Download Ocular Surface Disease: A Comprehensive Approach to the

3/27/2014
Ocular Surface Disease: A
Comprehensive Approach to
the Diagnosis and
Treatment of the Dry Eye
The OSD Wellness
Symposium
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Dr. Jack Schaeffer
DR. Mark Schaeffer
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Faculty
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Mile Brijic
Paul Karpecki
Marguerite Mcdonald- Ophthalmolgy
Jim Murphy- Industry
Clayton Neighbors _ Pshychology
Jason Nichols
Kelly Nichols
Jack Schaeffer
John Valenza- Dean School of Dentistry
Gina Wesley
Lucile White - Dermatology
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The OSD Symposium
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24 Doctors
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22 Ods
2 MDS
Research
Lectures
 Professors
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Jill Awtry
Marc Bloomenstein
Derek Cunningham
Barry Eiden
Art Epstein
Lance Forstat
Ben Gaddie
Amber Giannoni
Al Kabat
Kelly Kersick
Donald Korb
Blair Lonsberry
Kathy Mastorta
Bill Miller
Scot Morris
John Rumpakis
Louise Sclafani
Kirk Smick
Chris Sindt
Sruthi Srinivasan
Loretta Szczotka-Flynn
Bill Townsend
Participants
Preventive vs. Reactive Care
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Dry Eye
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Re invent the practice
Prevent patient problems
White eyes
Perfect Vision
Patient Referrrals
Sunwear sales
Decrease Contact lens dropout
Look Better Feel better
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There is preventive care within medicine. There is preventive care within eyecare (AMD, glaucoma). However, we are doing a poor job with preventive care to the ocular surface.
The main concern with ocular surface disease is the negative impact on the patient’s quality of life; a very small percentage of patients go blind compared to other ocular conditions (AMD, glaucoma).
Don’t go to the consumer until you get the profession on board. We need to change the culture of both patients and doctors. The professions must agree on an algorithm for diagnosis and treatment.
© 2014 Novartis
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Preventive vs. Reactive Care
Patient Management
• Prescreening Level 1 History/OSDI
• Prescreening Level 2 Stain/LWE/topography/blink/SLE
• Predicting the Future: blink, systemic history, skin, females, SLE, CL wear
• Diagnosis
– TBUT, stain, osmolarity, Schirmer, LipiView, tear meniscus, PRTT, topography, lid evaluation/expression, symptoms, LWE, chalasis
• Treatment
– ATs, environmental, omega‐3, Restasis, steroid, compounded meds, expression, lid scrubs, warm compresses, debridement, blink pattern, doxycycline, punctal plugs, humidifier, sunglasses, LipiFlow, contact lens (PROPER EVALUATION AND FOLLOW‐UP VISITS)
• What are the barriers to the profession? No consistency as to what would be ideal OSW evaluation, two tiered system (one visit for refraction and separate visit for health issues), perceived lack of importance (patient and doctor), misconception as to prevalence, no fear factor, time consuming, not accustomed to examining the ocular surface, reimbursement (coding).
• We need to determine the people who are at risk. We need to give more than a questionnaire: tear osmolarity, risk factor profile, gland assessment, etc. We need to have a conversation with the patient designed to elicit certain responses. 7
© 2014 Novartis
Communicate preventative messages patients and ECPs
Patient Management
• Counselling/Health: blank, vitamins, sunglasses, artificial tears
• Electronic devices: blink, ergonomics, reduce illumination, ARC, blink app, handouts, fixation disparity/phoria
• Ocular surface wellness
– Creating a new culture
– Change the doctor’s perception, save the practice, public health issue, being proactive, educating patients, perfect vision, every patient every time, increase CL comfort, CL dropout, eye whitening, look better see better, think about your eyes campaign, referrals, sunwear, ATs, iCare
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© 2014 Novartis
• Patients
– Videos/pictures utilizing iPads, e‐newsletters and other technology
– Simple and consistent messages (repetition)
– Aesthetic, loss of lashes, red eyes, inability to wear CLs, wrinkles, vision
– Analogies, make it part of the office culture
• ECP
– Financial, painless integration, other benefits
– Starting at the institution
– Starting a non‐branded initiative
© 2014 Novartis
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The OSD Wellness Initiative
OTC labeling and professional org communication
