Learn Connect Succeed. JCAHPO Regional Meetings 2017

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Eileen Anderson
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1 Learn Connect Succeed JCAHPO Regional Meetings 2017

OSC, BGS University of Miami BGS graduate in communications and leadership Technology/orthoptics certification at University of Florida

2 Unveiling Dry Eye Evaluation LOOKING AT DRY EYE DIFFERENTLY: GAINING KNOWLEDGE AND SKILL BY MARTHA TELLO, COMT,OSC, BGS JCAHPO MIAMI, FLORIDA CONTINUING EDUCATION PROGRAM FRIDAY, JUNE 2, 2017 TRUMP NATIONAL DORAL, MIAMI PIXABAY FREE IMAGE About Me Martha C Tello, COMT, OSC, BGS University of Miami BGS graduate in communications and leadership Technology/orthoptics certification at University of Florida 11 years experience at Bascom Palmer Eye Institute Ophthalmic multispecialty experience Ophthalmic technician trainer Published author 1

$Why are we talking about dry eyes? Have you ever seen a patient s refraction fluctuate before and after blink?$

3 Why are we talking about dry eyes? Have you ever seen a patient s refraction fluctuate before and after blink? It is a possible cause of itching, burning, tearing, gritty feeling, blurry vision, irritation Could make a difference in surgical outcomes (cataract, blepharoplasty, refractive procedure) It is a very common pathology in the ophthalmology practice It is not valid to say everyone has dry eyes If left untreated, dry eye could lead to eye damage, and vision loss It could be the cause of erroneous topography measurements leading to inaccurate IOL calculations What is Dry Eye? In 2007, The Dry Eye Workshop defined Dry eye syndrome as a multifactorial disease of the tears and ocular surface that results in a range of symptoms, including discomfort, visual disturbance, tear film instability and potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. The Ocular Surface, 2007, pp Report of the International Dry Eye Workshop (DEWS). at: 2

$Dry Eye Facts Physicians offer multifocal IOL, refractive cataract surgery, LASIK and other refractive procedures, patients expect great satisfaction You should support your doctors by keeping an eye$

4 Dry Eye Facts Physicians offer multifocal IOL, refractive cataract surgery, LASIK and other refractive procedures, patients expect great satisfaction You should support your doctors by keeping an eye on dry eyes in your preliminary work up. Remember a patient with a bad outcome could say, the procedure gave me dry eye Focus on LASIK: If dry eye is left untreated prior to surgery, patients may be disappointed with their LASIK results. Remember that very severe dry eye, might disqualify a candidate for surgery. Identify clues in your medical history : Patients are more likely to have dry eye if they are older, especially a woman after menopause. Different Types of Dry Eye Aqueous tear-deficient dry eye - This is a disorder in which the eye does not produce enough of the watery part of tears. Evaporative dry eye This disorder is caused by inflammation of the glands that produce the lipid or oily layer of tears. Without this layer, tears can be unstable and evaporate too quickly. 3

com How do Tears Relate to Dry Eye Bathe the

5 Other Names for Dry Eye Other names: KeratoConjunctivitis Sicca Ocular surface Disease Tear film insufficiency Picture courtesy of How do Tears Relate to Dry Eye Bathe the surface of the eye keep it moist wash away dust and debris Protect from bacteria 4

Where do Tears Come From & How do they Leave the Eye?

6 What Are Tears? Made of proteins electrolytes and vitamins Critical to maintain the health of the eye surface Vital to prevent infection. Where do Tears Come From & How do they Leave the Eye? Tears are produced at the lacrimal gland which is connected to the brain Tears leave each eye by way of upper and lower canalicular ducts, called puncta The canaliculi leads to the lacrimal sac which itself empties into the nasolacrimal duct, a structure that directs tears into the nasal cavity. 5

Each Layer of Tear Film Serves a Purpose Graphic by Fsciencenotes.

of Conjunctiva produces Mucin for wetting of ocular surface, without mucus, tears would not stick to eye www.virtualmedicalcenter.

constant shield keeping dirt and debris away Reflex tears are formed when your eyes need to wash away harmful irritants, such as smoke, foreign bodies or

