DOCSLIB.ORG

Dr. Bozung, Not Your Average Dry

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Dr. Bozung, Not Your Average Dry 9/11/2019 Not Your Average Dry Eye WHAT IS DRY EYE? Alison Bozung, OD, FAAO Bascom Palmer Eye Institute 1 2 Dry Eye Dry Eye • TFOS DEWS II, 2017 • Symptoms – “A multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular – Redness, burning, blurred vision, pain, tearing symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.” • Prevalence – Anywhere from 5-50% of individuals have symptoms of dry eye (TFOS DEWS II) Thinkaboutyoureyes.com, https://medicaldialogues.in/new-delhi-20-people-develop-blur-vision-after-being-given-contaminated-avastin-injection/, https://www.lasikmd.com/blog/the-risks- that-come-with-rubbing-your-eyes, https://www.powerofpositivity.com/10-things-that-cause-eye-pain/ 3 4 Dry Eye Dry Eye • Signs 1. Aqueous Deficient (ADDE) • Conjunctival injection, meibomian gland dysfunction, corneal and conjunctival staining, reduced tear prism, rapid tear break up, 2. Evaporative (EDE) corneal scarring and thinning 3. Mixed Does that explain everything..? https://www.eyedolatryblog.com/2011/12/patients-guide-to-dry-eye-syndrome_15.html, https://www.pharmaceutical-journal.com/eye-care/pharmacy-technicians-guide-blepharitis- managing-eyelid-inflammation/20203771.article?firstPass=false, 5 6 1 9/11/2019 Beyond your “Typical” Dry Eye • Today’s Discussion: 1. Exposure Keratopathy 2. Ocular Graft Versus Host Disease 3. Neurotrophic Keratopathy Craig JP et al. TFOS DEWS II report executive summary. Ocul Surf. 2017;15:802-812. 7 8 What defines exposure keratopathy? • Desiccation of the cornea occurring from inadequate eyelid closure or decreased blink frequency. EXPOSURE KERATOPATHY 9 10 Clinical Assessment Causes of Exposure • • Examination findings The etiology behind exposure is variable, and management strategy should be individually tailored to the patient – Incomplete lid closure on natural or forced blink • Eyelid laxity – Inferior or central corneal • Ectropion – Floppy eyelid syndrome punctate erosions – Cicatricial – Aging changes – Ectropion or facial scarring – Senile ectropion – Paralytic – Snap back test • Proptosis – Loose lids – Thyroid eye disease – Prominent globe 11 12 2 9/11/2019 Eyelid Laxity + Floppy eyelids Involutional Ectropion • Floppy eyelid syndrome • Horizontal laxity due to lateral or Researchgate.net – Do they favor one side to sleep? medial canthal tendon laxity Eyerounds.org – Is patient an eye rubber? – Sleep apnea? • Examination – Lax lower lid, poor apposition to Eyerounds.org the globe • Refer? – When topical lubricants do not provide • Refer? effective treatment – Horizontal tightening of lower lid – Horizontal eyelid tightening procedure Reviewofophthalmology.com Andrew Rong, MD 13 14 Cicatricial Ectropion Paralytic Ectropion (CN7 palsy) • Shortening of anterior lamella leads • Loss of orbicularis tone to outward rotation • Examination • Co-morbid conditions – Upper or complete hemifacial weakness – Seen in eczema, dermatitis, thermal • Complete: lower motor neuron burns, scleroderma, etc • Upper spared: likely contralateral CVA (!) • Management • Etiology – Treat underlying condition – Bell’s Palsy – Temporary tarsorrhaphy may be indicated – Vestibular Schwannoma – Likely cicatrix release and full thickness – Neurofibromatosis Flattening of nasolabial fold (NLF) skin grafting www.scielo.br – Infectious (Lyme) 15 16 Paralytic Ectropion (CN7 palsy) Proptosis: Thyroid Eye Disease • Medical management • Enlargement of extraocular Eyerounds.org muscles or orbital fat expansion – Generous lubrication causing proptosis, lid retraction – Tape lids closed at night – Monitor for improvement if Bell’s Palsy • Management – Generous lubrication Morancore.Utah.edu • – Orbital decompression