• OTC labeling
– Current DE monograph is outdated
– Active ingredients must be listed, but inactives are critical
• To improve doctors working with OTC
– Education
– Coupons
– Generics being ingested vs going onto eye
– Prescribe ATs
– Financial repercussions
• Professional Organization
– Define, create model, come to consensus before go to other org
– Sense of belonging, develop a mentor group
© 2014 Novartis
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© 2014 Novartis
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OD’s
Need education
Staff Training
 Change the culture
 Inform the Public
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I Care
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The OSD Wellness Initiative
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The OSD Wellness Initiative
Tech Driven
Pre Screening
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Diagnosis
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Treatment
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Patient Education
The OSD Wellness Initiative
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Preventive Medicine
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The OSD Wellness Initiative
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Dermatology
 Dentistry
 Psychology ( behavior modification)
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OSDI / Speed questionnaire
History
Topography / keratometry
Visual Acuity
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All Contact lens patients
All females
All light skin ( easily burned)
All Systemic / auto immune
Sysemic medications
Allergic Conjunctivitis Patients
The OSD Wellness Initiative
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OD’s
Need education
Staff Training
 Change the culture
 Inform the Public
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I Care
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Conjunctival
Staining
VITAL STAINS
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Sodium Fluorescein
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Rose Bengal
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Premier dye of conjunctiva
Stains devitalized cells on
cornea and conjunctiva
Stains mucin strands
Stains unprotected tissue
Phototoxic, sting is dose
dependent, antiviral?
Lissamine Green
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Epithelial defects
Accumulates intracell. space
Same purpose as RB
Less stinging
Fluramene
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Noctural Lagophthalmos?
Moderate / Severe lissamine green staining
Dry Eye Evaluation
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Fluorescein Staining
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Fluorescein Staining
Lissamine Green Staining
Exposure zone staining
with limbal sparing
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Exposure zone staining
with limbal staining
Intense diffuse staining
of exposure zone,
limbal staining
Lissamine green detects dead or degenerated conjunctival cells
Degree of severity increases from left to right
Images from Dry Eye and Ocular Surface Disorders, 2004
Tear Film Break Up Evaluation
0 seconds
1 second
2 seconds
3 seconds
4 seconds
5 seconds
6 seconds
16 seconds
Tear film break up is indicated by the
dark areas that appear on the cornea.
Caution: amount of fluorescein
instilled alters results
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Lid Disease
We cannot treat the dry eye until we
understand and treat
LWE
MGD
Blepharitis
Epihora
IT IS ALL ABOUT THE LIDS
Anterior Blepharitis
• Inflammation of the eyelids
usually caused by bacterial
infection (staphylococcal) of the
eyelid margin
• Infection normally occurs at the
origins of the eyelashes and
involves the lash follicles and the
meibomian glands
• Signs and symptoms include:
– Morning crusting of lids
– Loss of lashes
– Collarettes - scales that encircle
lash
– Lid margin redness
– Conjunctival hyperemia
Demodex
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Diagnosis
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Demodex
Exclusion
Cylindrical Dandruff
Microscopic evaluation of Cilia base
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Cliradex
Ocusoft Demodex Kit
Tea tree Oil : 50%
BlephEx
Treatment Anterior
Blepharitis
Treatment Goals for Anterior Blepharitis Patients
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Antibiotic
Antibiotic / steroid combination
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84% infection/inflammation!
