Dry eye syndrome in steps

Transcription

1 4 Dry eye syndrome in steps Detection, invasive and non-invasive evaluation, and action to deal with eye dryness. Guidelines for optometrists treatment of patients of dry eye syndrome

2 We would like to express our thanks to Dr. Mª Assumpta Peral Cerdá from the Faculty of Optics and Optometry at the Complutense University of Madrid, and to Ramon Solà Parés, head of the Clinical Contact Lens Unit at the Advanced Ophthalmology Department, for the cooperation provided.

3 What syndrome? is dry eye Eye dryness is a multi-factor condition of the tear and eye surface which manifests in symptoms of discomfort, vision problems and instability in the tear film with potential damage to the eye surface. It is accompanied by an increase in the osmolarity of the tear film and the inflammation of the eye surface [...]. It is often associated with a decrease in tear production or an increase in tear evaporation (according to DEWS, 2007). 1 º Instability of the tear film 4 º Damage to tissue 2 º Increase in osmolarity 3 º Inflammation

4 1STEP DETECTION Gathering and evaluating symptoms. Medical history. Dry eye syndrome may be caused by multiple factors, many of these associated with patient lifestyle and environment. And that is why it is important to build up an accurate medical history to establish the causes of the problem and be able to provide the most appropriate diagnosis and treatment. It is important to have an informal chat with the patient regarding his/her habits, the subjective symptoms he/she is suffering from, the level and frequency of discomfort, and whether the patient presents any systemic condition (such as diabetes, rheumatoid arthritis, etc.), associated with eye dryness. During this chat we can also observe how often the patient blinks (a normal value would be around 15 blinks per minute), and whether the eyelid closes completely. Following this preliminary meeting it is advisable to formally record the answers to these questions. This will help us to monitor how the condition progresses and be able to assess, through an initial approximation, the level of dry eye syndrome suffered by the patient. There are surveys that have been recognised by the scientific community and which are available

5 to all healthcare professionals: OSDI test, McMonnies, DEQ-5, SPEED. Reducing symptoms and bringing about relief is the primary aim of the optician/optometrist. Often the patient s subjective feeling of discomfort goes far beyond the clinical signs it presents. As a result it is particularly necessary to continue with the procedure to assess signs of eye dryness in order to arrive at the most appropriate diagnosis. TIP Establish a procedure and gather symptoms methodically, recording the results. OUR SUGGESTION Carry out a brief questionnaire with the patient regarding his/her symptoms: - Do you feel eye discomfort? - Do you have weepy eyes? - Does your vision fluctuate, especially in dry surroundings? - Do you use eye drops? In the event of an affirmative reply to any of the above questions, add one further question: - Do you have a dry mouth? If the patient answers any of these questions in the affirmative, it is advisable to: 1. Go into the medical history in greater depth. 2. Record the patient data. 3. Evaluate any possible risk factors (age, medication, systemic conditions, etc.) 4. Carry out a patient symptom questionnaire (OSDI, McMonnies ) to establish the level of eye dryness. 5. Make a record of the frequency with which symptoms appear, and whether they do so sporadically or continuously. Follow this procedure with the evaluation of signs of the condition through diagnostic tests. (According to the Canadian Journal of Optometry. Vol. 76. Suppl. 1, p 6.)

6 2STEP EVALUATION OF SIGNS USING NON-INVASIVE TECHNIQUES Diagnostic tests using non-invasive techniques. One of the parameters which is affected in cases of dry eye syndrome is visual acuity. This should be borne in mind when embarking on the evaluation. A large number of tools exist which help in assessing the signs of dry eye syndrome, but the one that is most widespread with optometrists is the slit lamp, and as such deserves a separate mention. OBSERVATION USING A SLIT LAMP Below we provide a suggestion of a logical order of exploration in order to avoid any test contaminating the results of the subsequent tests: 1. Estimate the height of the lower tear meniscus in order to assess the individual s volume of basal secretion and identify whether it is normal or below average. This test should be carried out at the beginning of the evaluation, in the interest of not dazzling the patient s pupil, or for a reflex tear secretion to be produced. Normal values lie between 0.2 and 0.4 mm (according to Shen M, Li J, Wang J, et al. 2009). Inexistent meniscus Low level of meniscus Average meniscus Normal meniscus 2. Evaluation of eyelashes and eyelids through visual exploration: Pay particular attention to the presence of flaking skin at the base of the eyelashes, which may point to blepharitis.

