Download A Patient-centric Approach to the Management of Dry Eye

Doctors of Optometry | Course Notes
B7 OD – 1CE
A Patient-Centric Approach to the Management of Dry Eye Disease
Supported by Alcon
Monday, February 27, 2017
8:00 am – 8:55 am
Plaza A/B/C – 3rd Floor
Presenter: Trevor Miranda, OD
Trevor Miranda is a private practice optometrist and partner in three full-scope optometric practices on
Vancouver Island in the Cowichan region. They all offer the Ultimate Eye Exam, which provides the latest
digital technology to focus on their patients’ current vision and related health conditions. He graduated from the
University of Waterloo, was a past president of the Eye Recommend network, and is the founder of the
Sunglass Cove, a sunglass boutique in Canada. Dr. Miranda is a well-respected member of the PDC team, and
is an innovator who is committed to ensuring that optometry continues to evolve and thrive into the future. He is
well known for his knowledge and expertise in many areas including glaucoma, dry eye, contact lenses, and
collaborative care models.
Course Description
This course will help participants understand how to properly screen to identify dry eye disease (DED) in patients.
They will also understand comprehensive DED workup, management strategies, economics as well as the latest
developments in addressing DED.
1
Doctors of Optometry | Course Notes
NOTES:
2
Dry Eye Disease Update
Management of dry eye disease
PRESENTATION OVERVIEW
1
Screening to identify dry eye patients
2
What constitutes a comprehensive DED workup
3
Management and follow-up strategies for DED
2
DEFINITION OF DRY EYE DISEASE
Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of
discomfort, visual disturbance, and tear film instability, with potential damage to the ocular
surface. It is accompanied by increased osmolarity of the tear film and inflammation of the
ocular surface.1
Less than 60% of patients with objective signs of
DED are symptomatic.2
3
1. DEWS Report. Ocul Surf. 2007;5:75-92. 2. Bron AJ, et al. Ocul Surf. 2014;12:S1-S31.
TEAR FILM
Surface area ~2cm2
K+
CI3 –40 μm thick
Lacrimal
punctum
Lipid layer
(up to 20 molecules thick)
Outer non-polar (air interface)
Inner polar (aqueous interface)
Inserted and absorbed proteins
Lipid layers
13 – 100 nm
Lacrimal gland
Na+
Mg2+
Ca2+
CI-
Intermediate aqueous
phase proteins, salts,
soluble mucins
Glycocalyx layer
membrane and secreted
mucins
MUC1, MUC4, MUC16,
MUC5AC, MUC2
Lacrimal sac
Corneal epithelium
squamous cells
Meibomian glands
Tear film secretion and drainage
4
Figure on the right adapted from Levin LA, et al. Adler’s Physiology of the Eye: Expert Consult. 2011
and Butovich IA, et al. Curr Eye Res. 2008;33:405-420.
CORE PATHOPHYSIOLOGIC MECHANISMS OF DED
Tear
Hyperosmolarity
1
2
– Reduced aqueous flow
Activate
epithelial
MAPK+
NFκB+
Tear film
instability
– Increased evaporation
Goblet cell,
glycocalyx mucin
loss epithelial
damage –
apoptosis
Inflammation
IL-1+
TNFα+
MMPs
Chronic surface damage of dry eye → ↓ corneal sensitivity, ↓ reflex tear secretion
5
Figure adapted from DEWS Report. Ocul Surf. 2007;5:75-92.
PREVALENCE OF DED1
 Prevalence variable: 7.8 to 33.7% (DEWS)
 Prevalence increases with:
▫
▫
▫
▫
▫
Age
Female gender
Asian ethnicity
Autoimmune diseases
Refractive surgery
The high prevalence of dry eye symptoms in refractive surgery
patients indicates need for objective DED diagnosis in all
patients preoperatively.2
6
1. DEWS Report. Ocul Surf. 2007;5:75-92. 2. McDonald MB. ASCRS, 2014.
RISK FACTORS FOR DED1









Ocular surgery
Age >40 years
Female gender
Medications
Systemic diseases (e.g., diabetes,2 hypertension, rheumatoid arthritis, Sjögren's
syndrome, thyroid disorders, etc.)
