Doctors of Optometry Course Notes

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1 Doctors of Optometry Course Notes OD2 1CE COPE: AS Straight Outta Tears Treating & Managing MGD, Lid Bugs & Other Lid Thugs Saturday, February 25, :40 am 9:35 am Plaza A/B 2 nd Floor Presenter: Marc Bloomenstein, OD, FAAO Dr. Marc Bloomenstein is an accomplished optometrist who lectures and publishes extensively in the fields of anterior segment disease and refractive surgery. Dr. Bloomenstein is at the Schwartz Laser Eye Center and is on the editorial board of Primary Care of Optometry and Contemporary Optometry. Dr. Bloomenstein served as the President of the Arizona Optometric Association, as well as an Optometric Advisor to STAAR Surgical and Medtronics Solan and is now the President of the Board of the Arizona Optometric Charitable Foundation. He graduated in 1990 from the University of California, Los Angeles with a degree in Biology, and received his optometric degree from the New England College of Optometry in After graduation, Dr. Bloomenstein finished a residency in secondary ophthalmic care at the Barnet Dulaney Eye Center in Phoenix, Arizona. He received his fellowship from the American Academy of Optometry in December 1998 and is a founding member of the Optometric Council on Refractive Technology. Moreover, Dr. Bloomenstein is an Adjunct Assistant Professor at the Southern California College of Optometry and New England College of Optometry. Course Description This course will focus on the eyelids and all the nasty and unsavory creatures that affect eye health. The advent of new diagnostic equipment has enabled clinicians to make point of service differentiating. Treatment options can range from over the counter management, to prescription medications, as well as office procedures. Getting the lids right will make the vision tight. 1

2 Doctors of Optometry Course Notes NOTES: 2

3 Straight Out of Tears: Treating and Managing MGD, Lid Bugs and Other Lid Thugs! Marc R. Bloomenstein, OD, FAAO Scottsdale, AZ

4 Disclosure Presenter is on speakers panel of: Akorn, Alcon, Allergan, AMO, B+ L, BlephEX, Lunovas, OcuSOFT, Tear Lab President of MRB Eye Consultants AOA CE Chairman Past-President of the Optometric Council on Refractive Technology (OCRT) OSSO Board Member Presenter has NO financial interest in any products mentioned

5 EyetubeOD.com

6 Incidence and Prevalence of Dry Eye 25% of teen-adults 28 million experience symptoms frequently 2015 Gallup Poll- 30 million Americans affected

7 Proactive and Preventive Risk Factors for Ocular Surface Inflammation Females Sjogren s Aging Environmental Issuse Refractive Surgery Vitamin deficiency Medications

8 Sea Change Managing the disease in the chair Insurance visits Glaucoma model 3-4 visits a year Compensation Vision plan Medical Insurance Cash pay-abn

9 Sea Change Patient retention Patient referrals Cutting Edge Treatment

10 Symptoms #1 most important VISION CHANGES Blurred Fluctuating Hazy Refractive changes Pain Light sensitivity Gritty Redness Itch Lid margin Conjunctival

11 Signs, Signs, everywhere Signs! Lid Debris Frothy tears collarettes

12 Anterior Blepharitis

13 Seborrheic Blepharitis

19 Signs and Symptoms Morning crusting Foreign body sensation Recurrent hordeola Loss of lashes Conjunctival hyperemia Collarretes (scales that encircle lash) Staph immune disease Phlyctenula Pannus Catarrhal infiltrates etc

20 Sequelae to Blepharitis Blepharitis Chalazia / hordeola Dry eyes Punctate keratitis Phlyctenules Recurrent conjunctivitis Pannus Corneal ulceration Endophthalmitis

21 MGD

22 Pathophysiology of Meibomian Gland Disease Normal meibomian gland secretions convert from unsaturated lipids that melt at body temperature to saturated fats that inspissate the meibomian glands Lid bacteria secrete lipases that break down lipids from soaps to fatty acids

23 Bacterial Lipases Break Down Lipids to Soaps

24 Photos courtesy of Justin Webb, OD, Alcon Research Ltd., NON-OBVIOUS MGD

25 Remove those pesky caps: MacGruber!

Examples of meibum stagnation and changes

requires more force than the MGE) Absence

26 Examples of meibum stagnation and changes that correspond to MGD Clear liquid secretion (glands are functional using the MGE) Cloudy liquid secretion (glands are functional using the MGE) Opaque solid secretion (glands not functional; requires more force than the MGE) Opaque solid secretion (glands not functional; requires more force than the MGE) Absence of secretion (glands not functional; even significant force does not yield secretion) Notching at gland orifice (indicates atrophy/drop out) 24

