Download Straight Outta Tears

Doctors of Optometry | Course Notes
OD2 – 1CE – COPE: 48272-AS
Straight Outta Tears – Treating & Managing MGD, Lid Bugs & Other Lid
Thugs
Saturday, February 25, 2017
8:40 am – 9:35 am
Plaza A/B – 2nd Floor
Presenter: Marc Bloomenstein, OD, FAAO
Dr. Marc Bloomenstein is an accomplished optometrist who lectures and publishes extensively in the fields of
anterior segment disease and refractive surgery. Dr. Bloomenstein is at the Schwartz Laser Eye Center and is
on the editorial board of Primary Care of Optometry and Contemporary Optometry. Dr. Bloomenstein served as
the President of the Arizona Optometric Association, as well as an Optometric Advisor to STAAR Surgical and
Medtronics Solan and is now the President of the Board of the Arizona Optometric Charitable Foundation. He
graduated in 1990 from the University of California, Los Angeles with a degree in Biology, and received his
optometric degree from the New England College of Optometry in 1994. After graduation, Dr. Bloomenstein
finished a residency in secondary ophthalmic care at the Barnet Dulaney Eye Center in Phoenix, Arizona. He
received his fellowship from the American Academy of Optometry in December 1998 and is a founding member
of the Optometric Council on Refractive Technology. Moreover, Dr. Bloomenstein is an Adjunct Assistant
Professor at the Southern California College of Optometry and New England College of Optometry.
Course Description
This course will focus on the eyelids and all the nasty and unsavory creatures that affect eye health. The advent
of new diagnostic equipment has enabled clinicians to make point of service differentiating. Treatment options
can range from over the counter management, to prescription medications, as well as office procedures. Getting
the lids right will make the vision tight.
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Doctors of Optometry | Course Notes
NOTES:
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Straight Out of Tears:
Treating and Managing MGD,
Lid Bugs and Other Lid
Thugs!
Marc R. Bloomenstein, OD, FAAO
Scottsdale, AZ
Disclosure
• Presenter is on speakers panel of: Akorn, Alcon, Allergan, AMO,
B+ L, BlephEX, Lunovas, OcuSOFT, Tear Lab
• President of MRB Eye Consultants
• AOA CE Chairman
• Past-President of the Optometric Council on Refractive Technology
(OCRT)
• OSSO Board Member
• Presenter has NO financial interest in any products mentioned
EyetubeOD.com
Incidence and Prevalence of
“Dry Eye”
• 25% of teen-adults
• 28 million experience symptoms frequently
• 2015 Gallup Poll– 30 million Americans affected
Proactive and Preventive
• Risk Factors for Ocular Surface Inflammation
– Females
– Sjogren’s
– Aging
– Environmental Issuse
– Refractive Surgery
– Vitamin deficiency
– Medications
Sea Change
• Managing the disease in the chair
– Insurance visits
• Glaucoma model
• 3-4 visits a year
– Compensation
• Vision “plan”
• Medical Insurance
• Cash pay-ABN
Sea Change
–Patient retention
–Patient referrals
–Cutting Edge Treatment
Symptoms
• #1 most important –
VISION CHANGES
– Blurred
– Fluctuating
– Hazy
– Refractive changes
• Pain
– Light sensitivity
– Gritty
• Redness
– Lid margin
– Conjunctival
• Itch
Signs, Signs, everywhere Signs!
• Lid Debris
– Frothy tears
– “collarettes”
Anterior Blepharitis
Seborrheic Blepharitis
Signs and Symptoms
Morning
crusting
Foreign
body
sensation
Recurrent
hordeola
Loss of
lashes
Conjunctival
hyperemia
Collarretes
(scales
that
encircle
lash)
Staph
immune
disease
• Phlyctenula
• Pannus
• Catarrhal
infiltrates
• etc
Sequelae to Blepharitis
Blepharitis
Chalazia /
hordeola
Dry eyes
Punctate
keratitis
Phlyctenules
“Recurrent
conjunctivitis”
Pannus
Corneal
ulceration
Endophthalmitis
MGD
Pathophysiology of
Meibomian Gland Disease
• Normal meibomian gland secretions convert from
unsaturated lipids that melt at body temperature
to saturated fats that inspissate the meibomian
glands
• Lid bacteria secrete lipases that break down lipids
from soaps to fatty acids
Bacterial Lipases Break
Down Lipids to Soaps
NON-OBVIOUS MGD
Photos courtesy of Justin Webb, OD, Alcon Research Ltd., 2010.