7 Observe the regularity of the palpebral edge or margin and assess the possible presence of blood vessels. It is normal for the edge to be regular, with neither swelling nor the presence of blood vessels. Observe the exit orifices of the Meibomian glands, whether or not they are visible and whether they present any kind of clogging. 3. Evaluation of integrity of the conjunctiva and cornea. Observation and annotation of the extent of conjunctival reddening. Quick tear evaporation may cause conjunctival reddening. Check presence of any conjunctival elevation with diffuse illumination or otherwise using the minimum setting on the slit lamp to superimpose the ray of light on the conjunctiva. Elevations in the conjunctival tissue, whether as a result of a pathology or due to some traumatism, generate an area of dryness on the eye surface. Conjunctival elevation Conjunctival elevation seen in section Corneal opacity adjacent to conjunctival elevation Analyse integrity and regularity of the cornea and its transparency at first glance. OTHER COMPLEMENTARY TESTS USING ADDITIONAL EQUIPMENT The observation of mires using a keratometer or an automatic refractometer and the time they take to break up provides us with information regarding the quality of the lacrimal film. Measuring osmolarity using specific apparatus such as an osmometer may also tell us something about the quality of the lacrimal film. The use of an interferometer alongside the slit lamp may help us to measure both non-invasive break-up time (NIBUT) as well as to improve the study of the lipid layer.

8 3STEP EVALUATION OF SIGNS USING INVASIVE TECHNIQUES Diagnostic tests using invasive techniques. As is well known, invasive techniques may cause excessive tear reflex and upset results. Taking this into account, methods exist which are more or less accepted by specialists, and which help us to evaluate the status of the cornea and lacrimal film. THE MOST COMMON TESTS TO ASSESS EYE SURFACE INTEGRITY Evaluation of conjunctival and corneal integrity after applying fluorescein + slit lamp with blue filter and yellow Wratten 12 filter. Both the BUT and corneal staining should be analysed. A range of values should be considered when evaluating BUT, depending on the volume of fluorescein applied: - Volumes between 1-3 µl (DET- Dry Eye Test) TRL 5 dry eye TRL > 5 normal eye - Volumes between µl (Fluorescein drop) TRL 10 dry eye TRL > 10 normal eye To assess corneal staining one should take into account that this tends to be associated with eye dryness when it appears in the lower corneal quadrant, and is due to a low level of, or incomplete, blinking, an obstruction of the Meibomian glands, or to nocturnal lagophthalmos (sleeping with your eyes half open). In the latter case staining tends to extend to conjunctival areas in the form of a stripe. Evaluation of conjunctival integrity through the application of lissamine green, a specific staining agent for conjunctival tissue. It proves extremely useful in the following cases:

9 - To evaluate the staining of the bulbar conjunctiva due to dryness. - To evaluate the staining on the internal edge of the eyelid close to the eyelashes, which may be due to epitheliopathy on the lid wiper of the upper eyelid (Lid Wiper Epitheliopathy, LWE). This staining appears most often with contact lens users. With regard to these tests we should take the following into account: If dotting appears on the cornea and conjunctiva, this is an indication that the tissue s integrity is compromised and that inflammatory mediators are present. It is advisable to eliminate the remains of the staining agent using saline solution without preservatives. The extent of the dotting and its location can provide us with information regarding the severity and cause of the dry eye condition. OXFORD SCHEMATICS Image A ABSENT Image B MINIMAL Image C MILD Image D MODERATE Image E SERIOUS OTHER AVAILABLE TESTS Measuring tear quantity using phenol red thread. This is a more comfortable alternative for evaluating tear volume. This technique consists of introducing a strip of cotton soaked in phenol red into the lower eyelid for 15 seconds. The part of the cotton which changes colour should be directly measured against the scale that comes with the packaging. Schirmer s test has long served to assess tear deficiency, but nowadays many sector professionals reject it due to the discomfort it causes patients.