for severe Surgical management exposure keratopathy or compressive – Gold weight optic neuropathy – Tarsorrhaphy – If possible, surgery better during non- active phase – LTS Audrey Ko, MD 17 18 3 9/11/2019 Proptosis: Prominent Globe Exposure Keratopathy: In Summary • Long axial length or shallow orbits • Severity determines our management strategy • Management Mehryar Taban, MD • Recognize when surgical intervention is the best step – Generous lubrication – If threatening corneal health, may • benefit from orbital decompression Early or mild exposure: treat with lubrication drops + ointments • Moderate to advanced exposure: referral to oculoplastics Weinberg DA1 19 20 What defines Graft Versus Host Disease? • Complication of allogenic hematopoetic stem cell transplantation (HSCT) GRAFT VERSUS HOST DISEASE (GVHD) 21 22 Why is stem cell transplantation done? Who gets GVHD? • Cancer • 9,000 HSCT in US in 2016 – Leukemia, lymphoma, multiple myeloma • 30-70% of individuals • History of chemotherapy or radiation develop GVHD • Blood disorders • 60-90% of individuals – Anaplastic anemia, sickle cell anemia, thalassemia, with cGVHD experience congenital neutropenia ocular symptoms 23 24 4 9/11/2019 Who gets GVHD? Who gets GVHD? • Risk Factors • Risk Factors – HLA mismatched – HLA mismatched • Most important factor! – Unrelated donor 25 26 Who gets GVHD? Who gets GVHD? • Risk Factors • Risk Factors – HLA mismatched – HLA mismatched – Unrelated donor – Unrelated donor – Female donor – Female donor • Increased risk after pregnancy/birth – + Intensity of radiation or chemotherapy 27 28 Who gets GVHD? Stem Cell Donations • Risk Factors • Stem cell sources – HLA mismatched – Bone marrow tissue – Peripheral blood stem cells – Unrelated donor – Umbilical cord blood – Female donor – + Intensity of radiation or chemotherapy – + Age of donor OR host 29 30 5 9/11/2019 Graft Versus Host Disease ! Stem cell donations also contain: 1. The donor’s immune cells Helper and killer T-cells • Are GOOD! – Recognize and kill cancer cells • Are sort of BAD! – They also may “recognize” the host’s tissue as foreign and dangerous. http://chemosabe-socks.blogspot.com/2013/07/graft-versus-host-disease.html?m=1 31 32 Graft Versus Host Disease Graft Versus Host Disease Acute Acute Chronic • Within 1 week • Within 1 week • Within 2-3 months • Organ systems affected • Organ systems affected • Organ systems affected – Ocular – Dermatologic – Dermatologic – Pulmonary – Hepatic – Hepatic – Neuromuscular – Gastrointestinal – Gastrointestinal – Genitourinary • Treatment • Treatment + – Mucosal membranes – Systemic corticosteroids – Systemic corticosteroids • Treatment – Corticosteroids + https://www.aao.org/eyenet/article/stepwise-approach-to-ocular-manifestations , immunosuppression agents healthdirect.com https://www.sciencedirect.com/science/article/pii/S108387911400398X 33 34 Graft Versus Host Disease Chronic • Within 2-3 months • Organ systems affected – Ocular – Pulmonary – Neuromuscular – Genitourinary OCULAR SIGNS OF GVHD – Mucosal membranes • Treatment Zeiser R, Blazar BR. Pathophysiology of Chronic Graft- versus-Host Disease and Therapeutic Targets. N Engl J – Corticosteroids + Med. 2017;377(26):2565-2579. immunosuppression agents 35 36 6 9/11/2019 Ocular GVHD Ocular GVHD • Lymphocytic infiltration of • Lymphocytic infiltration of conjunctiva and lacrimal gland conjunctiva and lacrimal gland and accessory lacrimal and accessory lacrimal structures structures • Decreased conjunctival goblet • Decreased conjunctival goblet cell density cell density • Epithelial cell necrosis • Epithelial cell necrosis • Increased conjunctival • Increased conjunctival squamous metaplasia squamous metaplasia 37 38 Ocular GVHD: Clinical Findings Ocular GVHD: Management Strategy • Elevated inflammatory markers