2020 Symposia Series 1 - Practicing Clinicians Exchange
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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
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 ⎻ Non-smoker, non-drinker • 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. 10
The 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 Bilateral presentation with: none Watery conjunctivitis • Diffuse hyperemia or • Mild or no pain Itching serous • 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. 13
Conditions/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. 14
Menopause • 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. 16
The 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. 17
Classification 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. 18
Case 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. 19
Further 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. 20
Management 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. 21
OTC 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 Horton M, et al. www.reviewofoptometry.com/article/master-the-maze-of-artificial-tears. Accessed April 28, 2020. 22
Case 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 23
Case 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 24
Chronic 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. 25
The 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 time
Classification 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. 27
Case 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. 29
Essential 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. 30
Examples 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. 31
Therapeutic 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]. 32
Procedures 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. 33
Case 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 34
PCE 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 35
2020 Symposia Series 1
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