Download AS-13 outlineR - American Academy of Optometry

"OVS PRESENTS: Dry Eye Disease"
Course Instructor: Michael Twa, OD PhD FAAO
The Academy's journal Optometry and Vision Science (OVS), based on citations of its
publications, enjoys a top ranking among all ophthalmology, optometry, and
vision/eye journals in the world. It publishes the latest research that impacts clinical
practice. In this CE course OVS focuses on issues related to dry eye disease and its
impact for primary eye care practice. A September 2015 Feature issue themed on the
topic raises all of the issues. Leading authors and Guest Editors for the Feature issue
will be presenters and panelists for the course. The course, moderated by the Editor in
Chief of OVS, calls on the authors (or Guest Editors) to very briefly express how the
authors’ recent discoveries can change clinical practice, by providing a brief focus of the
Dry Eye Disease clinical application of their work.
The presenting Guest Editors are international leaders and clinicians in this field.
Meng C Lin, OD FAAO, OVS Lead Guest Editor & Author
Kenneth A Polse, OD MS FAAO, Guest Editor & Author
Nancy A McNamara, OD PhD FAAO, Guest Editor & Author
Jason J Nichols OD MPH PhD, FAAO, Guest Editor & Author
Kelly K Nichols, OD MPH FAAO, Guest Editor & Author
Background
Dry eye is one of the most frequently encountered ocular disorders that affect millions
of people worldwide, and dry-eye symptoms are among the most common reasons for
patients to visit eye-care professionals. In the past decade, there has been a noticeable
increase in interest and attempts to elucidate underlying mechanisms of dry eye. And
provide guidelines for care. Perhaps the most publicized efforts have come from two
reports: International Dry Eye Workshop (2007) and International Workshop on
Meibomian Gland Dysfunction (2011).1-2 The field has attracted considerable research
interest since these landmark reports, and there have been changes and advances in our
understanding of this enigmatic ocular condition in the past 5 years.
As various ocular-surface conditions or diseases can lead to the same ocular symptoms,
diagnosing, treating, and managing patients with dry eye symptoms can be challenging
and frustrating to both clinicians and patients. Awareness of how significantly dry eye
symptoms negatively impact quality of life has risen. In the past decade, clinicians and
scientists have made significant strides in improving care for patients with dry eye
symptoms.
Last month OVS published a theme issue on “Dry Eye Disease”. This course is based on
the clinical implications from 12 of the papers selected by 5 of our Guest Editors and
author instructors. (The 27 Feature Issue publications ranged from Reviews, Original
(‘discovery’) Articles, Clinical Reports and Clinical Perspectives).
The course papers are presented under the topics of (1) Risk Factors, (2) Diagnosis and
Physiology, (3) Treatment and Management, and (4) Clinical Perspectives.
Panel discussions, each after the short session on a particular Dry Eye Disease related
theme, will be a central part of the course and will address questions raised by course
participants and the panelists. It is intended that audience driven questions, and
commentary on significant clinical practice issues, will enrich the learning experience.
In addition series of questions will be posed to the course participants prior to each
session, seeking anonymous and instant electronic summaries of overall audience
opinion. The “Clicker” instrumentation, distributed to the audience will provide instant
feedback to attendees -- as a group response.
OUTLINE BY TOPIC:
Risk Factors papers
AUDIENCE QUESTION
(i) Meibomian Gland Dysfunction:
Of the most common types of evaporative dry eye is thought to be MGD.
Meibomian glands are the main source of tear lipids, which are essential for retardation
of tear aqueous evaporation. (JJN)
(ii) Damaged MG with Acne Treatment:
We learn that patients with prior history of acne treatment using isotretinoin can
also have dry eye symptoms due to damaged meibomian glands.12 The effect of
isotretinoin on the meibomian glands likely mimics its effects on the sebaceous glands
of the skin in the treatment of acne.12 (ML) Consequently, it is important for clinicians
to be aware of isotretinoin-associated meibomian gland dysfunction, especially on
young adults.
(iii) LASIK
Some cases of post-LASIK dry eye are neuropathic in etiology and warrant
treatment of the underlying neuralgia rather than treatment of aqueous deficient or
evaporative dry eye, according to our authors.10 (NmcN)
PANEL DISCUSSION
AUDIENCE QUESTION
Diagnosis and Physiology
(i) Tear Film Stability
is essential for maintaining ocular surface homeostasis and for providing good vision
and ocular comfort. Ocular surface cooling always precedes tear film breakup.13 (ML)
The lag time between tear cooling and breakup is explained by the time necessary to
first disrupt the tear lipid layer that eventually forms a localized rupture, which
accelerates evaporation.13
(ii) Tear film stability measurement:
Can be assessed with an invasive method (e.g., instilling fluorescein dye on the eye) or
with a non-invasive method (e.g., placido rings projecting on the pre-corneal tear film
or other custom built optical devices). n another study, a direct comparison with
automated and traditional measures of tear film breakup shows poor agreement,
perhaps because each method exhibits poor repeatability.14,15 (JJN) Further research is
needed to refine and improve methods for assessing tear film stability as it is
considered an important end point in clinical trials.