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Lemp MA, Nichols KK. Blepharitis in the United States 2009: A survey‐based perspective on prevalence and treatment. Ocular Surface 2009;7(2): S1‐14. Graph reproduced with permission from Campbell Alliance Group.
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gtts
Ung
BlephEx
BlephSteam
Doxycycline
Lid scrubs / Ocusoft cliradex
Mineral or Coconut Oil
Blepharitis
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Heat over your closed eye for 5 minutes 
Immediately afterward, use lid scrubs to reduce colony counts and wash away any oily debris or scales at the base of your eyelashes
Rinse your eyelid with warm water and gently pat it dry with a clean, dry towel
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Shower..please!
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Treatment Strategies Blepharitis
Infectious or Non‐Infectious Inflammation of Eye Lid Margins
Anterior
What is OCuSOFT® Lid Scrub™?
Posterior / MGD
• Mild eyelid cleanser that effectively removes oil, debris and desquamated
(dead) skin from the eyelids
• Recommended for routine daily eyelid hygiene and maintenance
• Ocusoft lid scrubs BID 1 week preop cataract surgery eradicated
Staph epidermidis equal to topical 5% Betadine intraoperatively¹
Anti‐inflammatories/
Anti‐infectives
• Eyelid hygiene
- Lid scrubs
- Warm compresses
- Massage of the eyelids
- Nutrition, e.g. Omega 3
•Tear film stabilization
Artificial tear designed to relieve dry eye associated with MGD
¹Jackson M. Endophthalmitis Prophylaxis: Ocusoft Lid Scrub Plus vs. Topical Betadine
(ESCRS Barcelona 2010 presentation and OSN supersite)
SYSTANETM Lid Wipes
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1.
Baby Shampoo…..really a myth
Daily lid hygiene is
recommended1
Gentle cleansing wipes remove
makeup and unwanted buildup
around the eye
Hypoallergenic, non-irritating
gentle cleansing wipes
It is the traditional method taught in school but is has disadvantages which include:
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Requires Mixing and Diluting (Convenience?)
Poor Patient Compliance (actually is irritating to eye)
Long Term Use Will Make the Skin Dry
More Professional Treatments are Available
Using soaps on soap producing Meibomian glands
Nichols KK, Foulks GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction: executive
summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929. doi:10.1167/iovs.10-6997a.
MGD
Meibomian Gland Disease
Meibomian Gland Dysfunction
and Management
Kelly K. Nichols, OD, MPH, PhD
FERV Professor
University of Houston College of Optometry
Chair, TFOS International Meibomian Gland Workshop
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Meibomian Gland Dysfunction
But first…
• The TFOS Report of the International
Meibomian Gland Dysfunction Workshop
– Etiologies
– Definition/ Classification
– Epidemiology
– Clinical characteristics
– Diagnosis/ Management
– Contact lenses, surgical implications
©KNichols 2012
©KNichols 2012
Current Dry Eye Definition
DEWS—Classification of Dry Eye
“Dry eye is a multifactorial
disease of the tears and
ocular surface that results in
symptoms of discomfort,
visual disturbance, and tear
instability with potential
damage to the ocular
surface. It is accompanied by
increased osmolarity of the
tear film and inflammation of
the ocular surface.”
©KNichols 2012
65%
35%80%
©KNichols 2012
Dry Eye and MGD
MGD is the most common cause of evaporative dry eye.
©KNichols 2012
20% 5%
TFOS International MGD Workshop
• Over 65 International clinicians,
scientists, and industry participants
• 2+ year process
• Published in March 2011, IOVS
• #1 Most downloaded IOVS article for
the last 12 months
• Downloaded over 5500 times
• All MGD workshop reports are in the
“top 10”
• Translation into 12 languages
©KNichols
2012
• www.tearfilm.org
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www.tearfilm.org
Lecture Description
Anatomy, Physiology and Pathophysiology of the Meibomian Gland Erich Knop, M.D., Ph.D. (Chair)
Nadja Knop, M.D., Ph.D.
Thomas J. Millar, Ph.D.
Hiroto Obata, M.D. David A. Sullivan, Ph.D.
©KNichols 2012
©KNichols 2012
Meibomian Gland ‐ ANATOMY
• Large sebaceous glands
• No direct contact to hair follicles
• Located in the tarsal plates
• Upper and lower eye lids
Meibomian Gland ‐ ANATOMY
• Length
• Follows the tarsus
• Number
• More in upper lid (30‐40)
• Less in lower lid (20‐30)
• Volume
• Higher in upper lid (26µl vs. 13µl)
• Relative functional contribution (upper vs. lower) to the tear film lipid layer is unknown
Modified from Sobotta Atlas der Anatomie des Menschen.
Urban & Schwarzenberg Verlag 1982, (reproduced from
Knop N & Knop E. Ophthalmologe 2009; 106:872–883)
Modified and colored from Krstic H. Human
