Alcon, Allergan, AMO, Bausch & Lomb, Ciba Vision, Cooper Vision, Paragon Visio Sciences, SynergEyes, & Vistakon

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1 Not Your Typical Dry Eye Clinical Considerations for Complex Cases American Academy Of Optometry November 12, 2009 Orlando, FL Michael DePaolis, OD, FAAO Visionary Eye Associates & University of Rochester Medical Center Rochester, NY FINANCIAL DISCLOSURE STATEMENT Clinical Investigator, Advisory Panel, Consultant Alcon, Allergan, AMO, Bausch & Lomb, Ciba Vision, Cooper Vision, Paragon Visio Sciences, SynergEyes, & Vistakon Optometric Editor, PRIMARY CARE OPTOMETRY NEWS Independent Board of Director, TLC Vision Not Your Typical Dry Eye Clinical Considerations for Complex Cases Case 1 KI (63 yof) cc: Red, irritated eyes x 6 months. +fb sensation. +grittiness. +photophobia. + variable vision. Moderate intensity. No significant discharge. Systemic hx: +asthma. +arthritis. +hypothyroid. +depression. + seasonal allergies. No recent uri. Medications: Advair, glucosamine/chondroitin, levothyroxine, & sertraline qd. Claritin D prn. NKDA. Family hx: Father AMD. Social hx: No smoking. Minimal alcohol. Medical receptionist

2 Case 1 KI (63 yof) Neuro: +alert, +calm, +well oriented. Va: OD x180 /+2.50 = 20/50 & OS x4 / = 20/70 Externals: Perrla ( )apd, eom f & s, cvf ftfc ou. No adenopathy. Iops: 14 OD & 14 OS Dfe: 0.35x0.35 OD & 0.4x0.4 OS with healthy nrr ou, vasculature normal ou, macula clear ou, posterior pole flat ou, +vitreous floathers ou. Biomicroscopy: Gr 1+ mgd ou, Gr 2 nasal & temporal LG conjunctival staining ou, Tear prism < 0.25 mm ou, Corneal filaments ou & gr1 ebmd ou, TBUT < 5 sec ou, Gr 2 exposure keratitis ou, Ac d&q ou, Iris normal ou, Gr1 nuclear sclerotic cataract ou Keratoconjunctivitis sicca ou, Epithelial basement membrane dystrophy ou, Filamentary keratitis ou, Nuclear sclerotic cataract ou 1. In office removal of filaments ou 2. Tobradex ung ou qid 3. Systane ou qid 4. Hot compress ou bid 5. f/u 1 week Case 1 KI (63 yof) 1 week f/u Cc: eyes feel about 50% better. Complying with all tx. c/o ung blurring va. No change in systemic health or meds. Neuro: Alert, calm & well oriented. Va: With habitual Rx OD 20/30 & OS 20/40 Externals: Perrla, eom f & s, and cvf ftfc ou. Biomicroscopy: Gr 1+ mgd ou, Gr 2 nasal & temporal LG conjunctival staining ou, Tear prism < 0.25 mm ou, Gr1 ebmd ou, TBUT < 5 sec ou, Gr 1 exposure keratitis ou, Ac d&q ou, Iris normal ou, Gr1 nuclear sclerotic cataract ou

3 Keratoconjunctivitis sicca ou, Epithelial basement membrane dystrophy ou, Nuclear sclerotic cataract ou 1. Tobradex ung ou bid x 2 week, then d/c 2. Restasis ou bid 3. Systane ou q2h 4. Hot compress ou bid 5. Increase hydration, limit caffeine, increase dietary omega 3 s Case 1 KI (63 yof) 3 week f/u Cc: eyes feel no better. Complying with all tx. c/o blurring va. No change in systemic health or meds. Neuro: Alert, calm & well oriented. Va: With habitual Rx OD 20/30 & OS 20/50 Externals: Perrla & eom f & s. Biomicroscopy: Gr 1+ mgd ou, Gr 1 nasal & temporal LG conjunctival staining ou, Tear prism < 0.25 mm ou, Gr1 ebmd ou with nasal & temporal Salzman s nodules ou!!, TBUT < 5 sec ou, Gr 1 exposure keratitis ou, Ac d&q ou, Iris normal ou, Gr1 nuclear sclerotic cataract ou Keratoconjunctivitis sicca ou, Epithelial basement membrane dystrophy ou, Salzman s corneal degeneration ou, Nuclear sclerotic cataract ou 1. Parasol punctal plug LL OU 2. Night & Day ou qd / Clear Care ou qhs 3. Restasis ou bid 4. Systane ou q2h 5. Hot compress ou bid 6. Increase hydration, limit caffeine, increase dietary omega 3 s

