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8/14/13 Cosmetic and Health Related Considerations of the Maturing Population President, Women of Vision Diplomate, Cornea, Contact Lens and Refractive Technology Section, AAO Diplomate, American Board of Optometry Past Chair, Cornea & Contact Lens Section, AOA Past President, Illinois Optometric Association IOA Optometrist of the Year, IOA Young OD Review of Optometry Top 10 Woman ODs NKCI, Chicago Site Director Consultant, Chicago Blackhawks and Hockey mom Consultant/Speaker for Bausch + Lomb, Alcon, Allergan, CooperVision, ISTA, husband Jeff McClimans works for Optos Kristin J. Tarbet, M.D. Past President of WOV Past Chair of the AOA CLCS Past President of Scleral Lens Education Society Chief Clinical Editor of Review of Optometry Contributing editor for CL spectrum GPLI Advisory board Fellow, American Academy of Optometry Review of Optometry Top 10 Woman OD Optometry degree from the University of Alabama at Birmingham Residency at the Illinois Eye Institute Dr. Reed is a frequent CE lecturer and writer in the areas of ocular disease management, pharmacology, and nutrition. She serves on numerous advisory boards regarding health and wellness Board of Directors, Ocular Nutrition Society Teacher of the Year 17 times! American Board of Ophthalmology American Board of Cosmetic Surgery - Facial Cosmetic Surgery Diplomat American Society of Ophthalmic Facial Plastic & Reconstructive Surgery (ASOPRS) 1 8/14/13 2013 – Anticipated TFOS Contact Lens Dryness Report 2007 – TFOS DEWS Report 1995 – Dry Eye is a “disorder” 2006 – ITF Guidelines; 4 Levels of Severity 2011 – TFOS MGD Report Osmolarity ¢ “central mechanism in the pathogenesis of ocular surface damage” ¢ Potentially the single best marker for dry eye disease ¢ Measurement possible, but can be hampered by reflex tearing while collecting sample, need for large volumes of tears, possibility of evaporation of the sample ² “Overall, MGD is an extremely important condition, conceivably underestimated, and very likely the most frequent cause of dry eye disease.” ² “A lipid deficiency occurred in 76.7% of dry eye patients compared with only 11.1% of those with isolated alterations of the aqueous phase.” ² “MGD is perhaps the most underdiagnosed, undertreated, and underappreciated disease in eye care worldwide” Investigative Ophthalmology and Vision Science (IOVS); March 31, 2011 (by Tear Film and Ocular Surface Society) (WC Posey, Diseases of the Eye, 1902) The Transillumination of meibomian glands lipid layer restricts evaporation to 5-10% of tear flow helps lubricate ¡ Also (Transillumination image from Dry Eye and Ocular Surface Disorders, 2004) Obstructive meibomian gland disease Squamous metaplasia of meibomian gland orifices Turbid secretions from meibomian gland orifices Lid margin morphology and turbidity of secretions can be graded to assess disease severity (Bron et al, 1991; Mathers et al, Inferior streak tear breakup Broad streak tear breakup 1991) Images from Dry Eye and Ocular Surface Disorders. 2004. Images from Dry Eye and Ocular Surface Disorders. 2004. 2 8/14/13 Lid Margin Disease → Definitions Anterior Blepharitis Ø Inflammatory condition of outside portion of the eyelids secondary to infection, or associated with acne rosacea or seborrheic dermatitis of the scalp or facial areas Ø Often Meibomian Gland Disease (MGD; Posterior Blepharitis) Anterior blepharitis Ø Tissue Inflammation of the inside portion of the eyelids Ø Associated with altered composition of the meibomian gland secretions, inflammation of local tissue Meibomian gland disease Omega 3 Fatty Acid Intake ¡ Consider ¢ A current intake