5/11/2015. Hallway controversies in ocular surface disease. Hallway controversies in ocular surface disease. Disclosures

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1 Hallway controversies in ocular surface disease Hallway controversies in ocular surface disease Milton M. Hom, OD, FAAO, FAAAAI. Diplomate, American Board of Optometry Disclosures Last 12 months: Allergan AMO Bausch/Valeant Alcon Cooper Shire 1

2 Is the slit lamp obsolete? Keratograph 5M LipiFlow MiBoFlo InflammaDry Sjo TearLab Tear Osmolarity Should I get a keratograph? 2

3 Corneal Topography Real Keratometry Meibography Tear Film Assessment (NIKBUT) Tear Meniscus Height Bulbar redness Non-invasive break up time (NIKBUT) Tear Meniscus Height measurement 3

2013 Poster #410 Session # 3210 lower meniscus may serve as overflow, rather than an indication of total volume upper

4 Hom MM. Nguyen AL. Bielory L. Tear meniscus height by optical coherence tomography (OCT) and ocular itch. Academy of Asthma Allergy and Immunology Poster #410 Session # 3210 lower meniscus may serve as overflow, rather than an indication of total volume upper meniscus height may be a better marker of dry eye than lower meniscus height alone. Harrison W. et. al. The role of the upper meniscus in tear film formation and dry eye. American Academy of Optometry 2005 #

Meibography Deconstructing the Keratograph Deconstructing the Keratograph I

You are now including another person in the procedure to place the device

huge shipping costs to go back to Germany to be fixed and down time is 4 to

5 Meibography Deconstructing the Keratograph Deconstructing the Keratograph I am very concerned about this type of procedure for a few reasons. 1. You are now including another person in the procedure to place the device back where it should be on the tracks and this takes a lot of time to set up. 2. If the device in not aligned on the tracks the images either left or right may not be in focus. 3. The K5M could be damaged if it falls over as it is unstable resulting in huge shipping costs to go back to Germany to be fixed and down time is 4 to 6 weeks. 4. This would void any warranty claims if it did get damaged. 5. Patient chair time is now going to be longer waiting for this type of setup. This type of procedure is not recommended by OCULUS. 5

6 Meibography Pros Unlimited uses Cons No established norms & unclear grading systems Run by technician Time consuming Cost about $15k Not covered by insurance Non-invasive Is MiBoFlo a poor man s Lipiflow? 6

7 Inflatable bladder pulses outer eyelids Disposable under the eyelid Heat and pressure upper and lower lids TearScience LipiView White light interferometry Specular reflection Interferogram Captures 32 fps 7

LipiView about $60k LipiFlow about $40k $1500 to $2000 bilateral treatment Disposables $350 per eye Pros Cons 79% effective Not a cure, repeat treatments needed Don Korb Expensive initial and

8 LipiView about $60k LipiFlow about $40k $1500 to $2000 bilateral treatment Disposables $350 per eye Pros Cons 79% effective Not a cure, repeat treatments needed Don Korb Expensive initial and disposables cost Corneal distortion with lid therapy Not covered by insurance Moderately invasive Other treatments Demodex? MiBoFlo ThermoFlo Meibomian Duct Therapy 8

pts SPEED change 4 pts 9 pts 12 pts TBUT change 3.6 sec 5.8 sec 9.2 sec Schirmer change 0mm 1mm 4.

9 Treatment 108 degrees Initial:12 min/lid 1 week:10 min/lid 2 weeks: 8 min/lid Dual eye pad cuts time in half Cost about $24k Typical charge $450/3 treatments Tom Kislan, OD n=51 1 month post tx 2m 4m OSDI change 3 pts 12 pts 15 pts SPEED change 4 pts 9 pts 12 pts TBUT change 3.6 sec 5.8 sec 9.2 sec Schirmer change 0mm 1mm 4.2mm Pros Cons Lower cost than LipiFlow No published data Corneal distortion with lid therapy Not covered by insurance Moderately invasive 9

10 InflammaDry-does it work? 10

11 Pros Covered by insurance Cons Low profit margin Run by technician One time use Minimally invasive Difficult to read (presbyopic doctors) No algorithm Is Sjogren s Syndrome the new dry eye? Nordic Health :15 11

12 Destruction :56 Shiboski, S. C., et al. "American College of Rheumatology classification criteria for Sjögren's syndrome: A data driven, expert consensus approach in the Sjögren's International Collaborative Clinical Alliance Cohort." Arthritis care & research 64.4 (2012): Henrik Sjogren Described in 1933 thesis Harsh critique Left academia Theander E. Wollheim FA. A note from Sweden: recollection of Henrik Sjogren. In: RI Rx, CM Fox (eds). Sjogren s syndrome Springer Science +Business Media, LLC. 12

Vitali C. Baldini C. Bombardieri S. Current concepts on classification criteria and disease status indexes in Sjogren s Syndrome. In: RI Fox, CM Fox (eds).