Preservative- • Corneal punctate staining Basic Topical free lubricants Autologous Severe corticosteroids Eyelid repair • Mucin deficiency serum Warm • Aqueous tear deficiency compresses Hyfrecation Cyclosporine Bandage or • Conjunctival hyperemia + fibrosis Scleral contact Punctal Moderate to Mild lenses Partial Occlusion Lifitegrast • Cicatricial entropion Severe to Moderate tarsorrhaphy • Corneal thinning and ulceration 39 40 GVHD : In Summary • Communication is KEY – Don’t forget to communicate your findings with the patient’s oncologist! NEUROTROPHIC • Aggressive management EARLIER is BETTER. – Lack of intervention leads to permanent cicatricial changes KERATOPATHY – It’s hard to come back late in the game! (NK) • We can make a BIG difference in these patients’ lives. 41 42 7 9/11/2019 What defines neurotrophic keratopathy? Who gets NK? Damage to V1 nerve • Degenerative disease • Herpetic keratitis characterized by corneal • Diabetics sensitivity reduction, • Trauma spontaneous epithelium breakdown, and impairment • Prior ophthalmic surgery of corneal healing. • Chronic topical ophthalmic medications • Corneal dystrophies 43 44 Reduced epithelial Clinical Assessment mitosis + migration - Punctate epithelial • Clues: erosions – Punctate erosions, low tear prism, reduced tear break up Reduced - Poor epithelial – Dry eye that appears much worse than it feels Corneal healing Sensation Decreased blink rate - Recurrent epithelial • defects Reduced tactile corneal sensation - Stromal thinning – Cotton wisp (qualitative) – Floss (qualitative) Decreased - Corneal perforation reflex – Cochet-Bonnet (quantitative) tearing 45 46 Mackie Classification Stage I • Diffuse corneal punctate staining • Hazy epithelium, neovascularization, scarring Stage II MANAGEMENT OF NEUROTROPHIC • Persistent or recurrent epithelial defect KERATOPATHY Stage III • Persistent epithelial defect • Stromal loss / ulceration,
Load more

Recommended publications
  • In Vivo Confocal Microscopy of Toxic Keratopathy
    Eye (2017) 31, 140–147 OPEN Official journal of The Royal College of Ophthalmologists www.nature.com/eye CLINICAL STUDY In vivo confocal Y Chen, Q Le, J Hong, L Gong and J Xu microscopy of toxic keratopathy Abstract Purpose To explore the morphological although a wide variety of chemicals and characteristics of toxic keratopathy (TK), systemic medications can also cause TK.1 Cases which clinically presented as superficial of drug-induced TK have been prevalent in punctate keratopathy (SPK), with the ophthalmic clinics for two reasons. On the one application of in vivo laser-scanning confocal hand, most of the topically applied drugs, either microscopy (LSCM), and evaluate its potential prescribed or sold over-the-counter, are capable in the early diagnosis of TK. of causing corneal damage at sufficient Patients and methods This was a cross- concentrations.2 Patients who have glaucoma, sectional study involving 16 patients with viral keratitis, keratoconjunctivitis sicca or other TK and 16 patients with dry eye (DE), ocular surface conditions, generally need demonstrating SPK under slit-lamp multidrug remedies, and these pre-existing observation, and 10 normal eyes were conditions may especially predispose them to enrolled in the study. All participants drug toxicity. The preservative in the eye drops, underwent history interviews, fluorescein mainly benzalkonium chloride (BAC), is another staining, tear film break-up time (BUT) tests, important cause for epithelial lesions. On the Schirmer tests, and in vivo LSCM. other hand, the use of eye drops for a week or Results The area grading of corneal more may cause TK, which can often be confused fluorescein punctate staining was higher in with the worsening of the patient’s initial disease the TK group than the DE group.