through dietary means popular first-line treatment ¡ Topical Steroid QID 2 weeks to 1 month in Duration ¡ Concurrent dosing of Restasis (cyclosporine) BID long-term ¡ Drawback? Healthy Fish (boiled, baked, grilled) ¡ Initiate And these are only the drops!! supplements if appropriate Between 1,500 to 3,000 mg/day is most appropriate dose. ¢ High “Pharmaceutical Grade” is essential. ¢ Ethyl-Ester vs. Triglyceride form ¢ EPA+DHA ≥ ½ total Omega 3 FA’s (75-80% common in quality supplements) ¢ Maintain with as low as 1,000 mg ¢ ¢ Cost, IOP concerns, Stinging Concerns, Off-label concerns, concerns with prior HSK/HZV? Not “new” per-say, except in Western culture standard treatment protocol Difficult to standardize methodology No Doxycycline 50 mg BID (Rosacea) Tranquil Eyes Warm Compress Has had positive results as a complementary therapy Balances the autonomic nervous system. Cholinergic anti-inflammatory effect by enhancing vagus nerve activity. Lipisome Spray Mastrota paddle Azasite 3 8/14/13 The role of androgens ¡ Promote lacrimal gland, salivary gland, and meibomian gland function. ¡ DHEA is important in maintenance of secretory glands, and in estrogen-deficient individuals, there is a proportional deficiency in DHEA. ¡ When the estrogen/androgen balance is disrupted, autoantigens form leading to auto-inflammatory and auto-immune conditions. ¡ May be the pathogenesis in Sjogren’s Syndrome. ¡ Topical DHEA drops are being used off-label in varying concentrations with mixed anecdotal results. Products derived from the patient’s own blood. Autologus serum Platelet-rich plasma “A Anakinra (Kineret; Amgen, Inc.) ¡ Recombinant version of human IL-1Ra approved for treatment of Rheumatoid Arthritis ¡ DED is associated with significant overexpression of inflammatory cytokines, including interleukin-1 in the eye. ¡ The IL-1Ra suppresses IL-1-mediated inflammation by completely inhibiting the binding of IL-1a and IL-1b to IL-1 receptor I. ¡ Randomized, double-masked trial. 75 participants received Artifical tear, 2.5% anakinra, or 5% anakinra revolutionary way to treat evaporative dry eye caused by meibomian gland dysfunction.” Controlled heat and massage for optimized stimulation of the meibomian glands. JAMA – Ophthalmology Reported online 23.April.2013 Contact: [email protected] Made in New Zealand by bees that pollinate the native manuka bush. UMF (Unique Manuka Factor) determines antibiotic effectiveness. Manuka honey used is pharmaceutical/medical grade and highly sterilized. 4 8/14/13 Tea tree treatments with 50% lid scrubs or 5% lid massages are effective in eradicating mites and reducing ocular scurface inflammation. Multiple Properties ¡ Anti-microbial ¡ Anti-inflammatory ¡ Anti-protozoalAnti-viral Christine Sindt, OD, FAAO Replacing ¡ Replace Make Up every 3 months Hand Lens Washing Case Care ¡ Rinse ¡ Wipe ¡ Store dry 5 8/14/13 Periorbital skin is only 0.55mm thick, compared to 2mm thick on rest of body Contributing Factors ¡ Lack of Sleep ¡ Allergies ¡ Smoking/ Caffeine/ Alcohol ¡ Dehydration ¡ Iron deficiency/ Anemia ¡ Genetics GP contact lens wear cause: Primary ¡ ¡ levator aponeurotic disinsertion presumably due to recurrent traction on the aponeurosis during rigid contact lens removal. Ophthalmology. 