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6/6/2016 Dr Jack L. Schaeffer financial disclosure form Alcon Allergan AMO / Abbott Bausch and Lomb Ciba Vision Cooper Vision Essilor Hoya Inspire Optos Optovue Zeis Vision The Greatest Ocular Surface Disease Course: Ever Dr Jack Schaeffer Dr Whitney Hauser Underlying Causes of Dry Eye Disease DEWS Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. Aqueous Deficiency Pemphigoid Neurological Lupus Stevens-Johnson Mucin Deficiency Lipid Deficiency Inflammation Sjögren’s Syndrome Ocular Surface Disease Combination Deficiencies Factors Influencing Dry Eye Dry eye is not just a disease, it’s a complex, multifactorial disorder. Age Gender Arthritis Osteoporosis Gout Lens Surgery Contact Lens Wear Blink Disorders Lid Disease Nutritional Problems Rheumatoid Arthritis Thyroid Problems LASIK Surgery Cosmetic Surgery Mechanical Disturbances Exposure Keratitis Entropion Ectropion Symblepheron Formation Large Lid Notches Lagophthalmos Incomplete Blinking Dellen Formation Illumination Systemic Medications Time of Day Temperature Humidity Air Movement Allergies Change in Environment Reading Preservatives in Topical Eye Medications Watching Movies Sleep Prause JU, Norn M. Relation Between Blink Frequency and Break-Up Time. Acta Ophthalmol. 1983; 61: 108-116. Cho P, Cheung P, Leung K, Ma V, Lee V. Effect of Reading on Non-Invasive Tear Break-Up Time and Inter-Blink Interval. Clin. Exp. Optom. 1997; 80: 62-8. Tsubota K, Seiichiro H, Okusawa Y, Egami F, Ohtsuki T, Nakamori K. Quantitative Videographic Analysis of Blinking in Normal Subjects and Patients with Dry Eye. Arch. Ophthalmol. 1996; 114(6): 715-720. Nally L, Ousler GW, Abelson MB. Ocular discomfort and tear film break-up time in dry eye patients: a correlation. IOVS 2000; 41(4): 1436. Collins M, Seeto R, Campbell L, Ross M. Blinking and Corneal Sensitivity. Acta Ophthalmologica 1989; 67(5): 525-531. Abelson MB, Holly FJ. A tentative mechanism for inferior punctate keratopathy. Am. J. Ophthalmol. 1977; 83: 866-869. Doane MG. Dynamics of the Human Blink. Ber. Disch. Ophthalmol. Ges. 1980; 77: 13-17. Kaneko K, Sakamoto K. Spontaneous Blinks as a Criterion of Visual Fatigue During Prolonged Work on Visual Display Terminals. Perceptual and Motor Skills 2001; 92(1): 234-250. 1 6/6/2016 Dry Eye Etiology Tear Deficient Evaporative Oil Def. Lid Related Contact Lens Sjogrens Tear Film Instability Non-Sjogrens Lacrimal Lacrimal Deficiency Obstruction Surface Change Note that a patient may have one or more of these deficiencies—they are not mutually exclusive Aqueous Deficiency Reflex Autoantibodies DRUGS ASSOCIATED WITH DECREASED TEAR PRODUCTION Mucin Deficiency Cause: insufficient or unhealthy mucin production Sign: rapid tear film break-up time (TFBUT) Sign: low Schirmer (tear volume/flow) score, tear meniscus height (better measurement) NEI Workshop - Classification of Dry Eye (1995) Tear Film Instability (cont) Cause: insufficient tear production by accessory and primary lacrimal glands Lipid Deficiency Cause: meibomian gland dysfunction (MGD) causing insufficient or unhealthy lipid production Sign: irregular meibomian gland expression, fast TFBUT -Adrenergic-blocking, Anti-anginals and Antihypertensives (e.g. Atenolol, Practolol, Propranolol) Tricyclic Anti-depressants Oral Anti-histamines (e.g. Amittriptyline, Doxepin) (e.g. Loratadine, Clemastine, Hydroxyzine, Ceterizine, Fexofenidine) Alkylating Immunosuppressives Diuretics (e.g. Busulfan, Cyclophosphamide) ( Inflammation present in SS-KCS and nonSS KCS Inflammation present in lacrimal glands, conjunctiva and meibomian glands Mediated by proinflammatory cytokines in tears Delayed tear clearance accentuates effect Inflammation adversely affects neural transmission t ) PHYSIOLOGY OF THE DRY EYE Role Of Inflammation Ti Pathologic Collagen vascular diseases or Autoimmune diseases Rheumatoid Arthritis Lupus Erythematosis Sjogren’s Syndrome 0.4 % incidence 95-98% women Fibromyalgia 2 6/6/2016 PHYSIOLOGY OF THE DRY EYE Marginal PHYSIOLOGY OF THE DRY EYE Antihistamines Contact lens wear--spk Keratoconus Associated with GPC and/or blepharitis Meibomian gland dysfunction(mgd) EBMD (map-dot dystrophy) Acne Rosacea (involves mgd, blepharitis, dry eye and leads to rosacea keratitis) Diuretics Dermatologic--i.e. Accutane SSRI’S (Selective Serotonin Reuptake Inhibitors--i.e. Prozac, Paxil, Zoloft, Lexapro, (Welbutrin- to a lesser degree) SSRI/NorEpi RI Combination—ie. Cymbalta PHYSIOLOGY OF THE DRY EYE HRT INDUCED Women on estrogen therapy (HRT) had a 69% greater risk of dry eye syndrome Women on estrogen plus progesterone/progestin had a 29% greater risk of dry eye syndrome Risk of dry eye increased 15% for every three year interval on HRT 38% of Postmenopausal women in the U.S. use HRT--translates into millions of women MEDICATION INDUCED Dry Eye Evaluation Vision care Exam CONVERSION Medical Exam Brigham and Woman’s Hosp. study—Nov. 2001, JAMA 3 6/6/2016 Examination Adnexa Lids / Lid Margins Tears Conjunctiva Cornea Lid Disease EXAMINATION ADNEXA Dermatological Inflammation Dermatochalasis Rosacea LIDS/ LID MARGINS Blepharitis Lid Wiper Epitheliopathy LWE Meibomian Gland Disease MGD GPC Infectious Inflammatory Allergic Physiologic( Lagophthalmos) DIAGNOSTIC TESTS EXTERNAL EXAMINATION THE CRANIAL