Optimizing the Ocular Surface Presentation Title Presenter Charlene M. Grice, Name MD Carolina Eyecare Physicians, LLC
Financial Disclosures I have no financial disclosures. I will discuss off label use of medications and devices.
We must optimize the ocular surface in order to achieve our desired surgical outcome.
Why is an optimized ocular surface important? Better postoperative results regardless of the surgery Happier patients Proactively addressing surface issues makes the surgeon look like a hero rather than making excuses for suboptimal visual outcome Better more reliable preoperative biometry/keratometry Opportunity to improve the quality of vision and have a better surgical outcome
Obvious surface issues that need to be addressed preoperatively
Conjunctivochalasis
Dry eye disease leads to a poor ocular surface 25 million American dry eye suffers $3.8 Billion spent yearly on dry eye symptoms annually Most frequently encountered disease state by eye care professionals The Global Market in Dry Eye Products. Market Scope. November 2011.
Definition of dry eye 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. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocul Surf.2007:5;75-92.
PHYSIOLOGY OF THE OCULAR SURFACE Slide courtesy of Springer Slides
Evolution in Understanding of Dry Eye Two primary forms of dry eye Aqueous deficiency-altered lacrimal function leads to poor aqueous layer production Evaporative deficiency- meibomian gland dysfunction (MGD) leads to abnormal or absent oil layer in tear film creating excessive evaporation of tears Lemp, MA Advances in understanding and managing dry eye disease. Am J Ophthalmol 2008 Sep:146(3):350-356.
Definition of Meibomian Gland Dysfunction Meibomian gland dysfunction(mdg) is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. This may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease. Nelson JD, Shimazaki J. Benitez-del-Castillo JM, et al. The international workshop on meibomian gland dysfunction: report of definition and classification subcommittee. Invest Ophthalmol Vis Sci 2011:52;1930-7.
MGD prevalence Recent study by Lemp et al reports 86% of patients evaluated had MGD 14% Aqueous deficiency 50% Meibomian gland deficiency 36% Mixed mechanism Lemp, MA Advances in understanding and managing dry eye disease. Am J Ophthalmol 2008 Sep:146(3):350-356.
Meibomian gland dysfunction
Figure 1: Hypothesized long-term changes of meibomian glands in MGD (1. Increased viscosity of the meibomian oil; 2. Orifice plugging and duct obstruction (hyperkeratinization); 3. Stasis and dilatation of glands; 4. Glands atrophy and dropout) Pult, Heiko. "Meibography in clinical practice." Ophthalmology Times 8.5 (2012).
DED workup History of systemic disease (autoimmune disease, DM) History of contact lens wear Medications including OTC and glaucoma agents Environmental factors computers, ceiling fans Specific patient complaints tired, eyes, fluctuating vision Previous surgery (refractive, blepharoplasty, LRIs ) Questionnaires are very useful and can be followed OSDI (Ocular Surface Disease Index) SPEED (Standard Patient Evaluation of Eye Dryness) NEIVFQ-25 (National Eye Institute Visual Function)
Examination Evaluation of the patient from across the room( with the lights on) to assess the eyelids, blink rate, lid closure, globe/lid apposition, facial clues, nocturnal lagophthalmos, Bell s phenomenon Evaluate the lid margins and apply pressure to the meibomian glands to assess the meibum-quality and quantity TBUT >10 sec Corneal and conjunctival staining with fluorescein, rose bengal, lissamine green
Corneal staining
Testing prior to instilling any drops TearLab osmolarity >308mOsm/L or difference of 8 between the eyes Lipid layer analysis and thickness >72nm Tear layer MMP-9 (InflammaDry) >40ug/ml Tear layer lactoferrin <1.4 Schirmer II (< 5 @ 5 minutes) Tear volume using OCT
Sensitivity Specificity Corneal Staining 63% Sensitivity 89% Specificity TBUT Corneal Staining 92% 63% 17% 89% Schirmer Testing 42% 42% 76% 76% InflammaDry TBUT 85% 92% 95% 17% TearLab Osmoloarity 73% 92% Questainnaires 80% 72% Lactoferrin 83% 98%
Meibography Transillumination of the everted eyelid with Finoff transillluminator or infrared light Direct illumination (non-contact ) Keratograph 5M Portable non-contact meibograph
Meibum Quality and Expressibility Pult, Heiko. "Meibography in clinical practice." Ophthalmology Times 8.5 (2012). Nichols, KK, Foulds GN, Bron AJ, et al. The international workshop on meibomian gland dysfunction:executive summary. Invest Ophthalmol Vis Sci 2011;52:1922-9.
Newer tests Sjö test in office Analysis of cells from the ocular surface (conjunctival impression cytology) EyePrim TearScan MicroAssay (IgE and Lactoferrin) The Tear Stability Analysis System (Tomey) Keratograph 5M
Aqueous deficiency treatments Patient education Environmental modification Artificial tears (lipid containing)/gels/ointments Topical cyclosporine A 0.05% Topical steroids (Loteprednol 0.5% gel or ung) Nutritional supplements (Omega 3/Omega 6 Fatty acids) Oral doxycylcine (40-50 mg daily) Punctal plugs/permanent closure Humidifiers Moisture goggles Autologous serum tears N-acetylcysteine 5% Boston Scleral Lens Lateral tarsorrhaphy/lid tightening/conjuntivoplasty
Mixed Mechanism (MGD) Patient education Lid hygiene (daily lid scrubs and massage) Tea Tree Oil lid scrubs/facial wash Topical azithromycin solution 1.5% Oral doxycycline (40-50 mg) Nutritional supplements Topical loteprednol 0.5% gel or ung Topical metronidazole 0.5% drops Liposomal sprays to the eyelids Eyelid debridement to open the gland orifice Meibomian gland probing Warming goggles Thermal pulsation
Thermal Pulsation works FDA clinical trials 79% of patients treated with a single thermal pulsation treatment reported improvement in dry eye symptoms within 4 weeks Patients continue to have improvements for up to 12 months The only FDA approved treatment for MGD Heat to eyelids from the tarsal side In office 12 minute procedure with few complications Comfortable for the patient
Thermal Pulsation Treatment Should not be considered a last resort treatment Should be considered as a primary treatment because it is a fast, effective way to improve the ocular surface in preparation for anterior segment surgery to optimize the surgical outcome
Thermal Pulsation treatment
Newer treatment modalities IPL ( Intense Pulse Light) Xenon flashlamp 500-800 nm Kills demodex and bacteria Closes abnormal telangiectatic vessels Decrease inflammatory mediators Stimulates fibroblasts to produce collagen
Why is the ocular surface optimization important? Allows for happy, comfortable patients Ensures reliable preoperative testing due to a stable tear film Gives us better surgical outcomes Gives our patients a better quality of vision and thus a better quality of life.
Thanks