7 Each Layer of Tear Film Serves a Purpose Graphic by Fsciencenotes.org Lacrimal Gland produces watery part of tear film called the aqueous Meibomian Gland produces lipids which keeps tear film from evaporating Goblet cells of Conjunctiva produces Mucin for wetting of ocular surface, without mucus, tears would not stick to eye Keep in mind: Not all tears are Created Equal Basal tears are in your eyes all the time to lubricate, nourish and protect your cornea / act as a constant shield keeping dirt and debris away Reflex tears are formed when your eyes need to wash away harmful irritants, such as smoke, foreign bodies or onion fumes. Your eyes release them in larger amounts than basal tears, and they may contain more antibodies to help fight bacteria. Emotional tears produced in response to joy, sadness, fear and other emotional states. 6

8 Let s look at the Role of the OT in Dry Eye Clinic Function of The Ophthalmic Technician Medical history ---curiosity OSDI : ocular Surface Disease Index: Questionnaire Special Dry Eye Testing: Follow Protocol 7

9 What To Ask Patient? Symptoms of Dry Eyes Gritty sensation? Burning? Irritation? Tearing? Blurry vision? Redness? Light sensitivity? Discomfort? Scratchiness? Pain? Not blinking enough Going Deeper into Pt s History in search of DES Menopause? Hormonal changes Autoimmune disease? Cigarette smoking? Daily activity? Duration of reading or computer use Frequent air traveling? Contact Lens wearer? How many hours? Working conditions? Air conditioning? Use of ophthalmic drops? Dusty environment? Outdoors? 8

Dry Eye and Medical Health Correlation Diabetes Rheumatoid Arthritis Sjogren s syndrome Steven Johnson Keratoconjunctivitis Lupus Thyroid Eye Disease Medication side effects

10 Dry Eye and Medical Health Correlation Diabetes Rheumatoid Arthritis Sjogren s syndrome Steven Johnson Keratoconjunctivitis Lupus Thyroid Eye Disease Medication side effects (decongestants,antihistamines, high blood pressure pills, topical drops preservatives ) Bone marrow transplant How to Complete Dry Eye Evaluation: Steps to Follow Create a Protocol Start with OSDI to Identify Perform Osmolarity Get Inflammadry Schirmer s Do Meibography Slit lamp examination Tear break up time Lissamine green 9

It contains 3 sections vision-related function ocular symptoms environmental triggers The final score is

11 OSDI: Description Description The OSDI is a 12-item questionnaire that evaluates both dry eye symptoms and their effects on vision-related functioning over the past week. It contains 3 sections vision-related function ocular symptoms environmental triggers The final score is calculated with 0 to 12 representing normal, 13 to 22 mild DED, 23 to 32 moderate DED, and 33 severe DED. (Grubbs et al. 2014, Cornea) OSDI: Ocular Surface Disease Index 10

Osmolarity Test: Definition of Hyperosmolarity Evaporation leads to both loss of tear volume and a disproportionate loss of water, resulting in Hyperosmolarity Less water and more salt in tears.

12 Osmolarity Test: Definition of Hyperosmolarity Evaporation leads to both loss of tear volume and a disproportionate loss of water, resulting in Hyperosmolarity Less water and more salt in tears. Osmolarity changes in dry eye are due to changes in the water content. Biomarker of Disease Severity Measurements >300 mosm/l demonstrate loss of homeostasis/ a Difference between eyes of 8 mosm/l or > indicates instability of the tear film Osmolarity Test performance Tips Research showed that Test is to be done 2 hours after using artificial tears, and 20 minutes after using proparacaine or dilating drops Always do Osmolarity test prior to any other invasive tests You have 40 seconds after collecting tear drop to place device in unit and obtain results Difference between two eyes is not saying instrument is not working Below range reading means technician s poor technique or patient had recently used artificial tears Position the pen tip parallel over inner margin of lower lid, ask patient to tilt head to right/ left to get accumulation of tears If having difficulty obtaining reading don t remove pen from eyelidavoid pressure downward into eyelid Advise from manufacturer 11

13 MGD: Evaporative Dry Eyes o Caused by Deficiency and/or alterations in lipid secretions by the Meibomian gland resulting in increase evaporation of aqueous tears from the ocular surface o Evaporation leads to both loss of tear volume and a disproportionate loss of water, resulting in Hyperosmolarity o Exposure and Mucin deficiency Inflammadry : MMP9 Facts Complimentary information, not duplicate If the tear film osmolarity test shows a high score or a large disparity between the two eyes, we can then proceed with MMP-9 testing. MMP-9 is a more specific detector Research showed that patients with positive test results with Inflammadry may benefit from treatment with anti-inflammatory therapy 12