(iii) Tear osmolarity
Increases can be amplified by either increased tear evaporation or decreased tear
supply. An accurate measurement of tear osmolarity on a localized ocular surface is
currently not possible. Taking osmolarity measurements from the tear meniscus is the
basis for current osmometers. The utility of these tools in a clinical setting continues to
be debatable relative to their reflection of what truly happens to the precorneal tear
film.15,16 (ML)
PANEL DISCUSSION
Treatment & Management
AUDIENCE QUESTION
A number of our Feature Issue papers address both treatment and management
of dry eye. Understanding tear film constituents and regulatory mechanisms for natural
production of tear components can be used to develop new concepts for potential
treatment strategies. Mucins play a major role in maintaining ocular surface
homeostasis by lubricating and protecting the ocular surface as well as providing
immunodulatory function, acting as antimicrobial factors and preventing pathogens
from binding to the ocular surface and clearing away pathogens.19
(i)
Pharmaceutical Treatment
An ophthalmic solution containing Diquafosol tetrasodium offers an alternate treatment
option to restore ocular surface integrity.20-21 Diquafosol tetrasodium is a P2Y2
purinergic receptor agonist that activates P2Y2 receptors on the ocular surface and
stimulates goblet-cell secretion of ocular mucins.20-21 (KKN) For advanced cases of
aqueous tear deficiency or ocular surface diseases, other treatment and management
options are available, such as thermal and electrocautery of the lacrimal puncta, lid
surgeries such as tarsorrhaphy, amniotic membrane, or scleral lens fitting.22
(ii) Omega-3 Supplements:
In a review, a manuscript draws attention to the fact that there are conflicting
reports about the benefits of Omega-3 supplements and the questions raised suggest the
need for a longitudinal randomized controlled clinical trial to provide appropriate
guidance on formulation, dosage, and duration of this essential fatty acid.24 (KKN)
(iii) Self-applied heat therapy has been the mainstay of therapy for meibomian
gland dysfunction; however, a clinical series reported here reveals that not all warm
compresses are equally effective.26,27 (KAP)
(iv) Thermal pulsation:
Although much more costly than traditional warm compresses, some
symptomatic patients with MGD find Lipiflow® (Thermal Pulsation System) treatment
to be beneficial. One team of authors suggests that an appropriate patient selection may
increase patient satisfaction with this procedure.28 (KAP)
PANEL DISCUSSION
Clinical Perspectives
AUDIENCE QUESTION
(i) Diagnostics viability:
Experts from different parts of the world have varying opinions about the most
viable diagnostic methodologies and treatments.29 In fact, dry eye disease may be the
wrong term to describe an eye that is not desiccated.
(ii) Etiology-Based Treatments:
Arguments are made that an etiology-based diagnosis allows clinicians to more
effectively treat and manage dry eye symptoms, compared with symptom-based or
definition-based approaches.29, 30 (KAP) Until more novel treatment strategies based on
etiology are developed to restore function, many treatment options addressing the signs
and symptoms will likely remain primarily palliative.
PANEL DISCUSSION
________________________________
Manuscripts referenced in OVS Feature Issue September 2015, “Dry Eye Disease”
References:
1. O’Brien PD, Collum LM. Dry eye: diagnosis and current treatment strategies. Current allergy and asthma reports
2004;4:314-319.
2. 2007 Report of the International Dry Eye WorkShop (DEWS). Ocul Surf 2007;5:179-93.
3. Nichols KK, Foulks GN, Bron AJ, Glasgow BJ, Dogru M, Tsubota K, Lemp MA, Sullivan DA. The international
workshop on meibomian gland dysfunction: executive summary. Invest Ophthalmol Vis Sci 2011;52:1922-9.
4. Schaumberg DA, Sullivan DA, Buring JE, Dana MR. Prevalence of dry eye syndrome among US women. American
Journal of Ophthalmology 2003;136(2):318–26.
