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Diagnosis and Treatment

of Dry Eye in Special

Populations

Jodi Luchs, MD, FACS

Co-Director, Department of Refractive Surgery

North Shore/Long Island Jewish Health System

Assistant Clinical Professor

Department of Ophthalmology

Hofstra University School of Medicine

Director of Clinical Research

Director of Corneal External/Diseases

South Shore Eye Care

Disclosures

• Consultant: Allergan, Bausch & Lomb, NiCox,

Doctors Allergy Rx, Optos, Tear Lab, Shire

• Clinical Research: Allergan, Alcon, Bausch &

Lomb, Shire, Eleven, Otsuka, Auven, Shire, Aerie

• Ownership Interest: CXLO, Insightful Solutions,

Omega Ophthalmics, RPS Diagnostics,

Calhoun Vision

Prevalence of Dry Eye Disease

• Over 25 million affected in US1

– Expected to rise to almost 30 million by 2022

– More common in women

– Increases with age

12.6 million post menopausal women1

3 million men over age 651

1Market Scope Date, Allergan, 2011

Dry Eye in Specific Populations

• Particularly prevalent in certain subgroups:

– Surgical Patients

– Autoimmune diseases

– Post menopausal women

– Contact lens wearers

Dry Eye is Common Among Patients

with Specific Ocular Co-morbidities

1Moss SE, Klein R, Klein BE. Long Term Incidence of Dry Eye in an Older Population. Optom Vis Sci. 2008;85(8):668-6742Doughty MJ, Fonn D, Richter D, Simpson T, Caffery B, Gordon K. A Patient Questionnaire Approach to Estimating the Prevalence of Dry Eye Symptoms in

Patients Presenting to Optometric Practices Across Canada. Optom Vis Sci 1997;74(8):624-6313Manaviat MR, Rashidi M, Afkhami-Ardekani M, Shoja MR. Prevalence of Dry Eye Syndrome and Diabetic retinopathy in Type-2 Diabetic Patients. BMC

Opththalmol. 2008; 8:104Leung EW, Madeiros FA, Weinreb RN. Prevalence of Ocular Surface Disease in Glaucoma Patients. J Glaucoma. 2008;17(5):350-355

25%

50%54%

59%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ocular Allergies Contact Lens Wearers Diabetics Glaucoma/OHT

Perc

en

tage

of P

atien

ts w

ith

Dry

Eye

Definition:

• 2001: “Tear film disorder due to tear deficiency or

excessive tear evaporation causing damage to the

interpalpebral ocular surface and associated with

symptoms of ocular discomfort …1

• Today: Multifactorial disease of the tears and ocular

surface that results in discomfort, visual disturbance,

and tear film instability with potential damage to the

ocular surface. It is accompanied by inflammation of the

ocular surface (DEWS report, 2007).2

1 1995 National Eye Institute (NEI)/Industry Dry Eye Workshop

2 2007 Report of the International Dry Eye Workshop (DEWS). Ocul Surf. 2007;(5)2:67-204

Pathophysiology

• Dry Eye is a complex disease that may result in discomfort, visual

disturbance and tear film instability1

• Inflammation, hormonal status, age, and environmental triggers all

play a role in dry eye disease1,2

• These factors set in motion a self-perpetuating series of events that

affect the ocular surface and lacrimal glands, and the neural feedback

network which connect them

• These events alter tear quantity and quality, which can damage the

corneal epithelium3

• Inflammation is present at all levels of disease severity3-7

1 Definition and Classification of Dry Eye Disease: 2007 Report of the International Dry Eye Workshop (DEWS). Ocul Surf. 2007;(5)2:75-92; 2 Research in

Dry Eye: Report of the Research Sub-committee of the International Dry Eye Workshop. 2007 Report of the International Dry Eye Workshop (DEWS). Ocul

Surf. 2007;(5)2:88-102; 3 Nelson JD, Helms H. Fiscella R, Southwell Y, Hirsch JD. A New Look at Dry Eye Disease and its Treatment: Adv Ther.

2000;17(2):84-93; 4Behrens A, Doyle JJ, Stern L, et al; and Dysfunctional Tear Syndrome Study Group. Dysfunctional Tear Syndrome: A Delphi Approach

to Treatment recommendations. Cornea. 2006;25(8):900-907; 5Stern ME. Pathophysiology and Allergy of the Lacrimal Functional Unit: What Goes Wrong

with our Tear Secreting Apparatus? In: Chew P, Rojanapongpun P, eds. Ophthalmic Disease Battlerfront-Maintaining the Health of the Ocular Surface.

