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Diagnosis and Treatment
of Dry Eye in Special
Populations
Jodi Luchs, MD, FACS
Co-Director, Department of Refractive Surgery
North Shore/Long Island Jewish Health System
Assistant Clinical Professor
Department of Ophthalmology
Hofstra University School of Medicine
Director of Clinical Research
Director of Corneal External/Diseases
South Shore Eye Care
Disclosures
• Consultant: Allergan, Bausch & Lomb, NiCox,
Doctors Allergy Rx, Optos, Tear Lab, Shire
• Clinical Research: Allergan, Alcon, Bausch &
Lomb, Shire, Eleven, Otsuka, Auven, Shire, Aerie
• Ownership Interest: CXLO, Insightful Solutions,
Omega Ophthalmics, RPS Diagnostics,
Calhoun Vision
Prevalence of Dry Eye Disease
• Over 25 million affected in US1
– Expected to rise to almost 30 million by 2022
– More common in women
– Increases with age
 12.6 million post menopausal women1
 3 million men over age 651
1Market
Scope Date, Allergan, 2011
Dry Eye in Specific Populations
• Particularly prevalent in certain subgroups:
– Surgical Patients
– Autoimmune diseases
– Post menopausal women
– Contact lens wearers
Dry Eye is Common Among Patients
with Specific Ocular Co-morbidities
100%
Percentage of Patients with Dry Eye
90%
80%
70%
59%
60%
50%
50%
54%
40%
30%
25%
20%
10%
0%
Ocular Allergies
1Moss
Contact Lens Wearers
Diabetics
Glaucoma/OHT
SE, Klein R, Klein BE. Long Term Incidence of Dry Eye in an Older Population. Optom Vis Sci. 2008;85(8):668-674
MJ, Fonn D, Richter D, Simpson T, Caffery B, Gordon K. A Patient Questionnaire Approach to Estimating the Prevalence of Dry Eye Symptoms in
Patients Presenting to Optometric Practices Across Canada. Optom Vis Sci 1997;74(8):624-631
3Manaviat MR, Rashidi M, Afkhami-Ardekani M, Shoja MR. Prevalence of Dry Eye Syndrome and Diabetic retinopathy in Type-2 Diabetic Patients. BMC
Opththalmol. 2008; 8:10
4Leung EW, Madeiros FA, Weinreb RN. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma. 2008;17(5):350-355
2Doughty
Definition:
• 2001: “Tear film disorder due to tear deficiency or
excessive tear evaporation causing damage to the
interpalpebral ocular surface and associated with
symptoms of ocular discomfort …1
• Today: Multifactorial disease of the tears and ocular
surface that results in discomfort, visual disturbance,
and tear film instability with potential damage to the
ocular surface. It is accompanied by inflammation of the
ocular surface (DEWS report, 2007).2
1 1995 National Eye Institute (NEI)/Industry Dry Eye Workshop
2 2007 Report of the International Dry Eye Workshop (DEWS). Ocul Surf. 2007;(5)2:67-204
Pathophysiology
•
•
•
•
•
1
Dry Eye is a complex disease that may result in discomfort, visual
disturbance and tear film instability1
Inflammation, hormonal status, age, and environmental triggers all
play a role in dry eye disease1,2
These factors set in motion a self-perpetuating series of events that
affect the ocular surface and lacrimal glands, and the neural feedback
network which connect them
These events alter tear quantity and quality, which can damage the
corneal epithelium3
Inflammation is present at all levels of disease severity3-7
Definition and Classification of Dry Eye Disease: 2007 Report of the International Dry Eye Workshop (DEWS). Ocul Surf. 2007;(5)2:75-92; 2 Research in
Dry Eye: Report of the Research Sub-committee of the International Dry Eye Workshop. 2007 Report of the International Dry Eye Workshop (DEWS). Ocul
Surf. 2007;(5)2:88-102; 3 Nelson JD, Helms H. Fiscella R, Southwell Y, Hirsch JD. A New Look at Dry Eye Disease and its Treatment: Adv Ther.
2000;17(2):84-93; 4Behrens A, Doyle JJ, Stern L, et al; and Dysfunctional Tear Syndrome Study Group. Dysfunctional Tear Syndrome: A Delphi Approach
