Advancing the Management of Dry Eye Disease. A Targeted Approach to the Diagnosis and Treatment of Meibomian Gland Dysfunction

Transcription

1 Advancing the Management of Dry Eye Disease A Targeted Approach to the Diagnosis and Treatment of Meibomian Gland Dysfunction

2 Scientific Committee Chair Rookaya Mather, MD, FRCSC Ophthalmologist, Cornea Specialist Ivey Eye Institute, St. Joseph s Hospital Associate Professor Schulich School of Medicine & Dentistry Western University London, Ontario Johanna Choremis, MD, FRCSC Ophthalmologist, Cornea Specialist Maisonneuve-Rosemont Hospital Jewish General Hospital Assistant Professor, McGill University Assistant Professor, Université de Montréal Montreal, Quebec Richard Bazin, MD, FRCSC Ophthalmologist, Cornea Specialist Hôpital du St-Sacrement Centre Universitaire d Ophtalmologie Clinical Professor, Université Laval Quebec, Quebec 2

3 Disclosures Dr. Mather has acted as a Speaker and participated in Advisory Boards for Alcon, Allergan, and Bausch and Lomb. Dr. Choremis has acted as a Speaker for Alcon, Allergan, and Bausch and Lomb. Dr. Bazin has acted as a Speaker for Alcon and Abbott Medical Optics. Drs. Mather, Choremis, and Bazin received an honorarium for their participation in this CME program This program has been supported by an educational grant from Alcon Canada 3

4 Accreditation Statement This program is approved for 1 hour of CE credit by the Council on Optometric Practitioner Education (COPE). The post-test was approved by the University of Waterloo School of Optometry and Vision Science. To obtain credit for each course, you must: Be a licensed optometrist View the slide/lecture presentation Complete the online post-test Obtain a grade of 70 percent or higher Print your certificate for record keeping 4

5 Learning Objectives Following this activity, participants should be better able to: Define dry eye disease (DED) and its impact on quality of life Recognize the different types of DED, including aqueous deficient and evaporative dry eye Identify the role of meibomian gland dysfunction as a cause of evaporative dry eye Perform a targeted clinical exam to uncover the etiology of DED utilizing tear film break-up time, Schirmer test, and meibomian gland expression Initiate an appropriate management plan that targets the underlying etiology of DED 5

6 Why are We Presenting This Dry Eye CME Program? DED is often under-recognized and even undiagnosed Moreover, evaporative dry eye and MGD are not well understood and are very often overlooked Here, we discuss a simple targeted approach to diagnosis and treatment of DED 6

7 Definitions of Dry Eye Dry Eye WorkShop (DEWS) Committee (1) Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. 1) DEWS Committee Report of the Dry Eye Workshop (DEWS). Ocul Surf. 2007;5(2):

8 Dry Eye Disease (DED) in Canada DED occurs in approximately 1 in 4 Canadian adults Canada Dry Eye Epidemiological Study (CANDEES) October 1997 (1) 28.7% of patients in Canadian optometrists offices (N=13 517) reported DED symptoms 1.6% of all patients surveyed had severe DED 7.8% had constant but moderate DED 1) Doughty MJ et al. Optom Vis Sci. 1997;74(8):

9 Percent Patient Profile of DED More prevalent in older patients ( 50 years) (1,2) Men Women < Age (years) 1) Schaumberg DA et al. Am J Ophthalmol. 2003;136(2): ) Schaumberg DA et al. Arch Ophthalmol. 2009;27(6): ) Galor P et al. Am J Ophthalmol. 2011;152(3):

10 Patient Profile of DED More prevalent in older patients ( 50 years) (1,2) However, association of DED with frequent use of computers and other electronic viewing screens means that DED can affect all ages 2.40 increased risk in women (3) 1) Schaumberg DA et al. Am J Ophthalmol. 2003;136(2): ) Schaumberg DA et al. Arch Ophthalmol. 2009;27(6): ) Galor P et al. Am J Ophthalmol. 2011;152(3):