4 Case 1 KI (63 yof) 2 month f/u Cc: eyes feel much better. Complying with all tx. c/o blurring va. No change in systemic health or meds. Neuro: Alert, calm & well oriented. Va: With habitual Rx OD 20/25 & OS 20/40 * Externals: Perrla & eom f & s. * Oh, by the way, my left eye is my lazy eye!!! Biomicroscopy: Each contact lens is central and mobile, Gr 1 mgd ou with punctal plug LL ou, Trace nasal & temporal LG conjunctival staining ou, Tear prism ~ 0.50 mm ou, Gr1 ebmd ou without filaments, nodules, or staining, TBUT < 5 sec ou, Ac d&q ou, Iris normal ou, Gr1 nuclear sclerotic cataract ou Keratoconjunctivitis sicca ou, Epithelial basement membrane dystrophy ou, Nuclear sclerotic cataract ou 1. D/C bandage lenses 2. Restasis ou bid 3. FreshKote ou bid, Systane ou prn 4. Hot compress ou qhs 5. TheraTears Nutrition po bid Case 1 KI (63 yof) Questions for consideration 1. Would a daily disposable have worked as well? 2. Would have upper lid punctal occlusion been a better option than bandage lenses? Doane Ophth 98(8):1981 UL occlusion slows Krehbiel flow 2. Would you consider ultimately tapering Restasis to qd? 3. What do you recommend for omega 3 supplementation? 4. Why FreshKote gtt? What do you recommend for omega 3 supplementation? Omega 6 fatty acids

5 Linoleic acid in all vegetable oils. BAD Gamma Linolenic acid in black current oil, borage oil, evening primrose oil Omega 3 fatty acids Alpha Linolenic acid black current oil & flax EPA fish oil & cod liver oil DHA fish oil & cod liver oil Case 2 AD (71 yof) cc: Irritated, watery eyes x 2 years. +grittiness. +photophobia. + variable vision. Moderate intensity. No significant discharge. Hx of dry eye. Limited relief with Genteal, Hypotears, and Systane gtt. Prefers TheraTears ou qid. Has Rosacea dermatologist Rx d tetracycline & eyes felt better. D/c d tetracycline due to yeast infection. Elestat ou bid prn. Systemic hx: +atrial fib. +arthritis. +gerd. +anxiety. + seasonal allergies. +rosacea. No recent uri. Medications: Atenolol, Tylenol, Zantac, Lexapro, & Clarinex qd. Rosula lotion prn. Case 3 JS (40 yom) Cc: c/o eye fatigue, strain, burning, grittiness, and photophobia x 18 months. PRK OU 18 months ago for myopia & astigmatism. Hx of dry eye and contact lens intolerance. Systemic hx: Seasonal allergies, dermatitis, & clinical depression. Medications: Claritin prn. Nizoral shampoo. KNDA. Family Hx: mgm with glaucoma. Social Hx: No nicotine. Social alcohol consumption. Graphic artist. Neuro: Alert, calm, and well oriented. Introverted. VA: OD sc 20/40 & OS sc 20/70. Externals: Perrla / no apd / 6mm ou. Eom f & s. Cvf full ou. IOP s: 15 OD & 15 OS 8:15am.