microscopic anatomy. Springer Medizin Verlag
1991, (reproduced from Knop N & Knop E
Ophthalmologe 2009; 106:872–883)
©KNichols 2012
Meibomian Gland – PATHOLOGY
©KNichols 2012
Interacting Pathways in MGD
• Obstructive MGD leads to a progressive ductal DILATATION and acinar ATROPHY Fom Knop E & Knop N. Meibom-Drüsen Teil IV. Funktionelle Interaktionen in der
Pathogenese der Dysfunktion (MGD). Ophthalmologe.2009;106:980–987
Modified from Knop E & Knop N. Meibom-Drüsen Teil IV. Funktionelle Interaktionen
in der Pathogenese der Dysfunktion (MGD). Ophthalmologe.2009;106:980–987
©KNichols 2012
©KNichols 2012
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Meibomian Gland Dysfunction
Definition & Classification
J. Daniel Nelson, M.D. (Co‐Chair)
Jun Shimazaki, M.D., Ph.D. (Co‐Chair)
Jose M. Benitez‐del‐Castillo, M.D., Ph.D.
Jennifer Craig, Ph.D., MCOptom
James P. McCulley, M.D.
Seika Den, M.D., Ph.D. Gary N. Foulks, M.D.
©KNichols 2012
Classification of MGD
©KNichols 2012
Epidemiology and Associated Risk Factors of Meibomian
Gland Dysfunction
Debra A. Schaumberg, Sc.D., O.D., M.P.H. (Chair)
Jason J. Nichols, O.D., M.P.H., Ph.D.
Eric B. Papas, M.Sc., O.D., Ph.D.
Louis Tong, F.R.C.S., M.B.B.S.
Miki Uchino, M.D.
Kelly K. Nichols, O.D., M.P.H., Ph.D.
©KNichols 2012
Evaluation, Diagnosis and Grading of Severity of Meibomian Gland Dysfunction
Alan Tomlinson, MCOpt, Ph.D. (Chair)
Anthony J. Bron, F.R.C.S.
Donald R. Korb, O.D. Shiro Amano, M.D., Ph.D. Jerry R. Paugh, O.D. E. Ian Pearce, Ph.D. Richard Yee, M.D.
Norihiko Yokoi, M.D., Ph.D.
Reiko Arita, M.D., Ph.D. Murat Dogru, M.D.
©KNichols 2012
Testing Summary
• Symptoms (no validated survey)
• Expression (not widely accepted)
– Quality/ Quantity
• Lid assessment
– Redness (difficult to grade)
– Irregularity
– MG location
• Staining (fluorescein)
– Photography
• Aq. Production (© 1903)
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Stages of MGD
Management and Therapy of Meibomian Gland Dysfunction
Gerd Geerling, M.D. (Chair)
Joseph Tauber, M.D.
Christophe Baudouin, M.D., Ph.D.
Eiki Goto, M.D.
Yukihiro Matsumoto, M.D.
Terrence O’Brien, M.D. Maurizio Rolando, M.D.
Kazuo Tsubota, M.D.
Kelly K. Nichols, O.D., M.P.H., Ph.D.
©KNichols 2012
Current Practice Patterns*
©KNichols 2012
Stages of MGD
• Lid hygiene, warm compresses and lid massage
• Cleaning of the lid margin with baby shampoo, cotton buds or wet towels, daily for 5‐15 minutes
•
•
•
•
Lubricants in cases with additional dry eye
Topical antibiotic oint (moderate to severe)
Systemic tetracyclines/ derivatives in recurrence
Incision and curettage with optional steroid injection in chalazion
*Excerpted from Moorfields Manual, Wills Eye Manual (Guidelines for posterior blepharitis and meibomitis)
©KNichols 2012
©KNichols 2012
WHY A NEW PARADIGM?
Definition
J. Daniel Nelson, M.D. (Co‐Chair)
Jun Shimazaki, M.D., Ph.D. (Co‐Chair)
Jose M. Benitez‐del‐Castillo, M.D., Ph.D.
Jennifer P. Craig, Ph.D., MCOptom
James P. McCulley, M.D.
Seika Den, M.D., Ph.D. Gary Foulks, M.D.
Clinical Trials
Penny A. Asbell, M.D.(Chair)
Fiona Stapleton, MScOD, Ph.D.
Kerstin Wickström, Ph.D.
Esen Akpek, M.D.
Pasquale Aragona, M.D., Ph.D.
Reza Dana, M.D., M.Sc., M.P.H.
Michael A. Lemp, M.D.
Kelly K. Nichols, O.D., M.P.H., Ph.D. Diagnosis
AlanTomlinson, MCOpt, Ph.D. (Chair)
Anthony J. Bron, F.R.C.S.
Donald R. Korb, O.D.
Shiro Amano, M.D., Ph.D.
Jerry R. Paugh, O.D. E. Ian Pearce, Ph.D.
Richard Yee, M.D.
Norihiko Yokoi, M.D., Ph.D.
Reiko Arita, M.D., Ph.D.
Murat Dogru , M.D. Anatomy
Erich Knop, M.D., Ph.D. (Chair)
Nadja Knop, M.D., Ph.D.
Thomas J. Millar, Ph.D.
Hiroto Obata, M.D. David A. Sullivan, Ph.D.
Team
Michelle Dalton
Cathy Frey
Amy Gallant Sullivan
Rose M. Sullivan, R.N.
Sabrina Zappia
Questions?
Thank You!
Industry Liaison
David A. Sullivan, Ph.D. (Chair)
Marco Betancourt
Kim Brazzell, Ph.D.
Amy Brill
Michael J. Brubaker, Ph.D.
Timothy L. Comstock, O.D., M.S.
Neil D. Donnenfeld, M.B.A.
Marie Laure Dupuy Perard, Pharm.D.
David Eveleth, Ph.D.
Fulvio Foschini
Sherryl Frisch, M.S., M.B.A.
Manal Gabriel, D.D.S., Ph.D.
Kazuto Masuda, M.Sc.
Katsuhiko Nakata, Ph.D.
Epidemiology
Debra A. Schaumberg, Sc.D., O.D., M.P.H.
(Chair)
Jason J. Nichols, O.D., M.P.H., Ph.D.
Eric B. Papas, M.Sc., O.D., Ph.D.
Louis Tong, F.R.C.S., M.B.B.S.
Miki Uchino, M.D.
Kelly K. Nichols, O.D., M.P.H., Ph.D. Management
Gerd Geerling, M.D. (Chair) Joseph Tauber, M.D.
Christophe Baudouin, M.D., Ph.D.
Eiki Goto, M.D.
Yukihiro Matsumoto, M.D.
Terrence O’Brien, M.D.
Maurizio Rolando, M.D.
Kazuo Tsubota, M.D.
Kelly K. Nichols, O.D., M.P.H., Ph.D. Lipid
Kari B. Green‐Church, Ph.D. (Chair)
Igor Butovich, Ph.D.
Mark Willcox, Ph.D.
Douglas Borchman, Ph.D.
