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Dry Eye: an Evidence-Based Approach to Diagnosis and Management

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Dry Eye: an Evidence-Based Approach to Diagnosis and Management Dry Eye: An Evidence-based Approach to Diagnosis and Management Jennifer Gould OD, MS, FAAO Disclosures • Aerie • Allergan • Zeiss Dry Eye Definition “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 DEWS II hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles” Definition – DEWS II Definition of dry eye Classification Evaluation Treatment Tear Film Neurosensory Ocular Surface Hyperosmolarity Instability Abnormalities Inflammation Dry eye disease is an interplay of aqueous deficiency and evaporative etiologies Dry Eye Evaluation American Society of cataract and “DED can cause a reduced visual function refractive surgery and might compromise the overall result of (ASCRS) corneal, cataract, and refractive surgery.” Preoperative “The impact of DED and OSD on topography, biometry, keratometry, and higher order diagnosis and aberrations is one of the major causes of treatment of ocular disappointing postoperative outcomes.” surface disorders Published 12/2018 Dry eye Screening • Symptoms - • Questionnaire – OSDI vs speed vs speed II • Signs - • Osmolality • Inflammatory Marker Further evaluation should be performed is one of these areas is abnormal Speed Score Interpretation Sum of scores / 28 Asymptomatic: ≤ 2 Mild: 3-4 Moderate: 5-7 Speed Survey Severe: ≥ 8 Speed II Survey OSDI Survey OSDI Score Interpretation Sum of scores x 25 / # Questions answered Normal: 0-12 Mild: 13-22 Moderate: 23-32 Severe: ≥ 33 Point of Care testing: Identify non-symptomatic patients MMP-9: Non-specific inflammatory marker > 307 mOsm/L = abnormal > 8 difference between eyes is significant Non-invasive - Objective testing • Meibomian gland imaging • Lipid Layer thickness • >=60 thickness highly indicative of Meibomian gland dysfunction • Non-invasive TBUT • Corneal topography • Surface irregularity indicative of dry eye disease • Sjogren’s antibody testing Clinical Examination • Performed on all patients – (+) or (-) screening • Goal to determine type, severity and visual significance of dry eye Clinical Examination • Look: • Lagophthalmos, proptosis • Lid abnormalities (i.e., entropion, trichiasis) • Anterior/posterior blepharitis (i.e., scurf, collarettes, foamy tears, demodex, capped mg, lid telangiectasia) • Palpebral conjunctiva (i.e., injection, follicles, conjunctivochalasis, pterygium) • Cornea (i.e., filaments, ebmd, prominent punctate keratitis) LOOK Don’t forget to watch the patient blink! Clinical Examination • LIFT AND PULL: • Examine superior cornea (superior limbic keratitis) • Lid laxity (Floppy eyelid syndrome) https://www.reviewofopto metry.co m/article/get-taut-on-floppy-eyelid-syndrome PUSH STAIN Evaluate for Lid Wiper Epitheliopathy Dry Eye Management Step 1: Modification Systemic and Lid Patient Dietary Topical of local topical hygiene/warm Education modification lubricants environment medications? compresses EDUCATION • Systemic associations • Chronicity • Iatrogenic causes • Surgery • Set expectations • Contact Lens Wear • Cosmetic Makeup • Humidifiers • Preservatives in other topical medications Risk factors (Modified from DEWS II) CONSISTENT ASSOCIATION SUGGESTIVE ASSOCIATION POSSIBLE ASSOCIATION Aging Diabetes Hispanic ethnicity Female sex Rosacea Menopause Asian race Viral infection Acne Non-modifiable Meibomian gland dysfunction Thyroid disease Sarcoidosis Connective tissue diseases Psychiatric conditions Sjögren Syndrome Pterygium Androgen deficiency Low fatty acids intake Smoking Computer use Refractive surgery Alcohol Contact lens wear Allergic conjunctivitis Pregnancy Hormone replacement therapy Demodex infestation Modifiable Hematopoietic stem cell transplantation Botulinum toxin injection Environment: pollution, low humidity, sick building syndrome Medications: antihistamines, antidepressants, anxiolytics, Medications: anticholinergic, diuretics, beta- Medications: multivitamins, oral isotretinoin blockers contraceptives Category Subcategory Drugs Antirheumatic Aspirin, Ibuprofen Analgesic Cannabinoid Dronabinol, Tetrahydrocannabinol Opioid Buprenorphine, Fentanyl, Methadone, Morphine, Opium, Oxymorphone, Tapentadol Anesthesia Ether, Nitrous Oxide Antiarrythmic/Bronchodilating Atropine, Diphenhydramine, Disopyramide, Homatropine, Ipratropium, Methscopolamine, Scopolamine, Tiotropium, Tolterodine