Asian J Ophthalmol. 2005;7(suppl 1):5S-8S; 6Stern ME, Beuerman RW, Fox RI, Goa J, Mircheff AK, Pflugfelder, SC. The Pathology of Dry Eye: The

Interaction Between the Ocular Surface and the Lacrimal glands. Cornea. 1998;17(6):584-589; 7Chotikavanich S, de Paiva CS, Li D, et al. Production and

Activity of Matrix Metalloproteinase-9 on the ocular surface increase in Dysfunctional Tear Syndrome. Invest Ophthalmol Vis Sci. 2009;50(7):3203-3209

Diagnosis

Diagnosis of Ocular Surface Disease

• History

– Dry eye symptoms

– Fluctuating vision

• Lids:

– Collarettes

– Meibomian gland disease

Express glands on exam

• Ocular Surface:

– Tear meniscus height

– Fluorescein staining pattern

Wait 1-2 minutes to evaluate staining pattern

– Break-up time

– Conjunctival Lissamine Green staining


• Point of Care Diagnostics:

– Tear Film Osmolarity

– MMP-9 testing

– Tear film Lactoferrin levels

– Automated imaging:

Meibography

Automated TBUT

Tear film interferometry (lipid layer)

Dry Eye Classification

• Level 1: Mild to moderate symptoms, no clinical signs, or mild

conjunctival staining

• Level 2: More significant symptoms, moderate conjunctival

staining, Mild corneal staining, visual signs

• Level 3: More severe symptoms, significant conjunctival

staining, more severe corneal staining, central corneal staining,

filaments

• Level 4: Severe symptoms, confluent corneal/conjunctival

staining, erosions, ulceration, scarring

1Behrens A, Doyle JJ, Stern L, et al; and Dysfunctional Tear Syndrome Study

Group. Dysfunctional Tear Syndrome: A Delphi Approach to Treatment

recommendations. Cornea. 2006;25(8):900-907

Treatment

Treatment of Ocular Surface Disease

• Lid disease:

– Warm compresses

– Lid scrubs

– Topical antibiotics

Azithromycin (off-label)

Doxycycline

– Cyclosporine (off label)

– Thermal pulsation system


• Dry Eyes:

– Preservative free tears, gels, ointments

– Topical Cyclosporine

– Topical steroids

– Punctal occlusion

– Serum tears

Dry Eye in Post Menopausal Women

• 12.6 million post menopausal women suffer from

Dry Eye

• Due to changing hormonal status

– Decreasing androgen levels

• Often overlooked by patients and practitioners.

– Patients chalk it up to “getting older”

• Role of hormone replacement therapy:

– Conflicting data

Dry Eye in Post-Menopausal

Women: Diagnostic Considerations

• Key in on the History:

– Autoimmune disease

– Medications

– Contact lens use

– Eyelid surgery

Dry Eye in Post Menopausal Women:

Treatment Considerations

• Preservative free tears

• Nightly ointment

– Particularly if prior eyelid surgery

• Cyclosporine

• Topical steroids

• Punctal plugs

• Consider Sjö testing if concomitant dry mouth

Dry Eye in Contact Lens Wearers

• Up to 50 % of contact lens wearers will develop dry

eye1,2

• 15% of lens wearers have “very severe” symptoms of

dry eye, in contrast to <5% of general dry eye subjects3

• Contact lens wear produces a thinning of the tear film4

• Contact lens wearers have elevated levels of IL-6, IL-8

and TNF-∂ in their tear film5

1Dumbleton K, Caffrey B, Dogru M, et al. Members of the TFOS International Workshop on Contact Lens Discomfort. TFOS

International Workshop on Contact Lens Discomfort: Report of the Subcommittee on Epidemiology. Invest Ophthalmol Vis Sci.

2013;54(11):TFOS20-TFOS36; 2Doughty MJ, Fonn D, Richter D, Simpson T, Caffery B, Gordon K. A Patient Questionnaire Approach

to Estimating the Prevalence of Dry Eye Symptoms in Patients Presenting to Optometric Practices Across Canada. Optom Vis Sci

1997;74(8):624-631; 3 Nichols JJ, et al. Invest Ophthalmol Vis Sci. 2005;46:2353-2361; 4 International Dry Eye WorkShop. Ocul Surf.

