DEWS Severity Analysis 11/30/12. Blephari/s, MGD and Ocular Surface Disease. Ben Gaddie, O.D., F.A.A.O. Louisville, KY

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1 Blephari/s, MGD and Ocular Surface Disease Ben Gaddie, O.D., F.A.A.O. Louisville, KY Advisory Board of Inspire, Allergan, Pfizer, Bausch & Lomb, Zeiss Humphrey, OcusoK Speakers Bureau of Alcon, VSP, Allergan, Pfizer, Inspire Consultant for Bausch and Lomb, Allergan Hononoraria from all of the above in the past Research support: Allergan, Alcon, Inspire, Zeimer Ophthalmics Approximately 25% of eye care visits are due to Dry Eye 1 Up to 40 million Americans may either have symptoms of Dry Eye or are at risk for it 2 Incidence of Dry Eye increases with age Up to 51% of pa/ents older than 65 years 3 Up to 31% of women between 40 and 59 years of age 3 Despite these numbers, Dry Eye remains remarkably under- diagnosed 4 Age Gender Environment Anterior segment disease Medica/ons Contact lenses Surgery Systemic diseases 1. O Brien PD, Collum LMT. Curr Allergy Asthma Rep. 2004;4: Sheppard JD. Manag Care. 2003;12(suppl): National Drug Treatment Information (NDTI) Sample Data : Perry HD, Donnenfeld ED. Curr Opin Ophthalmol. 2004;15: American Academy of Ophthalmology. Preferred Practice Pattern : Dry Eye Syndrome DEWS Severity Analysis Diabetes mellitus Acne rosacea Thyroid disease Lymphoma Inflammatory diseases Allergy Asthma Vasculi/s Sjögren s syndrome Autoimmune diseases Rheumatoid arthri/s Lupus Neuromuscular disorders Parkinson s disease Bell s palsy 1. American Academy of Ophthalmology. Preferred Practice Pattern : Dry Eye Syndrome O Brien PD, Collum LMT. Curr Allergy Asthma Rep. 2004;4: Dalzell MD. Manag Care. 2003;12(suppl):

2 What Types of MGD Exist? Dry Eye can exist in associa/on with several other ocular surface inflammatory diseases (OSIDs) Seasonal allergic conjunc/vi/s (SAC) 1 Giant papillary conjunc/vi/s (GPC) 1 Blephari/s 2,3 Meibomi/s 2,3 Anterior Posterior Mixed Seborrhea Psoria/c Atopic Rosacea 1. Howes JF. Pharmazie. 2000;55: American Academy of Ophthalmology. Preferred Practice Pattern : Dry Eye Syndrome O Brien PD, Collum LMT. Curr Allergy Asthma Rep. 2004;4: Anterior Blephari/s Morning crus;ng with foreign body sensa;on Recurrent hordeola Loss of lashes Conjunc;val hyperemia CollareGes - scales which encircle lash Staphylococcal immune disease u Phlyctenule u Inferior conjuc;val and corneal punctate keratopathy u Pannus u Catarrhal infiltrates Terminology of Blephari1s/ MGD IOVS,

3 Classifica1ons of MGD IOVS, 2011 Burning, foreign body sensa;on with dry eye symptoms (contact lens intolerance) Filmy vision with foam in tear film (soaps and fagy acids) Dilated meibomian gland orifices with plugged toothpaste like material Chalazia Thickened lid margin Kera/n on Lids Kera/n in orifices of Meibomian opening Erythema Telangiectasia Pustules Prominent sebaceous glands Rhinophyma 58% of all rosacea pa/ents Presen/ng sign in : 20%! 3

4 MANAGEMENT OF MGD Meibomian gland dysfunc/on Dry eye Blephari/s Liposomal Spray Tetracyclines: Doxycycline 20-50mg bid x 1-2 months Taper to qd for 1-6 months depending on response Periostat long term (20mg doxycycline) can also be pulsed if seasonal Managing Side Effects. AzaSite pairs DuraSite drug delivery technology with azithromycin (1.0%) Azithromycin has not been previously used in eye care A stable aqueous formula/on is difficult to produce AzaSite : A stable, easily delivered formula/on of azithromycin All the advantages of topical ophthalmic delivery All the advantages of the an/- microbial proper/es of azithromycin Other Off Label Treatments Steroid/An/bio/c combina/on medicines applied to lids( Tobradex ST, Zylet, generic combos) Topical an/bio/cs (azithromycin, emycin. Gmycin Therapeu/c gland manipula/on (automated of manual) In progressive states, I try to seek a dermatologist and/or rheumatologist consult as well 4

5 Broad- spectrum, an/- inflammatory ophthalmic products 1 Mechanism of ac/on spans virtually every aspect of the inflammatory response 1 Nuclear Decreases produc/on of inflammatory precursor proteins Cellular Suppresses prolifera/on of mast cells and lymphocytes 1 Biochemical Inhibits synthesis and enhances breakdown of histamine 1 14 to 22 million people who are steroid responders 1,2 3 to 6 million people with ocular hypertension 3 3 million people with glaucoma 3,4 1. Slonim CB, Boone R. Formulary. 2004;39: McDonald MB. Refract Eyecare. 2005;9(suppl): EyeMDLink.com. Steroid induced glaucoma. Available at: hqp:// Accessed November 16, U.S. Census Bureau. U.S. POPClock projec/on. Available at: hqp:// bin/ popclock. Accessed November 16, E- medicine Consumer Health. Ocular Hypertension. Available at: Accessed November 16, Lee J, Bailey G. Glaucoma: The second- leading cause of blindness in the US. Available at: hqp:// Accessed November 16, Topical NSAIDS for Dry Eye? Refresh Op/ve Advanced MANAGEMENT OF MGD Should be hiung distribu/on in spring and sampling Lipid based tear 5

6 Lubricant Eye Drops Tetracyclines: Doxycycline 20-50mg bid x 1-2 months Taper to qd for 1-6 months depending on response Periostat long term (20mg doxycycline) can also be pulsed if seasonal Managing Side Effects. Look at the Cornea With heavy staining: steroid qid for 1-2 weeks alone; Then add cyclosporine and taper steroid Tranquileyes with mositure chamber goggles Bland ung hs Heavy lubricants day/me With some staining, but not confluent: Start steroid and cyclosporine at the same /me Con/nue steroid bid for 2-4 weeks then D/C With no staining: Restasis bid without steroid Look at the Limbal Conjuc;va If Lissamine Green (LG) stain is heavy in the intrapaelbral areas Steroid qid for 2 weeks alone: then add cyclosporine and taper steroid If LG stain is mild to moderate without punctate dense areas Cyclosporine alone If no LG stain is present, consider a secondary mechanism for the dryness 6