to Treatment recommendations. Cornea. 2006;25(8):900-907; 5Stern ME. Pathophysiology and Allergy of the Lacrimal Functional Unit: What Goes Wrong
with our Tear Secreting Apparatus? In: Chew P, Rojanapongpun P, eds. Ophthalmic Disease Battlerfront-Maintaining the Health of the Ocular Surface.
Asian J Ophthalmol. 2005;7(suppl 1):5S-8S; 6Stern ME, Beuerman RW, Fox RI, Goa J, Mircheff AK, Pflugfelder, SC. The Pathology of Dry Eye: The
Interaction Between the Ocular Surface and the Lacrimal glands. Cornea. 1998;17(6):584-589; 7Chotikavanich S, de Paiva CS, Li D, et al. Production and
Activity of Matrix Metalloproteinase-9 on the ocular surface increase in Dysfunctional Tear Syndrome. Invest Ophthalmol Vis Sci. 2009;50(7):3203-3209
Diagnosis
Diagnosis of Ocular Surface Disease
•
History
– Dry eye symptoms
– Fluctuating vision
•
Lids:
– Collarettes
– Meibomian gland disease
 Express glands on exam
•
Ocular Surface:
– Tear meniscus height
– Fluorescein staining pattern
 Wait 1-2 minutes to evaluate staining pattern
– Break-up time
– Conjunctival Lissamine Green staining
Diagnosis of Ocular Surface Disease
• Point of Care Diagnostics:
– Tear Film Osmolarity
– MMP-9 testing
– Tear film Lactoferrin levels
– Automated imaging:
 Meibography
 Automated TBUT
 Tear film interferometry (lipid layer)
Dry Eye Classification
•
Level 1: Mild to moderate symptoms, no clinical signs, or mild
conjunctival staining
• Level 2: More significant symptoms, moderate conjunctival
staining, Mild corneal staining, visual signs
• Level 3: More severe symptoms, significant conjunctival
staining, more severe corneal staining, central corneal staining,
filaments
• Level 4: Severe symptoms, confluent corneal/conjunctival
staining, erosions, ulceration, scarring
1Behrens A,
Doyle JJ, Stern L, et al; and Dysfunctional Tear Syndrome Study
Group. Dysfunctional Tear Syndrome: A Delphi Approach to Treatment
recommendations. Cornea. 2006;25(8):900-907
Treatment
Treatment of Ocular Surface Disease
• Lid disease:
– Warm compresses
– Lid scrubs
– Topical antibiotics
 Azithromycin (off-label)
 Doxycycline
– Cyclosporine (off label)
– Thermal pulsation system
Treatment of Ocular Surface Disease
• Dry Eyes:
– Preservative free tears, gels, ointments
– Topical Cyclosporine
– Topical steroids
– Punctal occlusion
– Serum tears
Dry Eye in Post Menopausal Women
• 12.6 million post menopausal women suffer from
Dry Eye
• Due to changing hormonal status
– Decreasing androgen levels
• Often overlooked by patients and practitioners.
– Patients chalk it up to “getting older”
• Role of hormone replacement therapy:
– Conflicting data
Dry Eye in Post-Menopausal
Women: Diagnostic Considerations
• Key in on the History:
– Autoimmune disease
– Medications
– Contact lens use
– Eyelid surgery
Dry Eye in Post Menopausal Women:
Treatment Considerations
• Preservative free tears
• Nightly ointment
– Particularly if prior eyelid surgery
• Cyclosporine
• Topical steroids
• Punctal plugs
• Consider Sjö testing if concomitant dry mouth
Dry Eye in Contact Lens Wearers
• Up to 50 % of contact lens wearers will develop dry
eye1,2
• 15% of lens wearers have “very severe” symptoms of
dry eye, in contrast to <5% of general dry eye subjects3
• Contact lens wear produces a thinning of the tear film4
• Contact lens wearers have elevated levels of IL-6, IL-8
and TNF-∂ in their tear film5
1Dumbleton
K, Caffrey B, Dogru M, et al. Members of the TFOS International Workshop on Contact Lens Discomfort. TFOS
International Workshop on Contact Lens Discomfort: Report of the Subcommittee on Epidemiology. Invest Ophthalmol Vis Sci.
2013;54(11):TFOS20-TFOS36; 2Doughty MJ, Fonn D, Richter D, Simpson T, Caffery B, Gordon K. A Patient Questionnaire Approach
to Estimating the Prevalence of Dry Eye Symptoms in Patients Presenting to Optometric Practices Across Canada. Optom Vis Sci
