2020 Symposia Series 1 - Practicing Clinicians Exchange
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2020 Symposia Series 1
New Options for a Common
Condition: Management of
Dry Eye Disease
Learning Objectives
• Evaluate patients for risk factors, symptoms, and signs of dry eye disease
• Identify pharmacologic and nonpharmacologic approaches to the treatment
of dry eye disease
• Apply strategies to educate patients on management of dry eye disease
3
Dry Eye Disease: Definition
• From the Tear Film and Ocular Surface Society Dry Eye Workshop II:
“Dry eye is a multifactorial disease of the ocular
surface characterized by a loss of homeostasis of
the tear film, and accompanied by ocular
symptoms, in which tear film instability and
hyperosmolarity, ocular surface inflammation and
damage, and neurosensory abnormalities play
etiological roles.”
Craig JP, et al. Ocular Surf. 2017;15:276-283. 4
Dry Eye Disease is Common
• Conservatively affects between Diagnosed Dry Eye Disease in the US
5.3% and 6.8% of adults in the 25 50+ years: 11.3%
US Male
Female
‒ As many as 16.4 million people
Prevalence (%)
20
• Women 2 to 3 times more likely to 15
be affected than men
18-49 years: 3.4%
• Prevalence increases linearly with 10
age
5
0
18-24 25-34 35-44 45-49 50-54 55-59 60-64 65-69 70-74 75+
Age (years)
Dana R, et al. Am J Ophthalmol. 2019;202:47-54; Farrand KF, et al. Am J Ophthalmol. 2017;182:90-98; Stapleton F, et al. Ocular Surf. 2017;15:334-365. 5
Normal Eye Physiology Clayton JA, et al. N Engl J Med. 2018;378:2212-222. 6
Pathophysiology and Classification of Dry Eye Disease
Aqueous Deficient
• Lacrimal gland
deficiency/obstruction • Patients may have both
• Systemic drugs aqueous-deficient and
• Autoimmune disorders
evaporative types
Deficient tear production • Evaporative is the most
and increased tear
evaporation lead to
common
hyperosmolarity and
inflammation
⎻ Meibomian gland
dysfunction (MGD) is
Evaporative
leading cause of dry
• MGD eye disease
• Allergic
conjunctivitis
• ~2/3 of all cases
• Contact lens
wear
• Low blink rate
Craig J, et al. Ocular Surf. 2017;15:276-283; Rabensteiner DF, et al. Acta Ophthalmol. 2018;96:e707-e711; Wolffsohn J, et al. Pharmaceutical J.
2017;299:7905. 7
Case Study: Kate
• 49-year-old white female • Medical history:
• Accountant ⎻ Nonsmoker, nondrinker
• Married with 1 child ⎻ Migraines, managed with
• Avid runner sumatriptan nasal spray
• Ocular history: ⎻ Elevated LDL-C, managed
with rosuvastatin
⎻ Daily contact lens wearer
for 20 years
• She is at your office today for her annual wellness exam
LDL-C = low-density lipoprotein cholesterol. 8
Case Study (cont’d): Kate’s Chief Complaints and Exam
• Feeling well overall, but her eyes have Physical Exam
been bothering her lately Vital signs normal
‒ When she runs outside, especially Ocular Exam
on a cold windy day, she starts Slight redness
tearing profusely
No mucus
‒ Sometimes she wakes up in the
Cornea clear, no opacities
middle of the night with eyes
“burning and stinging,” like sand was No sign of crusting on the eyelids
thrown in them Visual acuity 20/20 with contacts
• It’s hard even to open them just to
add tetrahydrozoline drops
9
Symptoms of Dry Eye Disease Are Nonspecific and May Be
Inconsistent With Clinical Signs in Mild Disease
Common Symptoms of
Dry Eye Disease • Symptoms usually:
Irritation or grittiness ⎻ Worsen over the