Smoking
Computer vision syndrome
Environmental factors (humidity, air currents/drafts, AC)
Contact lens wear3
7
1. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31. 2. Afsharkhamseh N, et al. Saudi J
Ophthal. 2014;28:164-7. 3. DEWS Report. Ocul Surf. 2007;5:93–107.
DIAGNOSING DED BEFORE EYE SURGERY IS IMPORTANT!
 Surgeons are likely underdiagnosing and undertreating DED in ocular surgical candidates1
 Healthy ocular surface improves postoperative outcomes2
▫ Avoid/reduce severity of postoperative DED2 (most common complaint) and postoperative vision
fluctuation3
▫ Reduce risk of patient dissatisfaction3
 DED is associated with worse vision outcomes and decreased
patient satisfaction in refractive surgery3
▫ LASIK: inaccurate preoperative wavefront measurements3
▫ Cataract surgery
 Interference with keratometry, topography3
 Inaccurate IOL power calculations and astigmatism
measurements3,4
Consider postponing surgery if ocular surface is suboptimal4
1. Shamie N. ASCRS Survey 2013. Available at http://www.eyeworld.org/supplements/oct-2013/Allergan_supplement_October2013.pdf. Accessed September 2, 2015. 2. Stephenson
M. Review of Ophthalmology. 2008. 3. Trattler WB. EyeWorld Supplement 2013. Available at http://www.eyeworld.org/supplements/oct-2013/Allergan_supplement_October2013.pdf.
Accessed September 2, 2015. 4. Holland E. EyeWorld 2016.
8
DIAGNOSING DED IS IMPORTANT!
DED is associated with:
Significantly decreased
vision-related quality of
life, with increased
anxiety and depression1
Significantly
decreased
functional visual
acuity2
Discontinuation of
contact lens wear
in one-third of
patients3
Highly prevalent
digital eye strain
syndrome4
1. Li M, et al. Invest Ophthalmol Vis Sci. 2012;53:5722–7. 2. Goto E, et al. Am J Ophthlamol. 2002;133:181-6. 3. Pritchard N, et al. Int Contact Lens Clin. 1999;26:157-62.
4. Computer vision syndrome. AOA. Available at http://www.aoa.org/patients-and-public/caring-for-your-vision/protecting-your-vision/computer-vision-syndrome?sso=y. Accessed
September 2, 2015.
9
SCREENING FOR DED
Reduced tear
meniscus height
(TMH)
Reduced corneal
sensitivity
Lid margin disease (anterior
and posterior blepharitis,
trichiasis, telangectasia,
madarosis)
Typical
Signs of
DED1
Epiphoria
Fluorescein-TBUT
<10 seconds
(less in patients of
Asian ethnicity2,3)
Punctate staining
(cornea and conjunctiva)
Mucus and
debris in tear film
1. College of Optometrists (UK). Available at
http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&sqi=2&ved=0CFYQFjAIahUKEw
jBrNCirNvHAhXHjA0KHSTwCkU&url=http%3A%2F%2Fwww.collegeoptometrists.org%2Fdownload.cfm%2Fdocid%2F4111ACA3-058B-45B5ADDFC10FF163263D&usg=AFQjCNEtBzqvuonH6dI6l4geikCQQUn6Eg&bvm=bv.101800829,d.eXY.
Accessed September 2, 2015. 2. Cho P, et al. Optom Vis Sci. 1992;70:30-38. 3. Cho P, et al. Optom
Vis Sci. 1993;69:879-85. .
DED SYMPTOMS1
Not every patient experiences the same dry eye symptoms, which can include:
 Ocular irritation and discomfort
 Foreign body, gritty or burning sensation
 Stringy mucous discharge
 Blurry or fluctuating vision, ocular fatigue
 Light sensitivity
 Intolerance to CL wear
• Symptoms may be exacerbated by smoke, wind or heat.