    [Show full text]
  • Refractive Surgery Faqs. Refractive Surgery the OD's Role in Refractive
    9/18/2013 Refractive Surgery Refractive Surgery FAQs. Help your doctor with refractive surgery patient education Corneal Intraocular Bill Tullo, OD, FAAO, LASIK Phakic IOL Verisys Diplomate Surface Ablation Vice-President of Visian PRK Clinical Services LASEK CLE – Clear Lens Extraction TLC Laser Eye Centers Epi-LASIK Cataract Surgery AK - Femto Toric IOL Multifocal IOL ICRS - Intacs Accommodative IOL Femtosecond Assisted Inlays Kamra The OD’s role in Refractive Surgery Refractive Error Determine the patient’s interest Myopia Make the patient aware of your ability to co-manage surgery Astigmatism Discuss advancements in the field Hyperopia Outline expectations Presbyopia/monovision Presbyopia Enhancements Risks Make a recommendation Manage post-op care and expectations Myopia Myopic Astigmatism FDA Approval Common Use FDA Approval Common Use LASIK: 1D – 14D LASIK: 1D – 8D LASIK: -0.25D – -6D LASIK: -0.25D – -3.50D PRK: 1D – 13D PRK: 1D – 6D PRK: -0.25D – -6D PRK: -0.25D – -3.50D Intacs: 1D- 3D Intacs: 1D- 3D Intacs NONE Intacs: NONE P-IOL: 3D- 20D P-IOL: 8D- 20D P-IOL: NONE P-IOL: NONE CLE/CAT: any CLE/CAT: any CLE/CAT: -0.75D - -3D CLE/CAT: -0.75D - -3D 1 9/18/2013 Hyperopia Hyperopic Astigmatism FDA Approval Common Use FDA Approval Common Use LASIK: 0.25D – 6D LASIK: 0.25D – 4D LASIK: 0.25D – 6D LASIK: 0.25D – 4D PRK: 0.25D – 6D PRK: 0.25D – 4D PRK: 0.25D – 6D PRK: 0.25D – 4D Intacs: NONE Intacs: NONE Intacs: NONE Intacs: NONE P-IOL: NONE P-IOL: NONE P-IOL: NONE P-IOL:
    [Show full text]
  • Posterior Cornea and Thickness Changes After Scleral Lens Wear in Keratoconus Patients
    Contact Lens and Anterior Eye xxx (xxxx) xxx–xxx Contents lists available at ScienceDirect Contact Lens and Anterior Eye journal homepage: www.elsevier.com/locate/clae Posterior cornea and thickness changes after scleral lens wear in keratoconus patients Maria Serramitoa, Carlos Carpena-Torresa, Jesús Carballoa, David Piñerob,c, Michael Lipsond, ⁎ Gonzalo Carracedoa,e, a Department of Optics II (Optometry and Vision), Faculty of Optics and Optometry, Universidad Complutense de Madrid, Madrid, Spain b Group of Optics and Visual Perception, Department of Optics, Pharmacology and Anatomy, University of Alicante, Spain c Department of Ophthalmology (OFTALMAR), Vithas Medimar International Hospital, Alicante, Spain d Department of Ophthalmology and Visual Science, University of Michigan, Northville, MI, USA e Ocupharm Group Research, Department of Biochemistry and Molecular Biology IV, Faculty of Optics and Optometry, Universidad Complutense de Madrid, Madrid, Spain ARTICLE INFO ABSTRACT Keywords: Purpose: To evaluate the changes in the corneal thickness, anterior chamber depth and posterior corneal cur- Scleral lenses vature and aberrations after scleral lens wear in keratoconus patients with and without intrastromal corneal ring Keratoconus segments (ICRS). Corneal curvature Methods: Twenty-six keratoconus subjects (36.95 ± 8.95 years) were evaluated after 8 h of scleral lens wear. Corneal aberrations The subjects were divided into two groups: those with ICRS (ICRS group) and without ICRS (KC group). The Anterior chamber study variables evaluated before and immediately after scleral lens wear included corneal thickness evaluated in Corneal thickness different quadrants, posterior corneal curvature at 2, 4, 6 and 8 mm of corneal diameter, posterior corneal aberrations for 4, 6 and 8 mm of pupil size and anterior chamber depth.