11 Effect of DED on Quality of Life (QoL) Survey of 589 subjects (190 with DED) (1) DED increased the likelihood to report problems with several regular daytime activities Activity Odds ratio to report problems associated with DED Reading 3.64 Specific tasks 3.49 Using a computer 3.37 Watching television 2.84 Driving day 2.80 Driving night ) Miljanovic B et al. Am J Ophthalmol. 2007;143(3):

12 Effect of DED on QoL Average rating scores of the impact of DED on QoL were equivalent to moderate/severe angina (1) DED patients more prone to depression and anxiety (2) Common antianxiety and antidepressant treatments may cause or exacerbate DED (3,4) 1) Schiffman RM et al. Ophthalmology. 2003;110: ) Li M et al. Curr Eye Res. 2011;36(1):1-7. 3) Schaumberg DA et al. Arch Ophthalmol 2009;27(6): ) Wong J et al. Ocul Surf. 2011;9(4):

13 Challenges of DED Frustration for patients (1) A chronic disease with NO cure Limits daily activities and has negative impact on QoL Significant treatment costs often not covered by insurance plans (2) Frustration for Eye Care Professionals (ECPs) (1,3) DED can be difficult to treat Time consuming: multiple office visits and telephone calls Most preserved topical ocular agents exacerbate DED Leads to reduced adherence to therapy (4) 1) AAO Retina Panel. Preferred Practice Pattern Guidelines. Bacterial Keratitis. San Francisco, CA: American Academy of Ophthalmology; Available at: 2) Yu J et al. Cornea. 2011;30(4): ) Whitcher JP. Br J Ophthalmol. 2004;88(5): ) Rossi GC et al. Eur J Ophthalmol. 2009;19(4):

14 Challenges for the ECP Perception that diagnosis and management of DED require excessive chair time Clinical signs may not always correspond to patient-reported symptoms Chronic condition that is not curable DED is multifactorial Aqueous deficiency and evaporative (lipid deficiency) Numerous exacerbating factors Glaucoma medications, systemic drugs, environmental factors, etc. Intolerance to contact lenses and increased susceptibility to opportunistic infections due to corneal epithelial damage DED patients are often unhappy following refractive or cataract surgery 14

15 The Decision to Refer the DED Patient Lack of response to topical lubricants Ongoing symptoms, leading to repeat visits and low patient satisfaction Referral to an Ophthalmologist can delay care Using a targeted approach to examining the DED patient, most cases can be managed effectively by the Optometrist 15

16 Major Etiological Causes of Dry Eye Lemp MA (Chair). The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye Workshop. Ocul Surf. 2007;5:77. 16

17 Main Classifications of DED Aqueous Deficient Dry Eye (ADDE) Lacrimal glands produce insufficient tears to maintain adequate lubrication of ocular surface (eg, Sjögren syndrome) Evaporative Dry Eye (EDE) Tear film itself is abnormal and does not remain on the ocular surface long enough (ie, may evaporate too quickly) to provide continuous adequate lubrication (eg, ocular rosacea) Combination ADDE + EDE These 2 conditions frequently exist concurrently 17

18 Role of the tear film Creates optically uniform surface across cornea Lubricates all tissue on ocular epithelium The Tear Film Cleanses anterior surface of debris and foreign matter Protects ocular surface from bacterial colonization 1) Jackson WB. Can J Ophthalmol. 2009;4(4):

19 Make up of the Tear Film 3 major layers (1) Mucin layer (0.2 1 µm thick) Helps tear film spread across ocular epithelium Helps eliminate microorganisms from epithelium (2) Aqueous layer (7 8 µm thick) Hydrates the cornea Lipid layer (0.1 µm thick) Limits evaporation of aqueous layer (3) 1) Lamberts DW. Physiology of tear film. In: The Cornea. Boston (MA): Little Brown & Co.; 1994: ) Asbell PA and Lemp MA. Dry Eye Disease: The Clinician's Guide to Diagnosis And Treatment. New York (NY): Thieme Medical Publishers; 2006:48. 3) Korb DR et al. Cornea. 1994;13(4):