• Symptoms are usually bilateral; may not be described as a feeling of dryness.
• There may be associated symptoms of dry mouth or systemic disease (consider Sjögren
workup).2
.
1. College of Optometrists (UK). Available at
http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=9&sqi=2&ved=0CFYQFjAIahUKEw
jBrNCirNvHAhXHjA0KHSTwCkU&url=http%3A%2F%2Fwww.collegeoptometrists.org%2Fdownload.cfm%2Fdocid%2F4111ACA3-058B-45B5ADDFC10FF163263D&usg=AFQjCNEtBzqvuonH6dI6l4geikCQQUn6Eg&bvm=bv.101800829,d.eXY.
12
Accessed September 2, 2015. 2. DEWS Report. Ocul Surf. 2007;5:75-92.
MANY CONDITIONS CAN MIMIC DED1












Allergy
Anterior basement membrane dystrophy
Binocular vision problems
Conjunctivochalasis (CCh)
Giant papillary conjunctivitis (GPC)
Infectious blepharitis
Lid problems
Ocular pemphigoid
Pingueculitis
Salzmann nodular degeneration
Superior limbic keratoconjunctivitis (SLK)
Visual system misalignment
Red, tearing eye
Giant papillary
conjunctivitis
Conditions that mimic DED must be ruled out.
13
1. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31.
SCREENING FOR DED1
CASE HISTORY
including 4 very specific
questions
1. Do your eyes feel
uncomfortable?
2. Do you have watery eyes?
3. Does your vision fluctuate,
especially in a dry
environment?
4. Do you use eye drops?
Any YES
Evaluation
of risk
factors
SCREENING
EXAMINATION
Evaluation
of
significant
clinical
findings
Schedule
patient for
complete Dry
Eye Disease
Workup
If yes to any of the above
questions:
1. Do you have dry mouth?
14
1. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31.
FULL WORKUP FOR DED
FULL DED WORKUP1
Patients who screen positive for DED
1
Book a separate dedicated appointment for full DED workup (30 to 45 minutes suggested)
2
Assess and test in the following order:
• Case history using validated DED questionnaire
• Tear osmolarity
• Tear quantity and volume
• Anterior segment evaluation
• Tear break-up time
• Integrity of cornea and conjunctiva
• Meibomian gland expression and assessment
• Adjunctive tests
3
Patient education (chronicity and progressive nature)
Tests must be performed in the order indicated.
16
1. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31.
VALIDATED DED QUESTIONNAIRES
OCULAR SURFACE DISEASE INDEX (OSDI)1,2





Symptoms
Lifestyle
Environment
High degree of sensitivity (80%) and specificity (79%)
Available as an app
Normal 0 - 12
Mild 13 - 22
Moderate 23 - 32
Severe 33 - 100
0
10
20
30
40
50
60
70
80
90
100
17 Accessed September 28, 2016. 2. Image adapted from Prokopich CL, et al. Can J Optom.
1. OSDI Questionnaire. Available at: http://www.dryeyezone.com/documents/osdi.pdf.
2014;76(Suppl 1):1–31.
DEQ 5
1. Questions about EYE DISCOMFORT:
a) During a typical day in the past month, how often did
your eyes feel discomfort?
VALIDATED DED QUESTIONNAIRES
DEQ-5 QUESTIONNAIRE1
Sometimes
2
Rarely
1
 Self-administered
Frequently
3
Constantly
4
b) When your eyes felt discomfort, how intense was this
feeling of discomfort at the end of the day, within two
hours of going to bed?
 Five questions
Never
 Assesses frequency of watery eyes,
discomfort, and increased intensity of
dryness during day
Not at all intense
0
1
Very intense
2
3
4
5
2. Questions about EYE DRYNESS:
a) During a typical day in the past month, how often did
your eyes feel dry?
