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Tear Break Up Time Conjunctival Staining Express Meibomian Glands • Cotton Tip Swab • Roll Upward • Observe & Grade • Discuss While Performing Procedure • Mild lissamine green staining Quantify Volume Traditional Treatment • Artificial Tears • Cyclosporine • Steroids • Lid Hygiene/Warm Compress Goals of Therapeutic Intervention Turn Off The Inflammatory Cascade Decrease Lacrimal Gland Inflammation - Improve Gland Function Ø Restasis – Cyclosporine Ophthalmic Emulsion .05% Ø Lotemax Gel– Loteprednol .5% Restore Normal Neural Feedback to Lacrimal Gland Normalize Tear Film Decrease Ocular Surface Inflammation - Stimulate Epithelial Healing Next Level Cyclosporine and MMP-9 MMP-9 expression was evaluated by immunohistochemistry. The mean percentage of MMP-9 expression of the conjunctival epithelial cells was significantly decreased. MMP-9 expression was evaluated semi-quantitatively by measuring cytoplasmic staining for MMP-9. • Punctal Occlusion – Collagen/silicone/surgical • Topical Anti-Allergy • Omega III’s N=24 eyes of patients with thyroid orbitopathy-related dry eye [1] Gürdal C, Saraç O, Genç, et al. Ocular surface and dry eye in Graves' disease. Curr Eye Res 2011; 36: 8-13. Calvin Roberts, M.D. Study • Dual Approach • Cyclosporine and Punctal Occlusion • Combination More Effective Than Monotherapy 2009 Study - McCabe Next Level • 108 Patients (216 eyes) 1 Year • 43% of Patients Measured a Visual Acuity Improvement After Punctal Occlusion • Moisture Chamber • 92% Retention Rate 1 Year • Slow Release Inserts – Night/Day • Autologous Serum • Androgen Treatment • Parasite Treatment Eyessentials – Protective Sunwear Environmental Treatments Panoptx “Dry Eye Wear” ® • Patented Orbital Seal – Maintains moisture – Blocks wind • Developed by maxillofacial surgeon – Different styles fit different faces Panoptx “Dry Eye Wear” ® • Patented Orbital Seal creates “moisture chamber” • New study findings demonstrate effectiveness Need for Treatment Flow Sheet Treatment Flow Sheet • Summary Sheet for Treatment • Show Current and Previous Treatment Role of Lid Disease in Chronic Dry Eye Disease • Co-Morbidity ??? • Anterior Blepharitis • Posterior Blepharitis (Meibomian Gland Dysfunction) • Chicken or Egg??? Posterior Blepharitis Meibomian Gland Expression 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. Meibomian Gland Expression BRUDER EYE COMPRESSES Microwave Activated Schaeffer Eye Protocol 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 FEATURES • Replenishes Moisture Naturally • Relieves Dryness • Refreshes Tired Eyes • Provides Drug Free Relief • Ready in Minutes from the Microwave • Naturally Hydrating • Washable & Reusable • Clean Moist Heat • Soft Conforming Design • Non-Allergenic • Dust-Free 1) OSD Evaluation 1) Includes test expression 2) All staining 2) RTC expression 1) At home massage with eye medibeads BRUDER STYE COMPRESS Item #34170 2) 15-20 minutes in waiting room with heat back ( or rear wait) 3) Expression 1 of 3 4) RTC 2 weeks BRUDER EYE HYDRATING COMPRESS Item #34160 08.10 Maskin Expressor MGD EXPRESSION Fees: • $ 575 $189 Out of pocket • Rhein Medical covers 3 visits 68 Per visit after those three 99213 / 99212 dry eye progress check before expression 2 visits at 3 level then One at 2 Blepharitis • Anterior Lid Disease Therapies – Infectious Ø Lid Hygiene – Samples or Written Instructions • Bacterial Ø Warm Compress/Tranquileyes Ø AzaSite, Zylet, Macrolide ung • Viral Ø Doxycycline 20 - 50 mg bid – Months • Parasitic Ø Alodox 20 mg w/scrubs • Posterior Ø Omega III – Meibomian gland dysfunction MGD???????? Lid Disease Ø Lid Hygiene – Samples or Written Instructions Ø Warm Compress/Tranquileyes Ø Erythromycin Ointment H.S./Zylet,AzaSite Ø Doxycycline 20 - 50 mg bid – Months Ø Alodox 20 mg w/scrubs Ø Nutritional Supplements TearScience® Solution Lid Treatments • Warm Compress/Lid Hygiene • Antibiotic and/or Combination – AzaSite – Zylet – Tobradex • Anti-inflammatory – Ester vs Keytone LipiView® OSI • Tetracycline/Doxycycline (Low Dose) LipiFlow® Auto • Omega III • Meibomian Gland Evaluator Disposable Caution: Investigational device. The LipiFlow Auto Console pictured is not approved for use in84 the U.S. Limited by United States law to investigational