1997;74(8):624-631; 3 Nichols JJ, et al. Invest Ophthalmol Vis Sci. 2005;46:2353-2361; 4 International Dry Eye WorkShop. Ocul Surf.
2007;5:65-204; 5 Craig JP, Wilcox MD, Argüeso P, et al. Members of the TFOS International Workshop on Contact Lens Discomfort.
TFOS International Workshop on Contact Lens Discomfort: Report of the Contact Lens Interactions with the Tear Film Subcommittee.
Invest Ophthalmol Vis Sci. 2013;54(11):TFOS123-TFOS156
Dry Eye in Contact Lens Wearers
• TFBUT and Tear volume significantly reduced in CL
wearers1
• ~30% of lens wearers develop some degree of
meibomian gland dysfunction (MGD) ~ 6 months
after initiating lens wear2
• Contact lens wear is directly related to meibomian
gland loss (determined by meibography) compared
with non-lens wear3
1Glasson
MJ, Stapleton F, Keay L, Sweeney D, Willcox MD. Differences in Clinical Parameters and tear Film of Tolerant and
Intolerant Contact Lens Wearers. Invest Ophthalmol Vis Sci. 2003;44(12):5116-51124
2Ong BL, Larke JR. Ophthalmic Physiol Opt. 1990;10:144-148;
3Arita R et al. Ophthalmology. 2009;116:379-384.
Dry Eye in Contact Lens Wearers:
Treatment Considerations
• Optimize contact lens fit
• Topical cyclosporine
• Consider punctal plugs
• Frequent replacement or daily wear lenses
• Try to avoid steroids
• Minimize wearing time
Dry Eye and Autoimmune Disease
• Suspect systemic autoimmune disease in
patients with dry eyes associated with dry
mouth, arthritis, skin rashes, chronic diarrhea
• Serological work-up
• Sjö Testing
– Novel biomarkers which can detect early Sjögren’s
syndrome 5-7 years earlier than conventional SSA/SS-B testing
Dry Eye and Autoimmune Disease
• Autoimmune diseases are often associated
with dry eye
– Sjögren’s syndrome
– Rheumatoid arthritis
– Systemic Lupus Erythematosus
Dry Eye and Autoimmune Disease
• Sjögren’s Syndrome
– 1.3 million adults have primary Sjögren’s syndrome1
– 10-15% of patients with Rheumatoid Arthritis develop
secondary Sjögren’s syndrome1
– Average of 4.7 years with the disease to reach an
accurate diagnosis2
– Potential life threatening complications:
 Lymphoma, interstitial nephritis, autoimmune hepatitis,
interstitial lung disease
1Vitali
C, Bombardieri S, Jonsson R, et al; European Study Group on Classification Criteria for Sjögren’s Syndrome: a revised
version of the European criteria proposed by the American-European consensus group. Ann Rheum Dis. 2002;61:554-558
2 Sjögren’s Syndrome Foundation. https://www.sjogrens.org/home/about-the-foundation/breakthrough-goal-/2yearupdate.
Dry Eye in Autoimmune Disease:
Treatment Considerations
• Inflammatory cycle driven by systemic autoimmune
disease
• May produce progressive worsening of dry eye
• May require more aggressive therapy
– Topical steroids, punctal plugs, cyclosporine, serum tears
– Tarsorrhaphy
– Systemic therapy for systemic symptoms may help dry eye
Dry Eye in Cataract and Refractive
Surgical Patients
• All Vision Starts with the Tear Film
Prevalence of Ocular Surface
Disease in Surgical Patients
• Blepharitis prevalence study
• PHACO study
How Common is Blepharitis in Patients
Scheduled for Cataract Surgery?
• Study of 100 Patients (200 Eyes) Scheduled for Cataract
Surgery at 2 Centers
– 59% of patients were diagnosed with Blepharitis
TBUT < 7 seconds:
- 61% of patients with blepharitis
Photo compliments of Hank Perry, MD
Jodi Luchs, MD, Carlos Buznego, MD, William Trattler, MD; Incidence of Blepharitis in Patients Scheduled for
Phacoemulsification. Poster presented at ASCRS, Boston, April 2010.
Dry Eye Study: P.H.A.C.O.:
Prospective Health Assessment of
Cataract Patients Ocular Surface
•
Objective:
–
•
Methods:
–
•
To determine the prevalence of dry eye in patients undergoing cataract surgery
Prospective, multi-center study (9 sites)