2007;5:65-204; 5 Craig JP, Wilcox MD, Argüeso P, et al. Members of the TFOS International Workshop on Contact Lens Discomfort.

TFOS International Workshop on Contact Lens Discomfort: Report of the Contact Lens Interactions with the Tear Film Subcommittee.

Invest Ophthalmol Vis Sci. 2013;54(11):TFOS123-TFOS156

Dry Eye in Contact Lens Wearers

• TFBUT and Tear volume significantly reduced in CL

wearers1

• ~30% of lens wearers develop some degree of

meibomian gland dysfunction (MGD) ~ 6 months

after initiating lens wear2

• Contact lens wear is directly related to meibomian

gland loss (determined by meibography) compared

with non-lens wear3

1Glasson MJ, Stapleton F, Keay L, Sweeney D, Willcox MD. Differences in Clinical Parameters and tear Film of Tolerant and

Intolerant Contact Lens Wearers. Invest Ophthalmol Vis Sci. 2003;44(12):5116-511242Ong BL, Larke JR. Ophthalmic Physiol Opt. 1990;10:144-148;3Arita R et al. Ophthalmology. 2009;116:379-384.

Dry Eye in Contact Lens Wearers:


• Optimize contact lens fit

• Topical cyclosporine

• Consider punctal plugs

• Frequent replacement or daily wear lenses

• Try to avoid steroids

• Minimize wearing time

Dry Eye and Autoimmune Disease

• Suspect systemic autoimmune disease in

patients with dry eyes associated with dry

mouth, arthritis, skin rashes, chronic diarrhea

• Serological work-up

• Sjö Testing

– Novel biomarkers which can detect early Sjögren’s

syndrome 5-7 years earlier than conventional SS-

A/SS-B testing


• Autoimmune diseases are often associated

with dry eye

– Sjögren’s syndrome

– Rheumatoid arthritis

– Systemic Lupus Erythematosus


• Sjögren’s Syndrome

– 1.3 million adults have primary Sjögren’s syndrome1

– 10-15% of patients with Rheumatoid Arthritis develop

secondary Sjögren’s syndrome1

– Average of 4.7 years with the disease to reach an

accurate diagnosis2

– Potential life threatening complications:

Lymphoma, interstitial nephritis, autoimmune hepatitis,

interstitial lung disease

1Vitali C, Bombardieri S, Jonsson R, et al; European Study Group on Classification Criteria for Sjögren’s Syndrome: a revised

version of the European criteria proposed by the American-European consensus group. Ann Rheum Dis. 2002;61:554-5582 Sjögren’s Syndrome Foundation. https://www.sjogrens.org/home/about-the-foundation/breakthrough-goal-/2yearupdate.

Dry Eye in Autoimmune Disease:


• Inflammatory cycle driven by systemic autoimmune

disease

• May produce progressive worsening of dry eye

• May require more aggressive therapy

– Topical steroids, punctal plugs, cyclosporine, serum tears

– Tarsorrhaphy

– Systemic therapy for systemic symptoms may help dry eye

Dry Eye in Cataract and Refractive

Surgical Patients

• All Vision Starts with the Tear Film

Prevalence of Ocular Surface

Disease in Surgical Patients

• Blepharitis prevalence study

• PHACO study

How Common is Blepharitis in Patients

Scheduled for Cataract Surgery?

• Study of 100 Patients (200 Eyes) Scheduled for Cataract

Surgery at 2 Centers

– 59% of patients were diagnosed with Blepharitis

Jodi Luchs, MD, Carlos Buznego, MD, William Trattler, MD; Incidence of Blepharitis in Patients Scheduled for

Phacoemulsification. Poster presented at ASCRS, Boston, April 2010.