NERVE FUNCTION For a 7th nerve palsy w/incomplete blink on one side Leads to asymmetric dry eye or exposure keratitis THE To be covered later in presentation EXAMINATION CONJUNCTIVA Goblet Cell function (ekc/post-op) Staining Mechanical abnormalities HANDS For typical arthritic changes suggestive of Rheumatoid or Osteoarthritis Heberden’s Nodes--Nodular Swelling of Distal Joints 4 6/6/2016 EXAMINATION CORNEA The Economics of Dry Eye Disease Staining Topographical Hypoxia Secondary Infectious/Inflammatory Dystrophy Type of Exam Average Revenue Eyeglasses examination $125‐200 Contact lens examination $150‐200 Dry Eye care $300‐800 *figures based on one year The Economics of Dry Eye Disease The Economics of Dry Eye Disease Medical Office Visit: OSD Evaluation 99212 99213 99214 $48.00 $64.93 $98.65 Level of Condition Annual Direct Costs Medical Office Visit: Follow-up Mild Dry Eye $678 99212 $48.00 99213 $64.93 If you anticipate three follow-up visits during the year, here’s what the revenue would look like: Moderate Dry Eye $771 Severe Dry Eye $1276 Follow-up Revenue per Year 99212(x3) 99213(x3) $144.00 $194.79 The Economics of Dry Eye Disease DIAGNOSTIC TESTS Level of Dry Eye Disease Cost of Lost Productivity Mild Dry Eye $12,686 Moderate Dry Eye $12,569 Severe Dry Eye $18,168 TEAR EVALUATION Tear Meniscus TFBUT Osmolarity Evidence of Fluorescein Staining Tear Consistency-i.e. thickness, debris, evidence of meibomian gland oil and sebaceous secretions Shirmers 5 6/6/2016 DIAGNOSTIC TESTS Schirmer--w/ or w/o anesthetic Phenol Red Thread Test Zone Quick-represents fluid present in the conjunctival sac Zone‐Quick Red cotton thread treated with phenolsulfonphthalein ◦ Yellow (acidic) = water absorption indicator ◦ Red (basic) = tear volume indicator Fluorescein Staining Rose Bengal Staining Lissamine Green Staining Tear Osmolarity Collagen Plugs Schaeffer Shirmer Always Tear Osmolarity do this as the last test Place strip in any part of the eye Count to three remove Osmolarity Provides Improved Standard of Care • Tear osmolarity is the most accurate diagnostic test for dry eye disease • Elevated osmolarity is the central mechanism causing ocular surface damage TearLab Ocular Surface Disease UPDATE 2011 • Allows a physician to rapidly diagnose & classify patients with a global assessment – In combination with a slit lamp exam, physicians can select therapies based on mechanism of disease and severity • Modulate therapy using a quantitative endpoint Tomlinson A, IOVS 2006. DEWS Ocular Surf 2007 6 6/6/2016 New measurement options of the Keratograph 5M Meibomian Gland Evaluator (MGE™) The number of FUNCTIONAL Meibomian Glands correlates with dry eye symptoms OCULUS TF-Scan - Tear meniscus height measurement With Symptoms1 (n=133) Symptom Score, SPEED (0-28) Severe Symptoms Moderate Symptoms Minimal Symptoms ≥10 (14.4 ± 0.7) 6–9 (7.3 ± 0.2) ≤5 (2.3 ± 0.2) 0 4.1 ± 0.6 5.1 ± 0.4 6.3 ± 0.4 10.6 ± 2.6 Number of functional MGs for lower eyelid 5 • Overview of the curvature along the lid • Digital measuring of the height and automatic documentation • Automatic calibrated and digital measuring of the TMH The NIKTMH measurement can be performed under infrared light conditions now → no influences on the tear film conditions!! FUNCTIONAL MGs in the Lower Lid 0-4 Asymptomatic healthy eyes2 (n = 24 glands) 6 7 8 DRY 9 ≤ 4, treatment necessary, (if glands present) 5-6, intervention highly advised 7-9, preventive treatment (PRN) 10+ NOT DRY Notes: 1. Korb DR, Blackie CA. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Cornea. 2008;27(10):1142-1147. 2. Blackie CA, Korb DR. Recovery time of an optimally secreting meibomian gland. Cornea. 2009;28(3):293-297. 37 Lipiview B.Sc. Florian Winzig 37 Lipiview ◦ Uses interferometry to measure lipid layer thickness between blinks ◦ Quantitative assessment in interferometric color units (ICU) Dry Eye Disease Cycle of Inflammation1 InflammaDry RPS Technologies Dry eye is often hidden until patients have progressed and experienced symptoms Dry eye symptoms overlap with other ocular surface diseases, complicating diagnosis Numerous clinical diagnostics exist, with no single method preferred Most ECPs use one or multiple tests, symptom assessment and patient history to diagnose [1] Definition and Classification of Dry Eye. Report of the Diagnosis and Classification Subcommittee of the Dry Eye Work Shop (DEWS). Ocular Surface 2007;5:75‐92. 7 6/6/2016 Dry Eye Disease and MMP‐9 Dry Eye Disease and MMP‐9 Matrix metalloproteinases (MMP) are proteolytic enzymes that are produced by stressed epithelial cells on the ocular surface1 MMP‐9 in Tears Increased concentrations of MMP‐9 can be found in other diseases or conditions, including: Ocular rosacea Meibomian gland disease syndrome Corneal ulcers Corneal erosions Sjögren’s Non‐specific inflammatory marker Normal range between 3‐41 ng/ml More sensitive diagnostic marker than clinical signs1 Correlates with clinical exam findings1 Ocular surface disease (dry eye) demonstrates elevated levels of MMP‐9 in tears1 [1] Chotiakavanich S, de Paiva CS, Li de Quan, et al. Invest Ophthalmol Vis Sci 2009; 50(7): 3203‐3209. InflammaDry® Limit of Detection InflammaDry 4‐Step Process Normal levels of MMP‐9 in human tears ranges from 3‐41 ng/ml POSITIVE TEST RESULT MMP‐9 ≥ 40 ng/ml