1995 Jun;102(6): 924-8. Acquired ptosis in the young and middle-aged adult population. Kersten RC, de Conciliis C, Kulwin DR. Mueller muscle degeneration PREVENTION Preparation for Lid SX One of the most common cosmetic operations and aesthetic benefits Long lasting benefits (years) Fast recovery time (1-2 weeks) May be covered by insurance Functional Severe Dermatochalasis Caffeine ¡ Tea bags White Night ¡ UV Lose eye liner cream with Vitamin K and retinol sensitive, should only be used at night the glitter make up Thinning of the dermis and atrophy of fat pads of elasticity Greater visibility of bony landmarks, blood vessels, wrinkles, and furrows Transverse forehead lines Lowering of the eyebrows Descent of the corners of the mouth 1. Yaar M, Gilchrest BA. Skin aging: postulated mechanisms and consequent changes in Ptosis of nasal tip structure and function. Clin Geriatr Med. Loss 2001;17:617-630; 2. Stern RS. Treatment of photoaging. N Engl J Med. 2004;350:1526-1534. . Discuss patient goals and expectations facial asymetry Look for brow / eyelid ptosis Document: fissures, margin reflex distance, Evaluate extraocular muscle function Note presence of Bell’s phenomenon Springback test for lower lids Preoperative photos Assess 6 8/14/13 Avoid Need visual fields – untaped and taped photos – frontal and side views Letter of medical necessity Lower eyelids are not covered Pseudoptosis Preoperative Measure and mark skin excess levator function pre-op Inject 2% Lidocaine with epinephrine Excise skin and remove excess periorbital fat [ don’t forget medial fat pad] Levator advancement if required for ptosis Close with subcuticular 6-0 prolene sutures Be conservative with regards to skin excision Assess anticoagulants for 10 days pre-op routine medications Be prepared for severe bruising and swelling day 2-4 Bruising may persist for 2-3 weeks No contact lens wear first week Continue If lateral hooding is present OK to extend past lateral canthus Minimize skin excision past lateral canthus in younger patients Younger patient Older Patient Marking Guidelines ¡ 2 cm of skin needed from brow to lid margin ¡ Use the pinch technique Chill eyelid skin for 24 hours [ frozen peas ] No vigorous exercise or heavy lifting Protect cornea with ointment Sleep with head at 45 degree angle Remove sutures at 1 week No contact lens use first week Rest! 7 8/14/13 Pain Too Bruising [ uncommon ] and swelling Itching Asymetry Healing issues Improper skin/fat excision Too It much skin removed much fat removed Asymmetric ptosis OTHER PROCEDURES Asymmetric ptosis: Levator advancement Dermatochalasis is easier to raise a lid crease than lower one in lower lids with post op ectropion Hollowing Louise A. Sclafani, OD, FAAO Kohl used in ancient times for eyeliner Three Components: Film Formers, Thickeners ( waxes, gums and clays to “help color stick” and Pigments ¡ ¡ Avoid products with “glitter” especially in dry eye Introduce new products one at a time: avoid allergy Don’t mix and match: no lip-liner on the eyes Never tug lashes with curlers, sharp objects Application Process: Respect the line ¡ Concealer… shadow…liner…powder…mascara… Apply after contact lens insertion/before presbyopic myopes, GPs! Remove cosmetics @bedtime, rinse removers Replace mascara q 3 months: don’t “top off ” AKA; Infection, Used Allergic ¡ Micro-pigmentation, Dermagraphics for cosmetic and medical purposes (vitiligo) Iron oxides= Black/brown Ultramarine= blue, Chromium oxide= green Titanium oxide=white Active, unable to wear cosmetics Most common is eye-liner… eyebrow….lips are no FDA “approved colors”: Iron oxide is inert, doesn’t migrate and less likely to cause allergic reaction than vegetable based products May reduce wrinkles and break down scar bands Importance of reputable Services: licensed There ¡ Dermatologists, Cosmetologist, Aesthetician, Nurses, Mac! Refresher due to fading from UV, products, skin type Hepatitis: prevention with disposables reaction: Avoid black India Ink and Henna Granulomas and Keloid (especially with removal) Dissatisfaction w/ appearance- go classic, not