Friedrich P. Paulsen, M.D., Ph.D. Stefano Barabino, M.D., Ph.D.
Ben J. Glasgow, M.D. ©KNichols 2012
Dry Eye has remained an enigma
“As anomalous results build up, science reaches a
crisis, at which point a new paradigm, which
subsumes the old results along with the anomalous
results into one framework, is accepted.”
Thomas S. Kuhn, 1962
The Structure of Scientific Revolutions
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Stable Tear Film Maintenance
DISRUPTIVE CONCEPTS
Meibomian gland dysfunction may be the leading cause of dry
eye syndrome throughout the world
Lacrimal
Gland
(Tear Film and Ocular Surface Society (TFOS), 2008 – 2010)
Anatomical
Aqueous and lipid deficient dry eye may not be
distinguishable: Low Schirmer score and thin-low lipid layer
thicknesses coexist
Aqueous
Meibomian
Gland
Lipid
Mucin
Goblet Cells
Isreb et al. Correlation of lipid layer thickness measurements with fluorescein tear film break-up time and Schirmer's
test. Eye (Lond). 2005 Apr;19(4):484-5
Stable
Tear
Film
The phenotypes of evaporative dry eye and aqueous dry eye
take on the form of each other
Bron et al. Predicted phenotypes of dry eye: proposed consequences of its natural history. Ocul Surf. 2009 Apr;7(2):78-92. Review.
Sensory
Motor
The most frequent form of MGD, obstructive MGD, frequently
presents without obvious signs (Nonobvious MGD (NOMGD))
Lid Blinking
Tear
Clearance
& Spread
Lid Closure
Evaporation
Blackie et al. Nonobvious Obstructive Meibomian Gland Dysfunction. Cornea: E-Pub ICO201681
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Structure of the Lipid Layer
MGD Classification
Normal
Two-Phase
Lipid Layer
Model
Normal – glands open, secreting clear oil
Non Obvious MGD
No inflammation or signs
Classical & Obvious MGD
Hypersecretion (seborrheic)
HC-Hydrocarbon
WE- Wax Ester
CE-Cholesterol Ester
TG- Triglyceride
F-Free Fatty Acid
C-Cerebroside
P-Phospholipid
Inflammatory (pouting & plugging)
Infective (glands and/or lids)
Diffuse inflammation of the lids/ blepharitis
Inspissated material, blocked glands
McCulley et al. A Compositional Based Model for the
Tear Film Lipid Layer. Tr Am Ophthal. Sci., 1997
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81
Non-Obvious MGD
(NOMGD)
MGD may be nonobvious without
inflammation and without other
obvious signs (NOMGD)
NOMGD may be precursor to obvious
MGD
Highly prevalent and under-diagnosed
– may be most common cause of
evaporative eye disease
In a recent dry eye study of the 52
subjects that had MGD, 48% of them
had NOMGD.
Korb and Henriquez, 1980; Mathers et al., 1991.
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Non-Obvious MGD
Obvious MGD with evidence of
inflammation and telangectasia
Non-Obvious MGD with no overt
inflammation or pathology
Healthy Lid Secreting Oil
83
Blackie et al. Nonobvious Obstructive Meibomian Gland Dysfunction. Cornea: E-Pub ICO201681
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Meibomian gland
transillumination
Courtesy of Wm. Townsend, OD
TearScience® Solution
Treatment of MGD/NOMGD
At Home Therapy
– Warm compresses
– Eyelid Scrubs
– Self expression
In-Office Therapy
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Manual Expression
Off-Label Pharmacotherapy
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Oral tetracycline/doxycycline
Topical Antibiotics – erythromycin, tobramycin
Topical Steroids – dexamethasone
LipiView® OSI
LipiFlow® Auto
Disposable
Meibomian Gland Evaluator
Caution: Investigational device. The LipiFlow Auto Console pictured is not approved for use in
the U.S. Limited by United States law to investigational use.
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Standard Patient Evaluation of
Eye Dryness (SPEED)
Questionnaire
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Evaluates the frequency
and severity of symptoms
Developed as an easy to
use fast screening tool for
dry eye disease
SPEED questionnaire is
one of the tools used to
identify candidates for
LipiView®
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Assess the Tear Film With
LipiView®
Light source:
the illuminator
Touch-screen
control panel
Chin rest
Camera,
computer and
drivers are
housed by the
device
Device dimensions:
28” x 17” x 17”
Measurement time:
20 seconds per eye
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Meibomian Gland
Evaluator™ (MGE)
LipiView® Report
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Produces a measurement
called the Ocular Index of Lipid
Interferometric Color Unit
(ICU)
Calculated on a frame-byframe basis and plotted for
~1 billion data points per eye
The results are then displayed
and are available for printout
The TearScience® Meibomian Gland
Evaluator