    [Show full text]
  • Diagnosis and Treatment of Neurotrophic Keratopathy
    An Evidence-based Approach to the Diagnosis and Treatment of Neurotrophic Keratopathy ACTIVITY DIRECTOR A CME MONOGRAPH Esen K. Akpek, MD This monograph was published by Johns Hopkins School of Medicine in partnership Wilmer Eye Institute with Catalyst Medical Education, LLC. It is Johns Hopkins School of Medicine not affiliated with JAMA medical research Baltimore, Maryland publishing. Visit catalystmeded.com/NK for online testing to earn your CME credit. FACULTY Natalie Afshari, MD Mina Massaro-Giordano, MD Shiley Eye Institute University of Pennsylvania School of Medicine University of California, San Diego Philadelphia, Pennsylvania La Jolla, California Nakul Shekhawat, MD, MPH Sumayya Ahmad, MD Wilmer Eye Institute Mount Sinai School of Medicine Johns Hopkins School of Medicine New York, New York Baltimore, Maryland Pedram Hamrah, MD, FRCS, FARVO Christopher E. Starr, MD Tufts University School of Medicine Weill Cornell Medical College Boston, Massachusetts New York, New York ACTIVITY DIRECTOR FACULTY Esen K. Akpek, MD Natalie Afshari, MD Mina Massaro-Giordano, MD Professor of Ophthalmology Professor of Ophthalmology Professor of Clinical Ophthalmology Director, Ocular Surface Diseases Chief of Cornea and Refractive Surgery University of Pennsylvania School and Dry Eye Clinic Vice Chair of Education of Medicine Wilmer Eye Institute Fellowship Program Director of Cornea Philadelphia, Pennsylvania Johns Hopkins School of Medicine and Refractive Surgery Baltimore, Maryland Shiley Eye Institute Nakul Shekhawat, MD, MPH University of California,
    [Show full text]
  • Medical Policy Gas Permeable Scleral Contact Lens
    Medical Policy Gas Permeable Scleral Contact Lens Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 371 BCBSA Reference Number: 9.03.25 Related Policies Corneal Topography/Computer-Assisted Corneal Topography/Photokeratoscopy, #301 Implantation of Intrastromal Corneal Ring Segments, #235 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members Rigid gas permeable scleral lens may be considered MEDICALLY NECESSARY for patients who have not responded to topical medications or standard spectacle or contact lens fitting, for the following conditions: Corneal ectatic disorders (e.g., keratoconus, keratoglubus, pellucid marginal degeneration, Terrien’s marginal degeneration, Fuchs’ superficial marginal keratitis, post-surgical ectasia); Corneal scarring and/or vascularization; Irregular corneal astigmatism (e.g., after keratoplasty or other corneal surgery); Ocular surface disease (e.g., severe dry eye, persistent epithelial defects, neurotrophic keratopathy, exposure keratopathy, graft vs. host disease, sequelae of Stevens Johnson syndrome, mucus membrane pemphigoid, post-ocular surface tumor excision, post-glaucoma filtering surgery) with pain and/or decreased visual acuity. Prior Authorization Information Commercial Members: Managed Care (HMO and POS) Prior authorization is NOT required. Commercial Members: PPO, and Indemnity
    [Show full text]
  • Eye Care in the Intensive Care Unit (ICU)