TBUT < 7 seconds:

- 61% of patients with blepharitis

Photo compliments of Hank Perry, MD

Dry Eye Study: P.H.A.C.O.:

Prospective Health Assessment of

Cataract Patients Ocular Surface

• Objective: – To determine the prevalence of dry eye in patients undergoing cataract surgery

• Methods:– Prospective, multi-center study (9 sites)

Mark Packer, MD

Damien Goldberg, MD

Parag Majmudar, MD

Eric Donnenfeld, MD

Marguerite McDonald, MD

Karl Stonecipher, MD

Jon Vukich, MD

Chaz Reilly, MD

Gregg Berdy, MD

Ranjan Malahotra, MD

William Trattler, MD

• 136 patients (272 eyes) scheduled for cataract surgery

– Avg Age: 70 yrs old (range: 54 to 87)

Courtesy of William Trattler, MD

Summary of PHACO Study

(Patients Scheduled for Cataract Surgery)

• 80% of patients had level 2 dry eye

• Patients are often asymptomatic

– Only 22% of patients had a known diagnosis

• 50% with Central staining (Level 3 dry eye)

• More than 60% with very abnormal TBUT (≤ 5 seconds)

• Schirmer’s score

21.3% with very low Schirmer’s (5mm)

• Dry eye signs are very common in patients scheduled for

cataract surgery

Trattler WB, et al. Clinical Study Report: Prospective Health Assessment of

Cataract Patient’s Ocular Surface Study: Presented at ASCRS 2010

The Tear Film is the Most Important

Refracting Surface of the Eye

Minimal Disruption of the Ocular Surface

Can Severely Degrade Visual Acuity

Consequences of Untreated Ocular

Surface Disease

• Infection (Blepharitis)

• Unstable tear film:

– Unreliable pre-op refraction, keratometry, wavefront measurement

– Unreliable IOL calculation

• Fluctuating post operative vision

• Delays in visual recovery

• Reduced post-operative visual acuity

• Worsened post-operative dry eye

• Discomfort

• Patient dissatisfaction

Ocular Surface Disease &

Diminished Surgical Outcomes

• Treatment of ocular surface disease is

essential for optimal surgical outcomes:

– Reduce risk of infection

– Maximize tear film stability

– Optimize recovery of vision

Keys to Success

• Preop Evaluation:

– Preop evaluation for dry eye/blepharitis

– Preop Topography

– Preop OCT of Macula


• Topography

– Can reveal undiagnosed tear film instability

– Corneal shape abnormalities

• OCT macula

– r/o occult retinal disease

Topography: Excellent Tool

for Diagnosing a Poor Tear Film


Dry Spots

Recommendations for All Cataract

Surgery Patients: Preop Topo


58 year old male with visually significant cataract OS, interested in a premium IOL

Preop Topo After 1 Day of Treatment


Same patient : 1 day after starting lubricating drops

Preop Topo After One Week

of Treatment


Same patient: one week after initiating therapeutic agents for dry eye

Preop Evaluation


60 year old male: Initial Consultation

for Presbyopic IOL

Dry Eye Identified: One Week After

Cyclosporine BID & Topical Steroids


Case

63 yr old Woman with 2+NS Cataract


2/8/2011

IOL Master OSWhat power toric IOL?

Topo: 2/8/2011


Now – what power toric IOL?

One Week After Treatment:

• Topical steroids

• Topical

cyclosporine


2/16/2011

Challenging Presbyopic IOL Case

• 81-year-old man with vis sig cataract

– Preop BCVA = 20/100

– Potential VA = 20/20

– Underwent Cataract Surgery with Presbyopic IOL

– Surgeons first Presbyopic IOL

Postop: UCVA = 20/80

BCVA = 20/40

OCT of macula: normal

– What tests would you perform to troubleshoot this case?


Presbyopic IOL Patient: 20/40 BCVA

Courtesy of William Trattler, MD EBMD

5 Important Preop Tests

to Avoid Postop Surprises

• Topography

• OCT of Macula

• Fluorescein stain of the cornea

• MMP-9 and Osmolarity


EBMDERM Dry eye On Topo


CONSIDER DEFERRING

SURGERY UNTIL OCULAR

SURFACE NORMALIZED

Conclusions

• Dry eye is extremely common, and the prevalence is

increasing

• Newer diagnostic tools make it easier to diagnose

• Growing number of therapies for dry eye

• Particularly common in certain subgroups of patients:

– Post menopausal women

– Patients with autoimmune disease

– Contact lens wearers

– Cataract and refractive surgical patients

Conclusions

• In today’s state-of-the-art eye care practice

we need to pro-actively identify and treat

dry eye in order to optimize both our

surgical outcomes as well as out patients’

quality of life

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