27 Is the most common and arguably the most important diagnosis presenting to the optometry Blepharitis Anterior Inflammation mainly centered around the eyelash and follicles BIOFILM Blepharitis Inflammation that involves the meibomian gland orifices Posterior

28 The Biofilm Biofilm: A biofilm community can be formed by a single bacterial species, but in nature biofilms almost always consist of rich mixtures of many species of bacteria in a polysaccharide matrix Thrives in moisture Smooth surface Bacteria

34 3 2

35 3 3

36 Treatment Blepharitis.MGD

37 ADJUNCTIVE THERAPY FOR MGD

38 Lipid/Oil-Based Lubricant Eye Drops Palliative None treat the cause Downside can be blurring & stinging with castor oil emulsions

39 Retaine MGDTM

Introducing the cationic A main issue is the loss of product while blinking A unique cationic oil-in-water nanoemulsion addresses unmet needs Lipid compound + innovative cationic

CORE Solubilizes the drugs SURFACTANT Stabilizes the interface CATIONIC AGENT Brings the positive charges Enhanced tear film and corneal epithelium 1,2 1. Lallemand F, et al.

40 Introducing the cationic A main issue is the loss of product while blinking A unique cationic oil-in-water nanoemulsion addresses unmet needs Lipid compound + innovative cationic (positively charged) technology emulsion Better attraction to the ocular surface Improvement of the residence time Better spreading on the ocular surface Better adsorption OILY CORE Solubilizes the drugs SURFACTANT Stabilizes the interface CATIONIC AGENT Brings the positive charges Enhanced tear film and corneal epithelium 1,2 1. Lallemand F, et al. J Drug Deliv. 2012;2012: Daull P, et al., Benefits of cetalkonium chloride cationic oil-in-water nanoemulsions for topical ophthalmic drug delivery. Draft for publication,

Regular cleansing with eyelid scrubs can provide significant relief and improve the

41 Seborrheic Blepharitis Seborrheic blepharitis is caused by seborrheic dermatitis, a skin condition that creates flaking and scaling including on the eyelids. Regular cleansing with eyelid scrubs can provide significant relief and improve the appearance of eyelids. Signs and Symptoms Red, irritated, itchy eyelids and the formation of dandruff-like scales on the eyelashes.

Original Formula OCuSOFT Lid Scrub removes oil, debris,

42 Seborrheic Blepharitis (continued) Take Home Recommendation OCuSOFT Lid Scrub Eyelid Cleanser Original Formula OCuSOFT Lid Scrub removes oil, debris, and desquamated skin from the eyelids and is non-irritating to the eyes.

43 TheraTears SteriLid Soothes and Cleanses Away External Irritants TheraTears Sterilid removes oil, debris and other contaminants that can accumulate on eyelids and eyelashes. M /15 41

44 Need More Eyelid Relief The root cause of anterior blephartitis is the overproduction of oils. Mild surfactants in OCuSOFT Lid Scrub PLUS eyelid cleanser act to dissolve and remove oil, debris, and desquamated skin. Other formulas do not. Hypochlorous Acid is produced by white blood cells as part of the body s natural defense mechanism against pathogens.

What Is Hypochlorous Acid? Hypochlorous acid is a weak acid that is formed when chlorine dissolves in water. Its chemical formula is HOCL. An acid is a ph below 7 (neutral).

45 What Is Hypochlorous Acid? Hypochlorous acid is a weak acid that is formed when chlorine dissolves in water. Its chemical formula is HOCL. An acid is a ph below 7 (neutral). Above 7 is considered base/basic or alkaline. Tap water is generally a ph of 7 whereas citric acid from lemons is highly acidic at around a 2. The ph of HOCL is between 6-7.

Spray and Gel formulation Avenova NovaBay Avenova

46 Hypochlorous Acid HypoChlor OCuSOFT HypoChlor is a 0.02% concentration of Hypochlorous acid in both Spray and Gel formulation Avenova NovaBay Avenova with Neutrox is a 0.01% concentration of Hypochlorous acid

47 Best MGD Treatment Warm up the lids In office expression Retaine MGD/RESTASIS (cyclosporine 0.05%) Low dose tetracycline derivatives LipiFlow for Severe Cases Omega fatty acids Get the patient early!

