Tear Structure. Structure = Stability. Disclosures. In Depth Management of Ocular Surface & Tear Film Disorders UNDERSTANDING THE OCULAR SURFACE

Transcription

1 Disclosures Arthur Epstein, OD, FAAO In Depth Management of Ocular Surface & Tear Film Disorders Art Epstein, OD, FAAO Dry Eye Center of Arizona Phoenix Eye Care Phoenix, AZ, USA All views in this talk, including off-label (non-usa-fda approved) use of medications, are solely those of the presenter. The presenter has served as consultant to, and/or received research support and/or speaking honoraria within the past 5 years from: Alcon Labs NiCox, Inc. BioTissue, Inc. Cooper Vision EyeEco, Inc. Hoya, Inc NovaBay Pharmaceuticals Paragon Vision Sciences Science Based Health, Inc. Tear Science, Inc. Contributing Editor, Review of Optometry Executive Editor, Review of Cornea & Contact Lens Chief Medical Editor, Optometric Physician Tear Structure Traditional Tear Film Model (3 Distinct Layers) Updated Tear Film Model (Aqueous phases with differing concentrations of mucins throughout) UNDERSTANDING THE OCULAR SURFACE Structure = Stability Ocular Surface & Epithelial Glycocalyx Tear Stability is the Key to Stable Comfortable Clear Vision FOUNDATION 1

2 Structure of the Lipid Layer Two-Phase Lipid Layer Model ROOF The Tears HC-Hydrocarbon WE- Wax Ester CE-Cholesterol Ester TG- Triglyceride F-Free Fatty Acid C-Cerebroside P-Phospholipid McCulley et 7al. A Compositional Based Model for the Tear Film Lipid Layer. Tr Am Ophthal. Sci., 1997 The Blink Understanding the Blink Blinking Supplies Energy to the Tears Fluid Mechanics Viscosity is a measure of the resistance of a fluid which is being deformed by either shear stress or tensile stress. Newtonian fluid behavior linear behavior like water Non Newtonian fluid behavior non linear Shear thinning Shear thickening Non Newtonian Fluid Mechanics Understanding the Blink Blinking provides propulsion to meibum in meibomian glands Blink rates have decreased with detailed close work Blinking a abnormalities may be the root cause of MGD and most dry eye disease 2

3 DRY EYE WORKUP 14 Quantify Patient Experience Osmolarity OSDI SPEED 16 InflammaDry MMP 9 Rapid TFBUT = Tear Film Instability SYS14023IR 18 3

4 Oculus Keratograph 5M Dry Eye Tools Oculus Keratograph 5M NIABUT Non invasive Breakup Time Meibography Meniscus Tear Height Tear Film Scan Tear Film Dynamics Lipid Layer Assessment 19 Oculus Keratograph 5M NIABUT Fluorescein Staining Rose Bengal Staining Lissamine Green Staining 4

5 Lid Evaluation Fluorescein Exposure Staining Check for exposure Check for closure/apposition Check for corresponding staining Check for Bell s phenomenon 25 Look Plugged Glands 27 5

6 End Stage Lid Disease MGD Classification Normal Normal glands open, secreting clear oil Non Obvious MGD No inflammation or signs Classical & Obvious MGD Hypersecretion (seborrheic) Inflammatory (pouting & plugging) Infective (glands and/or lids) Diffuse inflammation of the lids/ blepharitis Obstructive Inspissated material, blocked glands 34 Korb and Henriquez, 1980; Mathers et al., Non Obvious MGD Meibography Non-Obvious MGD with no overt inflammation or pathology but no clear oil with normal pressure expression White filamentous secretions upon max force manual expression indicating narrowing of the distal portion of the ducts 35 Blackie et al. Nonobvious Obstructive Meibomian Gland Dysfunction. Cornea: 2010 Dec;29(12):

7 Meibography Meibography Meibography A NEW INSTRUMENT & METRIC THE MGE STANDARDIZED Dx EXPRESSION FOR MG FUNCTIONALITY Concept : an active functional meibomian gland should yield liquid secretion Korb & Blackie Cornea 2008 copious MGE INSTRUMENT DIAGNOSTIC CONSIDERATIONS 1. Standard force to mimic force of blink 1.0 gram/mm2 (.3 PSI ) 2. Application = 10 to 15 seconds 3. Secretion must be liquid (MGYLS) (Wipe off with Q-tip) 39 MGE The LipiView Ocular Surface Interferometer Light source: The Illuminator Chin rest Touch screen control panel Camera, computer and drivers are housed by the device Device dimensions: 28 x 17 x 17 Measurement time: ~ 3 minutes

