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"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