Sometimes
2
Rarely
1
 Score ≥6 indicates suspicion of DED
Frequently
3
Constantly
4
b) When your eyes felt dry, how intense was this feeling
of discomfort at the end of the day, within two hours of
going to bed?
 Score ≥12 may indicate Sjögren’s
syndrome
Never have it Not at all intense
 High sensitivity (90%) and specificity
(81%)
0
1
3
2
4
5
3. Questions about WATERY EYES:
a) During a typical day in the past month, how often did
your eyes look or feel excessively watery?
Never
0
1. Chalmers RL, et al. Cont Lens Anterior Eye. 2010;33:55-60.
Very intense
18
+
Score
1a
Sometimes
2
Rarely
1
+
1b
2b
Constantly
4
=
+
+
2a
Frequently
3
3
TOTAL
TEAR HYPEROSMOLARITY AND DED
Tear hyperosmolarity:
 Central mechanism in pathogenesis of DED1
 Stimulates inflammatory cascade1,2,3
 Not suitable for corneal epithelium
Causes:1
 Low aqueous tear flow and/or excessive evaporation
Clinical interpretation:4,5
 DED diagnosis >308 mOsm/L
 Interocular difference >8 mOsm/L
Osmometer
Photo courtesy of E Bitton
1. DEWS Report. Ocul Surf. 2007;5:75-92. 2. De Paiva CS, et al. Exp Eye Res. 2006;83:526-35. 3. Li DQ, et al. Invest Ophthalmol Vis Sci. 2004;45:4302-11.
4. Lemp19MA, et al. Am J Ophthalmol. 2011;151(5):792-8. 5. Karpecki PM. Rev Optom. 2015;152:32-35.
TEAR VOLUME MEASUREMENT METHODS
Tear Meniscus Height (TMH)
• Subjective at the slit lamp (≤0.35mm)1
• Objective calculation2
Cotton Thread Test (CTT)1
• Sensitivity = 86%, Specificity = 83%
• Interpretation: >9mm/15 sec
Schirmer I Test1
• Sensitivity = 85%, Specificity = 83% for values <5.5mm/5min
• Interpretation: >5mm/5min
Photos courtesy of E Bitton
1. DEWS Report. Ocul Surf. 2007;5:108-52.
Accessed September 27, 2015.
2. OCULUS Keratography 5M. Available at: http://www.oculus.de/us/products/topography/keratograph-5m/highlights/.
20
ANTERIOR SEGMENT EVALUATION1
 Systematic assessment of:
▫ Lashes: madarosis (loss),
debris/collarettes, cylindrical dandruff (CD),
trichiasis (misdirected)
▫ Lid margin: apposition, notching/scars,
blepharitis, tylosis, telangiectasia, punctum
apposition
▫ Cornea: SPK (especially inferiorly),
basement membrane dystrophy
▫ Conjunctiva: chalasis,
pterygium/pinguecula, staining of the
conjunctiva (bulbar and palpebral)
Madarosis
Trichiasis
Photos courtesy of E Bitton
21
1. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31. 2. Nelson D. In: Dry eye disease: The clinician’s guide to diagnosis and treatment. Thieme Medical Publishers, Inc. 2006.
STAINING
Moderate inferior
staining
Advanced diffuse
staining
22
Upper lid margin staining (ULMS)
or lid wiper epitheliopathy (LWE)
Photos courtesy of E Bitton
TEAR BREAK-UP TIME (TBUT)
 With Fluorescein (F-TBUT)
▫
▫
▫
▫
Minimize variability by using standardized methodology1
Wet fluorescein strip with sterile saline; shake off excess2
Tap lower tarsal palpebral conjunctiva and deliver small volume2
Use a wide beam illumination, low intensity
 Non-invasive (NIBUT)
