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Diagnosing Dry Eye

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Diagnosing Dry Eye MEDICAL ED NG UC UI AT A CONTINUING TIN IO CON N MEDICAL EDUCATION PUBLICATION CME ISSUE 14 Diagnosing Dry Eye ERIC D. DONNENFELD, MD Dry eye a ects tens of millions of patients and is among the most common reasons for eye care provider visits. Knowing what to look for, how, and in whom (hint: everyone) can help stem the tide of this quiet epidemic. Th e exact prevalence of dry eye is diffi cult to ascertain, for several reasons, including the absence of a single test (or universally accepted sequence of tests) for its diagnosis, and the fact that patient-reported symptoms are oft en poorly con- cordant with objective assessments.1 Estimates based on cohort studies suggest that about 5% to 35% of adults worldwide have dry eye, a rate that is expected to rise in the upcoming decades FIGURE 1 Lid margin with inspissated meibomian glands and pasty as common risk factors, including advanced age, increase.2,3 secretions indicative of MGD. Sometimes even higher estimates are cited, as dry eye symp- toms are oft en camoufl aged by other ocular surface condi- tions such as allergic conjunctivitis, surgery, and contact lens CATEGORIES AND MECHANISMS discomfort; in addition, many patients—up to 60% of those Dry eye is generally divided into two main categories based with objective evidence of dry eye—are pre-symptomatic.3 on the underlying cause: aqueous defi cient and evaporative.4 Th e landmark 2007 International Dry Eye Workshop Aqueous defi ciency describes inadequate tear production by (DEWS) report off ered the fi rst thorough expert review around the lacrimal glands. In contrast, evaporative dry eye relates to dry eye, including a defi nition and characterization of two impaired production of the lipid component of the tear fi lm, broad forms—aqueous defi ciency and evaporative—with an essential for lubricating the ocular surface and keeping the emphasis on aqueous defi ciency.4 aqueous layer from evaporating.3 Several years later, as it became clear that meibomian gland function was critical to ocular surface health, proceedings from the Meibomian Gland Workshop provided similarly See INSIDE for: specifi c illumination around evaporative dry eye.5 Th e s e w o k- r Ocular Surface Disease among Glaucoma Patients: shops, along with ongoing eff orts in basic science and clinical A Review research, off er guidance to eye care providers in recognition, by Richard A. Lewis, MD diagnosis, and management of the condition. To obtain CME credit for this activity, go to http://cme.ufl .edu/ed/self-study/toai/ Supported byTopics an unrestricted in OCULAR educational ANTIINFLAMMATORIES grant from Shire. 1 Evaporative and mixed forms of TOPICS IN OCULAR ANTIINFLAMMATORIES, ISSUE 14 dry eyes are more prevalent than the STATEMENT OF NEED Internet connection required: Cable modem, DSL, or better. pure aqueous-deficient form.6 This The control of ocular inflammation is a critical aspect of DATE OF ORIGINAL RELEASE September 2016. Approved medical and surgical ophthalmic practice. Despite their side for a period of 12 months. article is focused on clinical fi ndings eff ects, antiinfl ammatory drugs are used to treat a very wide ACCREDITATION STATEMENT This activity has been planned and diagnosis of evaporative dry eye range of conditions throughout the eye, from ocular surface and implemented in accordance with the Essential Areas and disease and allergic conjunctivitis to posterior segment Policies of the Accreditation Council for Continuing Medical caused by meibomian gland disease; conditions. Use of antiinfl ammatory agents is also critical in Education (ACCME) through the joint sponsorship of the ocular surgery, contributing greatly to patient comfort and University of Florida College of Medicine and Candeo Clinical/ disease management will be covered in positive outcomes. Science Communications, LLC. The University of Florida a subsequent article. The ocular antiinflammatory landscape is changing as College of Medicine is accredited by the ACCME to provide research reveals more about the role of infl ammation in a continuing medical education for physicians. Evaporative dry eye is almost always range of ocular conditions and as new antiinflammatory CREDIT DESIGNATION STATEMENT The University of Florida 1,2 agents enter the market. Twenty years ago, for example, College of Medicine designates this educational activity for due to chronic disease of the meibomian the idea of using a topical corticosteroid to treat dry eye and/ a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians glands, oft en referred to as meibomian or allergic conjunctivitis was viewed with alarm; today, it is should only claim credit commensurate with the extent of accepted practice. their participation in the