Disclosure. Sea Change. Sea Change. Straight Out of Tears: Treating and Managing MGD, Lid Bugs and Other Lid Thugs! Proactive and Preventive
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1 Straight Out of Tears: Treating and Managing MGD, Lid Bugs and Other Lid Thugs! Marc R. Bloomenstein, OD, FAAO Scottsdale, AZ Disclosure Presenter is on speakers panel of: Akorn, Alcon, Allergan, J&J, B+ L, BlephEX, Lunovas, OcuSOFT, Tear Lab President of MRB Eye Consultants AOA CE Chairman Past-President of the Optometric Council on Refractive Technology (OCRT) OSSO Board Member Presenter has NO financial interest in any products mentioned Incidence and Prevalence of Dry Eye 25% of teen-adults 28 million experience symptoms frequently 2015 Gallup Poll- 30 million Americans affected Proactive and Preventive Risk Factors for Ocular Surface Inflammation Females Sjogren s Aging Environmental Issuse Refractive Surgery Vitamin deficiency Medications Sea Change Sea Change Managing the disease in the chair Insurance visits Glaucoma model 3-4 visits a year Compensation Vision plan Medical Insurance Cash pay-abn Patient retention Patient referrals Cutting Edge Treatment 1
2 Symptoms Signs, Signs, everywhere Signs! #1 most important VISION CHANGES Blurred Fluctuating Hazy Refractive changes Pain Light sensitivity Gritty Redness Lid margin Conjunctival Itch Lid Debris Frothy tears collarettes Anterior Blepharitis Seborrheic Blepharitis 2
3 Signs and Symptoms Morning crusting Foreign body sensation Recurrent hordeola Loss of lashes Conjunctival hyperemia Collarretes (scales that encircle lash) Staph immune disease Phlyctenula Pannus Catarrhal infiltrates etc Sequelae to Blepharitis MGD Blepharitis Chalazia / hordeola Dry eyes Punctate keratitis Phlyctenules Recurrent conjunctivitis Pannus Corneal ulceration Endophthalmitis Pathophysiology of Meibomian Gland Disease Bacterial Lipases Break Down Lipids to Soaps Normal meibomian gland secretions convert from unsaturated lipids that melt at body temperature to saturated fats that inspissate the meibomian glands Lid bacteria secrete lipases that break down lipids from soaps to fatty acids 3
4 NON-OBVIOUS MGD Remove those pesky caps: MacGruber! Photos courtesy of Justin Webb, OD, Alcon Research Ltd., Examples of meibum stagnation and changes that correspond to MGD Clear liquid secretion (glands are functional using the MGE) Opaque solid secretion (glands not functional; requires more force than the MGE) Cloudy liquid secretion (glands are functional using the MGE) Absence of secretion (glands not functional; even significant force does not yield secretion) Opaque solid secretion (glands not functional; requires more force than the MGE) Notching at gland orifice (indicates atrophy/drop out) Is the most common and arguably the most important diagnosis presenting to the optometry Blepharitis Anterior Inflammation mainly centered around the eyelash and follicles BIOFILM Blepharitis 22 Inflammation that involves the meibomian gland orifices Posterior The Biofilm Biofilm: A biofilm community can be formed by a single bacterial species, but in nature biofilms almost always consist of rich mixtures of many species of bacteria in a polysaccharide matrix Thrives in moisture Smooth surface Bacteria 4
5 4/2/18 Treatment Blepharitis.MGD BlephEx Treatment BlephEx Treatment
6 Mibo Medical Group ADJUNCTIVE THERAPY FOR MGD Lipid/Oil-Based Lubricant Eye Drops Palliative None treat the cause Downside can be blurring & stinging with castor oil emulsions Retaine MGD TM Introducing the cationic emulsion A main issue is the loss of product while blinking A unique cationic oil-in-water nanoemulsion addresses unmet needs Lipid compound + innovative cationic (positively charged) technology Better attraction to the ocular surface Improvement of the residence time Better spreading on the ocular surface Better adsorption Enhanced tear film and corneal epithelium 1,2 OILY CORE Solubilizes the drugs SURFACTANT Stabilizes the interface CATIONIC AGENT Brings the positive charges Seborrheic Blepharitis Seborrheic blepharitis is caused by seborrheic dermatitis, a skin condition that creates flaking and scaling including on the eyelids. Regular cleansing with eyelid scrubs can provide significant relief and improve the appearance of eyelids. Signs and Symptoms Red, irritated, itchy eyelids and the formation of dandruff-like scales on the eyelashes. 1. Lallemand F, et al. J Drug Deliv. 2012;2012: Daull P, et al., Benefits of cetalkonium chloride cationic oil-in-water nanoemulsions for topical ophthalmic drug delivery. Draft for publication,