6 Dfe: 0.4x0.4 with HNRR, normal vasculature, macula clear, vitreous clear, posterior pole and periphery intact ou. Biomicroscopy: Gr1 blepharitis & mgd ou, Trace LG conjunctiva stain ou, Tear prism < 0.5mm ou, TBUT ~ 10 seconds ou, Arcuate corneal haze OD, Central corneal haze OS, AC d & q ou, Iris normal ou, Lens clear ou Pre operative Rx: OD x 165 = 20/15 & OS x 170 = 20/15 Post operative Rx: OD x 21 = 20/25+ & OS x 142 = 20/25+ Keratometry: OD x & OS x Blepharitis ou, Keratoconjunctivitis sicca ou, Corneal scar (haze) ou, Hyperopia & astigmatism OD / Myopia & astigmatism OS, Asthenopia ou 1. Lid hygiene, hot compresses, and Zylet ou bid 2. Blink ou qid 3. Extended duration collagen plugs LL ou 4. F/u in one month Case 3 JS (40 yom) 1 month f/u Cc: Eyes feel much better. Still experience eye strain, fatigue, and photophobia. Complying with all tx. No change in systemic hx or medications. Neuro: Calm, alert, and well oriented. Externals: Perrla (no apd), eom f & s, no periocular dermatitis. VA: With habitual Rx OD 20/30+ & OS 20/30. Biomicroscopy: No blepharitis, gr1 mgd, conjunctiva clear, cornea stable. Tear prism ~ 0.5mm & TBUT > 10mm Improved keratoconjunctivitis sicca ou, Resolved blepharitis ou, Corneal scar (haze) stable ou, Anisametropia with asthenopia ou.

7 1. PureVision toric x 20 OD & x 140 OS. Clear Care qhs and Replace lenses q1 month. 2. Daily lid hygiene. 3. Blink ou qid. 4. Surgical enhancement pending. Case 3 JS (40 yom) Questions for consideration 1. Should we have JS on Restasis as well? Peyman, etal ASCRS 2007 (poster) 1. Are permanent punctal plugs indicated? 2. What should our surgical plan be for JS? 3. Does vitamin C play a role in the peri operative care of patients such as JS? POST PRK HAZE PREVENTION Stojanovic, etal J Ref Surg 19(3):2003 N = 314 Eyes Tx w/o Vitamin C N = 204 Eyes Tx w Vitamin C (500mg po bid x 3 wks) Haze was significantly less at 1 week & 1, 3, & 6 month visits in the Vitamin C group Late presenting haze in 11 eyes in the group w/o Vitamin C & in 0 eyes in the Vitamin C group Case 4 KL (36 yof) Cc: c/o extreme dry eye and diplopia ou. Hx of MVA with bilateral 7 th N crush injury. +lagophthalmus +neurotropic keratitis. Acute bilateral corneal ulceration tx with partial tarsoraphy, punctal cauterization, & moisture chamber goggles. Now uses saline gtt ou q15 minutes, ung ou qhs, Pred Forte ou bid. Systemic hx: Excellent. No medications taken. NKDA. Family Hx: non contributory. Social Hx: No nicotine. No alcohol. Office administration. Neuro: Alert, calm, and well oriented. VA: OD x 4 = 20/100 OS x 120 = 20/400. Externals: Perrla (no apd), EOM constant OS 20pd et, cvf grossly ftfc ou.

8 IOP s: 15 OD & 14 OS 10 am. Dfe: 0.3x0.3 with HNRR, normal vasculature, clear macula, posterior pole flat, vitreous clear and periphery intact ou. Biomicroscopy: Bilateral punctal occlusion ou, Conjunctiva clear ou, Cornea with stromal neovasc and stromal scarring ou, AC d & q ou, Iris normal ou, Lens clear od & Gr3 NS os Neurotrophic keratoconjunctivitis sicca ou, Corneal neovascularization ou, Cornea scar ou, Esotropia os Cataract os 1. Continue with sterile saline ou prn 2. Pataday ou qam & Alrex ou qhs 3. Return for therapeutic contact lens fitting Case 4 KL (36 yof) 2 week f/u Cc: Here for therapeutic contact lens fitting. No changes. Compliant with all tx. No change in systemic history or meds. Neuro: Alert, calm, and well oriented. VA: With habitual Rx OD 20/100 and OS 20/400. Externals: Perrla (no apd) and eom constant 20pd OS et. Biomicroscopy: Eyelids with punctal cautery, conjunctiva clear, corneal neo and scar stable, AC d & q, and iris normal ou. Lens clear OD and gr 3 nuclear sclerosis OS. Diagnostic fitting: OD SynergEyes sc Central, acceptable mvmt, VA = 20/20 OS B&L Soflens 1 day Central, optimal mvmt, VA = < 20/400 Neurotrophic keratoconjunctivitis sicca ou, Corneal neovascularization ou, Corneal scar ou, Esotropia os Cataract os