activity. gland disease or dysfunction (MGD). Although corticosteroids and nonsteroidal antiinfl ammatory FACULTY AND DISCLOSURE STATEMENTS drugs (NSAIDs) have been the mainstays of the ocular Marguerite B. McDonald, MD, FACS, (Faculty Advisor) Characterized by glandular duct ob- antiinfl ammatory armamentarium, a number of new agents practices at Ophthalmic Consultants of Long Island, and is a with novel mechanisms of action (and new ocular drug struction and diminished quality and/or clinical professor of ophthalmology at the New York University delivery systems) have come to market or are being made School of Medicine. She is also an adjunct clinical professor of quantity of sebaceous secretions, MGD ready for market.3,4 ophthalmology at Tulane University Health Sciences Center. prevents the ocular surface from being As indications expand and change, and as new drugs, She’s a consultant to Allergan, Alcon, Abbott Medical Optics, formulations, and delivery systems become available, clinicians Bausch + Lomb, FOCUS Laboratories, Shire, OCuSOFT, and coated with its normal lipid layer, result- require up-to-date protocols for drug selection and use. Such Altaire. protocols are also needed for routine (but nevertheless off - John D. Sheppard, MD, MMSC, (Faculty Advisor) is the ing in evaporation of aqueous tears and label) uses of corticosteroids and NSAIDs because important president of Virginia Eye Consultants and is a professor of diff erences in effi cacy, safety, and tolerability exist between a hyperosmolar tear fi lm. MGD is also ophthalmology, microbiology, and molecular biology at these classes and among formulations within each of these the Eastern Virginia Medical School. He is also the research associated with increased bacterial li- classes.5,6 director of the ophthalmology residency program and pase activity, which break down meibum By putting the latest published evidence into the context of clinical director of the Thomas R. Lee Center for Ocular current clinical practice, Topics in Ocular Antiinfl ammatories Pharmacology at Eastern Virginia Medical School. Dr. Sheppard lipids into their substructures, soaps and equips ophthalmologists to maintain competencies and is on the advisory board for 1-800-DOCTORS, Alcon, Aldexa fatty acids. A tear fi lm containing soap narrow gaps between their actual and optimal infl ammation Pharmaceuticals, Allergan, Bausch + Lomb, Clearside, EyeGate management practices, across the range of clinical situations Research, EyeRx Research, Imprimis Pharma, Inspire/Merck and acid certainly explains the com- in which current and novel ocular antiinfl ammatories may Pharmaceuticals, Isis Pharmaceuticals, Kala Pharmaceuticals, be used. Lacrisciences, Lux Biosciences, Nicox, NovaBay, Novartis/Ciba mon complaints among patients with REFERENCES Vision, OcuCure Inc., Rapid Pathogen Screening, Santen, Shire, evaporative dry eye, namely tearing and 1. Song JS, Hyon JY, Lee D, et al. Current practice pattern for Stemnion, Synedgen, Talia Technology, TearLab, TearScience, dry eye patients in South Korea: a multicenter study. Korean and Vistakon. He has received grant/clinical research support burning! Th ese processes destabilize the Journal of Ophthalmology. 2014;28(2):115-21. from Alcon, Aldexa Pharmaceuticals, Allergan, Bausch + tear fi lm resulting in increased evapora- 2. Ciulla TA, Harris A, McIntyre N, Jonescu-Cuypers C. Lomb, EyeGate Research, EyeRx Research, Insite, Inspire/Merck Treatment of diabetic macular edema with sustained-release Pharmaceuticals, Isis Pharmaceuticals, Kala Pharmaceuticals, tion, hyperosmolarity, bacterial growth glucocorticoids: intravitreal triamcinolone acetonide, Lux Biosciences, Pfi zer, Rapid Pathogen Screening, Rutech, dexamethasone implant, and fluocinolone acetonide Santen, Senju, Shire, Topcon, Vistacon, and Xoma/Servier. He on the lid margin, and increased ocular implant. Expert Opin Pharmacother. 2014;15(7):953-9. is a consultant for AbbVie, Aldexa Pharmaceuticals, Allergan, 5 Bio-Tissue, Eleven/Lexitas, Mededicus, NovaBay, Science Based 3. Maya JR, Sadiq MA, Zapata LJ, et al. Emerging therapies for surface infl ammation. Health, Stemnion, TearLab, and TearScience. Dr. Sheppard is noninfectious uveitis: what may be coming to the clinics. J on the speakers bureau for Abbvie, Alcon, Allergan, Bausch Ophthalmol. 2014;2014:310329. + Lomb, Bio-Tissue, Eleven/Lexitas, EyeGate Research, MORBIDITY 4. Sheppard JD, Torkildsen GL, Lonsdale JD, et al, and the Inspire/Merck Pharmaceuticals, Isis Pharmaceuticals, Kala OPUS-1 Study Group. Lifi tegrast ophthalmic solution 5.0% Pharmaceuticals, Lacrisciences, Lumenis, Mededicus, Nicox, Dry eye has been associated with re- for treatment of dry eye disease: results of the OPUS-1 phase Novartis/Ciba Vision, Omeros, Pentavision, Pfizer, Rutech, duced quality
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