Remove those pesky caps:
MacGruber!
Examples of meibum stagnation and changes
that correspond to MGD
Opaque solid secretion (glands not functional;
Clear liquid secretion
Cloudy liquid secretion
(glands are functional using the MGE)
(glands are functional using the MGE)
requires more force than the MGE)
Opaque solid secretion (glands not functional;
Absence of secretion
Notching at gland orifice (indicates
requires more force than the MGE)
(glands not functional; even significant force does not yield
secretion)
atrophy/drop out)
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Blepharitis
Is the most common
and arguably the most
important diagnosis
presenting to the
optometry
Anterior
Inflammation
mainly
centered
around the
eyelash and
follicles
BIOFILM
Blepharitis
Inflammation
that involves
the meibomian
gland orifices
Posterior
The Biofilm
• Biofilm: A biofilm community can be formed by a single
bacterial species, but in nature biofilms almost always
consist of rich mixtures of many species of bacteria in a
polysaccharide matrix
– Thrives in moisture
– Smooth surface
– Bacteria
3
2
3
3
Treatment
Blepharitis….MGD
ADJUNCTIVE THERAPY
FOR MGD
Lipid/Oil-Based Lubricant Eye Drops
Palliative – None treat the cause
Downside can be blurring & stinging with castor oil
emulsions
Retaine® MGDTM
•
Introducing the cationic
emulsion
A main issue is the loss of product while
blinking
•
A unique cationic oil-in-water
nanoemulsion addresses unmet needs
–
Lipid compound + innovative cationic
(positively charged) technology
•
Better attraction to the ocular surface
→ Improvement of the residence time
•
Solubilizes the drugs
SURFACTANT
Stabilizes the interface
Better spreading on the ocular surface
→ Better adsorption
•
OILY CORE
CATIONIC AGENT
Brings the positive charges
Enhanced tear film and corneal
epithelium1,2
1. Lallemand F, et al. J Drug Deliv. 2012;2012:604204.
2. Daull P, et al., Benefits of cetalkonium chloride cationic oil-in-water nanoemulsions for
topical ophthalmic drug delivery.
Draft for publication, 2013.
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Seborrheic Blepharitis
Seborrheic blepharitis is caused by
seborrheic dermatitis, a skin condition that
creates flaking and scaling — including on the
eyelids. Regular cleansing with eyelid scrubs
can provide significant relief and improve the
appearance of eyelids.
Signs and Symptoms
Red, irritated, itchy eyelids and the formation
of dandruff-like scales on the eyelashes.
Seborrheic Blepharitis
Take Home Recommendation
OCuSOFT ® Lid Scrub ® Eyelid Cleanser
Original Formula
OCuSOFT ® Lid Scrub ® removes oil, debris,
and desquamated skin from the eyelids and
is non-irritating to the eyes.
(continued)
TheraTears® SteriLid®
Soothes and Cleanses Away External Irritants
TheraTears® Sterilid® removes oil, debris and other contaminants
that can accumulate on eyelids and eyelashes.
M15-056 12/15
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Need More Eyelid Relief
The root cause of anterior blephartitis is the
overproduction of oils. Mild surfactants in
OCuSOFT® Lid Scrub® PLUS eyelid
cleanser act to dissolve and remove oil,
debris, and desquamated skin. Other
formulas do not.
Hypochlorous Acid is produced by white
blood cells as part of the body’s natural
defense mechanism against pathogens.
What Is Hypochlorous Acid?
Hypochlorous acid is a weak acid that is
formed when chlorine dissolves in water.
Its chemical formula is HOCL. An acid is
a pH below 7 (neutral). Above 7 is
considered base/basic or alkaline. Tap
water is generally a pH of 7 whereas
citric acid from lemons is highly acidic at
around a 2. The pH of HOCL is between
6-7.
