Download Conjunctival Staining

Tear Break Up Time
Conjunctival Staining
Express Meibomian Glands
•  Cotton Tip Swab
•  Roll Upward
•  Observe & Grade
•  Discuss While Performing
Procedure
•  Mild lissamine green staining
Quantify Volume
Traditional Treatment
•  Artificial Tears
•  Cyclosporine
•  Steroids
•  Lid Hygiene/Warm Compress
Goals of Therapeutic Intervention
Turn Off The Inflammatory Cascade
Decrease Lacrimal Gland Inflammation
- Improve Gland Function
Ø Restasis – Cyclosporine Ophthalmic Emulsion .05%
Ø Lotemax Gel– Loteprednol .5%
Restore Normal
Neural Feedback
to Lacrimal Gland
Normalize
Tear Film
Decrease Ocular Surface Inflammation
- Stimulate Epithelial Healing
Next Level
Cyclosporine and MMP-9
MMP-9 expression was
evaluated by immunohistochemistry. The mean
percentage of MMP-9
expression of the conjunctival
epithelial cells was significantly
decreased.
MMP-9 expression was
evaluated semi-quantitatively by
measuring cytoplasmic staining
for MMP-9.
•  Punctal Occlusion
–  Collagen/silicone/surgical
•  Topical Anti-Allergy
•  Omega III’s
N=24 eyes of patients with thyroid
orbitopathy-related dry eye
[1] Gürdal C, Saraç O, Genç, et al. Ocular surface and dry eye in Graves' disease. Curr Eye Res 2011; 36: 8-13.
Calvin Roberts, M.D. Study
•  Dual Approach
•  Cyclosporine and Punctal Occlusion
•  Combination More Effective Than Monotherapy
2009 Study - McCabe
Next Level
•  108 Patients (216 eyes) 1 Year
•  43% of Patients Measured a Visual Acuity
Improvement After Punctal Occlusion
•  Moisture Chamber
•  92% Retention Rate 1 Year
•  Slow Release Inserts
–  Night/Day
•  Autologous Serum
•  Androgen Treatment
•  Parasite Treatment
Eyessentials – Protective Sunwear
Environmental
Treatments
Panoptx “Dry Eye Wear”
®
•  Patented Orbital
Seal
–  Maintains moisture
–  Blocks wind
•  Developed by maxillofacial
surgeon
–  Different styles fit different
faces
Panoptx “Dry Eye Wear”
®
•  Patented Orbital Seal creates
“moisture chamber”
•  New study findings demonstrate
effectiveness
Need for Treatment Flow Sheet
Treatment Flow Sheet
•  Summary Sheet for Treatment
•  Show Current and Previous Treatment
Role of Lid Disease in
Chronic Dry Eye Disease
•  Co-Morbidity ???
•  Anterior Blepharitis
•  Posterior Blepharitis (Meibomian Gland Dysfunction)
•  Chicken or Egg???
Posterior Blepharitis
Meibomian Gland Expression
New! Ophthalmic Surgical Instruments
Collins Expressor Forceps (Item 98610)
For aggressive expression of the Meibomian gland.
Livengood Expressor Paddles
Angled (Item 98620) & Flat (Item 98630)
For mild or gentle expression of the Meibomian gland.
Meibomian Gland Expression
BRUDER EYE COMPRESSES
Microwave Activated
Schaeffer Eye Protocol
Bruder Eye Hydrating Compress and Stye Compress conveniently provide an effective yet natural
and drug-free way to help provide and maintain proper eye moisture.
BENEFITS
FEATURES
•  Replenishes Moisture Naturally
•  Relieves Dryness
•  Refreshes Tired Eyes
•  Provides Drug Free Relief
•  Ready in Minutes from the Microwave
•  Naturally Hydrating
•  Washable & Reusable
•  Clean Moist Heat
•  Soft Conforming Design
•  Non-Allergenic
•  Dust-Free
1)  OSD Evaluation
1)  Includes test expression
2)  All staining
2)  RTC expression
1)  At home massage with eye medibeads
BRUDER STYE COMPRESS Item #34170 2) 15-20 minutes in waiting room with heat back ( or rear wait)
3) Expression 1 of 3
4) RTC 2 weeks
BRUDER EYE HYDRATING COMPRESS Item #34160 08.10 Maskin Expressor
MGD EXPRESSION
Fees:
• $ 575
$189 Out of pocket
• Rhein Medical covers 3 visits
68 Per visit after those three
99213 / 99212
dry eye progress check before expression
2 visits at 3 level then One at 2 Blepharitis
•  Anterior
Lid Disease Therapies
– Infectious
Ø Lid Hygiene – Samples or Written Instructions
• Bacterial
Ø Warm Compress/Tranquileyes
Ø AzaSite, Zylet, Macrolide ung
• Viral
Ø Doxycycline 20 - 50 mg bid – Months
• Parasitic
Ø Alodox 20 mg w/scrubs
•  Posterior
Ø Omega III
– Meibomian gland dysfunction
MGD????????
