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TITLE: Presentation 6 Mr Y Ghosh
DATE: 20th February 2017
NUMBER OF SPEAKERS: 1 Numbers Speakers
TRANSCRIPT STYLE: Intelligent Verbatim
FILE DURATION: 26 Minutes 31 Sec
TRANSCRIPTIONIST: Marg Searing
SPEAKERS
YG: Mr Y Ghosh
A1:/A2 etc - Audience members
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GP Eye Health Network: Dry Eyes, Mr Y
Ghosh
YG: My name is Yaj Ghosh and I am one of the Consultants here at the
Eye Hospital. And, thank you very much for asking me to talk here.
What this stems from is my speciality interest is ocular plastics. And part
of it is watery eyes. So, I run a watery eye clinic every alternate Friday
here. And believe me, half of them are actually, mismanaged dry eye
conditions, because they present with watery eyes as well.
So, one of the pearls for you to take away here, from here, is if you see
watery eyes then there might be an element of dry eyes there. So, just a
little bit of an overview. Everybody does a test in the end. So, I’ll start
off with the small test for you all.
So, what conditions do you see with red eyes in the community?
[unclear audience responses/mumbled/murmured 00:00:57]
YG: Yeah. Anything else?
[unclear audience responses/mumbled/murmured 00:01:05]
YG: Okay, yeah. Anything else? Okay. So, whatever you have said,
they are all here. And believe me, lumps and bumps and cataracts can
also cause red eyes. Because if you’ve got a nasty lump and a bump
that can cause red eyes and cataracts, if they’re leaking or if they’re
causing uveitis, that can cause red eyes as well.
So, just a few photographs to take you through. What’s this? If you can
see the lid margins?
[unclear audience mumbling 00:01:43].
YG: Blepharitis, that’s right.
What’s this?
[unclear audience mumbling 00:01:50]
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YG: So, this, that it doesn’t have the typical discharge but it’s more
watery. So, this is more likely to be a viral conjunctivitis.
So, this dry eyes, because see the whole idea of showing these
photographs is, they all look the same.
[laughing]
YG: So, I know your problems. So, what’s this?
[unclear audience mumbling 00:02:27]
YG: Yeah, can we …
[pause to dim lights]
A1: It’s normal.
A2: That’s much better.
YG: See this bit, the reflection from the tear meniscus that’s actually
quite high. You wouldn’t normally see this. So, that’s actually a watery
eye.
[laughing]
YG: What’s this?
[unclear audience mumbling 00:02:53]
YG: So, the idea of showing this is, when you see somebody come in
with this, that’s a corneal ulcer or keratitis, always lift the eyelid and turn
it because there might be a sub-tarsal foreign body causing that. And
that?
[unclear audience mumbling 00:03:11]
YG: So, that’s a dendritic ulcer. And that’s more likely to be a bacterial
one because this is much more severe. What’s that?
[unclear audience mumbling 00:03:23]
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YG: Yeah. So, that’s the hyperopia and that’s an angry red eye. And
you could get a similar picture, if you see that after a cataract surgery,
that’s endophthalmitis. So, that needs to be referred straightaway. And
that? And that? So, these are different grades of cataracts. And this
one is my favourite. What’s that?
[unclear audience mumbling 00:03:58]
YG: Yeah, and what’s that?
[unclear audience mumbling 00:04:00]
YG: So, that’s a chalazion. And that’s a sty. And we always get,
everything is sty. So …
[laughing]
YG: So, sty is actually a folliculitis whereas chalazion is a swelling of the
meibomian gland. Yeah. Again, if you don’t take anything away from
this talk, remember that.
Okay, so I’ve already said as the preamble that 50% of what I see is
actually dry eyes which hasn’t been managed properly. So, it’s a huge
subject and it’s not possible to cover it in 20 minutes. So, I’ll try to give
you an overview and some pearls to help you diagnose and probably
manage them better.
So, just a quick run through of the anatomy. The lacrimal gland is
present on the outer side of the socket, whereas the sac or the drainage
system is on the inner side of the socket. So, if you see any swellings
on the outer side that’s from the lacrimal gland system whereas if there
is a swelling there and there is mucopurulent discharge from the inner
side, then then that’s from the drainage system.
So, what does the eyes do. There, you know, the blink is very important
to us, because it spreads the tears and it helps protect against
infections. It washes away any sort of foreign bodies that come in to the
eye and it is rich with glands which secrete the different components of
tears.