20 Tear Film Instability Dysfunction of either the aqueous-secreting lacrimal glands or the meibomian glands, or both Insufficient tear production OR Insufficient lipid production Leads to tear film instability Lack of uniformity of the tear film surface across cornea Causes discomfort and blurred vision 20

21 Why Does Tear Film Instability Cause DED? Tear Hyperosmolarity Increased evaporation of lipid layer Increased hyperosmolarity Concentration of electrolytes and inflammatory mediators Tear film instability Change in osmolarity of the aqueous layer Epithelial cells die, goblet cells and mucin expression are compromised Inflammatory cascade; damages ocular surface 1) Jackson WB. Can J Ophthalmol. 2009;4(4): ) DEWS Committee Report of the Dry Eye Workshop (DEWS). Ocul Surf. 2007;5(2):

22 Why Does Tear Film Instability Cause DED? Inflammation Inflammation (eg, preservatives in eye drops, allergies, etc) irritates the epithelium Increased inflammation Greater discomfort and increased blinking Increased friction between eyelid and globe Increased tear production Washes away/dilutes mucin layer 1) Jackson WB. Can J Ophthalmol. 2009;4(4): ) DEWS Committee Report of the Dry Eye Workshop (DEWS). Ocul Surf. 2007;5(2):

23 Limitations in Current Practices in Managing DED No test provides all necessary information Conventional therapies are ineffective Primarily tear supplementation Little attention paid to underlying cause(s) of DED MGD is frequently overlooked Exacerbating conditions and medications often not addressed Targeted work-up focuses on: Identification of the underlying cause(s) of DED MGD as a frequent contributing factor 23

24 How Will a Targeted Approach Improve Patient Outcomes? Evidence-based approach to managing DED Target each factor contributing to DED Posterior / anterior blepharitis Preservatives in eye drops (eg, benzalkonium chloride) Environmental factors, contact lens wear Allergic conjunctivitis Systemic medications (antihypertensives, antidepressants, etc.) Systemic diseases Sjögren syndrome Parkinson disease Atopic disease 1) Lin PY et al. Invest Ophthalmol Vis Sci. 2005;46(5): ) Arita R et al. Jpn J Ophthalmol. 2010;54(5):

25 What are the Benefits of a Targeted Approach to DED? A management plan that addresses each patient s needs Better understanding of the condition for ECP and patient Realistic goals and expectations Better patient satisfaction with therapy Fewer follow-up visits and telephone calls Importance of patient counseling Clarify patient expectations Ways to cope 25

26 2012 Thinkstock / altrendo images Key Examination Findings Symptoms Lower tear meniscus Tear film break-up time (TBUT) Fluorescein staining Lid features MG expression Schirmer test Tear osmolarity testing Blink rate Patient s general facial skin condition 1) Tomlinson A et al. International Workshop on Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):

27 Symptoms of DED Poor correlation with objective findings Only ~57% of patients who report symptoms of DED also have objective signs (1) Symptoms remain the first step in patient assessment Early indicator of disease Symptom severity scores follow patient progress 1) Khanal S et al. Invest Ophthalmol Vis Sci. 2008;49(4):

28 Symptoms of DED (cont.) Symptoms in Canadian Dry Eye Assessment questionnaire (1) Sensitivity to light Gritty or scratchy sensation Burning or stinging Blurred/unclear vision Vision that fluctuates with blinking Vision that improves with artificial tears Tearing/watering Pain/burning during the night or upon awakening in the morning 1) Jackson WB. Can J Ophthalmol. 2009;4(4):