"Meibomian gland dysfunction in patients with Sjögren syndrome." Ophthalmology 105.8 (1998): 1485-1488.

13 Vitali C. Baldini C. Bombardieri S. Current concepts on classification criteria and disease status indexes in Sjogren s Syndrome. In: RI Fox, CM Fox (eds). Sjogren s syndrome Springer Science +Business Media, LLC. p SS, 29 ATD dry eye controls MGD expression Meibography Shimazaki, Jun, et al. "Meibomian gland dysfunction in patients with Sjögren syndrome." Ophthalmology (1998): Fluorescein and rose bengal staining significantly higher 57.9% gland dropout Shimazaki, Jun, et al. "Meibomian gland dysfunction in patients with Sjögren syndrome." Ophthalmology (1998):

14 1. My mouth feels dry when eating a meal 2. I do not have enough saliva 3. I have difficulty in eating dry foods 4. I have difficulties swallowing certain foods 5. My lips feel dry 6. I sip liquids to aid in swallowing food eyemage@mminternet.com 14

15 Venus Fatigue Sound 2:09 Case 33 year old Male Discomfort with CL Dry mouth: Frequently Dry eyes: Frequently 15

16 OSDI: 25.0 Moderate dry eye Schirmer I: RE 9 LE 22 normal Dx: Sjorgren s syndrome Diagnosis CONFIDENTIAL 48 16

17 Pros Covered by insurance Cons No profit margin Run by technician Costly Effective Time consuming Invasive 855 Treatments Rituxan B-cell targeted Orencia (abatacept) T-cell targeted Enbrel (etanercept) Arthritis medication Ambrus J. Emerging therapies for Sjogren s syndrome make way for collaboration. PCON

18 Sjögren s seems to fade when we prescribe etanercept (Enbrel, Amgen) When patients are diagnosed earlier therapy may turn out to be successful the glands are fixed as opposed to when they are already dead and scarred. Ambrus JL. Emerging therapies for Sjögren s syndrome make way for collaboration. Optometry Times December 2013; 5(12):24. Early intervention the [tear] glands are fixed as opposed to when they are already dead and scarred. Ambrus JL. Emerging therapies for Sjögren s syndrome make way for collaboration. Optometry Times December 2013; 5(12):24. Pros Covered by insurance Cons Reliability of results Run by technician Disposables required-one time use Minimally invasive Low profit margin Lots of supporting data 18

19 Is diabetes important to dry eye? "Diabetes cases are rising h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 rapidly in the US AOA First Look October 29, 2009 Diabetes is now quickly emerging as one of the biggest health catastrophes the world has ever witnessed. Ghasemi H Gharebaghi R Heidary F. Diabetes as a possible predisposer for blepharitis (Blepharitis: current strategies for diagnosis and management 43(2))Can J Ophthal 2008;43:

20 "The future of diabetes in America looks bleak cases projected to h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 double, even triple, by 2050." Diabetes cases projected to double or even triple by 2050, report says. AOA First look. October 22, 2010 "lowering fat and calories...and increasing regular exercise to h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 min/week cut the rate by 34 percent in overweight people." AOA First Look October 29, 2009 "the number with full-on diabetes grew from 23.6 million to 26 million h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust= AOA First Look, March 21,

21 "nearly a third of the people in the diabetes belt were considered to be h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 obese" AOA First Look March 8, 2011 "without [lifestyle] changes, most people with prediabetes will h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 develop type 2 diabetes within years" AOA First Look, March 21, 2011 Unless Americans drastically change diabetes may play a major role in nearly 90 percent of h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 all patients seen by U.S. physicians in five to 10 years. Bar RS. Guest column: Lifestyle changes could stop tsunami of diabetes cases. Des Moines Register May 23,

22 But the alternative is a U.S. medical profession that is h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 overwhelmed by type 2 diabetes in 5 to 10 years. Bar RS. Guest column: Lifestyle changes could stop tsunami of diabetes cases. Des Moines Register May 23, Theory: Autonomic neuropathy decreases corneal h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 sensitivity Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust= Affects lacrimal gland secretion Increased amounts of glucose in tears Chous P. Dry eyes and diabetes often go hand in hand. dlife. September ( Hyperglycemia Impairs inflammatory cell function Allows bacterial invasion Diabetes = endophthalmitis risk factor Ghasemi H Gharebaghi R Heidary F. Diabetes as a possible predisposer for blepharitis (Blepharitis: current strategies for diagnosis and management 43(2))Can J Ophthal 2008;43:

Case 52 year old female http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&docid=qiduqd4 h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.