Lid Disease
Ø Lid Hygiene – Samples or Written Instructions
Ø Warm Compress/Tranquileyes
Ø Erythromycin Ointment H.S./Zylet,AzaSite
Ø Doxycycline 20 - 50 mg bid – Months
Ø Alodox 20 mg w/scrubs
Ø Nutritional Supplements
TearScience® Solution
Lid Treatments
•  Warm Compress/Lid Hygiene
•  Antibiotic and/or Combination
–  AzaSite
–  Zylet
–  Tobradex
•  Anti-inflammatory
–  Ester vs Keytone
LipiView® OSI
•  Tetracycline/Doxycycline (Low Dose)
LipiFlow® Auto
•  Omega III
• 
Meibomian Gland Evaluator
Disposable
Caution: Investigational device. The LipiFlow Auto Console pictured is not approved for use in84
the U.S.
Limited by United States law to investigational use.
LipiFlow® Thermal Pulsation
System
• Heat applied to the
palpebral surfaces of the
upper and lower eyelids
directly over the
meibomian glands
Overall Therapeutic Goal of the
LipiFlow®
• Alleviate meibomian gland
obstruction in both upper
and lower eyelids
simultaneously, using a
short in-office procedure
(12mins per eye)
Lid Warmer
Applies directional
heat to inner eyelid
Eye Cup
Applies
intermittent
pressure to the
outer eyelid
Insulated lid
warmer shields eye
from heat and
vaults above the
cornea to prevent
corneal contact
• Graded pulsatile pressure
delivered to the outer
eyelid
Heat facilitates release of
secretion from obstructed
meibomian glands
Inflatable air
bladder
85
86
Therapeutic Goal of Heat
Therapy
• Liquefy the meibomain
Lid Warmer
Applies directional
heat to inner eyelid
gland contents
• Facilitates release of
secretion from the
meibomian gland
Eye Cup
Applies
intermittent
pressure to the
outer eyelid
Insulated lid
warmer shields eye
from heat and
vaults above the
cornea to prevent
corneal contact
• Increase likelihood that the
glands can resume normal
function
Heat facilitates release of
secretion from obstructed
meibomian glands
LipiFlow® Contraindications
Do not use the LipiFlow® System in patients with the
following conditions:
•  Ocular surgery, ocular injury, ocular herpes of eye or eyelid within prior 3
months
•  Active ocular infection or inflammation, or history of chronic, recurrent ocular
inflammation within prior 3 months
Inflatable
air bladder
•  Eyelid abnormalities that affect lid function
•  Eyelid abnormalities or ocular surface abnormalities that may affect/compromise
corneal integrity or lid function
87
88
Macrolides
• Reduce gene expression of proinflammatory
cytokines and adhesion molecules at the
transcriptional factor level
• Inhibit cytokine production
• Reduce production of proinflammatory
mediators
AzaSite® Suppresses MMP9 in HCEC
Results
•  Cultured HCEC secrete abundant pro-MMP-2 and pro-MMP-9
– HCEC exposed to AzaSite® demonstrated MMP-9 expression reduced by 33%1
•  Suppressive effect greater than vehicle treatment
•  Cultured HBEC secrete abundant pro-MMP-2
– BCEC exposed to AzaSite® did not demonstrate reduced MMP-2 expression
Conclusion
•  AzaSite® inhibits MMP-9 expression in HCEC, providing preliminary data for
exploring the use of AzaSite® in corneal disorders associated with pathologic
MMP-9 expression
• Antiinflammatory effect
Jacot J, et al. Evaluation of MMP2/9 Modulation by Azithromycin and DuraSite on Human Corneal Epithelial Cells and Bovine Corneal Endothelial Cells in vitro. 2008 Annual Meeting Abstract and Program Planner
[on CD-ROM]. Association for Research in Vision and Ophthalmology. Abstract 1985.
Essential Fatty Acids
Nutritional Therapy
•  Over the past 6-8 years EFAs have been in the
spotlight as having positive effects related to reduced
inflammatory response in the eye and other body areas
•  EFAs are:
Building a Solid Foundation for Ongoing Relief
of Symptoms-Eye Health and General Health
Nutritional Supplements
•  In inflammatory conditions 3-4 grams of EPA/DHA
•  Thera Tears Nutrition - 330 mg Flaxseed ALA, Fish 150mg
EPA, 100 DHA, Vitamin E
•  Bio Tears - Omega 3 & 6 — stable Cod Liver and Black
Currant Seed oils, 100 mg EPA per capsule, 70 mg DHA
per capsule, 235 mg GLA per capsule (Omega 6),
Vitamins A, C, B6 and Mg
–  Omega 3-EPA, DHA & ALA -found in cold water
fish, walnuts and cod liver oil
–  Omega 6-LA & GLA-found in milk, ice cream, butter,
beef and other natural sources
Omega III Dosing
•  Adults should consume at least
2 grams of EPA/DHA per day
•  Adults with specific chronic conditions should
consume at least 3.5-4.0 grams of EPA/DHA per day
•  LifeGuard - TG Form of Omega 3 (90% absorbability), Omega
3-Fish Oil (triglyceride base), EPA-420 mg per capsule,
DHA-140 mg per capsule, Other Omega 3s-110 mg per capsule
•  Nordic Naturals
Experience with Omega Formulations
•  Average time to symptomatic relief reported by patients is 4-8
weeks
•  Patients begin taking full dosage for 2-3 months and many
reduce to lower levels and maintain relief
•  Patients that discontinue the formulations experience
recurrence of symptoms in 2-3 days
•  In moderate to severe dry eye, Omega 3 plus Restasis is a
good long-term combination with early use of Loteprednol
Merchandising and Compliance