NEGATIVE TEST RESULT MMP‐9 < 40 ng/ml * * Release the lid after every 2‐3 dabs. Allow the sampling fleece to rest along the conjunctiva for 5 seconds. Patient /Busy Doctor Ocular Surface Disease Secondary to Systemic Disease 64 YOM History of Dry eye with all signs and symptoms Restasis UNG PM PP PFAT Signs / symptoms vary at each visit over a year 8 6/6/2016 Systemic Disease VITAL STAINS Diabetes Rheumatoid Arthritis Sjogren’s Causes of Clinical Dry Eye Mucin deficiency Goblet cell dysfunction Epithelial surface disease 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 Rose Bengal syndrome Thyroid Eye Disease Rosacea Sleep Apnea Graft Vs Host Disease Many others Sodium Fluorescein Same purpose as RB Less stinging Fluramene Developing a Specialty Ocular Surface Disease Practice Lid Disease Aqueous deficiency Lacrimal gland dysfunction Keratoconjunctivitis sicca Meibum deficiency Meibomian gland disease Evaporative dry eye Lid Disease We cannot treat the dry eye until we understand and treat LWE MGD Blepharitis Epihora IT IS ALL ABOUT THE LIDS Case #2 52 year old, white female Occupation: Web designer Hobbies: Pinterest on her iPad, reading, yoga Ocular history: Dry Eye Disease, mild cataracts Medical history: Occasional migraine headaches, mild hypertension Meds: Lorazepam, Cymbalta, flax seed oil 9 6/6/2016 Case #2 Case #2 Complaint Dry symptoms worsening, “OTC’s don’t work,” Associated symptoms Effect to ADL’s Eye fatigue, discomfort, worsening in the evening, often matted Effects work, limits reading Medications for DED Similasan “Dry Eye Relief” (has used “all” artificial tears), warm compresses, cold packs cc DVA 20/20 OD 20/20 OS EOMs FROM OU Pupils ERRL(‐)APD SPEED 14/28 OSDI 54/100 Inflammadr Negative y NIKBUT 4.72 OD 4.33 OS (initial) Osm Case #2 294 OD 277 OS Microscopy Visit 3: ◦ Patient reports significant improvement and relief ◦ ADL’s not effected at the end of the day ◦ Continuing Cliradex qhs OU and Systane Balance QID OU ◦ Switching to Avenova BID OU in 2 weeks Demodex visible at slit lamp ◦ Cylindrical dandruff ◦ Base of lashes Microscopy for patient education Microscopy Microscopy Epilation maneuver Plate to slide Rotation is key Observe under lower magnification Increase magnification Photograph 10 6/6/2016 Demodex • Ubiquitous obligatory ectoparasites of man • Two forms: D. brevis and D. folliculorum • Lifecycle of 14.5 days • Negatively phototaxic • Move in dark environment, stop with Demodex • 84% of patients at 60, 100% over 70 • Increased incidence with: • Age • Immunocompromised • Skin disorders (Rosacea) • Eye environment- increased pH and amino acids bright ones Lacey N et al. Demodex Mites – Commensals, Parasites or Mutualistic Organisms? Dermatology 2011;222:128–130 61 Demodex • Blepharitis secondary to demodex consuming epithelial cells • Micro-abrasions causes reactive hyperkeratinization which leads to cylindrical dandruff Lacey N et al. Demodex Mites – Commensals, Parasites or Mutualistic Organisms? Dermatology 2011;222:128–130 62 Demodex Treatment • 50% TTO in-office weekly, 10% TTO wipes bid OU • 5% TTO ointment massage Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in Demodex Blepharitis J Korean Med Sci. Dec 2012 27(12), 1574-9. Liu J et al. Pathogenic role of Demodex mites in blepharitis Curr Opin Allergy Clin Immunol. 63 Oct 2010; 10(5): 505 510 Gao YY et al. Treatment of Ocular Itching Associated With Ocular Demodicosis by 5% Tea Tree Oil Ointment. Cornea. Jan 2012: 31(1), 1464 17 Demodex Treatment • Commercially available: • Cliradex- 25% TTO wipe • OcuSoft Demodex kit (for in-office) 65 6 6 11 6/6/2016 BlephEx Treatment OcuSoft Tea Tree Kit • Contains Tea Tree Oil + Buckthorn seed oil • Ung QHS • OcuSoft Cleansers 67 6 8 Lid Hygiene – Surgical Considerations Types of Blepharitis: ◦ Anterior ◦ ◦ ◦ ◦ Staphylococcal Seborrheic Demodex Angular ◦ Posterior ◦ Meibomian Gland Dysfunction (MGD) 6 9 Baby Shampoo…..really a myth 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 Case #1 84 year old, white, female (+) severe dry eye for 1 year Oral Medications: ◦ Metformin ◦ Lisinopril ◦ Glyburide ◦ Lovastatin ◦ Sertraline ◦ ASA ◦ Glucosamine 12 6/6/2016 Case #1 Complaint Associated symptoms Effect to ADL’s Medications for DED Case #1 Chronic dryness, increasing for 1 year Fluctuating vision, photophobia Unable to read, cannot go outside comfortably Restasis BID, Non‐preserved Systane, doxycycline 100mg BID, Omega 3FA cc DVA 20/100 OD 20/200 OS EOMs FROM OU CFV FTFC OD, OS Pupils ERRL(‐)APD SPEED 22 OSDI 75 Osm 301 OD 321 OS Inflamm Negative adry Case #1 Case #1 Diagnosed with glaucoma in 1970’s Instilling 2 glaucoma medications ◦ Latanoprost qhs OU ◦ Brimonidine BID OU Case #1 Case #1 Treatment: Follow up examination ◦ Lipiflow treatment – begin Acuvail bid for 2 weeks, then qd for 2 weeks ◦ Lid hygiene – Cliradex wipes bid x 10 days then qhs for 20 days ◦ “Good days and bad days” ◦ Dryness less of a problem since treatment and vision is improving ◦ Able to read the newspaper ◦ RTC 4‐6 weeks 13 6/6/2016 Case #1 Case #1 cc DVA 20/60 OD (PH: 20/30) 20/100 (PHNI) EOMs FROM OU Patient returned for PROKERA® at follow‐up visit. S/p removal of amneotic membrane results: cc DVA CFV FTFC OD, OS EOMs PUPILS ERRL(‐)APD CFV FTFC OD, OS SPEED 14 PUPILS ERRL(‐)APD OSDI 62.5 SPEED 8 Osm 308 OD 308 