9 1. Dispense SynergEyes OD & Soflens 1 Day OS 2. Aosept Clear Care qhs 3. Pataday ou qam & Alrex ou qhs 4. Sterile saline gtt ou q prn Case 4 KL (36 yof) 1 month f/u Cc: Eyes feel much better. Vision great! CL s ou qd x 14 hrs. Compliant with lens care and all tx regimens. Using saline gtt q 1h. No change in systemic health or medications. Neuro: Alert, calm, and well oriented. VA: With CL s OD 20/20 & OS <20/400. Externals: Perrla (no apd), eom 20pd os et. Biomicroscopy: Eyelids normal, Conjunctiva clear, Cornea stable / no spk, AC d & q, Iris normal Lens clear OD & Gr3 NS OS Neurotrophic keratoconjunctivitis sicca ou, Corneal neovascularization ou, Corneal scar ou, Esotropia os, and Cataract os. 1. Continue with CL s ou qd and Aosept qhs. 2. Continue with Pataday ou qam and Alrex ou qhs. 3. Continue with sterile saline gtt ou prn (decreasing dosage). 4. F/u visit in 2 months. Case 4 KL (36 yof) Questions for consideration 1. Should I have prescribed Restasis? 2. Should I a prescribe a prophylactic antibiotic gtt qhs? 3. Should we more aggessively address the corneal neovascularization ( argon laser or anti vegf)?

10 4. Is there any other tx options for neuroparalytic keratoconjunctivitis sicca? Case 5 RA (52 yom) Cc: I think my allergies are affecting my eyes. +itch +tear +irritation. No significant discharge. No blurred va. No recent URI. Systemic hx: Hypothyroidism. Seasonal allergies. Medications: Synthroid qd. Claritin D prn. Family hx: Father with brvo. Social hx: No nicotine. No alcohol. Catholic Priest (ok, maybe a little wine once in a while). Neuro: Alert, calm, and well oriented. VA: Habitual Rx OD 20/20 & OS 20/20. Externals: Perrla (no apd). Mild LL edema. Biomicroscopy: Gr1 inferior follicles ou, Gr1 conjunctival chemosis ou, Trace EBMD ou, AC d & q ou, Iris normal ou, & Lens clear ou Allergic conjunctivitis ou, Epithelial basement membrane dystrophy ou. 1. Allergen avoidance. 2. Cool compress ou prn. 3. Patanol ou bid. 4. F/u visit in 2 weeks. Case 5 RA (52 yom) 1 month f/u Cc: Eyes feel a little better. + grittiness + burning. Tearing causing double vision. Very compliant with all tx. No change in systemic health or medications. Neuro: Alert, calm, and well oriented. VA: Habitual Rx OD 20/20 & OS 20/20. Externals: Perrla (no apd), eom diplopia in extreme lateral gaze, cvf ftfc ou. Exophthalmometry 23mm od & 24mm os.

11 Dfe: 0.3x0.3 with HNRR, normal vasculature, macula clear, posterior pole and periphery intact, vitreous clear ou. Biomicroscopy: Gr1 follicles LL ou, Gr1+ superior bulbar conjunctival injection ou, Gr1+ superior spk ou, AC d & q ou, Iris normal ou, Lens clear ou IOPs: 19 od 19 os 4pm. Allergic conjunctivitis improved ou, Superior limbic keratoconjunctivitis ou, Epithelial basement membrane dystrophy ou, & Thyroid orbitomyopathy ou. 1. Punctal plugs UL ou 2. Lotemax ou bid 3. Optive ou qid 4. Gen Teal gel ou qhs 5. Orbital consult Case 5 RA (52 yom) Orbital consult results Endicinology Labs TSH, T3, & T4 levels normal Orbital CT scan EOM infiltration with fat distention Non responsive to oral prednisone up to 60mg po qd Bilateral 2 wall orbital decompression ou Eventual resolution of diplopia sx Case 5 RA (52 yom) Questions for consideration 1. What is the underlying pathophysiology of SLK? 2. Is there a better way to treat SLK? Tsubota, etal 3. When are imaging studies indicated in suspected thyroid eye disease (TED)? Ben Simon, etal Ophth Surg Las Im 37(4): What % of TED patients have normal laboratory studies?