▫ Several instruments available with placido disk mires (i.e.,
topographer)3
▫ If using OCULUS Keratograph®, objective NIKBUT calculated
 Clinical interpretation
▫ F-TBUT: >10 sec; DED: <5 sec3
 Shorter in patients of Asian ethnicity4,5
▫ NIBUT > F-TBUT3
Photo courtesy of E Bitton
Keratograph® is a registered trademark of OCULUS, Inc
1. Abdul-Fattah AM, et al. Optom Vis Sci. 2002;79(7):435-8. 2. Bron AJ, et al.
23Cornea. 2003;22:640-50. 3. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31. 4. Cho
P, et al. Optom Vis Sci. 1992;70:30-38. 5. Cho P, et al. Optom Vis Sci. 1993;69:879-85.
MEIBOMIAN GLAND (MG) EVALUATION
 Assess MG orifices for:1
▫ Capping
▫ Frothing (saponification)
▫ Linearity (posterior
displacement may be
indicative of MGD)
Finger/cotton swab
 Expressing the MG will
assess the appearance
and consistency
of meibum
Meibomian Gland
Evaluator (MGE)
Mastrota paddle
24
1. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31.
SIMPLIFIED MGD CLINICAL INTERPRETATION1
NORMAL
ABNORMAL
Expression
Easy
Difficult
Secretion colour
Clear
Yellow, white
Secretion consistency
Liquid
Thick, pasty
Clear, smooth
Scalloped, gland
dropout, thickened
Lid margin appearance
25
1. Adapted from Tomlinson A, et al. Invest Ophthalmol Vis Sci. 2011;52:2006-49.
ADJUNCTIVE TESTS1
Several new instruments are available to:
 Assess lipid layer thickness
 Assess inflammatory biomarkers (MMP-9)
 Apply thermal pulses for MG expression
 Image MGs
Corneal topography with keratometry
Assesses TMH, MG viewing, NIKBUT, bulbar
redness, viscosity
Meibomian Gland Evaluator
Assesses MG expression using a standard force
26
1. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31.
DRY EYE DIAGNOSIS AND
CLASSIFICATION
DEWS 20071
Dry Eye
Effect of the Environment
Milieu Interieur:
• Low blink rate behaviour, VTU,
microscopy
• Wide lid aperture gaze position
• Aging
• Low androgen pool
• Systemic drugs:
antihistamines, beta-blockers,
antispasmodics, diuretics, and
some psychotropic drugs
Milieu Exterieur:
• Low relative humidity
• High wind velocity
• Occupational environment
Evaporative
Aqueous-deficient
Sjögren’s
Syndrome
Dry Eye
Primary
Secondary
Intrinsic
Non-Sjögren
dry eye
Lacrimal
deficiency
Lacrimal
gland duct
obstruction
Reflex block
Systemic
drugs
28
Meibomian oil
deficiency
Disorders of
lid aperture
Low blink rate
Drug action
Accutane
Extrinsic
Vitamin A
deficiency
Topical drugs
preservatives
Contact
lens wear
Ocular surface
disease (e.g.,
allergy)
Major etiological causes of dry eye
1. Adapted from DEWS Report. Ocul Surf. 2007;5:75-92.
DED CLASSIFICATION GUIDELINES
DED must be classified consistently
– Many classification systems are available, which link to management approaches
– Some are more practical than others
– Gold standard, Levels 1 to 4
Dry Eye WorkShop (DEWS)1
Dry Eye Disease Guidelines for Canadian Optometrists, CJO (Canadian
National
Journal of Optometry)
2
– Episodic, chronic, recalcitrant
Canadian Ophthalmological Society consensus
3
– Mild, moderate, severe
1. DEWS Report. Ocul Surf. 2007;5:75-92. 2. Prokopich CL, et29al. Can J Optom. 2014;76(Suppl 1):1–31. 3. Jackson WB. Can J Ophthalmol. 2009;44:385–94.