use. LipiFlow® Thermal Pulsation System • Heat applied to the palpebral surfaces of the upper and lower eyelids directly over the meibomian glands Overall Therapeutic Goal of the LipiFlow® • Alleviate meibomian gland obstruction in both upper and lower eyelids simultaneously, using a short in-office procedure (12mins per eye) Lid Warmer Applies directional heat to inner eyelid Eye Cup Applies intermittent pressure to the outer eyelid Insulated lid warmer shields eye from heat and vaults above the cornea to prevent corneal contact • Graded pulsatile pressure delivered to the outer eyelid Heat facilitates release of secretion from obstructed meibomian glands Inflatable air bladder 85 86 Therapeutic Goal of Heat Therapy • Liquefy the meibomain Lid Warmer Applies directional heat to inner eyelid gland contents • Facilitates release of secretion from the meibomian gland Eye Cup Applies intermittent pressure to the outer eyelid Insulated lid warmer shields eye from heat and vaults above the cornea to prevent corneal contact • Increase likelihood that the glands can resume normal function Heat facilitates release of secretion from obstructed meibomian glands LipiFlow® Contraindications Do not use the LipiFlow® System in patients with the following conditions: • Ocular surgery, ocular injury, ocular herpes of eye or eyelid within prior 3 months • Active ocular infection or inflammation, or history of chronic, recurrent ocular inflammation within prior 3 months Inflatable air bladder • Eyelid abnormalities that affect lid function • Eyelid abnormalities or ocular surface abnormalities that may affect/compromise corneal integrity or lid function 87 88 Macrolides • Reduce gene expression of proinflammatory cytokines and adhesion molecules at the transcriptional factor level • Inhibit cytokine production • Reduce production of proinflammatory mediators AzaSite® Suppresses MMP9 in HCEC Results • Cultured HCEC secrete abundant pro-MMP-2 and pro-MMP-9 – HCEC exposed to AzaSite® demonstrated MMP-9 expression reduced by 33%1 • Suppressive effect greater than vehicle treatment • Cultured HBEC secrete abundant pro-MMP-2 – BCEC exposed to AzaSite® did not demonstrate reduced MMP-2 expression Conclusion • AzaSite® inhibits MMP-9 expression in HCEC, providing preliminary data for exploring the use of AzaSite® in corneal disorders associated with pathologic MMP-9 expression • Antiinflammatory effect Jacot J, et al. Evaluation of MMP2/9 Modulation by Azithromycin and DuraSite on Human Corneal Epithelial Cells and Bovine Corneal Endothelial Cells in vitro. 2008 Annual Meeting Abstract and Program Planner [on CD-ROM]. Association for Research in Vision and Ophthalmology. Abstract 1985. Essential Fatty Acids Nutritional Therapy • Over the past 6-8 years EFAs have been in the spotlight as having positive effects related to reduced inflammatory response in the eye and other body areas • EFAs are: Building a Solid Foundation for Ongoing Relief of Symptoms-Eye Health and General Health Nutritional Supplements • In inflammatory conditions 3-4 grams of EPA/DHA • Thera Tears Nutrition - 330 mg Flaxseed ALA, Fish 150mg EPA, 100 DHA, Vitamin E • Bio Tears - Omega 3 & 6 — stable Cod Liver and Black Currant Seed oils, 100 mg EPA per capsule, 70 mg DHA per capsule, 235 mg GLA per capsule (Omega 6), Vitamins A, C, B6 and Mg – Omega 3-EPA, DHA & ALA -found in cold water fish, walnuts and cod liver oil – Omega 6-LA & GLA-found in milk, ice cream, butter, beef and other natural sources Omega III Dosing • Adults should consume at least 2 grams of EPA/DHA per day • Adults with specific chronic conditions should consume at least 3.5-4.0 grams of EPA/DHA per day • LifeGuard - TG Form of Omega 3 (90% absorbability), Omega 3-Fish Oil (triglyceride base), EPA-420 mg per capsule, DHA-140 mg per capsule, Other Omega 3s-110 mg per capsule • Nordic Naturals Experience with Omega Formulations • Average time to symptomatic relief reported by patients is 4-8 weeks • Patients begin taking full dosage for 2-3 months and many reduce to lower levels and maintain relief • Patients that discontinue the formulations experience recurrence of symptoms in 2-3 days • In moderate to severe dry eye, Omega 3 plus Restasis is a good long-term combination with early use of Loteprednol Merchandising and Compliance