UNDERSTANDING DRY EYE TREATMENT AND PROTOCOL

Size: px

Start display at page:

Download "UNDERSTANDING DRY EYE TREATMENT AND PROTOCOL"

Linda Melton
5 years ago
Views:

1 UNDERSTANDING DRY EYE TREATMENT AND PROTOCOL Tim Trinh, O.D., F.A.A.O. Box Medical Solutions Date: September 19 th,

The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry E ye Work Shop (2 0 0 7) THE OCULAR SURFACE / APRIL

2 The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry E ye Work Shop ( ) THE OCULAR SURFACE / APRIL 2007, VOL. 5, NO. 2 Hyperevaporative disorders, mostly caused by dysfunction of the meibomian glands, and mixed hyperevaporative/aq ueous-deficient forms account for more than 80% of cases

3 Baudouin C, et al. Br J Ophthalmol 2016;100: doi: /bjophthalmol Causes: Blepharitis Meibomian Gland Dysfunction Chalasis Tear Film Instability Increased Evaporation Increased Osmolarity Causes: Eyelid dysfunctions, Tear film instability Allergies Cytokine Release Vicious Cycle of Dry Eyes Cell Damage Causes: Cellular damage Systemic inflammatory factors Inflammation Nerve Stimulation Cellular Death Causes: Direct trauma, Friction Exposure Increased osmolarity

4 What testing is necessary to do a dry eye evaluation? 1. Meibography 2. Meibomian Gland Quality 3. Lid Assessment 4. Tear Break Up Time Tear Film Instability Increased Evaporation Increased Osmolarity 1. Tear Lab 2. Eyelid Assessment 3. Blink Rate 4. Lagopthalmos Eval 5. Tear Lake Assessment Cytokine Release Testing Procedures Cell Damage 1. MMP-9 testing 2. Health History 3. Sjo Testing 4. Autoimmune blood panel Inflammation Cellular Damage 1. Corneal Staining Assessment 2. Conjunctival staining Assessment Nerve Stimulation

5 What is the best order of testing and evaluation? History Survey Dry Eye Questionnaire Observation Tear Meniscus Blink Rate Assessment Lid Position LIPCOF Osmolarity/ Inflammation Tear Lab* MMP-9* Structural Assessment Tear Break Up* Time Conjunctival Staining Corneal Staining Marx Line Tear Film Stability Blepharitis Assessment Lid Margin Meibography *Testing recommended on separate visit Least invasive to most invasive:

7 Survey Scoring can help determine prevalence SPEED TEST OSDI

8 DRY EYE SPECIFIC PATIENT QUESTIONNAIRE

9 TEAR MENISCUS > mm Normal <0.2 mm Hyposecretion Think Aqueous Deficiency >0.40 mm Hypersecretion

BLINK RATE ASSESSMENT Normal Blink Rate: 15.5 +/- 13.7 blinks/minute Reading/Computer: 5.3 +/- 4.

10 BLINK RATE ASSESSMENT Normal Blink Rate: / blinks/minute Reading/Computer: 5.3 +/- 4.5 blinks/minute The most prevalent symptom associated with Computer Vision Syndrome was tired eyes, which was reported by 40% of subjects as occurring "at least half the time". 32% and 31% of subjects reported symptoms of dry eye and eye discomfort, respectively, with this same frequency Mark Rosenfield; Yuliya Bababekova; Joan K. Portello Investigative Ophthalmology & Visual Science March 2012, Vol.53, doi: Prevalence Of Computer Vision Syndrome (CVS) And Dry Eye In Office Workers

11 EYELID POSITION ASSESSMENT Lagophthalmos Floppy eyelid Syndrome Velvety papillary conjunctivitis Swollen lids Strong association with Sleep Apnea

Graded Scale 0-3 84.9% Sensitivity for Dry Eyes 90% Specificity for Dry Eyes Elisabeth M.