trendy ¡ Removal via dermabrasion and surgery may lighten skin MRI : risks vs. benefits of discomfort Peri-Operative; pain, swelling, bleeding COST: $400-$800 …. PARA-MEDICAL Report Adverse Events ¡ FDA 1800-332-1088 Premier Pigment July 2004 8 8/14/13 Fake or False Eyelashes SERUMS ¡ Human, Synthetic, Feather ¡ Self-Application Technique ¡ Removal without damage and Maintenance “Permanent” ¡ Evening ACTIVE Salon Applied contain just mineral oils. Read order of ingredient ¡ Myristoyl Pentapeptide-17 ¡ CITY Lash, OBAGI ElastiLash, Lash Allure MD Band or Weaved Complications Example ¡ Potential for damage to natural lash and lid ¡ $300 : last for several months!! ¡ Associated Boost RESTING PHASE 60% of lashes in this phase for 9 mos. TRANSITION Programmed Death 15 days hair falls out anagen NEW GROWTH Lasts 1-2 months (scalp=6yrs) 41% lash active (scalp = 84%) Bulb Lash Intensifying Serum by Lili Fan, MD conditioner and patented lipopeptide technology Anagen phase: Stimulates keratin genes and hair follicles to stimulate growth Catagen Phase: Strengthens, Repairs and protects Prolongs the Telagan phase by conditioning Only available thru eye care professional Zoria Mascara Sensitive eyes A telogen catagen Hair shaft Dermal papilla INGREDIENT (OTC) ¡ Many ¡ Individual, Growing (Anagen follicle) and CONDITIONERS conditioner: Vaseline, Baby Oil, Aquaphor Lash grow .15 mm/day (scalp = .4) Matrix 51 Treatment for “Hypotrichosis” Requires a prescription. .03% Bimatoprost ophthalmic Applied to base of upper eye lashed QD to increase thickness and darkness of lashes Prolongs Anagen or Growth phase to increase the proportion of lashes in this phase Stimulates transition from telogen to anagen phases resulting in thicker lashes Increases melanogenesis to increase amount of Determine why eyes are red and treat it! But for a party or photo….. ¡ ¡ ¡ Main ingredients: Vasoconstrictors Naphazoline, Saline Caution for Rebound Hyperemia Blue Tinting used by film industry uses light absorption properties of blue dye to eliminate yellow eyes. CAUTION ¡ melanin in the follicle to result in darker lash Results in 12-16 wks, must be continued SE: pigmentation of lid margin, iris, sting, $$ ¡ PAP= Prostaglandin Associated Periorbitopathy Detox and increase Vitamin A Cool compresses Topical OTC drops: Murine, Visine, OTC- US Formula by Verseo contains the food color blue dye C142051 (stains!) boric acid (astringent/antiseptic), chamomilla recutita extract, sodium chloride (wash) and malva sylvestris FRENCH FORMULA COLLYRE BLEU by Laiter contains Methylene Blue & Naphazoline Side Effects of Alpha-2 adrenergic agonists Surgical intervention: I-Brite technique by Boxer Wachler ¡ Conjunctival resection 9 8/14/13 Joan Kaestner, MD ¡ Enhance aesthetic appearance facial rhytids ¡ Treat volume loss ¡ Address facial asymetry ¡ Augment surgical proceedures ¡ Reduce Carruthers J, Carruthers A. Dermatol Surg. 2003;29:802-809. Thinning of the dermis and atrophy of fat pads of elasticity Greater visibility of bony landmarks, blood vessels, wrinkles, and furrows Transverse forehead lines Lowering of the eyebrows Descent of the corners of the mouth 1. Yaar M, Gilchrest BA. Skin aging: postulated mechanisms and consequent changes in Ptosis of nasal tip structure and function. Clin Geriatr Med. Loss The Pyramid of Age 2001;17:617-630; 2. Stern RS. Treatment of photoaging. N Engl J Med. 2004;350:1526-1534. . Reprinted with permission from Cosmetic Dermatology. 