Applies consistent, moderate pressure
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Between 0.8 g/mm2 and 1.2 g/mm2
Allows evaluation of secretions from
Grade
Secretion Characteristics
Meibomian gland
orifices
through a slit lamp
3
Clear liquid oil
biomicroscope 2
Colored/cloudy liquid
1
Inspissated (toothpaste consistency)
0
No secretion (includes capped orifices)
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LipiFlow® Thermal
Pulsation System
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LipiFlow® Offers a Solution
for Patients With MGD
Lid warmer
Applies directional
heat to inner eyelid
Activator
Applies
intermittent
pressure to the
outer eyelid
Insulated lid
warmer shields
eye from heat and
vaults above the
cornea to prevent
corneal contact
Heats comfortably to
liquefy the Meibomian
gland contents
LipiFlow safely and effectively treats Meibomian gland
obstruction in both upper and lower eyelids simultaneously,
in an in-office procedure, taking only 12 minutes per eye
Inflatable air
bladder
99
99
100
Therapeutic Goal of
Pulsation
Lid warmer
Applies directional
heat to inner eyelid
MGD TREATMENT
Activator
Applies
intermittent
pressure to the
outer eyelid
Insulated lid
warmer shields
eye from heat and
vaults above the
cornea to prevent
corneal contact



)