    Ophthalmic Services Guidance Eye Care in the Intensive Care Unit (ICU) June 2017 18 Stephenson Way, London, NW1 2HD T. 020 7935 0702 [email protected] rcophth.ac.uk @RCOphth © The Royal College of Ophthalmologists 2017 All rights reserved For permission to reproduce any of the content contained herein please contact [email protected] Contents Section page 1 Summary 3 2 Introduction 3 Protecting the eye of the vulnerable patient 4 3 Identifying disease of the eye 6 Exposure keratopathy and corneal abrasion 6 Chemosis 8 Microbial infections 8 4 Rare eye conditions in ICU 10 Red eye in a septic patient: possible endogenous endophthalmitis 10 Other problems 11 5 Delivering treatment to the eye when it is prescribed 11 Red eye in ICU patient 12 6. Systemic fungal infection and the eye for intensivists 14 7. Tips for ophthalmologists seeing patients in ICU 14 8. Authors 16 9. References 17 Date of review: July 2020 2017/PROF/350 2 1 Summary This document aims to provide advice and information for clinical staff who are involved in eye care in the ICU. It is primarily intended to help non-ophthalmic ICU staff to: 1. protect the eye in vulnerable patients, thus preventing ICU-related eye problems 2. identify disease affecting the eye in ITU patients, and specifically those which might need ophthalmic referral 3. deliver treatment to the eye when it is prescribed It concentrates primarily on the common problems of the eye surface but also touches on other less common conditions. As such, it should also be helpful to those ophthalmologists asked for advice about ICU patients.
    [Show full text]
  • Toxic Keratopathy Following the Use of Alcohol-Containing Antiseptics in Nonocular Surgery
    Research Brief Report Toxic Keratopathy Following the Use of Alcohol-Containing Antiseptics in Nonocular Surgery Hsin-Yu Liu, MD; Po-Ting Yeh, MD; Kuan-Ting Kuo, MD; Jen-Yu Huang, MD; Chang-Ping Lin, MD; Yu-Chih Hou, MD IMPORTANCE Corneal abrasion is the most common ocular complication associated with nonocular surgery, but toxic keratopathy is rare. OBSERVATION Three patients developed severe toxic keratopathy after orofacial surgery on the left side with general anesthesia. All patients underwent surgery in the right lateral tilt position with ocular protection but reported irritation and redness in their right eyes after the operation. Alcohol-containing antiseptic solutions were used for presurgical preparation. Ophthalmic examination showed decreased visual acuity ranging from 20/100 to 20/400, corneal edema and opacity, anterior chamber reaction, or stromal neovascularization in the patients’ right eyes. Confocal microscopy showed moderate to severe loss of corneal endothelial cells in all patients. Despite prompt treatment with topical corticosteroids, these Author Affiliations: Department of Ophthalmology, National Taiwan 3 patients eventually required cataract surgery, endothelial keratoplasty, or penetrating University Hospital, College of keratoplasty, respectively. After the operation, the patients’ visual acuity improved to 20/30 Medicine, National Taiwan University, or 20/40. Data analysis was conducted from December 6, 2010, to June 15, 2015. Taipei, Taiwan (Liu, Yeh, Huang, Lin, Hou); Department of Pathology, National Taiwan University Hospital, CONCLUSIONS AND RELEVANCE Alcohol-containing antiseptic solutions may cause severe College of Medicine, National Taiwan toxic keratopathy; this possibility should be considered in orofacial surgery management. University, Taipei, Taiwan (Kuo). Using alcohol-free antiseptic solutions in the periocular region and taking measures to protect Corresponding Author: Yu-Chih the dependent eye in the lateral tilt position may reduce the risk of severe corneal injury.