2007;20(11):739-742. ©2007, Quadrant HealthCom Inc. Courtesy of Wm. Philip Werschler, MD. Etiology of Lines and Wrinkles 52.2% of the population is between 25 and 64 years of age1 Resisting aging is an important value to “baby boomers” Fillers and Botulinum toxin can restore volume, reduce dynamic facial lines and improve facial contour Careful selection of treatment modalities will maximize patient satisfaction l Genetic factors l Photoaging l Smoking l Underlying diseases l Gravity l Muscular action 1. Meyer J. Washington, DC; U.S. Census Bureau; 2001 1. Stern RS. Treatment of photoaging. N Engl J Med. 2004;350:1526-1534; 2. Administration on Aging. A profile of older Americans: 2003. Washington, DC: U.S. Department of Health and Human Services; 2003; 3. American Society for Aesthetic Plastic Surgery, Cosmetic Surgery National Data Bank. 2002 statistics. New York, NY: ASAPS Communications; 2003. Available at: http://www.surgery.org/press/statistics-2002.php. Accessed August 20, 2004.. 10 8/14/13 Plastic Surgery PMMA Implants Silicone PLLA Lasers/Light Sources/RF (LLRO) Peels + MDAB The best thing that comes out of the bottle for a cosmetic surgeon” Patient satisfaction is high with low procedure morbidity Active ingredient is Serotype A Biologic products differ in behavior Used medically since 1989 FDA approved for cosmetic use 2001 “ Nonsurgical Botulinum Toxin Type A HA Collagen CaHA Topical Products Emerging Technology ¡ [ BOTOX ] Courtesy of Wm. Philip Werschler, MD. BOTOX® Cosmetic is a purified, natural protein derived from the bacterium Clostridium botulinum works by blocking acetylcholine impulses that trigger hyperactive muscle contractions over 20 years successful clinical experience in therapeutic conditions. BOTOX® FDA approved for ¡ strabismus, blepharospasm, cervical dystonia, hyperhidrosis and migraine headache, in addition to the glabellar lines Approved in over 70 countries Ongoing studies for a broad range of medical indications including: ¡ Corrugator Procerus Frontalis Orbicularis Oculi spasticity, cerebral palsy, back spasm and facial aesthetics Glabellar Creases Rhytids Frontalis Lines Depressor Anguli Oris / Mentalis Perioral Rhytids Platysmal bands Crow’s Feet! Naso-labial Folds Periorbital 11 8/14/13 Frontalis - brow ptosis, secondary dermatochalasis Glabella - retained corrugator function Periorbital area – ectropion, diplopia Perioral area – mouth dysfunction Asymetry Transient eyelid ptosis Avoid all of the above with better understanding of facial anatomy Nasolabial Marionette Lip Long-lasting Minimal side effects Painless injection No allergy testing required Easy to use/inject Cost-effective (physician and patient) Efficacious on a variety of facial wrinkles folds lines rhytids creases Glabellar Permanent Natural-looking Non-permanent ¡ Nondegradable ¡ Last ¡ Long-term ¡ Degradable ¢ side effects Granulomas, asymmetry, migration ¡ Must be removed if effect is undesirable ¡ Silicone oil, Artefil less than 24 months ¡ Temporary ¡ Side effects usually mild and transient ¡ HA, Radiesse, Sculptra HA is a naturally occurring linear polysaccharide polysaccharide units are largely water soluble Optimal volume use improves persistence in the skin Important component of the extracellular space1 Maintains proper structure and tissue function Maintains volume and viscoelasticity HA concentrations decrease with age Ideal skin-filling agent The 12 8/14/13 Tear Evaluation Jaw Selection trough line contouring Brow elevation Cheek augmentation Chin augmentation Nasal tip elevation Ear lobe reconstruction of facial anatomy of treatment areas Selection of product Informed patient Incremental steps in treatment Focus on facial contouring and rejuvenation Combined use of Botulinum Toxin, Fillers and Surgical Procedures Facial Distortion Filler Tear Through Under eye Filler OverRx frontalis - brow