12 Etiology of thyroid orbitomyopathy Autoimmune inflammation of eom s & orbital fat increasese orbital bulk > increases apex pressure Restriction of retropulsion > increases optic neuropathy Exophthalmos > increases corneal involvement EOM inflammation & fibrosis > Restricts ductions Associated Risk Factors : Thyroid disturbance, antigen release, infection, malignancies, & smoking Treatment : Orbital radiotherapy, Orbital decompression Immunotherapy IV methylprednisone, oral prednisone, cyclosporin, somatostatin analogs (?) Moorfields Eye Hosp Eye 20(10):2006 N = 6 patients with inactive thyroid disease All patients had symptoms of postural TVO Elevated IOP s, ONH swelling, exophthalmos, & restricted ductions Orbital wall decompression effective treatment Ben Simon, etal Ophth Surg 37(4):2006 N = 595 patients with thyroid orbitopathy N = 20 (3.4%) developed optic neuropathy Tx: Orbital decompression & oral prednisone Results: Mean VA 20/150 > 20/30, Color vision 5/14 plates > 11/14 plates, APD reversed in 25/26 eyes Exophthalmos decreased from mean 26.4mm > 21.5mm HOW SIGNIFICANT IS SMOKING? Thornton, etal Eye 20(9):2006 Meta analysis of 15 peer reviewed studies Evaluated significance of smoking

13 Results: Graves disease patients who smoke are at increased risk of developing thyroid eye disease Graves ophthalmopathy patients who smoke have more rapid progression of thyroid eye disease Graves ophthalmopathy patients who smoke have poorer treatment outcomes Clinical Case: DC 44 yof Ocular History: Previously wore soft contact lenses, but d/c due to dryness Referred by corneal specialist Has tried Optive, Systane, & TheraTears as well as Pred Forte & Alrex Current eye gtt: Patanol ou bid, Restasis ou bid. Cc: I get eye hemorrhages q 1 mth. I d like to get back into wearing contact lenses if possible. Systemic History: (+) Anxiety. ( ) Thyroid. ( ) Arthritis. ( )Rosacea. ( ) Blood dyscrasias / hematology work up. Medications: Fluoxetine qd, Fish oil qd. VA: OD Rx 20/20 & OS Rx 20/20. Externals: (+) malar flush Biomicroscopy: Grade 3 mgd ou, Grade 2 conjunctival chalasis ou, Grade 1 LG stain ou, Cornea clear with TBUT < 10 sec ou, Tear prism <0.5mm ou, AC d&q ou, Iris normal, lens clear ou 1. Keratoconjunctivitis sicca ou 2. Ocular rosacea ou 3. Menstrual related subconjunctival hemorrhage ou 1. Spoke with ob gyn r/o ocular endometriosis 2. Spoke with pcp rosacea 3. Hot compresses with digital massage ou bid

14 4. Lotemax ou bid, Patanol ou bid, & Restasis ou bid 5. TheraTears nutrition 2 softgels po qd 1 month f/u 1. Hot compresses with digital massage ou bid 2. Restasis ou bid, Soothe ou tid, & Patanol ou prn 3. Parasol punctal plug LL ou 4. Doxycycline 50 mg po bid x 2 wks, 50 mg po qd 5. TheraTears nutrition 2 softgels po qd. 3 month f/u: CC: doing great, no hemorrhages in 2 months. VA: OD Rx 20/20 & OS Rx 20/20. Biomicroscopy: Grade 1 mgd, grade 1 conjunctival chalasis w/o LG stain ou, cornea clear with TBUT ~ 10 sec ou, ac d&q ou, iris normal ou, lens clear ou. 1. Continue hot compress ou 2. Continue Restais ou bid & Patanol ou prn 3. Continue Theratears Nutrition po qd 4. Doxycycline 50 mg po qod 5. Proclear daily disposable OD & OS Questions for consideration. 1. Is it safe for this patient to resume contact lens wear? 2. Do you prefer a daily disposable or a silicone hydrogel for patients with this degree of dryness? 3. When is a conjunctivoplasty indicated? 4. If the menstrual cycle subconjunctival hemorrhages return, is a low dose oral contraceptive indicated?