Download ocular surface disease syndromes - Loma Linda University Medical

OCULAR SURFACE DISEASE
SYNDROMES
WAYNE ISAEFF, MD
LOMA LINDA UNIVERSITY
DEPARTMENT OF
OPHTHALMOLOGY
SURFACE DISEASE
„ DRY
EYE
„ DYSFUNCTIONAL TEARS SYND
„ ALLERGIC DISORDERS
„ MEIBOMIAN GLAND PROBLEMS
„ OCULAR IMMUNE RESPONSE
DYSFUNCTIONAL TEAR
SYNDROME
DRY EYE
DTS AND DRY EYE DIAGNOSIS
RELIES ON PATIENT
SYMPTOMS AND SIGNS FOR
THE LEVEL OF SEVERITY OF
DISEASE AND TREATMENT
OCULAR SURFACE DISEASE
INDEX
SURFACE DISEASE INDEX
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DO YOUR EYES FEEL GRITTY
ARE YOUR EYES LIGHT SENSITIVE
ARE YOU HAVING BLURRED VISION
HAVING TROUBLE DRIVING AT NIGHT
DIFFICULTY WATCHING TV OR COMPUTER
BOTHERED BY WIND, LOW HUMIDITY,AC’S
OSDI IS SCORED ON A SCALE
FROM NORMAL TO SEVERE
AND HAS A NUMERICAL VALUE
FROM 0 TO 100
DTS TREATMENT
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1. LUBRICANTS
2. ANTI-ALLERGY MEDICATIONS
3. TOPICAL STEROIDS
4. TOPICAL ANTIBIOTICS
5. CYCLOSPORINE A
6. TEAR DUCT PLUGS
7. TEAR DUCT MODIFICATION
8. EYELID MODIFICATION
ALLERGIC SURFACE DISORDERS
SEASONAL ALLERGIC CONJUNCTIVITIS
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CAUSES: PLANT, POLLEN, GRASS, FLOWERS
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TREATMENT ANTIHISTAMINES MAST CELL STABILIZERS
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PERENNIAL ALLERGIC CONJUNCTIVITIS
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CAUSES: ANIMAL, DUST MITES, DOGS, CATS
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TREATMENT ANTIHISTAMINES MAST CELL STABILIZERS
ENVIRONMENT CHANGE
SPECIFIC TREATMENT
ATOPIC KERATOCONJUNCTIVITIS
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CHRONIC
CORNEA AND EYELIDS
SCARRING
TREATMENT
MAST CELL STABILIZERS
STEROIDS
CYCLOSPORINE
MEIBOMIAN GLAND DYSFUNCTION
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AGE
ANDROGEN DEFICIENCY
ROSACEA
SEBORRHEIC DERMATITIS
KERATINIZATION FROM TOXICITY,
ATOPIC DISEASE, EPINEPHRINE
MEIBOMIAN GLANDS
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SECRETE OVER 100 DIFFERENT LIPIDS,
FATS, AND WAXES
MEIBOMIAN GLANDS FELT TO BE
AFFECTED BY NEURAL CONTROL
ANY LOSS OF FUNCTION MAY INCREASE
TEAR EVAPORATION
HYPERKERATINIZATION OF THE LID
MARGINS CAN CAUSE LOWER SECRETION
MGD TREATMENT
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CONTROL INFLAMMATION
TOPICAL CYCLOSPORINE
SHORT TERM STEROIDS
SYSTEMIC TETRACYCLINES
LID SCRUBS
MY MGD TREATMENT
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HOT COMPRESSES FOLLOWED WITH EXTERNAL
APPLICATION OF ANTIBIOTIC OINTMENT WITH
STEROIDS FOR ABOUT 1 WEEK DURATION.
RUB OINTMENT ON EYELIDS AND MARGINS
REPEAT OCCASIONALLY
THIS WILL CLEAR ALMOST 100% OF CASES IN
A FEW DAYS
DRY EYE ASSOCIATED WITH
MEIBOMIAN GLAND DISEASE
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DECREASED LIPIDS IN THE TEAR FILM
CAN LEAD TO INCREASED EVAPORATION
WHICH CAN CAUSE A NEURAL FEEDBACK
TO THE LACRIMAL GLAND AND MAKE
DRY EYE CONDITIONS WORSE.