5. Yang W, Yang Y, Cao J, Man Z, Yuan J, Xiao X, Xing Y. Risk factors for dry eye syndrome: A retrospective case-control
study. Optom Vis Sci 2015;92:XXX-X
6. Pucker AD, Jones-Jordan LA, Li W, Kwan JT, Lin MC, Sickenberger W, Marx S, Srinvasan S, Jones L. Associations with
Meibomian Gland Atrophy in Daily Contact Lens Wearers. Optom Vis Sci 2015;92:XXX-X
7. Rueff EM, King-Smith PE, Bailey MD. Can binocular vision disorders contribute to contact lens discomfort? Optom Vis
Sci 2015;92:XXX-X
8. Ramli N, Supramaniam G, Samsudin A, Juana A, Zahari M, choo MM. Ocular surface disease in glaucoma: effect of
polypharmacy & Preservatives. Optom Vis Sci 2015;92:XXX-X
9. Chen H, Lin C, Tsai Y, Kao C. Association between glaucoma medication usage and dry eye in Taiwan. Optom Vis Sci
2015;92:XXX-X
10. Theophanous C, Jacobs DS, Hamrah P. Corneal neuralgia after LASIK. Optom Vis Sci 2015;92:XXX-X
11. McMonnies CW. Blink anomaly contributions to post-Lasik-neurotrophic epitheliopathy. Optom Vis Sci 2015;92:XXXX
12. Moy A, McNamara NA, Lin MC. Effects of isotretinoin on Meibomian glands. Optom Vis Sci 2015;92:XXX-X
13. Li W, Graham AD, Selvin, Lin MC. Ocular surface cooling corresponds to tear film thinning and breakup. Optom Vis Sci
2015;92:XXX-X
14. Yeh TN, Graham AD, Lin MC. Relationships among rear film stability, Osmolarity, and Dryness Symptoms. Optom Vis
Sci 2015;92:XXX-X
15. Cox SM, Nichols KK, Nichols JJ. Agreement between automated and traditional measures of tear film breakup. Optom
Vis Sci 2015;92:XXX-X
16. Pena-Verdeal H, Garcia-Resua C, Miñones M, Giráldez MJ, Yebra-Pimentel E. Accuracy of a freezing point depression
technique osmometer. Optom Vis Sci 2015;92:XXX-X
17. Tesón M, López-Miguel A, Neves H, Calonge M, González-García MJ, González-Méijome JM. Influence of climate on
clinical diagnostic dry eye tests: A Pilot Study, González-García. Optom Vis Sci 2015;92:XXX-X
18. Villani E, Garoli E, Termine V, Pichi F, Ratiglia R, Nucci P. Corneal confocal microscopy in dry eye treated with
corticosteroids. Optom Vis Sci 2015;92:XXX-X
19. Stephens DN and McNamara NA. Altered mucin and glycoprotein expression in dry eye disease. Optom Vis Sci
2015;92:XXX-X
20. Yang JM, Choi W, Kim N, Yoon KC. Comparison of topical cyclosporine and diquafosol treatment in Dry Eye. Optom
Vis Sci 2015;92:XXX-X
21. Kobashi H, Kamiya K, Igarash A, Miyake T, Shimizu K. Intraocular scattering after instillation of diquafosol ophthalmic
solution. Optom Vis Sci 2015;92:XXX-X
22. Bartlett AH and Bartlett JD. Ophthalmic procedures for treatment of advanced Ocular Surface Diseases. Optom Vis Sci
2015;92:XXX-X
23. Nosch DS, Foppa D, Tóth M, Joos RE. Blink animation software to improve blinking and dry eye symptoms. Optom Vis
Sci 2015;92:XXX-X
24. Hom MM, Asbell PA, Barry B. Omegas and dry eye: more knowledge, more questions. Optom Vis Sci 2015;92:XXX-X
25. Ngo W, Caffery B, Srinivasan S, Jones L. The Effect of lid debridement-scaling in Sjӧgren's syndrome dry eye. Optom
Vis Sci 2015;92:XXX-X
26. Wang M, Jaitley Z, Lord SM, Craig JP. Comparison of self-applied heat therapy for Meibomian gland dysfunction.
Optom Vis Sci 2015;92:XXX-X
27. Murkami DK, Blackie CA, Korb DR. All Warm Compresses Are Not Equally Efficacious. Optom Vis Sci 2015;92:XXXX
28. Satjawatcharaphong P, Ge S, Lin MC. Clinical Outcomes Associated With Thermal Pulsation System. Optom Vis Sci
2015;92:XXX-X
29. Lin MC and Polse KA. Improving Care for Patients with Dry Eye Symptoms: See What the Experts Say. Optom Vis Sci
2015;92:XXX-X
30. Blackie CA and Korb DR. "Dry Eye" is the Wrong Diagnosis for Millions. Optom Vis Sci 2015;92:XXX-X