    [Show full text]
  • Refractive Management/Intervention 2017-2019
    Academy MOC Essentials® Practicing Ophthalmologists Curriculum 2017–2019 Refractive Management/Intervention *** Refractive Management/Intervention 2 © AAO 2017-2019 Practicing Ophthalmologists Curriculum Disclaimer and Limitation of Liability As a service to its members and American Board of Ophthalmology (ABO) diplomates, the American Academy of Ophthalmology has developed the Practicing Ophthalmologists Curriculum (POC) as a tool for members to prepare for the Maintenance of Certification (MOC) -related examinations. The Academy provides this material for educational purposes only. The POC should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the best results. The physician must make the ultimate judgment about the propriety of the care of a particular patient in light of all the circumstances presented by that patient. The Academy specifically disclaims any and all liability for injury or other damages of any kind, from negligence or otherwise, for any and all claims that may arise out of the use of any information contained herein. References to certain drugs, instruments, and other products in the POC are made for illustrative purposes only and are not intended to constitute an endorsement of such. Such material may include information on applications that are not considered community standard, that reflect indications not included in approved FDA labeling, or that are approved for use only in restricted research settings. The FDA has stated that it is the responsibility of the physician to determine the FDA status of each drug or device he or she wishes to use, and to use them with appropriate patient consent in compliance with applicable law.
    [Show full text]
  • Overflow Tearing in Infants
    The Tearing Patient: Diagnosis and Management Written By: Kristina M. Price, MD, and Michael J. Richard, MD Edited by Ingrid U. Scott, MD, MPH, and Sharon Fekrat, MD Excessive tearing, also known as epiphora, is due to a disruption in the balance between tear production and tear loss. Numerous etiologies lead to an excess of tears, and there are a number of ways to diagnose and treat this condition. Currently, there is not a firm consensus on the best way to evaluate the tearing patient. However, a simple algorithm may aid the general ophthalmologist in the evaluation and management of this common condition. Anatomy and Physiology of the Lacrimal System The main lacrimal gland, the accessory lacrimal glands and the conjunctival epithelium are responsible for producing tears. Tears are spread over the surface of the eye by blinking to establish the precorneal tear film. Each contraction of the orbicularis muscle helps move the tears across the ocular surface toward the lacrimal drainage system. Ideally, the basal tear secretion rate equals the rate of tear drainage and evaporation. Basal tear secretion occurs at a rate of about 1.2 µl/minute, although reflexive tear secretion can increase this up to 100-fold. Tears enter the puncta at a rate of 0.6 µl/min; about 90 percent are reabsorbed through the nasolacrimal duct mucosa and 10 percent drain into the floor of the nasal cavity. Tears evaporate from the ocular surface at a variable rate, but ideally tear evaporation roughly equals the difference between basal secretion and drainage. The ocular surface (including the lacrimal lakes in the conjunctival fornices, the marginal tear strip and the precorneal tear film) can hold only 8 µl of tears at any time.
    [Show full text]
  • Scleral Lenses to the Rescue in the Management of Ocular Surface