29 Steps to a Targeted Diagnosis Tear film Reproduced with permission from Copyright 2012 Genesis Framework. 29

30 2012 Thinkstock / BananaStock Steps to a Targeted Diagnosis Blink rate Normal range: 6 10 blinks/min Blink rate varies considerably when performing visual tasks (1) At rest 17 During conversation 26 Reading 5 Significant effect of concomitant diseases (eg, Parkinson disease) (2) Altered by drops instilled as part of the clinical examination 1) Bentivoglio AR et al. Mov Disord. 1997;12(6): ) DEWS Committee Report of the Dry Eye Workshop (DEWS). Ocul Surf. 2007;5(2):

31 Steps to a Targeted Diagnosis Tear film break-up time (TBUT) 31

32 Ocular Surface Staining Fluorescein staining (1% - 2% solution) Rose bengal or lissamine green staining 32

33 2012 Alamy Images. Schirmer Test Interpretation of basic Schirmer test (with topical anesthesia) Normal >10 mm of wetting Equivocal >5 10 mm Abnormal 5 mm (<10-15 mm without anesthesia) 1) Jackson WB. Can J Ophthalmol. 2009;4(4):

34 Tear Osmolarity Copyright 2012 TearLab Corporation. 34

35 Lid Features Examine for changes in lid morphology Examination of the lid margins Signs of rosacea Pouting indicates blockage of the ducts Thickening of the lid margins Position of the orifices 35

36 Blepharitis Leads to DED Staphylococcus A strains hydrolyze cholesteryl oleate (1) Change in viscosity of the meibum can block the ducts (2) Ocular rosacea (3) Styes (4) 1) Dougherty JM, McCulley JP. Invest Ophthalmol Vis Sci. 1986;27(1): ) Mathers WD, Lane JA. Adv Exp Med Biol. 1998;438: ) Goto E, Tseng SC. Arch Ophthalmol. 2003;121(2): ) Lemp MA, Nichols KK. Ocul Surf. 2009;7(2): S

37 Meibomian Gland Expression 37

38 Meibomian Gland Expression Expression of meibomian glands is routinely performed with gentle pressure on the eyelids using a cotton swab or fingertip. The expression of clear fluid indicates healthy meibomian glands. The necessity for increased pressure to express more viscous meibum is indicative of meibomian gland dysfunction. This video segment shows the characteristic inspissated, or toothpaste-like, consistency of meibum that correlates with grade 3 meibomian gland dysfunction. 38

39 Grading MG Expression Grade Meibum quality Expressibility 0 Clear fluid All glands Easily expressed 1 Cloudy fluid 3 4 glands Easily expressed 2 Cloudy particulate fluid 1 2 glands Expressed with moderate pressure 3 Inspissated ( toothpaste consistency) No glands Inexpressible even with hard pressure 1) Tomlinson A et al. International Workshop on Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):

40 MG Dropout Partial or total gland loss / atrophy Quantified by meiboscopy, meibography, and confocal microscopy May be most accurate means to identify EDE Interpretation No loss of MG Loss of 25%-33% of glands expressed >33% of glands either absent, atrophied or nonexpressing = Good = Within acceptable limits = MGD 1) Tomlinson A et al. International Workshop on Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):

41 MGD is More Common Than We Think 46% 86% of patients with DED also have MGD (1,2) 85.5% of 159 subjects with confirmed DED had some degree of MGD (2) MGD alone 79 (49.7%) ADDE alone 23 (14.5%) Mixed MGD and ADDE 57 (35.8%) Cataract surgery candidates 59% of 100 patients had blepharitis (3) 60% of 136 patients had signs of DED; 87% were asymptomatic (4) 1) Viso E et al. Cornea. 2011;30(1):1-6. 2) Lemp MA et al. Cornea. 2012;31(5): ) Buznego C. Presented at the 2010 ASCRS Symposium and Congress. 4) Trattler W. Presented at the 2011 AAO Annual Meeting. 41