12 TEMPORAL LID PARALLEL CONJUNCTIVAL FOLDS (LIPCOF S) Slit Lamp Evaluation Lid Parallel Conjunctival Folds: Results from increased friction between the lids and conjunctiva. Graded Scale % Sensitivity for Dry Eyes 90% Specificity for Dry Eyes Elisabeth M. Messmer. The Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease Dtsch Arztebl Int 2015; 112: 71 82

13 TEAR BREAK UP TIME Normal range lies between 20 and 30 seconds. <10 seconds Dry Eyes <5 seconds Severe Dry Eyes

14 STAINING AND GRADING

15 MARX S LINE Presence would signify potential benefit of lid debridement

16 LID MARGIN ASSESSMENT:

17 MEIBOGRAPHY: LOOKING BELOW THE SURFACE Role of Meibography: - Establish baseline for future visits - Patient education and compliance - Determination of chronic disease state - Prognostic factors

ARRANGEMENT OF MEIBOMIAN GLANDS Heinrich Meibom (1638-1700) first published in 1666. Number of upper glands: 25-40, Median: 31 - Average length: 5.

18 ARRANGEMENT OF MEIBOMIAN GLANDS Heinrich Meibom ( ) first published in Number of upper glands: 25-40, Median: 31 - Average length: 5.5mm - Calculated volume: 26 microliters Number of lower glands: 20-30, Median: 26 - Average length: 2 mm - Calculated volume: 13 microliters Active glands in only 45% of gland openings at one time and a decrease of Active glands by 50% between age 20 to 80. Sobotta Ð. Atlas der Anatomie des Menschen. Ferner H, Straubesand J, eds. Ed. 18, Vol. 1, p. 215, Urban & Schwarzenberg 1982

HISTOLOGIC APPEARANCE OF MEIBOMIAN GLANDS Acinus: 150-200 um diameter - Contain secretory cells called meibocyte - Meibocyte develops on outer layers and migrate centrally Connecting Ductule:

19 HISTOLOGIC APPEARANCE OF MEIBOMIAN GLANDS Acinus: um diameter - Contain secretory cells called meibocyte - Meibocyte develops on outer layers and migrate centrally Connecting Ductule: 150um long and 30-50um wide -stratified squamous epithelium Central Duct: um in diameter, wider lumen - stratified squamous epithelium Excretory Duct: 0.50mm long. - cornified epithelium

20 PHYSIOLOGY OF MEIBOMIAN GLANDS Greater build up of Meibum during the sleeping hours. Mechanical contraction of M. Orbicularis muscle during blink milks glands towards external epidermis with relaxation of margina muscle of Riolan leading to the expression. Muscles work in opposi

21 PATHOPHYSIOLOGY OF MEIBOMIAN GLAND DYSFUNCTION

22 Kelly K. Nichols,1 Gary N. Foulks,2 Anthony J. Bron,3 Ben J. Glasgow,4,5 Murat Dogru,6 Kazuo Tsubota,6 Michael A. Lemp,7 and David A. Sullivan8,9 The International Workshop for Meibomian Gland Dysfunction

24 Gland Shortening

25 Gland Hypertrophy

26 Advanced gland Hypertrophy and Loss due to Hyperkeratinization

27 Track gland Hypertrophy and Loss

28 EVAPORATIVE DRY EYE TREATMENT Tim Trinh, O.D., F.A.A.O. All EyeCare Optometry Vision Source Administrator Date: November 6 th, 2016

29 Lid Hygiene Omega 3 Supplements Blephex Lipiflow Miboflo Baudouin C, et al. Br J Ophthalmol 2016;100: doi: /bjophthalmol Cytokine Release Tear Film Instability Increased Evaporation Vicious Cycle of Dry Eyes Increased Osmolarity Artificial Tears Environmental Stressors Work Environmental management Allergy Management Medicated Preservatives Cell Damage Steroids Restasis Xiidra Doxycycline Omega 3 Supplements Inflammation Cellular Death Contact Lens Adjustments Medicated Therapy Amniotic Membranes Nerve Stimulation

30 Demodex Blepharitis DEMODEX BLEPHARITIS MANAGEMENT Recalcitrant blepharitis Collarettes located at base of eyelashes Diagnosis removal of lash and placing on slide of microscope plate. Only 7% of the patients were Demodex-free after eyelid scrubbing without TTO, on the other hand, 24% were Demodex-free after eyelid scrubbing with TTO.

