Graded Scale 0-3
84.9% Sensitivity for Dry Eyes
90% Specificity for Dry Eyes
Elisabeth M. Messmer. The Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease Dtsch Arztebl Int 2015; 112: 71–82
TEAR BREAK UP TIME
Normal range lies between 20 and 30 seconds.
<10 seconds Dry Eyes
<5 seconds Severe Dry Eyes
STAINING AND GRADING
MARX’S LINEPresence would signify potential benefit of lid debridement
LID MARGIN ASSESSMENT:
MEIBOGRAPHY: LOOKING BELOW THE SURFACE
Role of Meibography: - Establish baseline for future visits
- Patient education and compliance
- Determination of chronic disease state
- Prognostic factors
ARRANGEMENT OF MEIBOMIAN GLANDS
Heinrich Meibom (1638-1700) first published in 1666.
Number of upper glands: 25-40, Median: 31- Average length: 5.5mm- Calculated volume: 26 microliters
Number of lower glands: 20-30, Median: 26- Average length: 2 mm- Calculated volume: 13 microliters
Active glands in only 45% of gland openings at one time and a decrease of Active glands by 50% between age 20 to 80.
Sobotta Ð. Atlas der Anatomie des Menschen. Ferner H, Straubesand J, eds. Ed. 18, Vol. 1, p. 215, Urban & Schwarzenberg 1982
HISTOLOGIC APPEARANCE OF MEIBOMIAN GLANDS
Acinus: 150-200 um diameter- Contain secretory cells called meibocyte- Meibocyte develops on outer layers and migrate centrally
Connecting Ductule: 150um long and 30-50um wide-stratified squamous epithelium
Central Duct: 100-150um in diameter, wider lumen- stratified squamous epithelium
Excretory Duct: 0.50mm long.- cornified epithelium
PHYSIOLOGY OF MEIBOMIAN GLANDS
Greater build up of Meibum during the sleeping hours.
Mechanical contraction of M. Orbicularis muscle during blink milks glands towards external epidermis with relaxation of marginamuscle of Riolan leading to the expression. Muscles work in opposi
PATHOPHYSIOLOGY OF MEIBOMIAN GLAND DYSFUNCTION
Kelly K. Nichols,1 Gary N. Foulks,2 Anthony J. Bron,3 Ben J. Glasgow,4,5 Murat Dogru,6Kazuo Tsubota,6 Michael A. Lemp,7 and David A. Sullivan8,9 The International Workshop for Meibomian Gland Dysfunction
Gland Shortening
Gland Hypertrophy
Advanced gland Hypertrophy and Loss due to Hyperkeratinization
Track gland Hypertrophy and Loss
EVAPORATIVE DRY EYE TREATMENTTim Trinh, O.D., F.A.A.O.
All EyeCare Optometry
Vision Source Administrator
Date: November 6th, 2016
Increased Osmolarity
Cellular DeathInflammation
Tear Film Instability
• Artificial Tears• Environmental Stressors
• Work• Environmental
management• Allergy
Management• Medicated
Preservatives
• Contact Lens Adjustments• Medicated Therapy• Amniotic Membranes
Increased Evaporation• Lid Hygiene• Omega 3
Supplements• Blephex• Lipiflow• Miboflo
• Steroids• Restasis• Xiidra• Doxycycline• Omega 3 Supplements
Baudouin C, et al. Br J Ophthalmol 2016;100:300–306. doi:10.1136/bjophthalmol-2015-307415
Vicious Cycle of Dry Eyes
Nerve Stimulation
Cyt
okin
e Re
leas
eC
ell Dam
age
DEMODEX BLEPHARITIS MANAGEMENT
Demodex Blepharitis
Recalcitrant blepharitis
Collarettes located at base of eyelashes
Diagnosis removal of lash and placing on slide of microscope plate.
Only 7% of the patients were Demodex-free after eyelid scrubbing without TTO, on the other hand, 24% were Demodex-free after eyelid scrubbing with TTO.