Hypochlorous Acid
HypoChlor
OCuSOFT® HypoChlor™ is a
0.02% concentration of
Hypochlorous acid in both
Spray and Gel formulation
Avenova
NovaBay Avenova with Neutrox
is a 0.01% concentration of
Hypochlorous acid
Best MGD Treatment
• Warm up the lids
• In office expression
• Retaine MGD/RESTASIS (cyclosporine
0.05%)
• Low dose tetracycline derivatives
• LipiFlow for Severe Cases
• Omega fatty acids
• Get the patient early!
Inflammatory Dry Eye Alters the
Tear Film
Image used with permission.
Dry Eye Disease reduces mucins, and alters concentrations of growth factors and tear proteins1,2. Fewer tears can
lead to increased inflammatory output from the lacrimal gland, which can cause ocular surface damage and altered
tear production. The resulting chronic inflammatory stimuli can then lead to further decreased tear production3-5
Treating The Inflammation
• Restasis (Allergan)
– Primary treatment option
– Multiple mediators of inflammatory
cascade
– Increase goblet cells density and
emulsion vehicle
– Proven
• Steroids
• Amniotic Membrane
Demodex
That other Thug!
HANDBOOK OF MEDICAL
ENTOMOLOGY
Dr. WM. A. RILEY, Professor of Insect
Morphology and Parasitology,
Cornell University
Dr. O. A. JOHANNSEN, Professor of
Biology, Cornell University
1915
Rosacea and Demodex?
• Rosacea and demodex
– Meta-analysis of 48 studies
– 10 different countries
– 28,527 subjects
– Rosacea patients 7-8x chance have Demodex
Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the
association between Demodex infestation and rosacea. Arch
Dermatol 2010;146:896Y902.
Remember Biofilm….
Biofilm is a
polysacharride
Perfect food source for a Demodex infestation
MICROBLEPHAROEXFOLIATION (MBE)
Doctor centered approach to lid health
Spins a micro-sponge 2,500
RPM along margin
Results in completely clean
lids
Repeated every 4-6 months
Private pay procedure,
typically $150-$250
In Office Treatment
• Patients with heavy scruff may need an in office
treatment to remove scruff (Blephex) or TTO will never
get to the target.
• I use of Cliradex/ Oust for those recalcitrant cases
• Typically doing 2 different in office TTO, rarely third
• Maintenance on: Cliradex, Oust, BlephaDex
Demodex Infestation of the Eyelids
Recommended Treatment
In-office procedure: Cleanse eyelids and
eyelashes in-office utilizing OCuSOFT® Lid
Scrub® PLUS Swabstix™ and Oust™
Demodex® Swabstix™.
Oust™ Demodex® Swabstix™ contain 50%
Tea Tree Oil, 40% Sea Buckthorn Oil, and
10% Caprylic Acid. These single-use,
disposable, self-saturating Swabstix™
provide convenient in-office use to effectively
eradicate demodex and remove oil, debris,
and other contaminants on the eyelids inoffice. A complete Demodex Kit is available
for in-office use.
BlephaDex
•
Aqua
•
Coconut Oil
•
Glycerol
•
Aloe Barbadensis Gel
•
Sodium Lauryl Sulfate
•
Cocoamidopropyl Betaine
•
DMDM Hydantoin
•
Laurel Glucoside
•
Melaleuca Alternifolia( Tea Tree) Leaf
Oil
Easier Way To Start In-Office
• Regular Maintenance-Like teeth cleaning
– Use Blephadex swab, with BlephEx, for annual
(bi-annual) in office treatment
– At-home treatment with Blephadex pads or foam
• Continue to use everyday for maintenance
Treatment Goal:
• NOT to eradicate 100%
• Want to knock down the “load” and reduce symptoms
– Watering
– Crusting
– Itching of lids
• Like to see some visible reduction in cylindrical
dandruff
• Improve redness profile of eye, lid and face
Conclusion
• Differentiate the condition in your practice
• Think Biofilm
– Remove the debris
– In-office treatments
• Have the options in your practice
– Provide options
– Utilize the products
• New comfortable Demodex treatments