31 TREATMENT DEMODEX Blephex In office cleaning procedure 12 minute procedure Effective jump start Cliradex Tea Tree Oil Scrub Avenova Hypochlorous acid Kills Nymph Demodex Mites Neutralizes Toxins Zocular Okra extract medical.net/health/new- Approaches-for-Fighting- Demodex-Mites.aspx

32 MEIBOMIAN GLAND MELTING POINT Melting point Normal Meibomian glands 28 to 32 Celsius (84 to 89.6 Fahrenheit) 5 minutes of treatment with Towel Compress (40 Celsius) applied to skin of eyelids increased tear film lipid layer by 80% with an additional 20% increase after 15 minutes of treatment (Olson et al) Warm moist air device use for 10 minutes twice daily for a period of 2 weeks provided symptomatic relief of ocular fatigue, improvement of tear stability and ocular surface epithelial damage in patients with MGD (Matsumoto et al)

Pro: Pulsation and heating milks glands and has been

33 LIPIFLOW IN OFFICE TREATMENT THERAPIES Treatment: Heat pulsation therapy from inside out. Pro: Pulsation and heating milks glands and has been shown to provide relief for 1 year. Con: Cost to patient and replacement parts.

16 minute procedure 8min/eye Pro: Low cost effective

34 MIBOFLO IN OFFICE THERAPY Treatment: Heat transfer using Thermal paddle and ultrasound gel. 16 minute procedure 8min/eye Pro: Low cost effective treatment Con: No studies for long term efficacy, may require 2-3 visits for longer lasting effects.

35 ARTIFICIAL TEARS Increase tear film stability Decrease tear osmolarity Rinse toxins and cytokines Reduce friction of conjunctiva and eyelid

LIPID BASED TEARS An emulsion-based lubricant eye drop has been studied in normal subjects and patients with aqueous-deficient dry eye, with or without MGD

Gerd Geerling,1 Joseph Tauber,2 Christophe Baudouin,3 Eiki Goto,4 Yukihiro Matsumoto,5 Terrence O Brien,6 Maurizio Rolando,7 Kazuo Tsubota,5 and Kelly K.

36 LIPID BASED TEARS An emulsion-based lubricant eye drop has been studied in normal subjects and patients with aqueous-deficient dry eye, with or without MGD emulsion-treated eyes showed rapid restructuring of the preexisting tear lipid film in tearinterference image examination. Gerd Geerling,1 Joseph Tauber,2 Christophe Baudouin,3 Eiki Goto,4 Yukihiro Matsumoto,5 Terrence O Brien,6 Maurizio Rolando,7 Kazuo Tsubota,5 and Kelly K. Nichols8 The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction Investigative Ophthalmology & Visual Science, Special Issue 2011, Vol. 52, No. 4

Age Restriction older than 8 years of age yellowing/graying of teeth

37 ORAL TETRACYCLINES Decrease inflammatory factors: MMP 9 s IL-1 TNF collagenase activity B-cell activation Side Effects: Photo-toxicity Age Restriction older than 8 years of age yellowing/graying of teeth GI upset Instructions: 50 to 100mg/day 6 to 12 weeks Do not take with dairy

38 CORTICOSTEROIDS Use of corticosteroids over a period of 2 to 4 weeks, improve the symptoms and clinical signs of moderate to severe dry eye disease (30, 31). After 2 weeks of treatment, symptoms regressed moderately (43%) or completely (57%).

39 OMEGA 3 FATTY ACIDS

40 OMEGA 3 ROLE IN INFLAMMATION SUPPRESSION Western diets contain about 10 to 20% of fatty acids as arachidonic acid, with about 0.5 to 1% EPA and about 2 to 4% DHA (Philip C. Calder. Nutrients Mar; 2(3): Published online 2010 Mar 18. doi: /nu ) EPA DHA

41 BIOAVAILABILITY/ABSORPTION OF DIFFERENT FORMS OF EPA/DHA Bioavailability of (EPA + DHA) via triglyceride form reported to be significantly better than ethyl ester form Bioavailability of EPA+DHA from re-esterified triglycerides was superior (124%) compared with natural fish oil, whereas the bioavailability from ethyl esters was inferior (73%). (Dyerberg et al., prost, leuk, and efa 83: (2010)) The absorption of epa/dha in ethyl ester form better on a high fat meal. (Lawson and hughes, bbrc, 156: (1988))