Itching course of the day
Redness ⎻ Have been
occurring
Soreness
chronically
Fatigue or heaviness
⎻ Affect both eyes
Burning sensation, stinging
Photophobia
Intermittent blurred vision
Ocular discomfort
Excessive tearing
American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020;
Cronau H, et al. Am Fam Phys. 2010;81:137-144; Shih KC, et al. HK Pract. 2016;38:113-119. Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574. 10The First Step in Achieving a Diagnosis of Dry Eye Disease Is a Detailed Patient History • Chief complaints and current symptoms • Medical history • Ocular history, including surgical history and contact lens use • Systemic medications • Allergies • Prior and current therapy for dry eye disease Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47. 11
The Next Step in Achieving a Diagnosis Is a Physical Exam Appropriate to Primary Care • Inspect eyelid and sclera for inflammation, abrasions, hemorrhage, erythema or lesions • Evert the upper eyelid if corneal abrasion or foreign body is suspected • Inspect the eyelid and periorbital region for rashes or vesicles • Examine the cornea for opacities • Examine conjunctiva for injection, erythema • Note evidence of discharge; assess eyelids for crusting • Assess visual acuity Kaur S, et al. www.acofp.org/ACOFPIMIS/Acofporg/PDFs/OFP/Articles/2019_MarApr/2019_MarApr_PrimaryApptoEyeCond.pdf. Accessed April 25, 2020; Pflipsen M, et al. Am Fam Phys. 2016;93:991-998. 12
Dry Eye Disease vs Other Common Ocular Disorders
That Cause Red Eye
Mild to
Viral
none
Bilateral presentation with: Watery conjunctivitis
• Diffuse hyperemia or
• Mild or no pain serous Itching
• Mild blurring or normal vision
Moderate Allergic
to severe conjunctivitis
Continuous
Discharge is…
Acute
bacterial
Intermittent conjunctivitis
Mucopurulent
to purulent
Chlamydial
Dry eye conjunctivitis
Cronau H, et al. Am Fam Phys. 2010;81:137-144.
Bacterial conjunctivitis image attributed to Tanalai at English Wikipedia. No alterations were made to the image by PCE. Image license:
creativecommons.org/licenses/by/3.0/legalcode; Chlamydial conjunctivitis image attributed to Jonathan Trobe, MD, University of Michigan
Kellogg Eye Center. No alterations were made to the image by PCE. Image license: creativecommons.org/licenses/by/3.0/legalcode. 13Conditions/Factors That May Cause or Contribute to Dry Eye Disease
Class Individual Factors
Environmental Dry climate ▪ long-term contact lens use ▪ prolonged periods of not blinking
Conditions (as when staring at a computer screen) ▪ smoke ▪ wind
Ocular Conditions Contact lens use ▪ ocular disease ▪ ocular surgery (especially LASIK) ▪
eyelid abnormalities
Medications Antidepressants ▪ anticholinergics ▪ antihistamines ▪ antihypertensives ▪
decongestants ▪ eye drops with preservatives ▪ hormone replacement
therapy
Systemic Conditions Androgen deficiency ▪ connective tissue disorders ▪ diabetes ▪ menopause
▪ rheumatoid arthritis ▪ Sjögren’s syndrome ▪ systemic lupus erythematosus
▪ thyroid conditions
Other Botulinum toxin application ▪ cosmetics ▪ eyelash growth enhancements ▪
LASIK ▪ use of a continuous positive airway pressure (CPAP) mask
American Optometric Association. www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/dry-eye.
Accessed April 25, 2020; Lee BS, et al. Clin Ophthalmol. 2020;14:119-126; Shih KC, et al. HK Pract. 2016;38:113-119; Zhang R, et al. Ocular Surf.