7 Seborrheic Blepharitis (continued) TheraTears SteriLid Take Home Recommendation OCuSOFT Lid Scrub Eyelid Cleanser Original Formula Soothes and Cleanses Away External Irritants TheraTears Sterilid removes oil, debris and other contaminants that can accumulate on eyelids and eyelashes. OCuSOFT Lid Scrub removes oil, debris, and desquamated skin from the eyelids and is non-irritating to the eyes. M /15 39 Need More Eyelid Relief What Is Hypochlorous Acid? The root cause of anterior blephartitis is the overproduction of oils. Mild surfactants in OCuSOFT Lid Scrub PLUS eyelid cleanser act to dissolve and remove oil, debris, and desquamated skin. Other formulas do not. Hypochlorous Acid is produced by white blood cells as part of the body s natural defense mechanism against pathogens. Hypochlorous acid is a weak acid that is formed when chlorine dissolves in water. Its chemical formula is HOCL. An acid is a ph below 7 (neutral). Above 7 is considered base/basic or alkaline. Tap water is generally a ph of 7 whereas citric acid from lemons is highly acidic at around a 2. The ph of HOCL is between 6-7. Hypochlorous Acid Working the MGD.. HypoChlor Avenova Lipiflow ( J& J) ilux (Tearfilm Innovations) OCuSOFT HypoChlor is a 0.02% concentration of Hypochlorous acid in both Spray and Gel formulation NovaBay Avenova with Neutrox is a 0.01% concentration of Hypochlorous acid 7
8 MGD Research (IPL) Intense Pulse Light Prospective, double-masked, placebo-controlled, paired-eye study 28 participants underwent IPL treatment, with homogeneously sequenced light pulses delivered to one eye and placebo treatment to the partner control eye at: 1 day 15 days 45 days Prospective Trial of Intense Pulsed Light for the Treatment of Meibomian Gland Dysfunction Jennifer P. Craig; Yen-Heng Chen; Philip R. K. Turnbull, Investigative Ophthalmology & Visual Science March 2015, Vol.56, MGD Clinical (IPL) Intense Pulse Light Potential mechanisms of action: Heating/loosening of meibum Reduction in telangiectasias Decrease in bacterial load on face Photos pre-ipl treatment DR WHITNEY HAUSER DR. WHITNEY HAUSER MGD Clinical (IPL) Intense Pulse Light Photos post-ipl treatment DR. WHITENY HAUSER 8
9 Inflammatory Dry Eye Alters the Tear Film Image used with permission. Dry Eye Disease reduces mucins, and alters concentrations of growth factors and tear proteins 1,2. Fewer tears can lead to increased inflammatory output from the lacrimal gland, which can cause ocular surface damage and altered tear production. The resulting chronic inflammatory stimuli can then lead to further decreased tear production 3-5 Treating The Inflammation Restasis (Allergan) Primary treatment option Multiple mediators of inflammatory cascade Increase goblet cells density and emulsion vehicle Proven Xiidra (Shire) ICAM-1 decoy Balanced saline vehicle Treating The Inflammation Steroids Amniotic Membrane Best MGD Treatment?? Warm up the lids In office expression Retaine MGD/Restasis/Xiidra Low dose tetracycline derivatives Lid Heat options Omega fatty acids Get the patient early..do it all!!! 9
10 HANDBOOK OF MEDICAL ENTOMOLOGY Demodex That other Thug! Dr. WM. A. RILEY, Professor of Insect Morphology and Parasitology, Cornell University Dr. O. A. JOHANNSEN, Professor of Biology, Cornell University
11 Rosacea and Demodex? Rosacea and demodex Meta-analysis of 48 studies 10 different countries 28,527 subjects Rosacea patients 7-8x chance have Demodex Remember Biofilm. Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol 2010;146:896Y902. MICROBLEPHAROEXFOLIATION (MBE) Doctor centered approach to lid health Biofilm is a polysacharride Spins a micro-sponge 2,500 RPM along margin Results in completely clean lids Repeated every 4-6 months Private pay procedure, typically $150-$250 Perfect food source for a Demodex infestation 11
12 In Office Treatment Patients with heavy scruff may need an in office treatment to remove scruff (Blephex) or TTO will never get to the target. I use of Cliradex/ Oust for those recalcitrant cases Typically doing 2 different in office TTO, rarely third Maintenance on: Cliradex, Oust, BlephaDex Demodex Infestation of the Eyelids Recommended Treatment In-office procedure: Cleanse eyelids and eyelashes in-office utilizing OCuSOFT Lid Scrub PLUS Swabstix and Oust Demodex Swabstix. Oust Demodex Swabstix contain 50% Tea Tree Oil, 40% Sea Buckthorn Oil, and 10% Caprylic Acid. These single-use, disposable, self-saturating Swabstix provide convenient in-office use to effectively eradicate demodex and remove oil, debris, and other contaminants on the eyelids inoffice. A complete Demodex Kit is available for in-office use. BlephaDex Aqua Coconut Oil Glycerol Aloe Barbadensis Gel Sodium Lauryl Sulfate Cocoamidopropyl Betaine DMDM Hydantoin Laurel Glucoside Melaleuca Alternifolia( Tea Tree) Leaf Oil Easier Way To Start In-Office Treatment Goal: Regular Maintenance-Like teeth cleaning Use Blephadex swab, with BlephEx, for annual (bi-annual) in office treatment At-home treatment with Blephadex pads or foam Continue to use everyday for maintenance NOT to eradicate 100% Want to knock down the load and reduce symptoms Watering Crusting Itching of lids Like to see some visible reduction in cylindrical dandruff Improve redness profile of eye, lid and face 12
13 Conclusion Differentiate the condition in your practice Think Biofilm Remove the debris In-office treatments Have the options in your practice Provide options Utilize the products New comfortable Demodex treatments 13
Doctors of Optometry Course Notes
Doctors of Optometry Course Notes OD2 1CE COPE: 48272-AS Straight Outta Tears Treating & Managing MGD, Lid Bugs & Other Lid Thugs Saturday, February 25, 2017 8:40 am 9:35 am Plaza A/B 2 nd Floor Presenter:
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