TREATMENT DEMODEX
Blephex• In office cleaning
procedure • 12 minute
procedure• Effective jump
start
Cliradex• Tea Tree Oil
Scrub
Avenova• Hypochlorous
acid • Kills Nymph
Demodex Mites• Neutralizes Toxins
Zocular• Okra extract
http://www.news-medical.net/health/New-Approaches-for-Fighting-Demodex-Mites.aspx
MEIBOMIAN GLAND MELTING POINT
Melting point Normal Meibomian glands 28 to 32 Celsius (84 to 89.6 Fahrenheit)
5 minutes of treatment with Towel Compress (40 Celsius) applied to skin of eyelids increased tear film lipid layer by 80% with an additional 20% increase after 15 minutes of treatment (Olson et al)
Warm moist air device use for 10 minutes twice daily for a period of 2 weeks provided symptomatic relief of ocular fatigue, improvement of tear stability and ocular surface epithelial damage in patients with MGD (Matsumoto et al)
LIPIFLOW IN OFFICE TREATMENT THERAPIES
Treatment: Heat pulsation therapy from inside out.
Pro: Pulsation and heating milks glands and has been shown to
provide relief for 1 year.
Con: Cost to patient and replacement parts.
MIBOFLO IN OFFICE THERAPY
Treatment: Heat transfer using Thermal paddle and ultrasound
gel. 16 minute procedure 8min/eye
Pro: Low cost effective treatment
Con: No studies for long term efficacy, may require 2-3 visits for
longer lasting effects.
ARTIFICIAL TEARS
Increase tear film stability
Decrease tear osmolarity
Rinse toxins and cytokines
Reduce friction of conjunctiva
and eyelid
LIPID BASED TEARS
An emulsion-based lubricant eye drop has been studied in
normal subjects and patients with aqueous-deficient
dry eye, with or without MGD
emulsion-treated eyes showed rapid restructuring of the
preexisting tear lipid film in tear-
interference image examination. Gerd Geerling,1 Joseph Tauber,2 Christophe Baudouin,3 Eiki Goto,4 Yukihiro Matsumoto,5
Terrence O’Brien,6 Maurizio Rolando,7 Kazuo Tsubota,5 and Kelly K. Nichols8 The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction Investigative Ophthalmology & Visual Science, Special Issue 2011, Vol. 52, No. 4
ORAL TETRACYCLINES
•MMP 9’s•IL-1•TNF collagenase activity•B-cell activation
Decrease inflammatory
factors:
•Photo-toxicity•Age Restriction older than 8 years of age – yellowing/graying of teeth•GI upset
Side Effects:
•50 to 100mg/day 6 to 12 weeks•Do not take with dairyInstructions:
CORTICOSTEROIDS
Use of corticosteroids over a period of 2 to 4 weeks, improve the symptoms and clinical signs of moderate to severe dry eye disease (30, 31). After 2 weeks of treatment, symptoms regressed moderately (43%) or completely (57%).
OMEGA 3 FATTY ACIDS
OMEGA 3 ROLE IN INFLAMMATION SUPPRESSION
EPA
DHA
Western diets contain about 10 to 20% of fatty acids as arachidonic acid, with about 0.5 to 1% EPA and about 2 to 4% DHA (Philip C. Calder. Nutrients. 2010 Mar; 2(3): 355–374.Published online 2010 Mar 18. doi: 10.3390/nu2030355)
BIOAVAILABILITY/ABSORPTION OF DIFFERENT FORMS OF EPA/DHA
Bioavailability of (EPA + DHA) via triglyceride form reported to be significantly better than ethyl ester form Bioavailability of EPA+DHA from re-esterified triglycerides was superior (124%) compared with natural fish oil, whereas the bioavailability from ethyl esters was inferior (73%). (Dyerberg et al., prost, leuk, and efa 83:137-141 (2010))
The absorption of epa/dha in ethyl ester form better on a high fat meal. (Lawson and hughes, bbrc, 156:960-963 (1988))
FISH OIL INTERACTION WITH WARFARIN
Fish oil supplementation could have provided additional anticoagulation with warfarin therapy. This fatty acid may affect platelet aggregation and/or vitamin K-dependent coagulation factors. Omega-3 fatty acids may lower thromboxane A(2) supplies within the platelet as well as decrease factor VII levels. ann pharmacother. 2004 Jan; 38(1)::50-2
OUTSIDE THE BOX TREATMENTTim Trinh, O.D., F.A.A.O.