23 Case 52 year old female h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 Dry eye symptoms: OSDI moderate Tear osmolarity: 293 normal 23

24 HA1c: 11.0% h9htxwm&tbnid=szsp9iz89tkskm:&ved=0cauqjrw&url=http%3a%2f%2fwww.cdc.g ov%2fdiabetes%2fnews%2fdocs%2fdiabetes_belt.htm&ei=3m0hvkbppirdoasjmyk4 June 2009 American Diabetes Association, European Dw&bvm=bv ,d.cGU&psig=AFQjCNGI9m97mlO2ez9aQarjVan1bYSUqg&ust=1 Association for Study of Diabetes, International Diabetes Federation. ( Corneal disease 24

25 Significantly higher rate of [endothelial] cell loss in type I diabetes Significant decrease in cell density in the fourth and fifth decades. SCHULTZ, KAREN J. "CORNEAL ENDOTHELIAL CHANGES IN TYPE I AND TYPE II DIABETES MELLITUS RICHARD 0. SCHULTZ, MD, MAMORU MATSUDA, MD, RICHARD W. YEE, MD, HENRY F. EDELHAUSER, PH. D." American journal of ophthalmology 98.4 (1984). These results clearly indicate that the diabetic endothelium is morphologically abnormal. SCHULTZ, KAREN J. "CORNEAL ENDOTHELIAL CHANGES IN TYPE I AND TYPE II DIABETES MELLITUS RICHARD 0. SCHULTZ, MD, MAMORU MATSUDA, MD, RICHARD W. YEE, MD, HENRY F. EDELHAUSER, PH. D." American journal of ophthalmology 98.4 (1984). significant neurotrophic corneal disease can occur in diabetic patients. Hyndiuk, Robert A., et al. "Neurotrophic corneal ulcers in diabetes mellitus." Archives of ophthalmology (1977):

26 Diabetes >peripheral neuropathy >fewer nerves > lower corneal sensitivity >lower stimuli >thin epithelium >abrasions Rosenberg, Maria E., et al. "Corneal structure and sensitivity in type 1 diabetes mellitus." Investigative ophthalmology & visual science (2000): Diabetes >peripheral neuropathy >fewer nerves > lower corneal sensitivity >lower stimuli >thin epithelium >abrasions Rosenberg, Maria E., et al. "Corneal structure and sensitivity in type 1 diabetes mellitus." Investigative ophthalmology & visual science (2000): Confocal microscopy [showed] decreases in nerve fiber bundle counts impairment of corneal sensitivity. Reduction in neurotrophic stimuli may induce a thin epithelium that may lead to recurrent erosions. Rosenberg, Maria E., et al. "Corneal structure and sensitivity in type 1 diabetes mellitus." Investigative ophthalmology & visual science (2000):

27 Patients with diabetes are more prone to having corneal abrasions I m finding myself turning to daily disposables more and more because you re not touching the eye as much. Paul Chous Orsborn G. Chous P. Gelb K. Managing Contact Lens Wear in Patients with Diabetes. Advanced Ocular Care With my own eyes, after 45 years of type 1 diabetes, I can get a corneal erosion at the drop of a hat, and it s not always in the same spot. glucose fixes to the hemidesmosomes cells on the basal epithelium, making it very fragile. Paul Chous Orsborn G. Chous P. Gelb K. Managing Contact Lens Wear in Patients with Diabetes. Advanced Ocular Care I definitely wouldn t fit somebody with a 10, either. I like their A1c to be at least in the 7 to 8 range, or certainly lower. But anything higher, I would look at really closely. Brittany Mitchell Orsborn G. Chous P. Gelb K. Managing Contact Lens Wear in Patients with Diabetes. Advanced Ocular Care

28 I think it s important to keep handling of the contact lens to a minimum Paul Chous Orsborn G. Chous P. Gelb K. Managing Contact Lens Wear in Patients with Diabetes. Advanced Ocular Care Steroid diabetes Steroids stimulates glucose Especially in the liver Unable to produce enough extra insulin to compensate Develops steroid diabetes 250 cataract surgery patients Topical dexamethosone vs. diclofenac Capillary blood sample 170 mg/dl 229 mg/dl 1month later p=0.038 Bahar, Irit, et al. "Effect of dexamethasone eyedrops on blood glucose profile." Current eye research 32.9 (2007):

topical corticosteroid eye drops may induce a significant increase in serum glucose concentration in diabetic patients may interfere with their glycemic control Irit, Bahar.