2020;18:158-169. 14Menopause • Hormonal influences of menopause can affect the tear film and cause dry eye • Women over 50 years of age have twice the risk of dry eye disease as men of the same age Peck T, et al. J Midlife Health. 2017;8:51-54; Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326. 15
Red Flags in a Patient Presenting With Red Eye
That Should Prompt Referral to an Ophthalmologist
• Clues: unilateral presentation, sudden onset
Diffuse No discharge Subconjunctival
hemorrhage
Mild or no pain, with
mild blurring or Hyperemia
normal vision
Focal Episcleritis
Vesicular rash (herpetic keratitis),
Vision loss, severe mucopurulent discharge
distorted pupil, (hyperacute bacterial Emergency
Moderate to conjunctivitis), keratitis, corneal
corneal ophthalmology
severe pain ulcer, acute angle glaucoma, iritis,
involvement referral
traumatic eye injury,
chemical burn, scleritis
Cronau H, et al. Am Fam Phys. 2010;81:137-144; Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574. 16The Workup Is Informed by Classification of Dry Eye Disease Types
Dry Eye
Aqueous-deficient Evaporative
Sjögren’s Non-Sjögren’s
Extrinsic Intrinsic
syndrome dry eye dry eye
Lacrimal Vitamin A
Primary deficiency MGD
deficiency
Lacrimal gland Topical drugs/ Disorders of lid
Secondary preservatives
duct obstruction aperture
Contact lens
Reflex block wear Low blink rate
Ocular surface disease Drug action (eg,
Systemic drugs (eg, allergy) from isotretinoin)
Craig JP, et al. Ocular Surf. 2017;15:276-283. 17Classification Criteria for Sjögren’s Syndrome
Must answer 1. Have you had daily, persistent, troublesome dry eyes for more than 3 months?
yes to ≥1 of 2. Do you have a recurrent sensation of sand or gravel in the eyes?
these 3. Do you use tear substitutes more than 3 times a day?
questions: 4. Have you had a daily feeling of dry mouth for more than 3 months?
5. Do you frequently drink liquids to aid in swallowing dry food?
Item Weight/Score
Labial salivary gland with focal lymphocytic sialadenitis and focus score ≥1 3
Must Anti-SSA (Ro) + 3
score ≥4 Ocular staining score ≥5 (or van Bijsterfeld score ≥4 on ≥1 eye) 1
Schirmer score ≤5 mm/5 min on ≥1 eye 1
Unstimulated whole saliva flow rate ≤0.1 mL/min 1
Shiboski CH, et al. Arthritis Rheumatol. 2017;69:35-45. 18Case Study (cont’d):
You Probe Further Into Kate’s Symptomatology
Kate’s responses
Mildly irritating How severe is the eye discomfort
No Do you have any mouth dryness or enlarged glands?
A couple months/gets How long have you had symptoms?
worse at night Were there any triggering events?
Yes Is your vision affected? Does it clear on blinking?
No Are the symptoms/redness much worse in one eye?
Do your eyes itch, are they swollen, crusty, or give off
No discharge?
Yes Do you wear contact lenses?
Any diagnosed conditions?
Medications, yes Are you taking any medications?
Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574. 19Further Clues From Kate’s Symptomatology
Kate’s responses
Mildly irritating How severe is the eye discomfort • If severe, could be trauma, infection, ulceration
No Do you have any mouth dryness or enlarged glands? • Trigger for Sjögren’s syndrome workup
A couple months/gets How long have you had symptoms? • Dry eye is chronic, typically worsening at the end of
worse at night Were there any triggering events? the day
Yes Is your vision affected? Does it clear on blinking? • Should clear on blinking
No Are the symptoms/redness much worse in one eye? • Dry eye is generally bilateral
Do your eyes itch, are they swollen, crusty, or give off • Itching associated with allergies
No discharge? • Mucopurulent discharge associated with infection
Yes Do you wear contact lenses? Contacts can cause dry eye
Any diagnosed conditions? • Certain systemic conditions and medications may
Medications, yes Are you taking any medications? cause dry eye
Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574. 20Management of Dry Eye Disease
• Treatment goals
‒ Restore homeostasis of the ocular surface
‒ Provide long-term options to prevent a resurgence of disease and
symptoms
• Management may require treatment individualized to the specific cause(s)
of dry eye disease
• Ongoing management is often required rather than short-term treatments
Jones L, et al. Ocular Surf. 2017;15:575-628. 21OTC Ophthalmic Products: A Quick Overview
May Contain Pros Cons Comment
Artificial Tears Difficulty with drops? Consider
(drops) Viscous agent, Tolerance of preservative free
Usually effective, preservative? (but expense)