OS OSDI 30 Osm 312 OD 306 OS Sutureless Amniotic Membrane ProKera – Amniotic Membrane for wound healing Biological Scaffolding Cryopreserved Bio Optix 20/60 OD (PH: 20/30) 20/50 (PH: 20/30) FROM OU Dry Membrane Helps initiate an active healing process by providing proteoglycans and growth factors Collagens, fibronectin and lamillin Cryopreserved membrane contains heavychain hyaluronic acid Inhibits proinflammatory cells Suppress T Cells Sutureless Amniotic Membrane Persistent Corneal Defect Recurrent Cornea Erosion Corneal Ulcer Pterygium Graft Bullous Keratopathy Band Keratopathy ProKera – Amniotic Membrane for wound healing Corneal Ulcer Bullous Keratopathy Folds in Descemet’s Chemical Burns Mechanical Complications 2ary to graft Disruption of surgical wound Non-healing surgical wound 14 6/6/2016 Inflammation is the Hallmark of All Ocular Surface Diseases The Amniotic Membrane • • The amniotic membrane is the innermost lining of the placenta (amnion) Amniotic membrane shares the same cell origin as the fetus • • Ocular Surface Disease Stem cell behavior Structural similarity to all human tissue Corneal Inflammation Conjunctival Inflammation Keratitis Inflammation’s Effect on Healing Inflammation: the first sign of wound healing & is also the hallmark symptom of all ocular surface diseases Uncontrolled inflammation leads to: Chronic pain and discomfort/irritation Delayed healing, more tissue damage Vision-threatening complication, e.g., scar/haze Effective control of inflammation is an important strategy to promote healing and minimize the risk of scar/haze Non-Resolved Inflammation Conjunctivitis Blepharitis PROKERA®: BIOLOGIC CORNEAL BANDAGE Tissue Damage Eyelid Inflammation PROKERA® utilizes the proprietary CryoTek™ cryopreservation process that maintains the active extracellular matrix of the amniotic membrane which uniquely allows for regenerative healing. PROKERA® is the only FDA-cleared therapeutic device that both reduces inflammation and promotes scar less healing PROKERA® can be used for a wide number of ocular surface diseases with severity ranging from mild, moderate, to severe Controlling Inflammation is Key to Preventing Tissue Damage! Insertion of Pro-Kera Remove from inner pouch Rinse with saline (prevents stinging from preservation media Apply topical anesthesia Hold upper lid and have patient look down Insert into superior fornix Slide under lower eyelid Check for centration Devries Amniotic Membrane VEE 2016 15 6/6/2016 BRUDER Dry Heat Glass Bead Sanitizer Suitable for all metal instruments including the Bruder Meibomian Gland Expression Instruments Fast acting and easy to use: • Chamber size: : 1 5/8" Diameter x 2 1/2" Deep. • Chamber with glass beads heats to 250 °C in approximately 30 minutes • Sanitizes in 30 seconds • Electrical Item #98201 Replacement Beads. Contain 2 refills. Item #98200 Sanitizer with 1 bag of glass beads. NOTE: Glass Beads Sanitizers are not FDA approved as sterilizers. Glass Bead sanitizers are a quick, easy and accurate alternative to traditional methods of sterilization and sanitizing. Meibomian Gland Expression Offering BRUDER Surgical Instrument Line Bruder Instrument Trays Autoclavable instrument trays are ideal for instrument storage or transport. Available in two convenient sizes. Item #98610 COLLINS Expressor Forceps GERMAN STAINLESS For mild to aggressive expression of Meibomian gland. 95mm Forceps with closed paddles COLLINS Forceps Item #98301 Instrument Tray Large ‐ 4” 4" x 6 1/2" x 3/4" Item #98300 Instrument Tray Small – 2 1/2” 2 1/2" x 6" x 3/4" Item #98620 LIVENGOOD Expressor Paddle ‐ Angled GERMAN STAINLESS For mild or gentle expression of the Meibomian gland. 75mm oval blades with 12 degree angle. Non‐slip knurled handle. Item #98630 LIVENGOOD Expressor Paddle – Straight GERMAN STAINLESS For mild or gentle expression of the Meibomian gland. 75mm flat oval blades. Non‐slip knurled handle. Specialty Instrument Offering BRUDER Surgical Instrument Line Item #98650 BRUDER Epilation Forceps These forceps feature non‐slip jaws/tips and an easy‐grip, no slip handle for precise eyelash removal. German stainless. Item #98651 KARPECKI Punctal Plug Forceps This instrument has a groove on the inside tip to hold the plug solidly in place during the procedure. Also if necessary the instrument can be turned 90 degrees to a flat side to push the plug into place. German stainless. Item #98652 KARPECKI Bandage Lens Forceps This instrument has a narrow, but rounded tip. The application of a special coating instead of serration assures the bandage will not slip when being removed. Slide the forceps under the edge of the bandage lens and easily pick it off the eye. German stainless. Item # 98653 KARPECKI Debrider The instrument has a slightly curved tip with a “crisp” edge on both sides. The edge is just right to remove the keratin easily by sliding the instrument, curve forward, along the eyelid in a single direction. German stainless. LIVENGOOD Forceps can be used together or in tandem. Sold separately. Popular Jeweler Forceps BRUDER Surgical Instrument Line Item #98703 BRUDER Jeweler Forceps 3 Item #98704 BRUDER Jeweler Forceps 4 Item #98705 BRUDER Jeweler Forceps 5 Item #98707 BRUDER Jeweler Forceps 7 Bruder Surgical Instruments ship in storage cases. 