So, it comprises of many structures without going in to the details, the
corneal epithelium, it’s integrity. The tear film and the general integrity of
the ocular surface is very important which is affected by dry eye
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conditions. So, the different glands that constitute tears is the lacrimal
gland, the meibomian glands which are on the lid margin and the goblet
cells on the conjunctiva which produce mucin.
So, the tear that you see is actually, a quite complex structure which is
made up, simplified in to three layers. The mucus layer which holds it to
the surface of the eye. Then there is an aqueous layer or the watery
component which is not really water but it has got lots of minerals in it as
well. Which is secreted from the lacrimal gland. And the final layer is
secreted from the lid margin which is the oily layer which prevents it from
evaporating. And so, any of these being affected will cause dry eyes.
So, that is how it looks. This is the biggest or the thickest layer which is
the aqueous layer. That’s the oily layer on top and this is the mucus
layer which holds it to the surface. So, as I said, it cleans it supports the
cornea and it takes the oxygen supply in to the cornea because it
doesn’t have any vascular supply and it keeps the eye comfortable.
So, just an idea how a healthy tear film looks like and when it breaks
down it just totally anatomically wrong. So, what are the different types
of dry eye disease? Broadly, it’s classified into aqueous deficient, which
means that the watery component is deficient and evaporated which
means that it’s there but it’s not staying in the eye for long. And the
reason for that is, that the oily layer is deficient and it’s not allowing it to
stay in the eye for long. And we’ll come to the causes in a minute.
So, aqueous deficient most of the time is because of the Sjogren’s type
of disease where they will also complain of: What other symptoms do
they complain of?
[unclear audience mumbling 00:08:02]
YG: Dry eyes and dry mouth mostly. But they can complain of dryness
wherever there is a mucus surface. And the non-Sjogren’s type is where
the lacrimal gland itself has got a problem. So, these, there the bulk of
the tears is not present.
Whereas in the evaporative type which is this group, so this is mainly
due to the meibomian glands not functioning properly. So, if somebody
has got blepharitis, they will suffer with these. If somebody has severe
posterior lid margin disease they will suffer with this. And then there is
you know vitamin A deficiency which we don’t see in this country that
much. And another big offender is people on eyedrops which have
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preservatives. So, that is becoming increasingly known as a big
problem.
So, as I said, there are three types of mainly broad dry eye conditions
and the kinetic disorders is obviously if their tears are being impeded.
So, if somebody has got a blocked tear duct then they can have
problems as well.
Any questions so far? No?
Okay, so, what do they present with? How do we diagnose them?
There are tests and we will come to that in a minute but their symptoms
are very characteristic. And the first thing that they come and tell us is,
I’ve got grit in the eye. And if somebody says that, they’ve got dry eyes.
Whether it’s severe, moderate or mild, that comes next.
But the other symptom which is becoming increasingly popular is
asthenopia. Do you know what asthenopia is? This is a sense of
tiredness of the eyes and this is because, if the eyes are dry, a lot of
people nowadays are dependent on their computer screens. And when
you are looking at computer screens for long hours, you stop blinking.
There is a very good video on YouTube, go and have a look. Normally,
we blink 12 to 14 times in a minute. There is a guy who is watching
television and he blinks once in a minute. So, you can imagine what
happens to the tear film. And that’s so important.
The more severe ones will present with burning sensations, stinging
sensation and in extreme cases they’ll present with a red eye which I
have already shown you. And if they suffer from disorders like
rheumatoid arthritis and Sjorgen’s Syndrome they are bound to have
some symptoms associated with dry eyes.
The other thing which we need to be careful about is contact lens
wearers. And again, as I said, earlier on, glaucoma patients because
they are on so many drops and most of the drops still have preservatives
in it, they cause problems with the tear film. So, another common term
that we use is tear film dysfunction.
So, how can we diagnose dry eyes. So, these are the common tests
that we do. So, lacrimal river width. I’ll show you each of these in a
minute which I showed you in one of the first photographs where the
actual tear meniscus is higher if they have a problem. The Schirmer test
actually measures the amount, of tears being secreted into the eye. The
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tear break-up time is valuable to assess if somebody has got
evaporative eye disease and again I’ll show how to do that. Staining
shows us if the corneal epithelium is intact or if there is drying anywhere.
And the tear lab, this is the latest toy we have. It’s complicated and
essentially it measures the osmolarity of the tears which gives an idea of
whether it’s a good tear or bad tear.