29 topical corticosteroid eye drops may induce a significant increase in serum glucose concentration in diabetic patients may interfere with their glycemic control Irit, Bahar. "The Effect of Topical Steroids on Blood Glucose Profile in Diabetic Patients." Journal of Clinical & Experimental Ophthalmology (2011). Begin with antibiotic treatment alone for 24 to 48 hours, then judiciously add a topical steroid thereafter Handbook of Ocular Disease Management Artificial tear review 29

Systane Ultra and Classic (Alcon) Optive & Refresh (Allergan) Blink tears

(Focus) Theratears (AVR) Product Mechanism of action Ingredient Systane

L-carnitine erythritol/cmc Refresh muco-adhesive cmc Blink tears high shear

Advanced FreshKote Theratears emulsion emulsion oncotic waterlogged /lipid

30 Systane Ultra and Classic (Alcon) Optive & Refresh (Allergan) Blink tears (AMO) Soothe XP (Bausch) Refresh Optive Advanced (Allergan) FreshKote (Focus) Theratears (AVR) Product Mechanism of action Ingredient Systane Ultra/Classic Optive ph activated adds viscosity compatible solutes HP Guar L-carnitine erythritol/cmc Refresh muco-adhesive cmc Blink tears high shear thinning sodium hyaluronate Soothe XP Systane Balance Refresh Optive Advanced FreshKote Theratears emulsion emulsion oncotic waterlogged /lipid Hypotonic hypo-osmo mineral oil castor oil Amisol Systane Systane Ultra Systane Classic HP guar 30

31 Blink tears Sodium hyaluronate 0.15% HA Systane Balance Balance Emulsion tear Refresh Optive Advanced ROA Emulsion tear 31

32 Soothe XP Bausch and Lomb Most dry eye is evaporative (MGD) Stage 2 -artificial tears (MGD workshop) Stage 1-1st line treatment: emulsion tears Barr JT. Hamrah P. Hom MM. et.al. Today s methods for managing dry eye. Review of Optometry Steroids- good or bad? 32

Loteprednol Site specific steroids http://www.google.com/imgres?imgurl=http://www.mastereyeassociates.

mastereyeassociates.com/restates- loteprednol (Alrex) prescription-eye- drops&h=402&w=600&tbnid=kx0ku4yt7wrz4m:&zoom=1&docid=nqf8wocvdqnz 0.

patients Lotemax gel (0.5%) BID At 12 weeks IOP safe as Restasis Williams J. Evans D. Torkildsen G. et.al.

33 Loteprednol Site specific steroids ls/60407/images/restasis%252520photo%252520of%252520one%252520tray- Pregnancy Category C 0.2% resized-600.png&imgrefurl= loteprednol (Alrex) prescription-eye- drops&h=402&w=600&tbnid=kx0ku4yt7wrz4m:&zoom=1&docid=nqf8wocvdqnz 0.5% loteprednol (Lotemax) SM&ei=m83CVNmxHJCgoQS_n4HQDw&tbm=isch&client=safari&ved=0CDMQM Systemic steroids appear ygamaa in milk 102 dry eye patients Lotemax gel (0.5%) BID At 12 weeks IOP safe as Restasis Williams J. Evans D. Torkildsen G. et.al. Safety and Efficacy of Lotemax Gel Compared with Restasis in the Treatment of Inflammation Associated with Dry Eye Disease. American Academy of Optometry Thank you! Milton M. Hom, OD, FAAO Azusa, CA eyemage@mminternet.com 33

Evidence for Technology in the Treatment of Advanced Dry Eye

Evidence for Technology in the Treatment of Advanced Dry Eye COPE 44435-AS Chris Lievens, OD, MS, FAAO Evidence for Technology in the Treatment of Advanced Dry Eye COPE: 44435-AS Chris Lievens, OD MS FAAO