Azelastine, Brompheniramine, Carbinoxamine, Cetirizine, Chlorpheniramine, Clemastine, Cyproheptadine, Desloratidine, Dexchlorphenamine, Diphenhydramine, Doxylamine, Epinastine, Fexofenadine, Hydroxyzine, Ketotifen, Loratidine, Olopatadine, Antihistamine Promethazine, Pseudoephedrine, Tripelennamine, Triprolidine Agomelatine, Amitriptyline, Bupropion, Chlomipramine, Cialopram, Desipramine, Doxepin, Duloxetine, Fluoxetine, Fluvoxamine, Anticholinergic (antimuscarinic) Antidepressant Imipramine, Mianserine, Mirtazapine, Nortripty, Paroxetine, Reboxetine, Sertraline, Tianeptine, Trazodone, Venlafexine Anti-Parkinson's Benapryzine, Benzhexol, Benztropine, Bornaprine, Levodopa, Methixine, Orphenadrine, Pamipexole, Procyclidine Aiprasidone, Aripiprazole, Brompheniramine, Carbinoxamine, Chlorpheniramine, Chlorpromazine, Clemastine, Clozapine, Cyproheptadine, Dexchlorphiniramine, Fluphenazine, Haloperidol, Lithium carbonate, Olanzepine, Perphenazine, Promethazine, Antipsychotic Quetiapine, Risperidone, Sulpiride, Thiethylperazine, Thioridazine Thiothixene, Trifluoperazine Antispasmodic Fesoterodine, Homatropine, Oxybutynin, Propantheline, Propiverine, Solifenacin, Tolterodine, Trospium Decongestant Oxymetazoline, Phenylephrine, Phenylpropanolamine, Pseudoephedrine, Xylometazoline Drugs associated with dry eye (adapted from DEWS II) Drugs associated with dry eye (continued) Category Subcategory Drugs Antihypertensive Adrenergic blocking Acebutolol, Atenolol, Carvedilol, Labetalol, Metoprolol, Nadolol, Pindolol, Clonidine, Prazosin, Oxprenolol, Propranolol Na+Cl- Co-transporter (diuretic) Bendroflumethiazide, Chlorothiazide, Chlortalidone, Hydrochlorothiazide, Hydroflumethiazide, Indapamide, Methyclothiazide, Metolazone, Polythiazide, Trichlormethiazide Antileprosy Clofazimine Antimalarial Chloroquine, Hydrochloroquine Antineoplastic Busulfan, Cetuximab, Cyclophosphamide, Docetaxel, Erlotinib, Gefitinib, Interferon, Methotrexate, Mitomicin C, Panitumumab, Vinblastine, Vertiporphin Anxiolytic/hypnotic Alprazolam, Diazepam, Eszopiclone, Lorazepam, Zolpidem, Zopiclone Chelator/Calcium Regulator Methoxsalen, Alendronate, Pamidronate, Risedronate Depressant Ethanol Herbal and Vitamins Isotretinoin*, Niacin, Echinacea, Kava Hormonal Antiandrogen/Estrogen replacement Alfuzosin, Doxazosin, Finasteride, Leuprorelin, Tamsulosin, Terazosin, Estrogen/progesterone, Medroxyprogesterone Neurotoxin Botulinum A or B Sedative Primidone, Phenylbarbitol Lubricants LID HYGIENE Step 2: Prescription Tear drugs conservation Intense pulsed Restasis Preservative Tea tree oil Overnight Gland Xiidra • Punctal occlusion light therapy for free lubricants treatment treatment Expression Cequa • Moisture chamber MGD spectacles/goggles Topical Antibiotics Topical Steroids? Oral Antibiotics PRESERVATIVE FREE TEARS IN OFFICE - LID HYGIENE LID HYGIENE - DEMODEX Overnight treatment PUNCTAL OCCLUSION Oasis PLUS – 2-5 days Oasis PLUS Extended – 3 months DuraPlug – 6 months IN OFFICE MANUAL LID HYGIENE TREATMENT PRESCRIPTION TREATMENT Cequa (cyclosporin Restasis (cyclosporin Xiidra (lifitegrast 0.09% with NCELL 0.05%) 5%) technology) Keratoconjunctivitis Keratoconjunctivitis Indication Dry eye syndrome sicca sicca Blocks LFA-1/ICAM-1 Immunosuppressive; Immunosuppressive; interaction. reduce ocular reduce ocular Mechanism of Minimizing Tcell inflammation to inflammation to activation; Inhibits Action increase tear increase tear inflammatory production production cytokines Burning, dysgeusia, Burning blurry vision Burning Hyperemia, FB Headache, Hyperemia, FB Side Effects sensation, blurry increased sensation, blurry vision lacrimation, vision hyperemia Onset of Symptom 3 months 3-4 weeks 3-4 weeks Reduction Step 3: Therapeutic contact lens options Autologous/allogeneic • Soft bandage lenses Oral secretagogues serum eye drops • Rigid scleral lenses Oral secretagogues • Pilocarpine (salagen) 5mg four times daily AUTOLOGOUS TEARS Keratoconjunctivitis sicca, dry eye Donated blood is centrifuged to extract serum and diluted (20-100%) most common 20% ~$100 per month Step 4: Topical Other surgical Amniotic Surgical corticosteroid approaches membrane punctal for longer (tarsorrhaphy, grafts occlusion salivary gland duration transplantation) Step 4 Summary • Combining Using the ASCRS Protocol for Dry Eye Evaluation with the DEWSII staged treatment approach can provide a systematic approach to patient diagnosis and management • Comprehensive Dry Eye Management can improve refractive outcomes (glasses and contact), and surgical outcomes. Putting it all Together Tear Lab: 289/305 Inflammadry: negative OU Thank you! [email protected].
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