So, Schirmer test, BUT, is tear break-up. And it’s based on … the tear
break-up time is obviously, based on, the fact that there is a time span
for which the tear film should stay in the eye. And if you ask the patient
to keep the eye open and it breaks up before that, that means it’s
unstable.
So, that’s the Schirmer’s test which is, if you see these are the two
papers that we put in. Some do it with drops, some do it without the
drops and the measurements are different. Normally, you would get 10
to 15 within two minutes. And in some it doesn’t even take two minutes
to get to that stage.
Tear break-up time, as I said. So, what we do is we put a fluorescein
and ask them to blink and then hold. And if you see these black spots
appearing within 10 seconds, that means they have an unstable tear
film. Now the point of me showing all this is, you can do this in your
practice and you can actually, make a diagnosis of these. So, they don’t
then need to be referred on to the ophthalmologist. It saves you money
and it saves us time. Because ultimately, they will be sent back to you
for looking after them. And it’s very easy to diagnose this. We are more
than happy to deal with the more complex ones which we will come to in
a minute. But this is a very simple test. All you need is a filter which you
can put it on the top of a torch which is an ultraviolet filter and a drop of
fluorescein. That’s all you need.
So, that’s the staining again. You put fluorescein in and as you can see
the areas which are dry will take it up because the epithelium is not wet
properly and then you can actually make a drawing of the areas.
And that’s the lacrimal river that’s as you see, normally you should not
be able to see this. And that’s the toy.
So, that brings us to meibomian gland dysfunction which means
essentially, if you see patients who are presenting who are saying that
the lids are really, red and at the margin of the lid, you see these kind of
meibomian gland openings are swollen, they have an inflammation, an
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active inflammation of the meibomian glands. And you have, to treat
that. If you just give them artificial tear drops and send them away they
will not get better and they’ll keep coming back.
So, the theory behind this is that the meibomian glands secrete an oily
secretion and there are bugs at the root of the eyelashes as well which
secrete a toxin. It sets up an inflammatory reaction and that just
compounds the problem. So, you have to treat the Meibomitis or the
inflammation of the glands and then you also have to treat the tear film
dysfunction.
So, I’m sure you see this every day, that people come in with a lid
margin like that. A lot of people who have rosacea would present like
that because they are more prone. And so, you will see this, the
meibomian gland opening sometimes, the atrophy due to chronic
inflammation. Can you see? Am I in your way? And as you can see
notching of the lid caused by the … because the meibomian gland is
virtual … you know dead. So, it’s not functioning.
So, because the top layer of the tear is deficient, so the patients would
complain that they do not get relief from whatever drops they put in. So,
they present with red eyes as a result.
The next group of disorders which cause problems, is ocular surface
disease. So, if I should you this, what is this? [unclear audience
mumbling 00:16:44]. It looks like a [unclear ? ipcoasis 00:16:46] doesn’t
it? But this particular one was actually Penfigoide. So, when you’ve got
something like this, as you can see. The lids are ectropic because they
are being pulled down by the skin condition. The whole surface is
ulcerated. So, that’s going to have a definite effect on the corneal
surface as well.
So, to treat the meibomian glands, three things again, you can do from
primary care. Hot fomentation which is you know dry fomentation. So,
flannel, ask them to warm it up on the radiators that’s the right
temperature. Ask them to hold it over the eye with a bit of pressure and
that liquefies the secretions there so that they can then discharge and
they don’t get clogged up. Because if they get clogged up, then you get
the chalazions which is another problem.
And the second thing is lid toilet. Again, you will hear different stories,
tea tree oil, sodium bicarbonate and lots. You will hear the latest advice
on the NHS website is, don’t use baby shampoo. I still feel that if you
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get a baby shampoo which does not have any essences in them or you
know the flavouring material and all that, they’re still the best. It’s the
way you do the lid toilet that is important. And what I always say, is take
an egg cup full of water, two to three drops of baby shampoo, take a
cotton bud, dip in that solution and use that as if you are putting make up
on your eyelashes. And that way you are actually scrubbing the lid
which is what you need and not just you know putting the make up on.
So, essentially you are getting rid of the toxins and that helps with the
inflammation.
And the third thing is they need a course of Doxycycline or Lymecycline
depending upon what, you know, they can tolerate. Because
Doxycycline some people have stomach upsets.