TFOS-DEWS SEVERITY LEVELS1
Dry Eye Severity Level
1
2
3
4
Discomfort, severity and
frequency
Mild and/or episodic, occurs
under environmental stress
Moderate episodic or chronic,
stress/no stress
Severe frequent or constant
without stress
Severe and/or disabling and
constant
Visual symptoms
None or episodic mild fatigue
Annoying and/or activitylimiting, episodic
Annoying, chronic and/or
constant, limiting activity
Constant and/or possibly
disabling
Conjunctival injection
None to mild
None to mild
+/–
+/++
Conjunctival staining
None to mild
Variable
Moderate to marked
Marked
Corneal staining
None to mild
Variable
Marked central
Severe punctate erosions
Filamentary keratitis, mucus
clumping, increased tear
debris, ulceration
Corneal/tear signs
None to mild
Mild debris, ↓ meniscus
Filamentary keratitis, mucus
clumping, increased tear
debris
Lid/meibomian glands
Meibomian Gland Dysfunction
variably present
Meibomian Gland Dysfunction
variably present
Frequent
Trichiasis, keratinization,
symblepharon
Tear break-up time (seconds)
Variable
≤10
≤5
Immediate
Schirmer score (mm in 5
minutes)
Variable
≤10
≤5
≤2
30
1. DEWS Report. Ocul Surf. 2007;5:75-92.
MANAGEMENT OF DRY
EYE DISEASE
MANAGEMENT: DEWS LEVEL 1, MILD, OR EPISODIC
 Institute the following:
▫ Educate patient1
▫ Modify environment and lifestyle, if
possible1,2,3
▫ Control allergies2
▫ Use artificial tears, gels, and ointments as
necessary1,2,3
▫ Increase dietary intake of omega-3 oils
▫ Implement lid hygiene, warm compresses2,3
o Patients are not compliant or do it
incorrectly
o Go over procedure and temperature
requirements for warm compress
(facecloth cools too quickly)
Photo courtesy of E Bitton
1. DEWS Report. Ocul Surf. 2007;5:163–78. 2. Jackson WB. Can J Ophthalmol. 2009;44:385–94. 3. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31.
4. Bitton E, et al. CLAE 2016;39:311-5.
32
TARGETED APPROACH: EXAMPLES
Diagnosis
Type of Artificial Tears
MGD
Lipid-based1
Aqueous
Disappearing/gentle preservative1
Friction (e.g., LWE)
Sodium Hyaluronate1
Hyperosmolarity
Hypo-osmolar2
Severe staining
Unpreserved2
1. Prokopich
33 CL, et al. Can J Optom. 2014;76(Suppl 1):1–31. 2. DEWS Report. Ocul Surf. 2007;5:163–78.
TYPICAL ARTIFICIAL TEAR PRODUCTS1,2
Stage of DED
Mild-Mod
Ingredient
Natural/synthetic polymers: CMC, HPGuar, HMC
Clinical Indication
Properties
Aqueous layer deficiency
Adds viscosity to tears, aids in stabilizing tear film by stabilizing mucin layer (surfactant) and
increased resident time
HP-Guar may preferentially bind to more desiccated epithelial cells
Mild-Mod
Electrolyte composition: potassium,
bicarbonate
Aqueous deficiency (AD), Sjögren’s syndrome,
laser eye surgery, high tear osmolarity
Maintains corneal thickness and may decrease tear osmolarity
Mild-Mod
Osmo-protectant solutes: glycerin,
erythritol, levocarnithine
Aqueous deficiency, high tear osmolarity
Protection against adverse effects of increased osmolarity
Mild-Mod
Lipid-based emulsions: castor oil,
mineral oil
Lipid layer deficiency,
evaporative disease (ED)
Lipid oil-in-water emulsions reduce tear evaporation rate and improve lipid layer
Mod-Severe
Polysaccharide: hyaluronic acid
Aqueous deficiency, corneal damage from
AD or ED
Adds viscoelasticity: increased tear stability, reduction of tear removal, protective effects on
the corneal epithelium. Water retaining and reduces shearing force of tears.