16 6/6/2016 Sjö Testing - Research 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: 26% of DED patient have autoimmune disease 11% have Sjögren’s syndrome Average delay of 10 years in receiving an accurate diagnosis Common Complaints: Respiratory dysfunction Renal dysfunction Lymphoma Dry eye Dry mouth Fatigue Joint pain Akpek EK, Klimava A, Thorne JE, et al. Evaluation of patients with dry eye for presence of underlying Sjögren Syndrome. Cornea. 2009 Jun;28(5):493-7 Sjö Testing - Research Sjö Testing - Clinical Cataract Surgery risks: Combines 4 traditional biomarkers with 3 novel, propriety biomarkers Helps detect Sjögren’s syndrome early in its disease course Offers significantly higher sensitivity and specificity than previous screening methods SPK Filamentary keratitis Lasik surgery risks: Severe and difficult-totreat dry eyes Conjunctivitis Refractive regression Infectious keratitis Recurrent epithelial defects *Some case reports note good safety and refractive stability Stromal keratolysis Corneal ulceration Complications occur more commonly with ECCE than phacoemulsification Aggravated dry eye after laser in situ keratomileusis in patients with Sjögren syndrome. Liang L, Zhang M, Zou W, Liu Z Cornea. 2008 Jan; 27(1):120-3. Advanced Recalcitrant PEK CONFIDENTIAL Autologous Serum Amniotic Membrane 101 17 6/6/2016 Autologous Serum Contains Epithelial Growth Factor (EGF) Transforming Growth Factor 8 (TGF8) Fibronectin Vitamin A Other Cytokines Autologous Serum Blood Draw at Lab Spin down to plasma @4000 rpm for 20 minutes Deliver to Compounding Pharmacy 2:1 Filtered Compounding with BSS 8 Bottles Frozen until used Autologous Serum 1 gtt q2h from morning until bedtime Keep Vial Refrigerated Keep Additional Vials Frozen Until Use 8 Straight Weeks Evaluate After 6-8 Weeks Possible Additional Course Autologous Serum Cost Lab Draw $30 Compounding Pharmacy $120 $150 for 8 Vials IF Patient delivers Serum to Pharmacy Autologous Serum Cost Lab Draw $30 Compounding Pharmacy $120 Virology Testing $210 Freeze and Shipment To/From Compounding Pharmacy Approximately $450 to $550 for 8 Vials SCLERAL LENSES 18 6/6/2016 Punctal / Lacrimal Occlusion LACRISERT® Rationale for occlusion therapy: Diminishes tear drainage from the ocular surface Enhances contact time between tears & ocular surface Utilizes “normal tears” Natural complement of proteins, enzymes, buffers, etc. Multiple modalities, manufacturers, products Collagen, silicone, acrylic polymers Intracanalicular vs. punctal occlusion (hydroxypropyl cellulose ophthalmic insert) A Novel Approach to Treating Dry Eye Syndrome Please see full Prescribing Information. LACRISERT (hydroxypropyl cellulose ophthalmic insert) Case #3 Indicated in patients with moderate to severe dry eye syndrome (DES), including keratoconjunctivitis sicca. Indicated especially in patients who remain symptomatic after an adequate trial of therapy with artificial tear solutions. Indicated for patients with exposure keratitis, decreased corneal sensitivity, and recurrent corneal erosions. 68 year old, white male Hospital‐based medical researcher Ocular history ◦ (+) Dry Eye – irritated, red, gritty OU ◦ (+) POAG OU ◦ (+) Retinitis pigmentosa OU Medical history ◦ Rosacea ◦ High cholestrol ◦ Osteoarthritis Lacrisert [package insert]. Aton Pharma, Inc.: Lawrenceville, NJ; 2007. MGD Case #3 Meibomian Gland Dysfunction cc DVA 20/60 OD 20/70 OS EOMs FROM OU Pupils ERRL *corectopia OS SPEED 28/28 OSDI 100/100 Inflammadry Negative NIKBUT (initial) 6.33 OD 5.41 OS Osm 311 OD 290 OS 19 6/6/2016 Meibomian Gland Dysfunction Level one Treatment: Available to all Doctors Medical : In office and home Procedures Meibomian Gland Dysfunction 1 Manual Expression 2 Miboflow 3 Lipiflow Level two Treatment: Specialized equipment needed 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 Meibomian Gland Dysfunction • The TFOS Report of the International Meibomian Gland Dysfunction Workshop – Etiologies – Definition/ Classification – Epidemiology – Clinical characteristics – Diagnosis/ Management – Contact lenses, surgical implications ©KNichols 2012 Current Dry Eye Definition “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 20 6/6/2016 DEWS—Classification of Dry Eye 20% 5% 65% TFOS International MGD Workshop 35%80% • 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 ©KNichols 2012 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 ©KNichols 2012 21 6/6/2016 Meibomian Gland – PATHOLOGY • Obstructive MGD leads to a progressive ductal DILATATION and acinar ATROPHY 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. Fom Knop E & Knop N. Meibom-Drüsen Teil IV. Funktionelle Interaktionen in der Pathogenese der Dysfunktion (MGD). Ophthalmologe.2009;106:980–987 ©KNichols 2012 Management and Therapy of Meibomian Gland Dysfunction 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. ©KNichols 2012 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. 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 MGD Exposed A new look at an old problem The prevalence of MGD is as high as 60-70%1,2 MGD is frequently nonobvious and therefore missed3 Under-Treated Meibomian Gland Dysfunction Meibomian lipids are critical for innate tear film host defense4 MGD decreases corneal adhesiveness5 Pretreatment optimizes post-cataract surgery ocular comfort 6 Evaporative stress causes MGD7 (Modern lifestyle, Contact lens wear and Chronic use of topical medications all induce evaporative stress) MGD is progressive: Early intervention optimizes outcomes8 How treating MGD improves your practice Identify early compromise to MG function and structure with the MGE and DMI9 1. 