8 The LipiView Information Display Interpreting Risk of Lipid Deficiency From the LLT (nm) LIPIVIEW: 1. Provides risk assessment of lipid deficiency 2. Patient and physician education, partial blink data High Moderate Low Risk Risk Risk % specificity for lipid deficiency MGD when LLT 60 nm * High Risk: High likelihood of Lipid Deficiency and need for Tx Low Risk: Tx is still a consideration depending on gland findings PARTIAL OR INFREQUENT BLINKING * Finis D, Pischel N, Schrader S, Geerling G: Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for Meibomian gland dysfunction. Cornea Dec;32(12): Sjögrens Syndrome TRADITIONAL DRY EYE MANAGEMENT OPTIONS 1 in 10 Dry Eye Patients 4 Million affected ¾ undiagnosed Current OTC Dry Eye Therapy What I Use OTC Contain various active and inactive agents Patients view products as interchangeable Differing mechanisms of action and efficacies A need exists for clear sub categories 8

9 Still the ONLY prescription therapeutic agent with FDAapproval for dry eye Cyclosporine is a complex molecule with antiinflammatory & immunomodulatory properties. Inhibits T cell mediated inflammation and cytokine driven inflammatory cell chemotaxis Restasis increases production of natural tears increases goblet cell density Readily accepted by most ODs & ophthalmologists as 2nd line therapy for moderate dry eye Reached sales for ODs over $100,000,000.00/year in 2010 Ophthalmic Azithromycin: AzaSite AzaSite pairs DuraSite drug delivery technology with azithromycin (1.0%) Stable, easily delivered formulation of azithromycin Reasonable Gram + coverage plus anti inflammatory activity Clinically comparable to low dose p.o. doxycycline with excellent safety profile Produces high tissue concentrations of drug in lid tissues Steroids for Dry Eye Broad spectrum anti inflammatory activity for dry eye patients with a significant inflammatory component Good for pulse therapy in severe dry eye BID for 2 3 weeks Control use carefully Benefits can last months Severe side effects possible Delayed wound healing Immune suppression Cataract and Glaucoma Caution in chronic conditions Steroids are a leading cause of malpractice in optometry IC necessary Other OSD Management Strategies Punctal occlusion Collagen plugs Silicone plugs Extended wear plugs New technology Tetracycline class oral drugs Decreases lipase production in sensitive and resistant strains of Staph epidermidis & aureus Inhibit collagenase, PMN Chemotaxis, & elaboration of other inflammatory mediators May increase risk of breast cancer even with short term use Other OSD Management Strategies Androgens (Testosterone cream) Human autologous serum drops Non preserved topical steroids Nutritional therapy Scleral (PROSE) lenses Bandage lenses Amniotic membrane bandage lenses 9

10 MGD: Underlying Cause of Most Dry Eye Evaporative Dry Eye is the most prevalent form affecting 86% of patients with dry eye symptoms FOCUSING ON THE PRIMARY CAUSE OF DRY EYE & TEAR INSTABILITY Lemp MA, et al. Distribution of aqueous deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012:31(5): Key Concept International Workshop on MGD MGD Leads to Evaporative Dry Eye 57 Traditional Therapy for MGD MGD THERAPY IS ESSENTIAL 59 10

11 Reusable MOIST HEAT Technologies Thermoeyes Instant Thermoeyes Beads Nutritional Support Lid Debridement Blink Training Blink Training LipiFlow Thermal Pulsation System The Lid Warmer: Comprised of a precision heater, eye insulation & vaulted shape The Eye Cup: Comprised of an inflatable bladder & rigid eye cup Caution: Investigational device. The LipiFlow Auto Console pictured (inset) is not approved for use in the U.S. Limited by United States law to investigational 66 use. 11

12 LipiFlow Thermal Pulsation System Pressure and Pulsation for MGD LipiFlow safely and effectively treats Meibomian gland obstruction in both eyes simultaneously by treating the upper and lower eyelids in a 12 minute, in office procedure Thank You! 12