Tim Trinh, O.D., F.A.A.O.Box Medical SolutionsDate: September 19th, 2017Tim.trinh@boxmedicalsolutions.comwww.boxmedicalsolutions.com

UNDERSTANDING DRY EYE TREATMENT AND PROTOCOL

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 2007, VOL. 5, NO. 2

Hyperevaporativedisorders, mostly caused by dysfunction of the meibomian glands, and mixed hyperevaporative/aqueous-deficient forms account for more than 80% of cases

Increased Osmolarity

Cellular DeathInflammation

Tear Film Instability

Causes:• Eyelid dysfunctions, • Tear film instability• Allergies

Causes:• Direct trauma, • Friction• Exposure• Increased osmolarity

Increased EvaporationCauses:• Blepharitis • Meibomian Gland

Dysfunction• Chalasis

Causes:• Cellular damage • Systemic inflammatory

factors

Baudouin C, et al. Br J Ophthalmol 2016;100:300–306. doi:10.1136/bjophthalmol-2015-307415

Vicious Cycle of Dry Eyes

Nerve Stimulation

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Increased Osmolarity

Cellular DamageInflammation

Tear Film Instability

1. Tear Lab2. Eyelid Assessment3. Blink Rate 4. Lagopthalmos Eval5. Tear Lake Assessment

1. Corneal Staining Assessment

2. Conjunctival staining Assessment

Increased Evaporation

What testing is necessary to do a dry eye evaluation?

1. Meibography2. Meibomian Gland

Quality3. Lid Assessment4. Tear Break Up Time

1. MMP-9 testing2. Health History3. Sjo Testing4. Autoimmune blood panel

Testing Procedures

Cell D

amage

Nerve Stimulation

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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

Structural Assessment

Tear Break Up* Time

Conjunctival Staining

Corneal Staining Marx Line

MMP-9*

Tear Film Stability

Least invasive to most invasive:

Tear Lab*

BlepharitisAssessment

Lid Margin Meibography

*Testing recommended on separate visit

SPEED TEST OSDI

Survey Scoring can help determine prevalence

DRY EYE SPECIFIC PATIENT QUESTIONNAIRE

TEAR MENISCUS

>0.2-0.4 mm Normal

<0.2 mm Hyposecretion –Think Aqueous Deficiency

>0.40 mm Hypersecretion

Normal Blink Rate: 15.5 +/- 13.7

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, 5459. doi: Prevalence Of Computer Vision Syndrome (CVS) And Dry Eye In Office Workers

Reading/Computer: 5.3 +/- 4.5

blinks/minute

BLINK RATE ASSESSMENT

Lagophthalmos

Floppy eyelid Syndrome• Velvety papillary

conjunctivitis• Swollen lids• Strong association with Sleep

Apnea

EYELID POSITION ASSESSMENT

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 0-3

84.9% 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

TEAR BREAK UP TIME

Normal range lies between 20 and 30 seconds.

<10 seconds Dry Eyes

<5 seconds Severe Dry Eyes

STAINING AND GRADING

MARX’S LINEPresence would signify potential benefit of lid debridement

LID MARGIN ASSESSMENT:

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: 5.5mm- 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: 150um long and 30-50um wide-stratified squamous epithelium

Central Duct: 100-150um in diameter, wider lumen- stratified squamous epithelium

Excretory Duct: 0.50mm long.- cornified epithelium

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 marginamuscle of Riolan leading to the expression. Muscles work in opposi

PATHOPHYSIOLOGY OF MEIBOMIAN GLAND DYSFUNCTION

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

Gland Shortening

Gland Hypertrophy

Advanced gland Hypertrophy and Loss due to Hyperkeratinization

Track gland Hypertrophy and Loss

EVAPORATIVE DRY EYE TREATMENTTim Trinh, O.D., F.A.A.O.

All EyeCare Optometry

Vision Source Administrator

Date: November 6th, 2016

Increased Osmolarity

Cellular DeathInflammation

Tear Film Instability

• Artificial Tears• Environmental Stressors

• Work• Environmental

management• Allergy

Management• Medicated

Preservatives

• Contact Lens Adjustments• Medicated Therapy• Amniotic Membranes

Increased Evaporation• Lid Hygiene• Omega 3

Supplements• Blephex• Lipiflow• Miboflo

• Steroids• Restasis• Xiidra• Doxycycline• Omega 3 Supplements

Baudouin C, et al. Br J Ophthalmol 2016;100:300–306. doi:10.1136/bjophthalmol-2015-307415

Vicious Cycle of Dry Eyes

Nerve Stimulation

Cyt

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DEMODEX BLEPHARITIS MANAGEMENT

Demodex Blepharitis

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.

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

http://www.news-medical.net/health/New-Approaches-for-Fighting-Demodex-Mites.aspx

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)

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.

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.

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

emulsion-treated eyes showed rapid restructuring of the

preexisting tear lipid film in tear-

interference 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

ORAL TETRACYCLINES

•MMP 9’s•IL-1•TNF collagenase activity•B-cell activation

Decrease inflammatory

factors:

•Photo-toxicity•Age Restriction older than 8 years of age – yellowing/graying of teeth•GI upset

Side Effects:

•50 to 100mg/day 6 to 12 weeks•Do not take with dairyInstructions:

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%).

OMEGA 3 FATTY ACIDS

OMEGA 3 ROLE IN INFLAMMATION SUPPRESSION

EPA

DHA

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. 2010 Mar; 2(3): 355–374.Published online 2010 Mar 18. doi: 10.3390/nu2030355)

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 83:137-141 (2010))

The absorption of epa/dha in ethyl ester form better on a high fat meal. (Lawson and hughes, bbrc, 156:960-963 (1988))

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. 2004 Jan; 38(1)::50-2

OUTSIDE THE BOX TREATMENTTim Trinh, O.D., F.A.A.O.

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

6 months prior

MEDICATIONS LIST

Systemic Medications: L Thyroxine Liothyronine Estradiol Progesterone Zyrtec PRNSupplements:Magnesium CitrateProbioticVit B-6/B-12IronVit D3 – 5000IU&10,000 IU

Ocular Medications:Azopt bid OU x 3+ yearsTravatan Z qpm OU x 3+ years

Dry Eye Treatments:Compress TherapyRestasis bid OU Refresh OptiveGenteal GelOmega 3 Fish Oilh/o plugs OU

CLINICAL EVALUATION:

VA: 20/30 OD 20/25 OS IOP: 13/13 mmHg @ 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

Meibography:

WHAT TREATMENT OPTIONS WOULD YOU OFFER THE PATIENT?

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

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

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

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.