Mod-Severe
Preservative-free minims
Aqueous layer deficiency, aqueous deficiency,
Sjögren’s syndrome, laser eye surgery
Surfactant ± electrolyte/osmolarity balanced
Mod-Severe
Preservative-free multi-dose
Aqueous deficiency, Sjögren’s syndrome
Polysaccharide-based (HA or similar): higher viscosity, higher retention time, no
preservatives
Mod-Severe
Gels and Ointments (high molecular
weight polymer/ointment): mineral oil,
petroleum
Aqueous layer deficiency
Higher retention time. Ointments do not support bacterial growth – usually no preservatives.
34
1. DEWS Report. Ocul Surf. 2007;5:163–78. 2. Prokopich CL, et al. Can J Optom. 2014;76(Suppl
1):1–31.
HYALURONIC ACID AND ARTIFICIAL TEARS, GELS, OINTMENTS




Hyaluronic acid is a naturally occurring compound in the human body1
It is found in the highest concentrations in fluids in the eyes and joints2
Medicinal hyaluronic acid is extracted from rooster combs or made by bacteria2
Benefits of hyaluronic acid in artificial tears:1
▫
▫
▫
▫
▫
Increased tear stability
Reduction of tear removal
Protective effects on the corneal epithelium
Contains water-retaining molecules
Reduces shearing force of tears
35
1. Rah M. Contact Lens Spectrum, Special Edition, 2010. pp. 30-32. 2. Hyaluronic acid. WebMD.
Available at: http://www.webmd.com/vitamins-supplements/ingredientmono-1062hyaluronic%20acid.aspx?activeingredientid=1062&. Accessed November 28. 2016.
HYALURONIC ACID AND ARTIFICIAL TEARS, GELS, OINTMENTS
 Cases that require preparations with hyaluronic acid (studies have shown HA is supportive in the
following cases):
▫
▫
Moderate dry eye from aqueous deficiency or evaporative disease1
Severe dry eye causing corneal damage



▫
Adjunctive corneal protection when other topical medications containing preservatives are being applied

▫
Recurrent corneal erosions
Fuch’s dystrophy
Pre- and post-operatively

▫
Glaucoma, keratitis, conjunctivitis
Preventative therapy for corneal dystrophies


▫
Sjögren’s syndrome
Neurotrophic keratopathy
Exposure keratopathy
LASIK, cataract
Improve adherence and reduce corneal complications for rigid contact lens and soft contact lens wearers1
36
1. Rah M. Contact Lens Spectrum, Special Edition, 2010. pp. 30-32.
ARTIFICIAL TEARS WITH HA
Systane® is a registered trademark of Alcon Inc.
is a registered trademark of Abbott Laboratories Inc.
Refresh Optive Fusion™ is a trademark of Allergan, Inc.
i-drop® is a registered trademark of I-Med Pharma Inc.
Hylo™ is a trademark of CandorVision.
Hyabak® is a registered trademark of Thea Pharmaceuticals Ltd.
Blink®
37
ARTIFICIAL TEARS, GELS, OINTMENTS: KEY POINTS
 Topical lubricant preparations improve but do not resolve DED1
 All artificial tears are NOT created equal1-3
▫ Current formulations are more complex and more targeted than in previous years
▫ Direct recommendations of products are needed for the practitioner to encourage compliance
▫ Other ocular drops (e.g., for glaucoma) need to be considered
 Preservatives1,2,4
▫ Recommend products with Polyquad®, Purite®, or perborate; avoid benzalkonium chloride (BAK)
▫ For any tear product used >4-6 times per day, consider preservative-free products
▫ Using other preserved ocular drops (e.g., for glaucoma) can lead to preservative sensitivity; consider
preservative-free products
 Understand active ingredients to target products more appropriately to the right patients
All trademarks are the property of their respective owners.