    SCLERAL LENSES TO THE RESCUE IN THE Lindsay B. Howse, OD MANAGEMENT OF OCULAR SURFACE [email protected] DISEASE FINANCIAL DISCLOSURES None. OUTLINE •Overview of OSD & Dry eye • Definition • Types of OSD • Current OSD management options •Role of Scleral CLs in managing OSD • Benefits • Case examples • Short-term effects • Long-term effects •Fundamentals of Scleral CL fitting • Tips and tricks for an ideal fit OSD is “clinical damage to the intrapalpebral ocular surface or symptoms of such disruption for a variety of causes”. (AOA Optometric Clinical Practical Guidelines) WHAT IS OCULAR SURFACE DISEASE? Report of the International Dry Eye WorkShop 2007 “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”. (International Dry Eye Workshop 2007) WHAT IS DRY EYE DISEASE? Report of the International Dry Eye WorkShop 2007 TOOLS FOR MANAGING OSD/DRY EYE •Mild/Moderate Disease: • Environmental modifications • Artificial tears • Hot compresses • Omega-3 supplementation • Punctal plugs/punctal cautery • Steroids • Cyclosporine A • Lifitegrast • Tetracyclines •Severe Disease: • Autologous serum tears • Bandage soft contact lenses • Amniotic membranes • Surgical intervention (Tarsorrhaphy) • Scleral Contact Lenses http://www.boringchoreshandyman.com.au/portfolio/boring-chores-handyman-10/ SCLERAL LENSES
    [Show full text]
  • Exposure Keratopathy After Cosmetic CO2 Laser Skin Resurfacing
    Cornea 19(6): 846–848, 2000. © 2000 Lippincott Williams & Wilkins, Inc., Philadelphia Exposure Keratopathy After Cosmetic CO2 Laser Skin Resurfacing Anita I. Miedziak, M.D., John D. Gottsch, M.D., and Nicholas T. Iliff, M.D. Purpose. To report two cases of exposure keratopathy after cos- had also a full face lift with bilateral lower lid blepharoplasty 25 metic CO2 laser skin resurfacing. Methods. Two patients pre- years before this evaluation. Patient’s past and present medical sented with bilateral intrapalpebral epitheliopathy. They were ex- history was negative. Her best corrected visual acuity was 20/20 amined, treated, and followed for several weeks. Results. Nonsur- OD and 20/30 OS. Her external examination revealed a 3-mm gical treatment options, including a variety of lubricants, punctal bilateral lower lid retraction, mild bilateral ptosis (Fig. 1A), and a plugs, and lid taping, did not lead to a complete resolution of 1-mm lagophthalmos OU. There was a mild, bilateral lower lid symptoms. Surgical options were recommended. Conclusion. Ex- posure keratopathy should be recognized as a potential side effect laxity noted (tested by distraction test) with slight left lower punc- tal ectropion. Otherwise lid approximation to the globe was good of not only incisional lid surgery but also facial CO2 laser skin resurfacing procedures. OU. Pupillary and visual field examinations were normal. Con- Key Words: Exposure keratopathy—CO2 laser skin resurfacing— junctivae were 2+ injected OD and 1+ OS. Corneas manifested Cosmetic lid surgery—Iatrogenic keratopathy—Lower lid retrac- intrapalpebral punctate epitheliopathy that was more prominent in tion. the right eye (Fig.
    [Show full text]
  • Controversies in Glaucoma Therapy
    Controversies in Glaucoma Therapy J. James Thimons, O.D.,FAAO Chairman, National Glaucoma Society Director, Glaucoma Institute @ Ophthalmic Consultants of Connecticutt 1. To Sleep Perchance to Dream! The Role of Sleep Dysfunction in Glaucoma To Sleep Perchance to Dream • Sleep Dysfunction: It’s Role in patient Health • Sleep Apnea: The Impact of sleep dysfunction in glaucoma TO SLEEP PERCHANCE TO DREAM • MOJON DS, etal • OPTIC NEUROPATHY / SLEEP APNEA • OPHTH 105:874-77 1998 • SEVEN PATIENTS • 3 SEVERE / NASAL STEPS 2 /ARCUATE DEFECT 3 • 2 MODERATE / ARCUATE DEFECT • 1 MILD • ETIOLOGY- DECREASED BLOOD FLOW Obstructive Sleep Apnea Bendel, R et al.( Mayo Clinic, Jacksonville) OAS- Repeated apnea episodes Daytime symptoms Daytime sleepiness Chronic fatigue Decreased cognitive function Etiology Collapse of the pharyngeal airway Last 10-60 seconds OSA Diagnosis Overnight polysomnography EEG, EMG, EOG EKG, Nasal buccal airflow,and pulse oximetry(arterial oxygen) Respiratory Disturbance Index 10 >= OASS 83 patients with apnea Outcomes Median age 62 Median RDI 37 Median IOP 16mmHg OSA • Outcomes • 2.4% patients with OHTN • 33% COAG • No relation to gender , age, or BMI • Relation between IOP increase and BMI level Sleep Apnea & NTG • Mojon DS et al; Ophthalmologica 2002 • 16 patients with NTG had PSN • RDI > defined as mild • < 45 - 0% • 46-64 - 50% • 65 & > 63% Sleep Apnea: The Silent Assassin • Co-Morbidities of Sleep apnea • Increased risk of CVA • Irregular Menstrual Cycles (40%) • Children May exhibit “ Failure to Thrive”: T & A
    [Show full text]