Mark Packer, MD

Damien Goldberg, MD

Parag Majmudar, MD

Eric Donnenfeld, MD

Marguerite McDonald, MD

Karl Stonecipher, MD

Jon Vukich, MD

Chaz Reilly, MD

Gregg Berdy, MD

Ranjan Malahotra, MD

William Trattler, MD
136 patients (272 eyes) scheduled for cataract surgery
–
Avg Age: 70 yrs old (range: 54 to 87)
Courtesy of William Trattler, MD
Summary of PHACO Study
(Patients Scheduled for Cataract Surgery)
•
80% of patients had level 2 dry eye
• Patients are often asymptomatic
– Only 22% of patients had a known diagnosis
•
50% with Central staining (Level 3 dry eye)
• More than 60% with very abnormal TBUT (≤ 5 seconds)
• Schirmer’s score
 21.3% with very low Schirmer’s (5mm)
•
Dry eye signs are very common in patients scheduled for
cataract surgery
Trattler WB, et al. Clinical Study Report: Prospective Health Assessment of
Cataract Patient’s Ocular Surface Study: Presented at ASCRS 2010
The Tear Film is the Most Important
Refracting Surface of the Eye
Minimal Disruption of the Ocular Surface
Can Severely Degrade Visual Acuity
Consequences of Untreated Ocular
Surface Disease
•
Infection (Blepharitis)
• Unstable tear film:
– Unreliable pre-op refraction, keratometry, wavefront measurement
– Unreliable IOL calculation
•
•
•
•
•
•
Fluctuating post operative vision
Delays in visual recovery
Reduced post-operative visual acuity
Worsened post-operative dry eye
Discomfort
Patient dissatisfaction
Ocular Surface Disease &
Diminished Surgical Outcomes
• Treatment of ocular surface disease is
essential for optimal surgical outcomes:
– Reduce risk of infection
– Maximize tear film stability
– Optimize recovery of vision
Keys to Success
• Preop Evaluation:
– Preop evaluation for dry eye/blepharitis
– Preop Topography
– Preop OCT of Macula
Diagnosis of Ocular Surface Disease
• Topography
– Can reveal undiagnosed tear film instability
– Corneal shape abnormalities
• OCT macula
– r/o occult retinal disease
Topography: Excellent Tool
for Diagnosing a Poor Tear Film
Dry Spots
Courtesy of William Trattler, MD
Recommendations for All Cataract
Surgery Patients: Preop Topo
58 year old male with visually significant cataract OS, interested in a premium IOL
Courtesy of William Trattler, MD
Preop Topo After 1 Day of Treatment
Same patient : 1 day after starting lubricating drops
Courtesy of William Trattler, MD
Preop Topo After One Week
of Treatment
Same patient: one week after initiating therapeutic agents for dry eye
Courtesy of William Trattler, MD
Preop Evaluation
60 year old male: Initial Consultation
for Presbyopic IOL
Courtesy of William Trattler, MD
Dry Eye Identified: One Week After
Cyclosporine BID & Topical Steroids
Courtesy of William Trattler, MD
Case
63 yr old Woman with 2+NS Cataract
2/8/2011
IOL Master OS
What power toric IOL?
Courtesy of William Trattler, MD
Topo: 2/8/2011
Now – what power toric IOL?
Courtesy of William Trattler, MD
One Week After Treatment:
2/16/2011
• Topical steroids
• Topical
cyclosporine
Courtesy of William Trattler, MD
Challenging Presbyopic IOL Case
• 81-year-old man with vis sig cataract
– Preop BCVA = 20/100
– Potential VA = 20/20
– Underwent Cataract Surgery with Presbyopic IOL
– Surgeons first Presbyopic IOL
 Postop: UCVA = 20/80
 BCVA = 20/40
 OCT of macula: normal
– What tests would you perform to troubleshoot this case?
Courtesy of William Trattler, MD
Presbyopic IOL Patient: 20/40 BCVA
Courtesy of William Trattler, MD
EBMD
5 Important Preop Tests
to Avoid Postop Surprises
• Topography
• OCT of Macula
• Fluorescein stain of the cornea
• MMP-9 and Osmolarity
ERM
Courtesy of William Trattler, MD
EBMD
Dry eye On Topo
Treatment of Ocular Surface Disease
CONSIDER DEFERRING
SURGERY UNTIL OCULAR
SURFACE NORMALIZED
Conclusions
• Dry eye is extremely common, and the prevalence is
increasing
• Newer diagnostic tools make it easier to diagnose
• Growing number of therapies for dry eye
• Particularly common in certain subgroups of patients:
– Post menopausal women
– Patients with autoimmune disease
– Contact lens wearers
– Cataract and refractive surgical patients
Conclusions
• In today’s state-of-the-art eye care practice
we need to pro-actively identify and treat
dry eye in order to optimize both our
surgical outcomes as well as out patients’
quality of life