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The Final Front Tear

The Final Front Tear

1/30/2021

1. Terminology related to dry 2. Anatomy of the 3. Anatomy of the tear and impact on vision 4. Clinical evaluation of the ocular The Final Objectives surface 5. Causes of dry eyes Front Tear 6. Tear testing Lynn E. Lawrence, CMSgt(ret), USAF 7. Dry eye treatment MSOL, CPOT, ABOC, COA, OSC

Anatomy • Dry Eye • Inflammatory Dry Eye • Aqueous Insufficiency • Evaporative Dry Eye • Sjogrens Disease • Sicca • Osmolarity • Tear Break-Up Time

Punctum

What function does the punctum have? Terms

Industry Issues Terms • AD Aqueous Deficiency • OSD - Ocular Surface • DED – Dry Disease • If left undiagnosed, this can cause • DES – • OSDI - Ocular Surface • Patients are leaving the office Disease Index complications with eye surgery • DEWS – Dry Eye Work undiagnosed in too many cases • POTF – Pre-Ocular Tear Shop Film • Systemic diseases can exacerbate the • DTS – Dysfunctional Tear • Patients are not volunteering the System • SPEED – Standard issue Patient Evaluation of Eye necessary information

• Lipid Insufficiency Dryness • MDG – Meibomian • Medications can cause a significant • Expression • Dysfunction Staff members are not asking the decline in the condition • Homeostasis of the tear necessary questions • NLDO – Nasal Lacrimal film Obstruction • Symptoms correlation • Too many products to choose from • Too much mis-information

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Anatomy and Physiology of the ocular adnexa

• • Corneal • sensitivity • (permanent make- up) • innovation • Accessory • th What is the opening between 5 Cranial - the upper and lower lid called? Trigeminal

Lacrimal Apparatus

• Sometimes a person cannot produce natural they might need punctal plugs to prevent the tears from draining off the eye. • Lacrimal gland • Reflex tearing • Faucet • Too much tearing… • Gland of Krause • Action • Superior fornix • Gland of Wolfring • Drain • Superior tarsal plate

Obstructive – vs- non-obstructive Tear Production – Secretory

A complex mixture of proteins, mucins, and electrolytes coated by a lipid layer Tear Anatomy

• Antimicrobial proteins • Growth factors & suppressors of inflammation • Soluble mucin helps stabilize tear film • Electrolytes for proper osmolarity (295-300) • pH slightly alkaline (7.4)

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Lacrimal System: Tear Film Layers • Refractive Status

• Health of the , oil the most refractive aqueous surface of the eye

• Visual Acuity snot

The Impact Of Tears On • Fluctuating vision

Vision What functions does each layer of the tear perform? What are functions of tears?

Two Primary Forms of Dry Lacrimal System: Tear Film Layers Eye

LIPID DEFICIENCY - evaporates TEAR DEFICIENCY – fails to hydrate properly oil aqueous

snot 800 nm 8,000 nm 100 nm

The two primary forms of dry eye are Evaporative Dry Eye, also known as What functions does each layer of the tear perform? Dysfunction or MGD and Aqueous Dry Eye. The majority of What are functions of tears? dry eye sufferers have MGD.

The Meibomian Glands Immunological Synapse Triggers

• T-Cell activation and recruitment to target tissue

• Release of proinflammatory The meibomian cytokines glands are located in the eyelids • Lymphocyte Function Associated Antigen-1

• In Vitro data shows T-cells can live up to 6 months once activated

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LipiView II: Interferometer Lipid Secretion: Meibomian Glands Avg LLT 35 nm Avg LLT 90 nm Left: Transillumination of showing meibomian glands

Right: Secretion of lipid Avg LLT – Average Lipid at lid margin Layer Thickness (LLT) in nanometers (nm). Number less than 90 indicates increased • The lipid layer restricts evaporation to 5-10% of tear flow probability for MGD. – Also helps lubricate

LipiView II: Dynamic Meibomian Imaging Intervention & Prevention

Meibomian gland structure is observed with Dynamic Meibomian Imaging (DMI). DMI produces three Upper Eyelid images (surface illumination, transillumination and merged) to capture a comprehensive view of meibomian gland structure. If left untreated, the glands can shrink and deteriorate. The loss of glands is unlikely to be reversible. Failure to treat blocked glands is likely to lead to further structural compromise. Meibomian

Surface Illumination Transillumination Merged (Surface + Transillumination) Lower Eyelid Glands Over Time

Normal Gland Structure Prevention Intervention

Current model of treatment is interventional.

Gland Truncation & Dilation Future of MGD treatment must be preventative.

Severe Gland Drop Out

• Lipid Layer – prevents • Pump Action evaporation • Lids • Lateral/medial • Aqueous Layer - • Muscles hydration • Disease • Punctum • Mucus Layer – sticks • Canniculli tear to the eye (goblet • cells) • • Palsy (7th CN) Tear Components Review • Other components Lacrimal Pump

4 1/30/2021

Mucin Secretion: Goblet Cells in conjuctiva

Superficial layer of bulbar . Goblet cells violet, epithelial cells blue.