Heats comfortably to
liquefy the Meibomian
gland contents
Inflatable air
bladder

Warm compresses
Meibomian gland scrubs
Home expression
Blinking
Office expression
Secretagogues – Androgens
101
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Additional Manual
Expression
Mastrota Paddle
Jaegar Platemodified by M.
Gutierrez, OD
You can use the BIO to get a lighted slightly magnified view
of the lids
New! Ophthalmic Surgical Instruments
Collins Expressor Forceps (Item 98610)
For aggressive expression of the Meibomian gland.
Livengood Expressor Paddles
Angled (Item 98620) & Flat (Item 98630)
For mild or gentle expression of the Meibomian gland.
Maskin Expressor


$ 575
Rhein Medical
BRUDER EYE COMPRESSES
Microwave Activated
Bruder Eye Hydrating Compress and Stye Compress conveniently provide an
effective yet natural and drug-free way to help provide and maintain proper
eye moisture.
BENEFITS
•
•
•
•
Replenishes Moisture Naturally
Relieves Dryness
Refreshes Tired Eyes
Provides Drug Free Relief
FEATURES
•
•
•
•
•
•
•
Ready in Minutes from the Microwave
Naturally Hydrating
Washable & Reusable
Clean Moist Heat
Soft Conforming Design
Non-Allergenic
Dust-Free
BRUDER STYE COMPRESS
Item #34170
BRUDER EYE HYDRATING COMPRESS
Item #34160
08.10
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WARNING

Hot compresses can change the corneal
tissues and structure
Meibomian Gland Expression
Schaeffer Eye Protocol
1) OSD Evaluation
1)
2)