2. 3. 4. 5. 6. 7. 8. 9. 040215 Foulks GN1, Nichols KK, Bron AJ, Holland EJ, et al. Improving awareness, identification, and management of meibomian gland dysfunction. Ophthalmology. 2012 Oct;119(10 Suppl):S1-12. M urakami DK, Blackie CA and Korb DR. The Prevalence of Meibomian Gland Dysfunction in a Caucasian Clinical Population. ARVO abstract 2015 Blackie et al. Nonobvious M GD. Cornea. 2010 Dec;29(12):1333-45. M udgil P. Antimicrobial role of human meibomian lipids at the ocular surface. Invest Ophthalmol Vis Sci. 2014 Oct 14;55(11):7272-7. Napoli PE, Coronella F, Satta GM, et al. Evaluation of the adhesive properties of the cornea by means of optical coherence tomography in patients with meibomian gland dysfunction and lacrimal tear deficiency., PLoS One. 2014 Dec 23;9(12):e115762. Jackson et al. Evaluation of Thermal Pulsation Treatment for Meibomian Gland Dysfunction in Cataract Surgery Patients ASCRS 2015 Suhalim JL, Parfitt GJ, Xie Y, et al. Effect of desiccating stress on mouse meibomian gland function. Ocul Surf. 2014 Jan;12(1):59-68. Holland et al. Patient Characteristics Associated with Improved Meibomian Gland Function after Thermal Pulsation Treatment for M eibomian Gland Dysfunction. ASCRS 2015 Grenon, Liddle and Grenon et al. A Novel M eibographer with Dual M ode Standard Noncontact Surface Infrared Illumination and Infrared Transillumination. ARVO 2014 132 22 6/6/2016 An Unstable Tear Film Negatively Impacts Premium Quality Vision Care Lipids Essential to Stable Tear Film 86% of dry eye patients have MGD1 causing instability Meibomian Glands Fluctuating Vision Ocular Discomfort Compromised Barrier to Infection1 Lipid Anatomical Aqueous Lacrimal Gland 63%+ of Cataract Patients (PHACO study results) Contact Lens Intolerance and LASIK Candidates Glaucoma and Retinal Patients Mucin Goblet Cells Unstable Tear Film Tear Clearance & Spread Lid Blinking Sensory Motor Lid Closure Evaporation 1Antimicrobial role of human meibomian lipids at the ocular surface. Mudgil P. Invest Ophthalmol Vis Sci. 2014 Oct 14;55(11):7272-7. 1. Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012;31(5):472-478. 134 133 Focus on the Gland Meibomian Gland Function “Meibomian Gland Dysfunction (MGD) is a chronic, diffuse abnormality of the Meibomian Glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion.” • A functional Meibomian Gland is a gland that releases its liquid contents during a deliberate blink. • The number of functional MGs along the lower eyelid can be used to diagnose MGD and to direct therapeutic intervention FUNCTIONAL MGs in the Lower Lid 0-4 Normal Structure Normal Function 5 6 7 DRY Function Structure 8 9 10+ ≤ 4, treatment necessary, (if glands present) 5-6, intervention highly advised 7-9, preventive treatment (PRN) NOT DRY When the total number of functional glands is 10 or higher, but there is evidence of compromise to gland function and/or structure, therapy should still be considered. Notes: Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for Meibomian gland dysfunction. Finis D, Pischel N, Schrader S, Geerling G. Cornea. 2013 Dec;32(12):1549-53. Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Korb DR, Blackie CA. Cornea. 2008 Dec;27(10):1142-7. Notes: The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Geerling G, Tauber J, Baudouin C, et al. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):2050-64 135 136 MGD is Progressive The Cycle of Inflammation Examples of Compromised Function and Structure Normal Function Nonobvious MGD Obvious MGD Stasis, inspissation and obstruction of the Meibomian Glands Meibomian Gland Dysfunction (MGD) Obvious MGD Function Decrease in Meibomian secretions Decrease in tear film stability, increased aqueous tearing1 Gland Duct Dilation & Drop Out Gland Truncation & Drop Out Gland Duct Dilation, Truncation & Drop Out Symptoms Increase Normal Structure Structure Increase in evaporative stress Ocular surface exposure (between blinks) & Micro-trauma (during blinking) Inflammation Notes: Siak JJ, et al. Prevalence and risk factors of meibomian gland dysfunction: the Singapore Malay Eye Study. Cornea. 2012;31(11):1223-1228. Viso E, et al. Prevalence of asymptomatic and symptomatic meibomian gland dysfunction in the general population of Spain. Invest Ophthalmol Vis Sci. 2012;53(6):2601-2606. Hom MM, et al. Prevalence of meibomian gland dysfunction. Optom Vis Sci. 1990;67(9):710-712. Tissue Changes 137 Potential Long-term Damage 1. Arita R, et al. Increased Tear Fluid Production as a Compensatory Response to Meibomian Gland Loss: A Multicenter Cross-sectional Study. Ophthalmology. 