ptosis, dermatochalasis UnderRx glabella - retained corrugator function overRx periorbital area - lower lid laxity, no movement with smile OverRx perioral area - mouth dysfunction Avoid all of the above with better understanding of facial anatomy! Excess Define patient goals appropriate treatment modality Reduce facial lines Restore youthful volume Retain function and expression Enhance overall facial contours Select OverRx frontalis - brow ptosis, dermatochalasis glabella - retained corrugator function overRx periorbital area - lower lid laxity, no movement with smile OverRx perioral area - mouth dysfunction Avoid all of the above with better understanding of facial anatomy! UnderRx Careful patient selection Surgical procedures when needed Balance patient goals with treatment realities 13 8/14/13 Kimberly Reed, OD, FAAO The Obvious ¡ Blood pressure (Total, HDL, LDL, ratios) ¡ Triglycerides ¡ Blood sugar ¡ Cholesterol Vitamin B D CRP or AA/EPA Vitamin Fat molecules carry critical nutrients to end-tissues and cells ¢ ¢ Xanthophylls: Lutein, Zeaxanthin – HDL!! Other fat-soluble nutrients – LDL or saturated fats Statins may lower total cholesterol AND HDL levels Ensure your HDL is high Which nutrients, foods, or supplements can help increase HDL? Critical for energy maintenance, proper neuropsychiatric functioning, nails/skin health Things that drive your B levels down: ¡ Excessive alcohol intake digestion issues ¡ Excessive antacid use ¡ Unhealthy GI ¡ Intrinsic Things that promote B vitamin health: ¡ Adequate ¡ B12 Arachidonic What Essentially acid to EPA estimates the omega-6 to omega-3 ratios “Silent inflammation marker” Should be about 3:1 or lower Average American score is about 11:1 High levels indicate more pro-inflammatory than anti-inflammatory mediators are circulating It sleep injections or supplements is your vitamin hydroxy-D3 level? should be AT LEAST 30 Some recommend as high as 50 Supplement: 5000 IU vitamin D for 3 months, then retest Why? ¡ Depression, Skin diabetes, obesity, bone health, cancer risk cancer risk vs. adequate vitamin D levels 14 8/14/13 Proper sleep is associated with ¡ Lower risk of obesity (abdominal) ¡ Lower risk of hypertension ¡ Better nutrient profiles ¡ Higher adiponectin levels ¡ Lower ghelin levels How HCG ¡ What is it? are the claims? ¡ What is the evidence? ¡ What Nutritional drinks and shakes with “nutritional fat burners” and “appetite suppressants” much? ¡ 7 hours is minimum ¡ 7.5 is a better bet ¡ 8 is going for the gold ¡ More than 9 starts to produce diminished return “Healthy” 1 Green coffee bean? Green extract? tea? “Too much coffee is bad for you! Use moderation.” is no such thing as too much tea, however you can drink it!” “The only artificial sweetener that has not been shown to do harm is Stevia.” “There ¡ AHA National Hoodia? Raspberry alcohol consumption glass of red wine per day for women Institute on Alcohol Abuse and Alcoholism position – for women: ¡ LESS than 2 drinks per day AND than 7 drinks per week ¡ For men 4/14 ¡ Fewer Please join us today at our networking event to further discuss these topics and watch a demonstration of BOTOX injections, Permanent Liners, Skin Analysis by JNJ. Win a chair massage & Enjoy refreshments ¡ MARRIOTT MARINA BALLROOM E TODAY 4:30-6:00 If you would like to learn more about these topics, join us on the WOV Inaugural Cruise Seminar with AEA Cruise Bahamas Women of Vision Spa Cruise, 1/30-2/3/14, 4 days, Celebrity Constellation. Ft. Lauderdale, Nassau, Key West, Ft. Lauderdale. Discover the tranquility of the AquaSpa, one of the largest, most luxurious spas afloat. From $649pp. Visit http://optometriccruiseseminars.com/ 15