anti-evaporative,
inexpensive
preservative
Artificial Tears Blurred vision Use overnight
(gels, ointments)
Antihistamines Pheniramine For allergy Can increase Only if allergy
dryness
Vasoconstrictors Naphazoline, “Get the red out” Rebound effect Avoid
tetrahydrozoline
Cleveland Clinic. health.clevelandclinic.org/choosing-right-eye-drops-itchy-dry-watery-eyes/. Accessed May 11, 2020; Cronau H, et al. Am Fam
Phys. 2010;81:137-144; Horton M, et al. www.reviewofoptometry.com/article/master-the-maze-of-artificial-tears. Accessed April 28, 2020. 22Case Study (cont’d): Management Plan
• You recommend that Kate try OTC artificial tears 4 times daily, with caveats
‒ Look for preservative-free products
‒ Avoid topical antihistamines, vasoconstrictors, or anything marketed to
“get the red out”
• You advise her to
‒ Use warm compresses on her eyes in the morning and at bedtime
‒ Apply an OTC artificial tear ointment at bedtime
• You ask her to take more frequent breaks from her computer and phone screen,
to wear her glasses instead of her contacts more regularly, and to blink more
• You ask her to try this regimen for 4 weeks
23Case Study (cont’d): Kate Comes Back After 4 Weeks
• After 4 weeks, Kate reports that her symptoms are a little better but she’s still
tearing profusely when she runs
• When you ask if she is adhering to her treatment she says she is:
‒ Using her artificial tears 4 times a day
‒ Applying the ointment at night
‒ Using warm compresses in the morning and night
‒ Wearing glasses more regularly
‒ Not taking breaks from her computer screen—she is “working on this”
‒ Blinking more
• You decide to refer her to an ophthalmologist for a full workup
24Chronic Dry Eye Can Become Serious if Not Treated
• Chronic, untreated dry eyes may result in ocular surface damage such as
abrasions and corneal ulcers, leading to vision impairment
• Without adequate tears, there is an increased risk of infection
Corneal ulcer
Mayo Clinic. www.mayoclinic.org/diseases-conditions/dry-eyes/symptoms-causes/syc-20371863. Accessed April 25, 2020. 25The Ophthalmologist’s Basic Diagnostic Algorithm for Dry Eye Disease
Subtype
Symptoms Classification
+ ≥1 of: Tests
Aqueous/Evaporative Spectrum
Homeostasis Markers Evaporation
Risk
Triaging • Tear breakup timeClassification of Dry Eye Disease Types
Dry Eye
Aqueous-deficient Evaporative
Sjögren’s Non-Sjögren’s
Extrinsic Intrinsic
syndrome dry eye dry eye
Vitamin A deficiency MGD
Primary Lacrimal deficiency
Topical drugs, Disorders of lid
Lacrimal gland duct
Secondary preservatives aperture
obstruction
Contact lens wear Low blink rate
Reflex block
Ocular surface disease eg, Drug action (eg,
Systemic drugs allergy from isotretinoin)
Craig JP, et al. Ocular Surf. 2017;15:276-283. 27Case Study (cont’d): Examination by the Ophthalmologist Examination: • Visual acuity: 20/20 with glasses • Tear breakup time: 10 seconds (cutoff is 10 seconds) • Tear osmolarity: 330 mOsm/L (cutoff is 308 mOsm/L) • Ocular surface staining: ‒ Punctate epithelial staining with fluorescein indicating mild keratopathy • No evidence of meibomian gland involvement Diagnosis: • Aqueous-deficient dry eye disease Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574. 28
Nonspecific Management of Dry Eye Disease
• Education
⎻ The condition, its management, treatment, and prognosis
⎻ Potential dietary modifications (including oral essential fatty acid supplementation)
• Modification of local environment and lifestyle
⎻ Humidification, breaks from screen time, avoiding smoke, avoiding direct fan
exposure to eyes in car and at home
• Identification and potential modification/elimination of offending systemic and topical
medications
• Ocular lubricants of various types
⎻ If MGD is present, consider lipid-containing supplements
• Lid hygiene and warm compresses of various types
American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020. 29Essential Fatty Acids in Dry Eye Disease: Evidence Not
Compelling, But Little Harm in Trying
• Supplementation
‒ Randomized, placebo-controlled DREAM study (N = 535)
• No significant differences between omega-3 and placebo
• Both groups experienced similar, significant improvement in signs/symptoms
‒ In contrast, a meta-analysis of 17 randomized clinical trials (N = 3363)
• Supported efficacy of omega-3 supplementation in improving
signs/symptoms vs placebo
• Diet
‒ A diet high in omega-3 fatty acids may protect against development of dry eye
disease
DREAM = Dry Eye Assessment and Management Study.