10 TIP Devote all the time that is necessary to any patient with dry eye problems. The health and comfort of the patient are important and have their place at the optician s. Normal values in tests to evaluate dry eye disease (According to the Canadian Journal of Optometry. Vol. 76. Suppl. 1, p 16 y Invest Ophtalmol Vis Sci.;50: ) EVALUATION TEST NORMAL VALUES Symptoms Questionnaire OSDI McMonnies < 12/100 < 14.50/45 DEQ-5 < 6 for dry eye Schirmer s Test > 10 mm /5 min Tear volume Phenol Red Test > 9 mm /15 sec Height of lacrimal meniscus mm Tear Osmolarity Evaluation of previous segment: 1 Tear Film Osmometer Slit Lamp Viscosity Residue < 308 mosm/l Average Little or none 2 Eyelashes Eyelashes No residues or flaking 3 4 Meibomian Glands Edge of the eyelids Stability of tear film Integrity of tissues (using ophthalmic staining agents) Expression Secretions Edge of the eyelids Tear Break-up Time with Fluorescein (FL-TBUT) Non-Invasive Break-Up Time (NIBUT) Cornea Conjunctiva Proving easy Clear appearance, liquid Well juxtaposed, smooth, without rough patches > 10 sec > FL- TBUT Without dotting or with fingerprint type dotting (< level 2) OUR SUGGESTION In as far as it is possible, check whether your patients present normal values for each one of the evaluations that you carry out.

11 4STEP ACTION Treatment, monitoring and remission. Use of moisturising drops is recommended as a complement to any treatment, whatever the severity of the eye dryness. In the event of their use being required more than four times a day, it is advisable to use preservative-free moisturising drops. TIP FOR THE TREATMENT OF DRY EYE SYNDROME: A NEW POINT OF VIEW Recent contributions propose a more practical approach to the classification of dry eye, which mainly takes into account the time that the patient has been suffering from the condition, and how its response to the various treatments progresses. (See Canadian Journal of Optometry. Vol. 76. Suppl. 1, p 17 et seq.) According to this, the types of dryness and treatments may be classified in accordance with the following table:

12 TYPE OF DRYNESS Episodic TREATMENT Drops/lubricants Ocular Non-ocular considerations HOW TO PROCEED It is advisable to consider the composition of available lipid-based agents and those that restore the mucin layer. Warm compresses, eyelid hygiene, moisture chamber glasses, modifications to contact lenses (changes in usage regime or maintenance system of contact lenses). Assess environmental characteristics (environmental humidity, exposure to air currents, use of computers), any medication being taken, alcohol, tobacco, hormonal conditions, sleep apnea. Chronic Short-term Long-term Complementary Treatment as applied in EPISODIC section + topical corticosteroids. Topical cyclosporine. Essential fatty acids. Oral tetracycline/ macrolide, tear occlusion, expression of Meibomian glands, sleep masks/dressing for eyelids. Resistant Ocular Systemic Scleral lenses, removal of filaments, autologous serum, amniotic membranes, tarsorrhaphy, other surgical techniques. Secretagogues, systemic, immunosuppressive therapies. TIP Recommend products which alleviate and minimize symptoms. For the person suffering from them this is often the most important thing. There are remedies available to opticians which are tailored to episodic patients with mild dry eye and also with more serious eye dryness (free from preservatives).

13 OUR PROPOSAL: PRESCRIPTION GUIDE PRODUCT WHAT IT PROVIDES DESCRIPTION PRESCRIPTION TARGET Acuaiss Wipes 20 units Removal of oil and residue Wipes with hyaluronic acid and natural extracts. Oily eye Acuaiss eye bath 360 / 100 ml Cleansing and hydration in one single step Saline solution with hyaluronic acid. Allergies Acuaiss Single-dose moisturising drops 20 x 0,35 ml Acuaiss Multi-dose moisturising 6 ml Immediate relief Drops with hyaluronic acid. Single-dose free from preservatives. Drops with hyaluronic acid. Multi-dose. Mild eye dryness. Occasional user. Mild eye dryness. Multi-use format. General public Acuaiss Roll - on 15 ml Hydration and elasticity for eyelids Refreshing gel with hyaluronic acid which hydrates and repairs eyelid skin. Eyelid fatigue. Palpebral stress. Disop Zero Moisturising drops 10 ml Disop Zero Spray by LipoNit with liposomes 10 ml Hydration in more serious cases of dryness Restructures the lipid layer Preservative-free drops. Hyaluronic acid with high molecular weight. Preservative-free eye spray. Comfortable to use, used with eyes closed. Mild - moderate eye dryness. Ongoing treatment. People with hyper-evaporative eye dryness or who find it difficult to use an eye drop system. More specific public (ongoing treatment)

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