2015 Jan 24. pii: S0161-6420(14)01195-6. doi: 10.1016/j.ophtha.2014.12.018. [Epub ahead of print] 138 23 6/6/2016 MGD First: If the etiology is not treated, the Dry Eye will not resolve A Change in Philosophy – MGD First Dry Eye Approach • • • • Wait for the onset of sequelae: The patient tells you there is a problem Measure and manage dry eye sequelae Lead with palliative artificial tears Gradually advance treatment as sequelae increase in severity1,2 MGD First does not mean that the sequelae of dry eye should be ignored. MGD First/Root Cause Approach Evaluate everyone for MGD: Identify MGD at its earliest stages Educate patients about the front line of defense of the tear film – the lipid layer Offer the most efficacious MGD treatment as early as possible Rehabilitate the ocular surface and manage sequelae with adjunctive therapy • • • • IDENTIFY AND TREAT THE CAUSE MOST COMMON MGD + MEASURE AND MANAGE DRY EYE SEQUELAE TREATMENT LipiFlow/ Manual Expression, Warm Compress, lid hygiene, Blinking, Lipid Drops Topical & Systemic Medications SYMPTOMS VISION TEAR INSTABILITY Goal: Treat Sequelae (primarily symptoms) • Root cause is not identified: Promotes confusion, and patient despair OCULAR SURFACE DAMAGE Goal: Restore and optimize gland function/intervene in progression • Compromised Lacrimal Function Promotes patient and physician confidence in MGD management. Allergy, Autoimmune Notes: 1. Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye WorkShop. Geerling G et al. Ocular Surface. 2007 Apr;5(2) 163-178, 2. The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Geerling G, Tauber J, Baudouin C, et al. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):2050-64 HYPEROSMOLARITY Treat Accordingly INFLAMMATION Treat Accordingly 139 140 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. MGD Medical treatment 142 141 Mild/Acute • • • • Hot compresses Lid hygiene Lipid based tears-mild/moderate Osmolarity lowering drops in moderate/severe 144 24 6/6/2016 Moderate/Acute • Tobradex ST • Zylet • AzaSite • Tobradex generic Moderate/severe or not improving • Add PO tetracycline • Recommendation: • Doxycycline 50mg bid x 4-8 weeks then taper to qd • Periostat (20 mg doxycycline) bid • OcuSoft: ALODOX – generic 20 mg Contraindications • Pregnant or child bearing age • Children Long Term • Pulse dose medications periodically • Restasis bid • Essential fatty acids – EPA – DHA – GLA Tetracyclines • Antibiotics inhibit bacterial protein synthesis by binding 30S ribosome • Anti-inflammatory properties – decreases IL-1, TNF- – decreases NO production – decreases HLA Class II antigen expression – decreases metalloproteinase production and activation • Decrease symptoms and joint destruction in RA Cautions • Photosensitivity • Chelates with dairy products, antacids etc. • Minocycline may cause vestibular toxicity • Number one drop-out reason? • GI problems 25 6/6/2016 How to Minimize Stomach Problems with Tetracycline MGD 1. Do not take the second pill (bid) before going to bed 2. Do not take pills with acidic beverages 3. Take pills with food (except a high dairy meal) 4. Prescribe the lowest dose available Medical-Instrument Treatment 152 Treatment of MGD/NOMGD New! Ophthalmic Surgical Instruments Collins Expressor Forceps (Item 98610) At Home Therapy For aggressive expression of the Meibomian gland. – Warm compresses – Eyelid Scrubs – Self expression In-Office Therapy Livengood Expressor Paddles Manual Expression Off-Label Pharmacotherapy Angled (Item 98620) & Flat (Item 98630) For mild or gentle expression of the Meibomian gland. Oral tetracycline/doxycycline Topical Antibiotics – erythromycin, tobramycin Topical Steroids – dexamethasone 153 Maskin Expressor $ 575 Rhein Medical 26 6/6/2016 Meibomina Gland Expression WARNING Hot compresses can change the corneal tissues and structure Schaeffer Eye Protocol OSD Evaluation 1) 1) Possible Link to Keratoconus Evidence Based Medicine 2) 2) Includes test expression All staining RTC expression At home heat with eye medibeads 15-20 minutes in waiting room with Bruden’s heat pack ( or rear wait) 3) Expression 1 of 3 4) RTC 2 weeks 1) 2) Meibomian Gland Expression Fees: $289 / $25 Out of pocket: ABN Covers 3 Office visits $68.00 Per visit after initial three visits MGD Maskin Expressor 99213 / 99212 Dry eye progress check before expression Maskin Probe 1)$ 158 box ( 10) 2) 1,2,4,6 MM intraductals Maskin Tube 3) Aluminum Handle $104 Meibomian gland Drug delivery system 27 6/6/2016 OBSTRUCTIVE MGD Warm Compress Treatment Maskin Probe Increase in LLT Following Treatment with Warm Compresses in Patients with MGD Leiter Pharmacy 8% lidocaine with 25% Jojoba in ung base Olson, Korb, Greiner, Eye & CL, 2003 Baseline LLT 5 minutes 15 minutes 30 minutes = 60 nm = 105 nm = 117 nm = 122 nm Not published: 1 to 2 mins – minimal or no improvement Warm Compresses: Olson et al., 2003: Matsumoto et al., 2006 Warming devices : Goto et al., 2002; Mori et al., 2003; Nagymihalyi et al., 2004; Mitra et al., 2005; Di Pascuale et al., 2005; Spiteri et al., 2007 Standard Patient Evaluation of Eye Dryness (SPEED) Questionnaire Meibomian Gland Evaluator™ (MGE) • The TearScience® Meibomian Gland Evaluator • 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® – Applies consistent, moderate pressure • Between 0.8 g/mm2 and 1.2 g/mm2 – Allows evaluation of secretions from Meibomian gland orifices through a slit lamp biomicroscope Grade Secretion Characteristics 3 Clear liquid oil 2 Colored/cloudy liquid 1 Inspissated (toothpaste consistency) 0 No secretion (includes capped orifices) 166 Indications for Use Meibomian Gland EvaluatorTM LipiView® Ocular Surface Interferometer • Intended for use by a clinician