42 ADDE and EDE Summary of Test Results DED Classification Test Characteristic Findings ADDE TBUT <10 sec is considered abnormal Ocular surface dye staining Schirmer test Fluorescein clearance test / tear function index Lacrimal gland function Tear osmolarity Pattern of exposure zone (interpalpebral) corneal and bulbar conjunctival staining typical 5 mm for Schirmer test with anesthesia considered abnormal Test result is compared with a standard colour scale Decreased tear lactoferrin concentrations Increased EDE TBUT <10 sec is considered abnormal Ocular surface dye staining Tear osmolarity Staining of inferior cornea and bulbar conjunctiva typical Increased 1) AAO Retina Panel. Preferred Practice Pattern Guidelines. Bacterial Keratitis. San Francisco, CA: American Academy of Ophthalmology; Available at: 42

43 DED Severity Grading Severity level Discomfort, severity, and frequency Visual symptoms Conjunctival injection Mild and/or episodic; occurs under environmental stress None or episodic mild fatigue Moderate episodic or chronic, stress or no stress Annoying and/or activity-limiting episodic Severe frequent or constant without stress Annoying, chronic and/or constant, limiting activity None to mild None to mild +/- +/++ Conjunctival staining None to mild Variable Moderate to marked Marked Corneal staining (severity/location) Severe and/or disabling and constant Constant and/or possibly disabling None to mild Variable Marked central Severe punctate erosions Corneal/tear signs None to mild Mild debris, meniscus Lid/meibomian glands Filamentary keratitis, mucus clumping, tear debris Filamentary keratitis, mucus clumping, tear debris, ulceration MGD variably present MGD variably present Frequent Trichiasis, keratinization, symblepharon TBUT (sec) Variable 10 5 Immediate Schirmer score (mm/5 min) Variable Reproduced with permission from Behrens A et al. Cornea. 2006;25(8): Copyright 2006, Lippincott Williams & Wilkins 43

44 Management by Severity Level Level 1: Level 3: Education and environmental/ dietary modifications Elimination of offending systemic medications Artificial tear substitutes, gels/ointments Eye lid therapy Add to Level 2 treatments: Serum Contact lenses Level 2: Level 4: Add to Level 1 treatments: Anti-inflammatories Tetracyclines (for meibomianitis, rosacea) Punctal plugs Secretogogues Moisture chamber spectacles Permanent punctal occlusion Add to Level 3 treatments: Systemic anti-inflammatory agents Surgery (lid surgery, tarsorrhaphy; mucus membrane, salivary gland, amniotic membrane transplantation) DEWS Committee Report of the Dry Eye Workshop (DEWS). Ocul Surf. 2007;5(2):

45 MGD Treatment Algorithm Stage Clinical Description Treatment 1 No symptoms of ocular discomfort, itching, or photophobia Clinical signs of MGD based on gland expression Minimally altered secretions: grade 2 4 Expressibility: 1 No ocular surface staining 2 Minimal to mild symptoms of ocular discomfort, itching, or photophobia Minimal to mild MGD clinical signs Minimally altered secretions: grade 4-<8 Expressibility: 1 None to limited ocular surface staining: DEWS grade 0 7; Oxford grade 0 3 Inform patient about MGD, the potential impact of diet, and the effect of work/home environments on tear evaporation, and the possible drying effect of certain systemic medications Consider eyelid hygiene including warming/expression as described below (±) Advise patient on improving ambient humidity; optimizing workstations and increasing dietary omega-3 fatty acid intake (±) Institute eyelid hygiene with eyelid warming (a minimum of 4 minutes, once or twice daily) followed by moderate to firm massage and expression of MG secretions (+) All of the above, plus (±) Artificial lubricants (for frequent use, nonpreserved preferred) Topical azithromycin Topical emollient lubricant or liposomal spray Consider oral tetracycline derivatives Reproduced with permission from Geerling G et al. International Workshop on Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):