42 FISH OIL INTERACTION WITH WARFARIN Fish oil supplementation could have provided additional anticoagulation with warfarin therapy. This fatty acid may affect platelet aggregation and/or vitamin K-dependent coagulation factors. Omega-3 fatty acids may lower thromboxane A(2) supplies within the platelet as well as decrease factor VII levels. ann pharmacother Jan; 38(1)::50-2

43 OUTSIDE THE BOX TREATMENT Tim Trinh, O.D., F.A.A.O.

44 CASE HISTORY: Chief Complaint: Severe red, irritated, dry eyes x 2 years. Epiphora and blurred vision x 6 months and unbearable now. Dry eyes x 10 years Wearing sunglasses indoors now that eyes are so red PMHx: Hypothyroid Lupus Sjogren s Disease Menopause POHx: Primary Open Angle Glaucoma Surgical Hx: Blepharoplasty x 6 months Punctal Plugs Occupation: Marriage Family Therapist

46 6 months prior

47 MEDICATIONS LIST Systemic Medications: L Thyroxine Liothyronine Estradiol Progesterone Zyrtec PRN Supplements: Magnesium Citrate Probiotic Vit B-6/B-12 Iron Vit D3 5000IU&10,000 IU Ocular Medications: Azopt bid OU x 3+ years Travatan Z qpm OU x 3+ years Dry Eye Treatments: Compress Therapy Restasis bid OU Refresh Optive Genteal Gel Omega 3 Fish Oil h/o plugs OU

CLINICAL EVALUATION: Meibography: VA: 20/30 OD 20/25 OS IOP: 13/13 mmhg @ 2:39pm I-care SLE: Lids: 4+

48 CLINICAL EVALUATION: Meibography: VA: 20/30 OD 20/25 OS IOP: 13/13 2:39pm I-care SLE: Lids: 4+ telangiectasia, +keratinization Cornea: 1-2+ staining Conjunct: 1-2+ staining, Injection 4+ Fundus: C/D: OD: 0.40 OS: 0.55

49 WHAT TREATMENT OPTIONS WOULD YOU OFFER THE PATIENT?

50 ADDITIONAL CASE HISTORY FROM PRIOR DOCTOR: Patient had negative reaction to Doxycycline in past causing urinary discomfort and had negative reaction to Minocycline caused Diarrhea. Patient put on Tobradex to help with irritated dry eyes, but had a steroid response to 28mmHg OU Patient was put on Combigan to decrease pressure, but irritation increased dramatically Patient was put on Xiidra, but had blurred vision and discontinued Lipiflow offered, but was cost prohibitive

51 TREATMENT PLAN: Tear film stability: Miboflo, blephex procedure to remove blockage Continue compress therapy reaffirmed instructions 108 F Converted standard Omegas to High EPA/DHA Triglyceride Forms Osmolarity: Retaine eye drops qid OU Sleep mask at bed time, decrease night evaporation d/c Azopt due to possible generic dorzolamide allergy and continued Travatan Z only Environment: Humidifier at bed time Inflammation: Continue Restasis bid OU No steroid due to response history Rely on natural Omega 3 Anti-inflammatory

52 SUCCESS AND ROADBLOCKS: Redness started to decrease to 2+ injection by 1 week follow up with just sleep mask and d/c Azopt Lid telangiectasia decreased s/p Blephex and Miboflo at 1 week treatment Two week follow up: IOP spiked to 25/21mmHg with Travatan Z alone Started Timolol 0.5% qam and d/c Travatan Z, changed to generic Latanoprost (cost) qpm. Pressure decreased to 16,13 but patient had difficulty breathing, shortness of breath. Changed medication to Timolol 0.25%qam and Latanoprost qpm OU and 2 week follow up, IOP was maintained at 17/17 mmhg OU, target IOP was 16-18mmHg

longer present Dry eye symptoms resolved Retaine drops only twice a

53 FINAL VISIT: Was able to discontinue Restasis bid OU completely TBUT increased to 9 seconds Telangectasia was completely gone Injection no longer present Dry eye symptoms resolved Retaine drops only twice a day. Changed quality of life, no longer has to wear sunglasses indoors.

Understanding the Role of Meibomian Gland Dysfunction in Dry Eyes

Understanding the Role of Meibomian Gland Dysfunction in Dry Eyes The International Dry Eye Workshop separated dry eyes into two main categories in 2007. Aqueous Deficient Dry Eyes as defined by an inability