Download DEWS Dry eye is not just a disease, it`s a complex, multi

6/6/2016
Dr Jack L. Schaeffer
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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.
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Age
Gender
Arthritis
Osteoporosis
Gout
Lens Surgery
Contact Lens Wear
Blink Disorders
Lid Disease
Nutritional Problems
Rheumatoid Arthritis
Thyroid Problems
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LASIK Surgery
Cosmetic Surgery
Mechanical Disturbances
Exposure Keratitis
Entropion
Ectropion
Symblepheron Formation
Large Lid Notches
Lagophthalmos
Incomplete Blinking
Dellen Formation
Illumination
Systemic Medications

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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.
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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


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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
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Examination



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
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

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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
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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
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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
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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
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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
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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
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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
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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
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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
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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


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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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