46 MGD Treatment Algorithm (cont.) Stage Clinical Description Treatment 3 Moderate symptoms of ocular discomfort, itching, or photophobia with limitations of activities Moderate MGD clinical signs lid margin features: plugging, vascularity Moderately altered secretions: grade 8 to <13 Expressibility: 2 Mild to moderate conjunctival and peripheral corneal staining, often inferior: DEWS grade 8 23; Oxford grade Marked symptoms of ocular discomfort, itching or photophobia with definite limitation of activities Severe MGD clinical signs lid margin features: dropout, displacement Severely altered secretions: grade 13 Expressibility: 3 Increased conjunctival and corneal staining, including central staining: DEWS grade 24 33; Oxford grade signs of inflammation: moderate conjunctival hyperemia, phlyctenules All of the above, plus: Oral tetracycline derivatives (+) Lubricant ointment at bedtime (±) Anti-inflammatory therapy for dry eye, as indicated (±) All of the above, plus: Anti-inflammatory therapy for dry eye (+) Reproduced with permission from Geerling G et al. International Workshop on Meibomian Gland Dysfunction. Invest Ophthalmol Vis Sci. 2011;52(4):

47 Simple Treatment Algorithm: When you hear or see evidence of MGD, treat it Symptoms indicating MGD Fluctuating vision, changing from blink to blink Burning, stinging Symptoms worse with air currents OR Signs of MGD MG plugging, inspissation, toothpaste sign Lid margin telangiectasia Rapid TBUT Treatment Treat inflammation Lid hygiene & massage Omega 3 supplements Oral tetracyclines Lipid containing tear supplements Behavioural and environmental modification 47

48 Management Lid Hygiene and Warm Compresses Effective for most forms of DED; particularly useful in MGD form of EDE Lid hygiene Regular removal of debris Avoid using soaps as this may cause irritation; use facial wash or lid shampoo in a gentle fashion Warm compresses Break down pathologically altered meibum, improving flow 5 minutes of warm towel compress (40ºC) increased tear film lipid layer thickness by 80% (1) Combine with meibomian gland expression by eyelid massage 1) Olson MC et al. Eye Contact Lens. 2003;29(2):

49 Lubricating Eye Drops Lubricating eye drops come in different formats Tear supplements (artificial tears) Lipid-containing artificial tears Gels and ointments Avoid preservative-containing eye drops when: Use artificial tears >4 times per day Patient using other ocular agents (eg, glaucoma) Tear supplements have been the mainstay of DED treatment with unsatisfactory results for most patients 49

50 Lipid-Containing Artificial Tears Most appropriate for use with EDE Replenish and supplement the eye s own lipid layer to stabilize the tear film Efficacy is not limited to lubricating volume effect (1) 1) Bujak MC et al. Ophthalmic Surg Lasers Imaging. 2011;42(4):

51 Lipid-Containing Artificial Tear Drops Systane Balance (Alcon) Contains mineral oil, anionic phospholipid, propylene glycol 0.6% Refresh Ultra (Allergan) Contains carbomer 1342, castor oil, glycerin, polysorbate 80 Refresh Endura (Allergan) Contains carbomer 1342, castor oil, glycerin, polysorbate 80 Preservative-free 51

52 Lipid-Containing Eye Drops Increase the Lipid Layer Scaffidi et al (1) (N=41) Mean increases in lipid layer thickness (LLT) after single drop Soothe XP (mineral oil) 60.0 nm Refresh Dry Eye Therapy 23.6 nm (carboxymethylcellulose) Korb et al (2) (N=40) Systane Balance raised LLT significantly greater than Soothe XP at up to 2 hours 1) Scaffidi RC, Korb DR. Eye Contact Lens. 2007;33(1): ) Korb D et al. Presented at the 6 th Annual Tear Film and Ocular Surface (TFOS) Society meeting; September 2010; Florence, Italy. 52

