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3/27/2014 Ocular Surface Disease: A Comprehensive Approach to the Diagnosis and Treatment of the Dry Eye The OSD Wellness Symposium Dr. Jack Schaeffer DR. Mark Schaeffer Faculty 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 The OSD Symposium 24 Doctors 22 Ods 2 MDS Research Lectures Professors 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 • • • Dry Eye Re invent the practice Prevent patient problems White eyes Perfect Vision Patient Referrrals Sunwear sales Decrease Contact lens dropout Look Better Feel better • 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 6 1 3/27/2014 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 9 © 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 10 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 8 © 2014 Novartis OD’s Need education Staff Training Change the culture Inform the Public I Care 11 2 3/27/2014 The OSD Wellness Initiative The OSD Wellness Initiative Tech Driven Pre Screening Diagnosis Treatment Patient Education The OSD Wellness Initiative Preventive Medicine The OSD Wellness Initiative Dermatology Dentistry Psychology ( behavior modification) OSDI / Speed questionnaire History Topography / keratometry Visual Acuity All Contact lens patients All females All light skin ( easily burned) All Systemic / auto immune Sysemic medications Allergic Conjunctivitis Patients The OSD Wellness Initiative OD’s Need education Staff Training Change the culture Inform the Public I Care 3 3/27/2014 Conjunctival Staining VITAL STAINS Sodium Fluorescein Rose Bengal 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 Epithelial defects Accumulates intracell. space Same purpose as RB Less stinging Fluramene Noctural Lagophthalmos? Moderate / Severe lissamine green staining Dry Eye Evaluation 4 3/27/2014 Fluorescein Staining 5 3/27/2014 Fluorescein Staining Lissamine Green Staining Exposure zone staining with limbal sparing 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 6 3/27/2014 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 7 3/27/2014 Diagnosis Demodex Exclusion Cylindrical Dandruff Microscopic evaluation of Cilia base Cliradex Ocusoft Demodex Kit Tea tree Oil : 50% BlephEx Treatment Anterior Blepharitis Treatment Goals for Anterior Blepharitis Patients Antibiotic Antibiotic / steroid combination 84% infection/inflammation! 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. gtts Ung BlephEx BlephSteam Doxycycline Lid scrubs / Ocusoft cliradex Mineral or Coconut Oil Blepharitis 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 Shower..please! 8 3/27/2014 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 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: • • • • • 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 9 3/27/2014 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 10 3/27/2014 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 11 3/27/2014 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) 12 3/27/2014 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 78 13 3/27/2014 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 80 79 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 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. 82 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 84 14 3/27/2014 15 3/27/2014 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 Manual Expression Off-Label Pharmacotherapy 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. 93 Standard Patient Evaluation of Eye Dryness (SPEED) Questionnaire 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® 94 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 96 16 3/27/2014 Meibomian Gland Evaluator™ (MGE) LipiView® Report 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 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) 97 LipiFlow® Thermal Pulsation System 98 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 17 3/27/2014 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 18 3/27/2014 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) 19 3/27/2014 Maskin Probe 1)$ 158 box ( 10) 2) 1,2,4,6 MM intraductals 3) Aluminum Handle $104 20 3/27/2014 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 21 3/27/2014 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. 22 3/27/2014 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. 23 3/27/2014 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 24 3/27/2014 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 25 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