Asbell PA, et al. N Engl J Med. 2018;378:1681-1690; Giannaccare G, et al. Cornea. 2019;38:565-573; Miljanović B, et al. Am J Clin Nutr.
2005;82:887-893. 30Examples of Specific Therapies for Dry Eye Disease
Evaporative Dry Eye Disease
Thermal pulsation
Doxycycline/ BlephEx or
azithromycin or IPL with manual
Conventional +/– Topical steroids expression
Therapy for all Maintenance
Subtypes: +/– Omega-3 antibiotics or
Artificial tears, Probing
artificial tear
ointment, warm Aqueous-deficient dry eye disease
compresses/
lid scrubs Punctal plugs or Autologous serum
Punctal plugs tears
lifitegrast or
or &
CsA 0.05% Frequency of Consider systemic
CsA 0.05% workup
IPL = intense pulsed light.
American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020;
Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47. 31Therapeutic Expression of the Meibomian Glands
• Therapeutic expression of
thickened and toothpaste-like
meibum in a patient with MGD
with use of a meibomian gland
compressor
Image courtesy of Arita R, et al.
Arita R, et al. Clin Exp Optom. 2020. [epub ahead of print]. 32Procedures for Dry Eye Disease
Aqueous tear deficiency Blepharitis/MGD (evaporative or IPL
• Punctal plugs nonevaporative)
• Cautery occlusion • In-office thermal pulsation and/or
lid massage
• Amniotic membrane
transplantation • Debridement of the lid margin
iLux
• Intranasal tear • Intense pulsed light (IPL)
stimulation (TrueTear) • Meibomian gland probing
⎻ Light-based heat and
TrueTear compression (iLux)
⎻ Open-eye wearable therapy TearCare
(TearCare)
⎻ EyeXpress (goggle system)
Lee BS, et al. Clin Ophthalmol. 2020;14:119-126; Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47.
Beye. www.beye.com/product/eyexpress-eye-hydration-system. Accessed April 25, 2020. 33Case Conclusion
• Ophthalmologist recommends 8-week trial of the following:
‒ Continue warm compresses, morning and night
‒ Prescription CsA, 0.05%, 4 times daily (may take 6-8 weeks to see results)
‒ Prescription tear ointment at night
• After 8 weeks, Kate reports:
‒ Symptoms have subsided dramatically
‒ No longer tearing profusely when running
‒ Has not experienced burning or stinging at night
• She is advised to continue her regimen indefinitely
34PCE Action Plan
✓ Bilateral involvement and gradual onset should prompt suspicion of dry
eye disease
✓ Examine the eyelids, conjunctiva, cornea, sclera, and periorbital region
when assessing for dry eye disease
✓ Advise patients with dry eye disease to avoid topical antihistamines,
vasoconstrictors, or anything promising to “get the red out”
✓ Be sure to educate patients that management of dry eye disease may be a
long-term process
PCE Promotes Practice Change
35
352020 Symposia Series 1
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