53 Lipid-Containing Eye Drops Improve TBUT Korb et al (1) (N=38) TBUT at 2 hours post-dose (P<0.0001) Systane Balance 8 seconds Soothe XP 6 seconds Foulks et al (2) (N=49) 34% improvement in TBUT (P=0.032) with Systane Balance 1) Korb D et al. Presented at the 6 th Annual TFOS Society meeting; September 2010; Florence, Italy. 2) Foulks G et al. Presented at the 6 th Annual TFOS Society meeting; September 2010; Florence, Italy. 53

54 Patient Evaluation of Efficacy of Lipid-Containing Eye Drops Foulks et al (1) : of 49 patients with MGD treated with Systane Balance: 86% reported fast symptomatic relief 79% reported satisfaction with drop comfort 79% reported overall product satisfaction Significant improvements in treatment satisfaction and symptom bother when measured by the Impact of Dry Eye on Daily Life (IDEEL) questionnaire Significant improvement in percentage of daily activities impacted by dry eye when measured with the Work Productivity and Activity Impairment (WPAI) questionnaire 1) Foulks G et al. Presented at the 6 th Annual TFOS Society meeting; September 2010; Florence, Italy. 54

55 Topical Antibiotics Most often used to reduce bacterial flora on the lid margin DED associated with blepharitis Pulse dosing Antibiotic ointment typically used 1-2 times daily for 1-2 weeks Common ointment preparations Bacitracin Fusidic acid Ciprofloxacin Erythromycin Tobramycin 55

56 Anti-inflammatory Therapy Used to reduce ocular surface inflammation and interrupt the inflammatory cascade Corticosteroids Ideally administered as a pulse therapy; tapered appropriately Rapid onset of action May be used concurrently with cyclosporine A Inappropriate for long-term use due to adverse events Formulations Methylprednisolone 1% Loteprednol etabonate ophthalmic suspension 0.5% Fluorometholone 0.1% Dexamethasone 0.1% 1) Jackson WB. Can J Ophthalmol. 2009;4(4):

57 Anti-inflammatory Therapy (cont.) Topical cyclosporine A (0.05%) Reduces inflammation by inhibition of T-lymphocyte activation Patients may only experience improvement 2-4 weeks after initiation Tetracyclines Anti-inflammatory, antibacterial, and antiangiogenic effects Prolonged use may promote bacterial resistance Formulations Doxycycline (100 mg daily for 3 months; alternatively, 20 mg/day) Minocycline ( mg daily for 3 months) 1) Jackson WB. Can J Ophthalmol. 2009;4(4):

58 Secretagogues Pilocarpine (muscarinic agonist; 5-10 mg tid or qid po; maximum 30 mg/day) Stimulates tear production and secretion in Sjögren syndrome Limited by systemic cholinergic adverse events Excessive perspiration (40%) and chill (20%) Nausea (13%) Oversalivation (13%) Intestinal cramping (7%) Usually reserved for moderate to severe DED 1) Jackson WB. Can J Ophthalmol. 2009;4(4): ) Pfizer Canada. Salagen (pilocarpine) Product Monograph

59 Punctal Plugs Help to retain tear volume on the ocular surface Commonly used for: Sjögren syndrome Filamentary keratitis Neurotropic / diabetic keratopathy Keratitis sicca Temporary neurotropic keratitis after refractive surgery Dissolvable plugs available for short- and medium-term use; non-dissolving removable plugs for long-term use; cautery for permanent closure Treat concomitant blepharitis and inflammation before insertion 1) Jackson WB. Can J Ophthalmol. 2009;4(4):

60 Management Lifestyle Measures Avoid exposure to allergens; take steps to control allergies Humidify the home environment; avoid air currents Avoid rubbing the eyes Quit smoking or avoid environmental tobacco smoke Prepare for periods of television watching, reading, or computer use Encourage increased consumption of water and omega-3 fatty acids Wrap-around sunglasses for outdoor activities 1) Jackson WB. Can J Ophthalmol. 2009;4(4):