1. DEWS. Ocul Surf. 2007;5(2):163–78. 2. Doughty MJ, et al. Ophthalmic Physiol Opt.
2009;29(6):573-83. 3. Dogru M, et al. Expert Opin Pharmacother. 2011;12(3):325-34 4. Anwar Z, et al.
38
Curr Opin Ophthalmol 2013;24(2):136-143.
MANAGEMENT: DEWS LEVEL 2, MODERATE, CHRONIC
 Anything from level 1 can be used at
this point, but you may also add the
following:1-3
▫ Switch to preservative-free artificial tears
▫ Topical anti-inflammatories (short- and
long-term use)
▫ Tetracycline
▫ Secretagogues
▫ Moisture chamber spectacles
▫ Sleep masks, lid taping
Photo courtesy of E Bitton
1. DEWS Report. Ocul Surf. 2007;5:163–78. 2. Jackson WB. Can
39 J Ophthalmol. 2009;44:385–94. 3. Prokopich CL, et al. Can J Optom. 2014;76(Suppl 1):1–31.
MANAGEMENT: DEWS LEVEL 2/31
 Punctal plugs should ONLY be recommended
when ocular surface inflammation is under control
(use InflammaDry® to check for MMP-9
inflammatory biomarkers)
 Try dissolvable plugs first to assess improvement
in symptoms
InflammaDry® is a registered trademark of Rapid Pathogen Screening, Inc.
40
1. DEWS Report. Ocul Surf. 2007;5:163–78.
MANAGEMENT: DEWS LEVEL 3, SEVERE, RECALCITRANT1
Add the
following
Autologous serum
eye drops
• Patient’s own blood is drawn,
centrifuged and serum cultivated
• For very severe cases
(sensitive to preservatives)
• Has natural growth factors
• Expensive, requires laboratory
Bandage CL
• Allows underlying tissue to heal
Scleral CL
• Provides a constant tear reservoir
under the lens
41
Fluorescein evenly distributed
under a scleral lens
1. DEWS Report. Ocul Surf. 2007;5:163–78.
MANAGEMENT: DEWS LEVEL 41
Add the
following
Systemic antiinflammatory agents
Surgery
• Tetracyclines and derivatives
such as doxycycline
• Lid surgery
• Tarsorrhaphy
• Amniotic membrane transplantation
(AMT)
• Salivary gland autotransplantation
• Mucus membrane grafting
42
1. DEWS Report. Ocul Surf. 2007;5:163–78.
DED: CLINICAL PEARLS
 Doctor’s recommendation is powerful1
▫
▫
Patients don’t know the products…target AT therapy!
Enhances compliance
 F/U appointment: to assess compliance and progression
 DED is underdiagnosed/underscored preoperative, and adversely affects postoperative refractive
outcomes2,3
▫
▫
Preoperative management
o Evaluate tear film at least 3–4 months before surgery
o Co-manage with surgeon, delay surgery if necessary4
o Decrease inflammation as much as possible
o Schedule follow-up based on severity
Postoperative management
o Assess and treat induced DED aggressively5
1. Brujic M. Rev Optom 2010. Available at: https://www.reviewofoptometry.com/ce/recalibrate-dry-eye-management. Accessed September 9, 2016.
2. Shamie N. ASCRS Survey 2013. Available at http://www.eyeworld.org/supplements/oct-2013/Allergan_supplement_October2013.pdf. Accessed September 2, 2015.
3. Stephenson M. Review of Ophthalmology 2008.
4. Holland E. EyeWorld 2016. 5. Quinto GG, et al. Curr Opin Ophthalmol. 2008;19:335-41.
43
DED: SUMMARY POINTS
DED is:
– complex, often presenting as mixed etiologies
– common and increases with age
– not to be underscored
– can adversely affect patient QoL, VA, surgical outcomes, and the ability to wear CL
Screen all patients (especially surgical candidates)
Always consider the TF as a potential source of visual disturbance/fluctuation
Conduct a comprehensive DED workup in a separate, dedicated appointment
44
THANK YOU