Possible Link to Keratoconus

Evidence Based Medicine
2)
Includes test expression
All staining
RTC expression
At home heat with eye medibeads
2) 15-20 minutes in waiting room with Bruden’s
heat pack ( or rear wait)
3) Expression 1 of 3
4) RTC 2 weeks
1)
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Maskin Probe
1)$ 158 box ( 10)
2) 1,2,4,6 MM intraductals
3) Aluminum Handle $104
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Maskin Tube
Meibomian gland Drug delivery
system
Rose Bengal
Maskin Probe
Leiter Pharmacy
8% lidocaine with 25% Jojoba in
ung base
Sjogren’s Syndrome
 Lymphocytic
infiltration of
lacrimal and salivary glands
 0.4% prevalence
 Women > Men (younger women)
 Much lower androgen counts
 Treat underlying immune disorder
Gender


Sjogren’s: Dry eye is characterized by a
triad of dry eye, dry mouth, and
associated auto-immune disorders
Prevalence
0.4%
 85% women

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Sjogren’s Syndrome

Medical Treatments: Secretagogues
 Salagen
5 mg
 Pilocarpine
tablets
in asthma patients, GI ulcer, acute
iritis or narrow angles
 Avoid
 Evoxac
drug
 Very
30 mg TID– saliva stimulating
Overview and Summary
Recent Clinical Findings
effective with a lot less side effects
Sjögren’s is a chronic, systemic, progressive autoimmune
inflammatory disease1
Characterized by the immune-mediated (lymphocytic)
destruction of the lacrimal and salivary glands1
Early hallmark symptoms include dry eyes and dry mouth1,2
The ocular manifestation of
Sjögren’s has typically been
viewed as a progressive form of
aqueous-deficient dry eye1
Recent evidence suggests that
all layers of tear film can be
affected2
The salivary manifestations
include difficulty speaking or
swallowing, sore or cracked
tongue, dry throat/lips, increased
dental decay1
1. Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93. 2. American
Academy of Ophthalmology Preferred Practice Pattern – Dry Eye, 2011.
1. American Academy of Ophthalmology Preferred Practice Pattern – Dry Eye, 2011. 2. Tincani A, et al. Novel aspects of Sjögren’s Syndrome
in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93.
The disease can present alone, classified as primary
Sjögren’s, or subsequent to another autoimmune condition
(e.g. rheumatoid arthritis), which is classified as secondary
Sjögren’s1,2
Sjögren’s is one of the most common autoimmune diseases1
It currently takes 4.7 years to receive an accurate diagnosis3
While the immune response is largely directed to the exocrine
glands (lacrimal and salivary), systemic effects are seen in
30-70% of patients1
1. Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93. 2. American
Academy of Ophthalmology Preferred Practice Pattern – Dry Eye, 2011. 3. http://www.sjogrens.org.
1. http://www.sjogrens.org/home/about-sjogrens-syndrome/symptoms.
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Sjögren’s is thought to be caused by a combination of genetic,
environmental, and hormonal factors1,2
Viral or bacterial infection is thought to activate the immune
system in pre-disposed individuals1,2
Objective ophthalmic clinical
procedures for the diagnosis of
Sjögren’s are well established,
including:1
o
o
o
Tear break-up time
Staining
Schirmer’s testing
An accurate diagnosis may require a
histological and serological evaluation
to ascertain:1,2
o
o
Early vs late stage disease
(degree of severity)
Local vs systemic disease status
Sjögren’s is a multisystem disorder
and referral/consultation with other
specialists is necessary (rheumatology
1. Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93. 2. Ice JA,
et al. Genetics of Sjogren’s Syndrome in the genome-wide association era. J Autoimmun 2012;39:57-63.
Traditional Serological Disease Markers for Sjögren’s
1. Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93. 2. SC Shiboski,
et al. American College of Rheumatology Classification Criteria for Sjögren’s Syndrome: A Data-Driven, Expert Consensus Approach in the
SICCA Cohort. Arthritis Care Res (Hoboken) 2012 Apr;64(4):475-87.
and oral medicine).2
Myth: “There are only a few patients in my practice”
• The ocular manifestation of Sjögren’s (primary or secondary) can present
as aqueous-deficient dry eye alone, or in combination with evaporative dry
eye1,2
o At least 25MM patients diagnosed with Dry Eye
o Patients with Dry Eye symptoms see ECP first
• Major dry eye classification scheme2
Dry Eye
Aqueous Deficient
Sjögren’s Dry Eye
Combination
Non-Sjögren’s Dry Eye
Lacrimal Deficiency
Primary
Lacrimal Gland Duct Obstruction
Reflex Block
Systemic Drugs
Myth: “There are only a few patients in my practice”
All layers of the tear film may be affected
since Sjögren’s is a chronic, progressive
disease1
Intrinsic
Meibomian Oil
Deficiency
Extrinsic
Vitamin A Deficiency
Topical Drugs Preservatives
Secondary
1. Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93.
Evaporative
Disorders of
Lid Aperture
Low Blink Rate
Contact Lens Wear
Ocular Surface Disease e.g. allergy
Drug Action e.g. isotretinoin
1. Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93. 2. American
Academy of Ophthalmology Preferred Practice Pattern – Dry Eye, 2011.
Disease progression can vary, so prognoses can also vary1
o Symptoms range from mild dry eye/mouth to severe organ
damage and/or lymphoma
o Symptoms may remain stable, worsen or improve in cycles
o As the disease progresses, debilitating fatigue and joint pain
can significantly impair quality of life
o Patient evaluation should include:
 Medical and ocular history
 Tear volume
 Tear film distribution and stability
 Clearance of the tear film
Early detection and treatment may assist in preventing
complications2
However, it currently takes 4.7 years to receive an accurate
diagnosis2
1. http://www.ninds.nih.gov/disorders/sjogrens/sjogrens.htm. 2. http://www.sjogrens.org/home/about-sjogrens-syndrome/diagnosis.
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Ocular symptoms are frequently the first to present in patients
with Sjögren’s, enabling ECP’s an opportunity to identify
disease before systemic development
Early diagnosis and treatment may delay the progression of
disease1
Active research is ongoing for additional therapeutic options for
Sjögren’s:1,2
o Biological therapeutic agents (e.g. monoclonal antibodies)
Sjogren’s syndrome is currently defined by:
Ocular symptoms – dry eyes
Oral symptoms – dry mouth
Ocular signs – abnormal Schirmer’s test or Rose Bengal or Lissamine Green staining
Oral signs – decreased salivary gland flow
Histopathology showing lymphocytic infiltration of salivary or lachrymal glands
Autoantibodies – anti-Ro and/or anti – La, ANA, RF
Exclude – hepatitis C, HIV, neck radiation, sarcoidosis, graft versus host disease,
lymphoma, anti-cholinergic drugs
Other manifestations include:
–
–
o Antimalarials
–
–
–
–
o Vitamin D supplementation
o Immunosuppressants
Lung disease – usually a lymphocytic interstitial pneumonia
Kidney disease – usually mild tubular disease, but may have glomerular disease
Peripheral neuropathy
Vasculitis involving skin, bowel, muscle, nerve and occasionally other organs
Vasculopathy, especially with secondary anti-phospholipid antibodies
5% of patients develop non-Hodgkin lymphomas
1.
Tincani A, et al. Novel aspects of Sjögren’s Syndrome in 2012. BMC Med Apr 4 2013;11:93. doi: 10.1186/1741-7015-11-93.
2. Ramos-Casals M, Brito-Zeron P. Emerging biological therapies in primary Sjogren’s Syndrome. Rheumatology 2007;46:1389-1396.
Sjogren’s syndrome leads to:
Corneal abrasions and other Keratopathies
Blepharitis
Uveitis
Other ocular infections
Dental caries
Other infections of the mouth
Systemic involvement in Sjogren’s syndrome may
lead to:
Respiratory dysfunction
Renal dysfunction
Lymphoma
CONFIDENTIAL
Sales Aid
CONFIDENTIAL
142
The Sjö™ In-Office Testing Kit
143
CONFIDENTIAL
144
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Filamentary Keratitis
Filamentary Keratitis





62 yo female
VA 20/200
Pain OU 2 years
Third doctor in 2 years
AT prn
Filaments adhere to the
cornea, causing discomfort
Epithelial cells
and mucin
bind to form
filaments
Blinking
stimulates
filamentary
traction and
corneal
microtrauma
Compromised
epithelial cells
become
desquamated
Inflammatory
stimuli induce
excess mucus
production
Corneal
inflammation
induces
epithelial
damage
Filamentary Keratitis

Debridement of filaments
Iris forceps
5 office visits
 Weekly


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3/27/2014
Filamentary Keratitis
Medications : week 1
Filamentary Keratitis

Month 2
Restasis tid
 PF AT q 1 hour
 PF UNG pm


Lotemax

Refresh Ung



Qid
Pm
PF AT

Q I hour
Month 3
 Lacriserts am /pm
 Restasis
 ( consider Bandage Contact lens)

Punctal Plugs

Mucomist

MGD treatment
26