Inflammatory Dry Eye Alters the Tear Film Image used with permission. Dry Eye Disease reduces mucins, and alters concentrations of growth factors and tear proteins 1,2.

48 Inflammatory Dry Eye Alters the Tear Film Image used with permission. Dry Eye Disease reduces mucins, and alters concentrations of growth factors and tear proteins 1,2. Fewer tears can lead to increased inflammatory output from the lacrimal gland, which can cause ocular surface damage and altered tear production. The resulting chronic inflammatory stimuli can then lead to further decreased tear production 3-5

49 Treating The Inflammation Restasis (Allergan) Primary treatment option Multiple mediators of inflammatory cascade Increase goblet cells density and emulsion vehicle Proven Steroids Amniotic Membrane

50 Demodex That other Thug!

51 HANDBOOK OF MEDICAL ENTOMOLOGY Dr. WM. A. RILEY, Professor of Insect Morphology and Parasitology, Cornell University Dr. O. A. JOHANNSEN, Professor of Biology, Cornell University 1915

58 Rosacea and Demodex? Rosacea and demodex Meta-analysis of 48 studies 10 different countries 28,527 subjects Rosacea patients 7-8x chance have Demodex Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol 2010;146:896Y902.

59 Remember Biofilm.

60 Biofilm is a polysacharride Perfect food source for a Demodex infestation

along margin Results in completely clean lids

61 MICROBLEPHAROEXFOLIATION (MBE) Doctor centered approach to lid health Spins a micro-sponge 2,500 RPM along margin Results in completely clean lids Repeated every 4-6 months Private pay procedure, typically $150-$250

62 In Office Treatment Patients with heavy scruff may need an in office treatment to remove scruff (Blephex) or TTO will never get to the target. I use of Cliradex/ Oust for those recalcitrant cases Typically doing 2 different in office TTO, rarely third Maintenance on: Cliradex, Oust, BlephaDex

Demodex Infestation of the Eyelids Recommended Treatment In-office procedure: Cleanse eyelids and eyelashes in-office utilizing OCuSOFT Lid Scrub PLUS Swabstix and Oust Demodex Swabstix.

64 Demodex Infestation of the Eyelids Recommended Treatment In-office procedure: Cleanse eyelids and eyelashes in-office utilizing OCuSOFT Lid Scrub PLUS Swabstix and Oust Demodex Swabstix. Oust Demodex Swabstix contain 50% Tea Tree Oil, 40% Sea Buckthorn Oil, and 10% Caprylic Acid. These single-use, disposable, self-saturating Swabstix provide convenient in-office use to effectively eradicate demodex and remove oil, debris, and other contaminants on the eyelids inoffice. A complete Demodex Kit is available for in-office use.

65 BlephaDex Aqua Coconut Oil Glycerol Aloe Barbadensis Gel Sodium Lauryl Sulfate Cocoamidopropyl Betaine DMDM Hydantoin Laurel Glucoside Melaleuca Alternifolia( Tea Tree) Leaf Oil

66 Easier Way To Start In-Office Regular Maintenance-Like teeth cleaning Use Blephadex swab, with BlephEx, for annual (bi-annual) in office treatment At-home treatment with Blephadex pads or foam Continue to use everyday for maintenance

67 Treatment Goal: NOT to eradicate 100% Want to knock down the load and reduce symptoms Watering Crusting Itching of lids Like to see some visible reduction in cylindrical dandruff Improve redness profile of eye, lid and face

68 Conclusion Differentiate the condition in your practice Think Biofilm Remove the debris In-office treatments Have the options in your practice Provide options Utilize the products New comfortable Demodex treatments

Disclosure. Sea Change. Sea Change. Straight Out of Tears: Treating and Managing MGD, Lid Bugs and Other Lid Thugs! Proactive and Preventive

Disclosure. Sea Change. Sea Change. Straight Out of Tears: Treating and Managing MGD, Lid Bugs and Other Lid Thugs! Proactive and Preventive Straight Out of Tears: Treating and Managing MGD, Lid Bugs and Other Lid Thugs! Marc R. Bloomenstein, OD, FAAO Scottsdale, AZ Disclosure Presenter is on speakers panel of: Akorn, Alcon, Allergan, J&J,