OCULAR SURFACE
IMMUNE RESPONSE
OCULAR SURFACE IMMUNE CELLS
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BASOPHILS
DENDRITIC CELLS
EOSINOPHILS
MACROPHAGES
MAST CELLS
PLASMA CELLS
LEUKOCYTES
T-CELL DIFFERENTIATION
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ANTIGENIC STIMULATION PROMOTES T-CELL
DIFFERENTIATION TO PLASMA CELLS, EOSINOPHILS,
AND MAST CELLS. THIS CAN STIMULATE A
HYPERSENSITIVE RESPONSE
TREATMENT
APPROPRIATE ANTIBIOTICS
MAST CELL STABILIZERS
STEROIDS
CYCLOSPORINE
DIAGNOSTIC APPROACHES TO
DRY EYE
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ASSESS CORNEAL SENSITIVITY
COCHET-BONNET ESTHESIOMETER
SCHIRMER TEST
TEAR MENISCUS EVALUATION
TEAR FILM OSMOLARITY
TEAR PROTEIN ANALYSIS
MEIBOMIAN GLAND ASSESSMENT
DYE STAINING LISSAMINE, FLUORESCEIN, ROSE BENGAL
TEAR BREAK UP TIME
NEUROKERATITIS
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CORNEAL DISEASE DUE TO REDUCED CORNEAL
SENSATION WHICH LEADS TO REDUCED
CORNEAL WETTING AND INCREASED DRYNESS
BLINK REFLEX IS REDUCED
TREATMENT DIRECTED TO LUBRICATION,
CONTROL OF INFECTION, REDUCE EXPOSURE
AND REDUCING INFLAMMATION
40 YEAR OLD FEMALE S/P PRP
LASER FOR PDMR PRESENTS WITH
INFERIOR CORNEAL PUNCTATE
KERATITIS
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CONDITION OF NEUROKERATITIS DIAGNOSED
WITH CORNEAL ESTHESIOMETER, AND EXAM
TREATED WITH AGGRESSIVE AT’S
CYCLOSPORINE AND MAST CELL STABILIZERS.
SHORT TERM STEROIDS REQUIRED
38 YEAR OLD FEMALE WITH RED
EYES AND TEARS RUNNING DOWN
HER CHEEKS
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PATIENT WITH DRY EYE SYMPTOMS FORMERLY
TREATED WITH TEAR DUCT PLUGS, WHICH HELPED
AND THEN HAD TEAR DUCT PERMANENT OCCLUSION
PATIENT NEVER HAD STEROIDS OR CYCLOSPORINE
INCOMPLETE DIAGNOSTIC WORKUP
ACTUAL DIAGNOSIS WAS ALLERGIC CONJUNCTIVITIS
IMPORTANT TO ADHERE TO
PROGRESSIVE DIAGNOSTIC
AND TREATMENT PROTOCOLS
BASED ON DEGREE OF
SEVERITY
STEROID THERAPY
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PREDNISOLONE IS LEAST EXPENSIVE, IS EFFECTIVE.
ABOUT 10% OF PATIENTS WILL GET INCREASED IOP
AFTER 1 MONTH OF CONTINUED TREATMENT
INTERMITTENT TREATMENT IS BEST TO AVOID IOP
PROBLEMS.
PATIENTS BEING TREATED NEED TO HAVE IOP
CHECKED EVERY MONTH
ALWAYS INDICATE THE TIME DURATION FOR
TREATMENT ON YOUR PRESCRIPTION
INDICATE ON THE MEDICAL RECORD THAT PATIENT
HAS BEEN TOLD OF IOP COMPLICATIONS.
PRACTICAL CONSIDERATIONS FOR
STEROID TREATMENT
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COST
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COMFORT
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LOW INCIDENCE OF IOP RISE
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DURATION OF TREATMENT
LOTEPREDNOL
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MODIFICATION OF THE SIDE CHAIN ON
THE STEROID RING FROM A KETONE TO
AN ESTER
REDUCES THE IOP INCREASE RATE TO
ABOUT 2%
OCULAR SURFACE WORKUP
SUMMARY
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DIAGNOSIS
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TREATMENT
NUTRITIONAL SUPPORT FOR
OCULAR SURFACE DISORDERS
When to treat and when to refer
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Most patients respond well to the lower level of
treatments described in this talk
Close follow up is essential
Make sure patients understand what they have
and how long the treatment is to be in play.
Some patients need to be told they will be using
meds for a long time
Failure to respond or patient low satisfaction is a
good reason to refer
Patients tend to be satisfied whether treated by
the original doctor or a referral doctor
Thank you to
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John Affeldt MD
Dry Eye and Ocular Surface Disorders by
Stephen Pflugfelder
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Ocular Surgery News
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