61 Management Patient Counseling Need to educate and empower patients Modifying patient expectations DED is a chronic condition Treatment is long-term and daily Not curable Treatment goals Symptom relief Restore tear film function (if possible) Reduce bacteria on the ocular epithelium and on the lid margin Reduce inflammatory and pro-inflammatory factors 61

62 Conclusions Dry eye disease (DED) is common, but is generally underdiagnosed and undertreated Challenging condition to treat because of its chronic course and numerous exacerbating factors A targeted evaluation of the DED patients includes eliciting symptoms of EDE and examination of the meibomian gland function 62

63 Conclusions Treatment options based on underlying cause(s) and severity Lifestyle factors, lid hygiene, and warm compresses Lubricating eye drops Lipid containing tear supplements Anti-inflammatories Secretagogues, omega 3 supplements Punctal occlusion 63

64 Case Study 56-year-old female Longstanding history of irritated eyes and dry mouth Scleroderma, hypertension, depression, and hypothyroidism Medications: Baclofen Citalopram Levothyroxine sodium Celecoxib Hydrochlorothiazide 64

65 Case Study Ocular symptoms Grittiness Light sensitivity Burning Redness Worse at the end of the day and worse with reading, television viewing, outdoor activities The patient enjoys reading, but must stop after 25 minutes 65

66 Case Study Patient had been using: artificial tears with vasoconstrictor prn (Visine ), allergy drops, and ointment at night Referring Eye Care Provider recognized Sjögren syndrome Recommended stopping allergy drops and switch to non-vasoconstricting artificial tears Samples of Refresh Liquigel, Systane Ultra and Genteal Gel drops to try qid Some improvement (grittiness) after 2 months However, difficulties remain with reading, watching television, and gardening 66

67 Case Study Slit Lamp Examination Visual acuity: 20/40 OU Schirmer testing: 2 mm OU without anesthetic ATD TBUT: 5 seconds OU tear film instability 67

68 Case Study Meibomian Gland Expression and Examination 68

69 Combination of: Case Study Diagnosis: Dry Eye Disease ATD due to Sjögren syndrome Lipid deficiency due to Meibomian gland dysfunction (MGD) Exacerbated by: Systemic medications Preservative-containing ocular agents Topical antihistamine Environmental factors 69

70 Case Study Discussion Why did this patient not improve on her eye drop regimen? Use of artificial tears alone does not address her MGD and tear film instability Her symptoms suggest lipid deficiency Examination confirms MGD 70

71 Simple Treatment Algorithm: When you hear or see evidence of MGD, treat it Symptoms indicating MGD Fluctuating vision, changing from blink to blink Burning, stinging Symptoms worse with air currents OR Signs of MGD MG plugging, inspissation, toothpaste sign Lid margin telangiectasia Rapid TBUT Treatment Treat inflammation Lid hygiene & massage Omega 3 supplements Oral tetracyclines Lipid containing tear supplements Behavioural and environmental modification 71

72 Reduce ocular surface inflammation with short course of topical steroid ADDE Preservative-free tear supplements at least qid Lubricating ointment qhs Cyclosporine A Improve meibomian gland functioning Lid hygiene, heat and massage Oral omega-3 supplements Doxycycline 100 mg bid Case Study Management Plan 72

73 Stabilize the tear film with lipid-containing tear supplement qid Avoid exposure to air currents Wrap-around sun glasses Case Study Management Plan (cont) Remind patient to blink while reading Systemic medications are contributing to her ADDE 73

74 Case Study Reduce Evaporative Loss: Protecting the Ocular Surface 74

75 Case Study Outcome Improved patient comfort and functioning Improved objective findings Corneal staining Tear film stability MG expression and quality of meibum 75

76 Case Study Even in a case of classic ATD due to Sjögren syndrome, MGD can be a contributing factor When MGD is not identified and treated, symptoms and inflammation persist When MGD is recognized as an underlying cause of DED, appropriate management can be initiated Stabilization of the tear film leads to a healthier ocular surface and improved patient outcome 76

77 Thank you for participating in this program. Please proceed to the post test.