INFLAMMADRY: MMP9 (Inflammatory biomarker) Ophthalmology Management, Volume: 19, Issue:

page(s): 2-6 INFLAMMADRY: MMP9 (Inflammatory biomarker) o InflammaDry reveals asymptomatic

patients with positive test results with InflammaDry may benefit from treatment with

14 INFLAMMADRY: MMP9 (Inflammatory biomarker) Ophthalmology Management, Volume: 19, Issue: Improve the Diagnosis, Management and Treatment of Inflammatory Dry Eye August 2015, page(s): 2-6 INFLAMMADRY: MMP9 (Inflammatory biomarker) o InflammaDry reveals asymptomatic ocular surface disease and the hidden inflammation of dry eyes o Research showed that patients with positive test results with InflammaDry may benefit from treatment with antiinflammatory therapy 13

LIPIVIEW Measures lipid layer thickness, evaluates blink

lipid deficiency and detect MGD The LipiView then records 32

target. What is Meibomian Gland Dysfuction? http://www.

15 LIPIVIEW Measures lipid layer thickness, evaluates blink rate, and visualizes Meibomian gland structure to determine lipid deficiency and detect MGD The LipiView then records 32 frames per second in real time as the patient fixates on a target. What is Meibomian Gland Dysfuction? Graphic by allaboutvision.com 14

LIPIFLOW BPEI MGD technician Plantation- has used the LipiFlow unit for our patients over

The LipiFlow thermal pulsation system is a 13- minute, minimally invasive treatment that

Our ophthalmologists tell their patients it may take several weeks to experience relief

However, they stress after one LipiFlow treatment, many patients are able to maintain the

16 LIPIFLOW BPEI MGD technician Plantation- has used the LipiFlow unit for our patients over the past few years with excellent results. The LipiFlow thermal pulsation system is a 13- minute, minimally invasive treatment that uses heat massage to soften the oils from the meibomian glands. Our ophthalmologists tell their patients it may take several weeks to experience relief from treatment. However, they stress after one LipiFlow treatment, many patients are able to maintain the treatment effect by continuing warm compresses on their own Picture courtesy of Bascom Palmer Slit Lamp Exam: Lid Margin Evaluation Demodex 15

break up The normal value is more than 10

17 Tear Break Up Time Evaluates tear film stability Stain tears with fluorescein dye and measure time between a complete blink and the appearance of the first dry spot or tear film break up The normal value is more than 10 seconds Photo courtesy of BPEI Treatments to Keep in Mind 16

PROSE-prosthetic replacement of The Ocular Surface Ecosystem The PROSE scleral contact lens (BostonSight) is a very important solution offer to severe dry eye

At BPEI, we draw patients blood, separate the serum and divide it with preservative-free saline in bottles from 20% to 50% concentration.

18 PROSE-prosthetic replacement of The Ocular Surface Ecosystem The PROSE scleral contact lens (BostonSight) is a very important solution offer to severe dry eye patients. Institute-New-York/Flaum-Eye-Institute-Doctors Serum Tears Autologous serum tears. At BPEI, we draw patients blood, separate the serum and divide it with preservative-free saline in bottles from 20% to 50% concentration. Drops get sored in the freezer and dispense to patients who thaw it for use 4 to 6 times a day. The hypothesis is that the serum contains various growth factors that are beneficial for the ocular surface 17

19 Ophthalmologists are Empowering Ophthalmic Techs to be Physician Extenders Participate in Dry eye Clinic in a collaborative effort Get Autonomy to do testing based on patient s complaints confirmed by Dry Eye OSDI Questionnaire More Involved in patient care by administering newer diagnostic tests More Aware of treatment options to be better supporters of patient s education 18

Dry eye syndrome. Lacrimal gland. Tear duct into nose. 1 of 6

Dry eye syndrome. Lacrimal gland. Tear duct into nose. 1 of 6 Dry eye syndrome The aim of this information sheet is to answer any questions you may have about dry eye syndrome. If you have any further questions or concerns, please ask a doctor or nurse caring for