CASE HISTORY: Chief Complaint:
Severe red, irritated, dry eyes x 2 years.
Epiphora and blurred vision x 6 months and unbearable now.
Dry eyes x 10 years Wearing sunglasses indoors
now that eyes are so red PMHx:
Hypothyroid Lupus Sjogren’s Disease Menopause
POHx: Primary Open Angle
Glaucoma
Surgical Hx: Blepharoplasty x 6
months
Punctal Plugs Occupation:
Marriage Family Therapist
6 months prior
MEDICATIONS LIST
Systemic Medications: L Thyroxine Liothyronine Estradiol Progesterone Zyrtec PRNSupplements:Magnesium CitrateProbioticVit B-6/B-12IronVit D3 – 5000IU&10,000 IU
Ocular Medications:Azopt bid OU x 3+ yearsTravatan Z qpm OU x 3+ years
Dry Eye Treatments:Compress TherapyRestasis bid OU Refresh OptiveGenteal GelOmega 3 Fish Oilh/o plugs OU
CLINICAL EVALUATION:
VA: 20/30 OD 20/25 OS IOP: 13/13 mmHg @ 2:39pm I-care SLE:
Lids: 4+ telangiectasia, +keratinization Cornea: 1-2+ staining Conjunct: 1-2+ staining, Injection 4+
Fundus: C/D: OD: 0.40 OS: 0.55
Meibography:
WHAT TREATMENT OPTIONS WOULD YOU OFFER THE PATIENT?
ADDITIONAL CASE HISTORY FROM PRIOR DOCTOR: Patient had negative reaction to Doxycycline in past causing urinary
discomfort and had negative reaction to Minocycline caused Diarrhea.
Patient put on Tobradex to help with irritated dry eyes, but had a steroid response to 28mmHg OU
Patient was put on Combigan to decrease pressure, but irritation increased dramatically
Patient was put on Xiidra, but had blurred vision and discontinued
Lipiflow offered, but was cost prohibitive
TREATMENT PLAN: Tear film stability:
Miboflo, blephex procedure to remove blockage Continue compress therapy – reaffirmed instructions 108 F Converted standard Omegas to High EPA/DHA Triglyceride Forms
Osmolarity: Retaine eye drops qid OU Sleep mask at bed time, decrease night evaporation d/c Azopt due to possible generic dorzolamide allergy and continued Travatan Z
only Environment:
Humidifier at bed time Inflammation:
Continue Restasis bid OU No steroid due to response history Rely on natural Omega 3 Anti-inflammatory
SUCCESS AND ROADBLOCKS:
Redness started to decrease to 2+ injection by 1 week follow up with just sleep mask and d/c Azopt
Lid telangiectasia decreased s/p Blephex and Miboflo at 1 week treatment
Two week follow up: IOP spiked to 25/21mmHg with Travatan Z alone
Started Timolol 0.5% qam and d/c Travatan Z, changed to generic Latanoprost (cost) qpm. Pressure decreased to 16,13…but patient had difficulty breathing, shortness of breath. Changed medication to Timolol 0.25%qam and Latanoprost qpm OU and 2
week follow up, IOP was maintained at 17/17 mmHg OU, target IOP was 16-18mmHg
FINAL VISIT:
Was able to discontinue Restasis bid OU completely
TBUT increased to 9 seconds
Telangectasia was completely gone
Injection no longer present
Dry eye symptoms resolved
Retaine drops only twice a day.
Changed quality of life, no longer has to
wear sunglasses indoors.