to evaluate meibomian gland secretions. Used to apply consistent light pressure to the outer eyelid skin of a patient while visualizing secretions from meibomian gland orifices through a slit lamp biomicroscope. • An ophthalmic imaging device intended for use in adult patients by a clinician to capture, archive, manipulate and store digital images of specular (interferometric) observations of the tear film, which can be visually monitored and photographically documented. • NO KNOWN CONTRADICTIONS • NO KNOWN CONTRADICTIONS Tear Conservation 167 28 6/6/2016 Categories of Lubricant Eye Drops Therapeutic Approaches Stabilize the tear film (subjective) Cellulose Derivative Products Increase lubricity decrease coefficient of friction Glycerin Containing Products Increase aqueous production Lipid Based Emulsion Products Decrease inflammation Polyethylene Glycol and Propylene Glycol Products Create a more normal tear film environment for epithelial healing Tear Conservation: Surgical Intervention Tear Conservation- Therapeutics Artificial tears Ointments Steroids Cyclosporine Doxycycline Lacriserts Lid disease therapy Glasses Sunglasses Punctal occlusion Lateral tarsorrhaphy Other procedures Ectropion correction Restasis™ Lifestyle Adaptations: Increase humidity Wear eye shield or goggles Avoid: wind, air conditioning, dry heat, high altitudes smog, exhaust, smoke prolonged computer use contact lens wear medications that contribute to KCS Sunglasses Ophthalmic emulsion of cyclosporine 0.05% Unique emulsion technology provides effective drug delivery to ocular tissue at low cyclosporine concentrations Cyclosporine is a complex molecule with antiinflammatory and immunomodulatory properties. In Inhibits T-cell mediated inflammation and cytokine driven inflammatory cell chemotaxis the eye: Restasis™ increases production of natural tears increases goblet cell density 29 6/6/2016 How Does Restasis Work? Restasis™ Dosing: BID Recommended Restasis™ regimen: 1 drop in each eye every 12 hours Concomitant Restasis™ prevents T-cell activation (Kunert et al, Arch Ophthalmol. 2000;118:1489) therapy Clinical study showed Artificial tears excellent adjunct Additional emulsion may be poorly tolerated Contact Inform patients: do not use “as needed” like traditional drops Activated T cells produce inflammatory cytokines that result in: Recruitment of more T cells (Stern et al, IOVS. 2002;43:2609) More cytokine production (Pflugfelder et al, Curr Eye Res. 1999;19:201) lens users Remove lenses, administer Restasis, replace lenses after 15 minutes 1 DOXYCYCLINE Steroids and Dry Eye Symptomatic improvement in irritation symptoms in 83% and objective improvement ( redness, dye staining and tarsal papillae, FTC) in 80% of 70 patients treated for 2 weeks with non-preserved methylprednisolone SIDE EFFECTS NVD, anorexia, dysphagia, severe photosensitivity, superinfection (fungus, vaginal candidiasis) benign IC-HTN, hepatoxicity, pancreatitis Prabhasawat & Tseng BJO 1998 Alodox 20 mg Doxycyline Hyclate Sub-antimicrobial dosage (<50mg) Enzyme modulation of inflammation By OCuSOFT Kit comes with lid scrub foam Claims to be a more potent collagenase inhibitor than minocycline and therefore less SE Long term use WARNINGS drink fluids to prevent esophagitis, use sun block, simultaneous ingestion of food OK. Link to Breast CA? ALTERNATIVES Tetracycline qid Minocycline $$ ALODOX ONCE DAILY DOXYCYCLINE Great for long term usage once controlled Blepharitis, dry eye, rosacea Brand Name Oracea® 40mg Long term –cycline therapy associated with pseudotumor cerebri TCN, Doxycycline, Minocycline 30 6/6/2016 Contraindications Pregnant Cautions Photosensitivity or child bearing age Chelates with dairy products, antacids etc. Minocycline may cause vestibular toxicity Children How to Minimize Stomach Problems with Tetracycline Omega-3s and Omega-6s: Essential Fatty Acids 1. 2. 3. 4. Do not take the second pill (bid) before going to bed Do not take pills with acidic beverages Take pills with food (except a high dairy meal) Prescribe the lowest dose available Omega-3 Essential Fatty Acids Essential fatty acids Optimum Omega-6:Omega-3 ratio for good health varies from 3:1 up to 1:1: Ratio in current American Diet is about 1:10 American diet too high in Omega-6s from dairy products, beef, vegetable oils, shortening American diet too low in Omega-3’s from salmon, cold-water fish, krill oil, flaxseed, walnuts, dark green leafy vegetable, beans LWE Omega-3’s American diet has undergone a 6-fold reduction in Omega-3’s since 1850 Increases “good” prostaglandins Inhibits “bad” prostaglandins Lid Wiper Epitheliopathy Omega 6’s US consumption of this fatty acid has doubled from what it was in 1940. Excess intake can increase water retention, raise blood pressure and increase blood clotting. 31 6/6/2016 © THE LID WIPER DEFINED Ocular surface That aspect of the marginal conjunctiva of the upper eyelid that wipes the ocular surfaces during blinking 16 M LID WIPER & AUTOMOBILE WINDSHIELD WIPER Width = .4 to .6 mm LID WIPER Ocular Surface Windshield Wiper Korb et al., 2002-2005 Windshield Wiper Clearance Space Kessing’s Space 16 M LID WIPER EPITHELIOPATHY DEFINED LWE is any compromise of the squamous epithelial cells or the protective coatings of the Lid Wiper A cascade of sequelae will follow 32