[unclear audience 00:19:06]
YG The cleaning, depending upon how severe it is, even once a day in
the morning is good enough. Sometimes you have to do it twice.
Now, in terms of local treatment, there is another element to dry eyes
which is inflammation. If the corneal surface is inflamed like I showed
you in necrosis or Steven-Johnson’s type disorders then you have to
treat the inflammation because otherwise the tear film is not going to get
stable. And the only drop available so far is, cyclosporine drops which
you may have heard about. So, if it is going in to that domain then
obviously, the patients need to be in the hospital.
This is, in advanced cases where you might have to reconstruct the
corneal surface altogether. But again, there are simpler things that we
do, which is like, putting in a punctal plug which is a piece of plastic
which blocks the tear duct openings and thereby retains the natural tears
that are being secreted. Because no matter how many types of eye
drops we have in the market, nothing comes even close to your natural
eye drops. So, if you can have that in the eye, patients get
instantaneous relief.
The second step further, if that’s not helping is, you can actually have
inserts put in which are continuous release and secrets tears. You can
use eye drops which stimulate the eye glands … the tear glands to
secrete more tears.
Now, whatever I am saying is based on International Dry Eye Disease
Workshop. They last met November last year and all the classifications,
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all the treatment modalities are based on their recommendations. And
this is just sort of like an aide memoire of what you should be doing in
your practice. And as I said, for mild to moderate disease, just eye
drops are good enough. Whereas moderate to severe they need more
intensive management. And for the really severe ones they need
sometimes even immunosuppression amongst other things.
So, this is just a simple treatment chart to show you how to manage.
And I thought this was quite a good one because there is an overlap of
all the different types and it gives you an idea, about, like it says or oil
deficiency dry eyes, meibomian gland dysfunction, so, you manage that.
But that overlaps with aqueous and obviously, that falls within the mixed
dry eye conditions. And, for those who are computer users, make sure
you take that in the history because they need to take breaks when
they’re working. No matter how much eye drops you give them, it’s not
going to get any better if they don’t look away from the screen and blink.
For those who want to read up on this there is probably about 100
different types of dry eye products in the market. And it was a very
interesting paper, sorry, where they compared whether one was better
than the other and they found that there was virtually no difference
between the different products. Unless you are looking at obviously, if
somebody has got evaporative eye disease and you’re giving them
condition … drops for aqueous deficient eye disease, then that makes a
difference. But amongst the other eye drops there’s hardly anything.
These are the different groups, can I just ask, how many people still use
hypromellose eye drops. Show of hands? Come on, don’t be shy.
Right. Again, when you go away from here, please throw that away
because it doesn’t work. And they will come back, you’ll have to give
them more. Hypromellose doesn’t work. So, that’s this group here.
These others, the most popular ones are hyaluronic acid because they
are closest to body secretions and they stay in the eye longer. So, that’s
the reason. And increasingly we are going away from preserved ones.
Because again, we are finding out the hard way the ill effects of
preservatives. So, that’s the kind of choices.
The other thing that really, works well, particularly in meibomitis is
omega-3s and there’s enough evidence now and literature to say that
those help.
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Again, this is a very short pathway which I find very useful of how to start
your treatment. So, for the mild ones, like I was saying, you can start
with hyaluronic acid, the least concentrated one. And then you can go
up in stages depending upon the severity of the condition.
So, what’s the future? We have so far looked only at the aqueous
component or the oily component. Nobody has looked at the mucus
side of things. So, this is in stage three trials now which actually causes
increased secretion of mucus. And platelet rich plasma is for people
who have the severe dry eye conditions. So, that, again is like a tear
analogue. And when you cut onions, how many people cry? So, that is
what is being done with this one. They are developing a stimulator
which stimulates the nasal epithelium and thereby makes you cry.
[laughing]
YG: I found this very interesting pathway which was developed in
Suffolk, where they were referring it to primary eye car triage service
which is the ophthalmic … optom led service. And again, obviously to
economise things. And if they couldn’t get a result then only the patient
was referred on to the hospital. What I couldn’t find out, is their audit of
how successful this was. But I thought it was interesting because that’s
the way things are going at, the moment.
So, to summarise, dry eyes is a complex thing but there are simple
things that you can do to help the patient. And in extreme cases
obviously, hospital care is essential. But there are simple things which
can help the patient both symptomatically and management wise. And
sometimes they might need supportive treatment for which we are more
than happy to give advice.
That’s all folks. Thank you.
END OF TRANSCRIPT
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