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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 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 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 CAUSES: PLANT, POLLEN, GRASS, FLOWERS TREATMENT ANTIHISTAMINES MAST CELL STABILIZERS PERENNIAL ALLERGIC CONJUNCTIVITIS CAUSES: ANIMAL, DUST MITES, DOGS, CATS TREATMENT ANTIHISTAMINES MAST CELL STABILIZERS ENVIRONMENT CHANGE SPECIFIC TREATMENT ATOPIC KERATOCONJUNCTIVITIS CHRONIC CORNEA AND EYELIDS SCARRING TREATMENT MAST CELL STABILIZERS STEROIDS CYCLOSPORINE MEIBOMIAN GLAND DYSFUNCTION AGE ANDROGEN DEFICIENCY ROSACEA SEBORRHEIC DERMATITIS KERATINIZATION FROM TOXICITY, ATOPIC DISEASE, EPINEPHRINE MEIBOMIAN GLANDS 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 CONTROL INFLAMMATION TOPICAL CYCLOSPORINE SHORT TERM STEROIDS SYSTEMIC TETRACYCLINES LID SCRUBS MY MGD TREATMENT 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 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 BASOPHILS DENDRITIC CELLS EOSINOPHILS MACROPHAGES MAST CELLS PLASMA CELLS LEUKOCYTES T-CELL DIFFERENTIATION 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 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 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 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 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 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 COST COMFORT LOW INCIDENCE OF IOP RISE DURATION OF TREATMENT LOTEPREDNOL 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 DIAGNOSIS TREATMENT NUTRITIONAL SUPPORT FOR OCULAR SURFACE DISORDERS When to treat and when to refer 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 John Affeldt MD Dry Eye and Ocular Surface Disorders by Stephen Pflugfelder Pharm Company Illustrations Ocular Surgery News LLU Eye Dept Resources THE GREAT HEALER