• Soluble mucins – Lower surface tension allowing tear film to spread over surface Mucus Problems Exist Lipid Aqueous Mucin

Meibomian Gland • Cleansing Dysfunction • Removal of old flora • New fresh flora • Draining of a tear • See the difference in • Use of the lacrimal gland structure? system

• Eye, nose, and throat • Normal glands look like piano keys With Every Blink

Formaldehyde Free Extension Glue Reviews - FDA Safe? - Minki Lashes

Time With The Patient • Keep the products that you want your patients to use on hand • The amount of time spent with the patient correlates into a higher level of • Don’t expect them to go out patient education and purchase the products that you desire them to use • The better educated the patient is the • Economical minded patients more likely they will be compliant to will purchase what cost less their wishes • Bolo on preservatives and • The more time you spend with the allergies to mineral/castor oil patient, the more patient satisfaction Lessons Learned • Research rumors… you are likely to have

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• Tear evaluation • Lipid layer • Aqueous layer • Mucus layer • Tear Break-up Time What structure produces mucin? • Lid evaluation a.The cornea • Meibomian gland b.The meibomian glands evaluation/expression c.The lacrimal gland • Meibography d.The conjunctiva • Lid position evaluation

Tear System Evaluation

Tear System Testing Tear System Treatments

• Thermal Expression • exam • Heat treatments • Schirmer Testing (quantity) • Lower Level Light Therapy • Tear Break-Up Time (quality) • Lid scrubs • Lipi-View (blink, LLT, Meibography) • IPL • Placido testing • LipiFlow • Speed/OSD questionnaire

Many Conditions and Risk Factors for Dry Eye • Meibomian Gland Disfunction (MGD) • Lid Margin Hygiene; ; / Hordeola; • Medications (i.e. Blood Pressure, Diuretics, Antihistamines, Antidepressants, ADHD, and more) • Hyperosmolarity, Scleroderma, HIV, Lupus, Bell’s Palsy, RA, Bone Marrow TP /grafts, Diabetes, Sjogrens Syndrome; Forms of Arthritis; Some Autoimmune diseases • Contact Lenses Wearers • General Aging for All (Menopause; Hormonal Changes for All) • Lifestyle (Dehydration, Lack of Sleep, Nutrition, Overuse of Digital Screens); Environment • Surgeries Pre & Post (, Lasik, Cosmetic, and more); Injections (Botox, Fillers, and more) • Allergies; Allergic ; Contact Dermatitis; • Additional Uses For Compress: Headaches / Migraines, Sinus Issues, TMJ, • Preventative Medicine Good practice for all Patients is daily moist heat for Lid Margin Maintenance and surrounding areas to promote continued healthiest outcomes; prevents New Technology foreseeable conditions from developing rapidly.

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6 1/30/2021

One key component of DED is a breakdown of the mucin layer that is responsible for converting the hydrophobic (repels water) corneal surface of the eye to one that Mucus Layer is hydrophilic (attracts water). This allows the pre- corneal tear film (PCTF) to coat the surface of the eye filling in surface irregularities and providing optimal coverage

• a genus of mites parasitic within the hair follicles of the host, including the species D. folliculo´rum in man, Demodex and several other species in Blepharitis domestic and other animals.

7 1/30/2021

Blepharitis is an inflammatory condition of the eyelids leading to red, irritated, itchy, and dandruff- like scales that form on the eyelashes. It is a common eye Not only in humans disorder caused by bacteria or a Blepharitis The skin condition, such as dandruff of – believe to come the scalp or acne rosacea.1 No from dogs Disease matter the cause, the only way we can beat blepharitis is to determine the location as anterior, posterior, or mixed; differentiate among the causative factors, and treat according to the severity of the condition.

• Reoccurring eye infections Nursing Homes • Obvious observations • Surgical intervention

http://optometrytimes.modernmedicine.com/optometrytimes/news/ods-look-lid- scrubs-first-blepharitis-treatment

Meibomian Gland Evaluator

Temporal Nasal Central

Meibomian gland function is evaluated by assessing how glands respond to gentle force, imitating that of a deliberate blink.

CLEAR OIL SECRETION NO OIL SECRETION (BLOCKED) OPAQUE SOLID SECRETION Glands are functioning using the No oil is expressed using the MGE Glands not functional; requires more MGE force than the MGE

8 1/30/2021

MeiboGrade LipiFlow: Cross Section

While there are multiple choices available for treating MGD, LipiFlow is the only FDA-cleared device for Meibomian Gland Therapeutic heat dir ected towards removing gland blockages and inner eyelids

restoring gland function. Gentle pressure a pplied to outer ey elids Through advances in the application Cornea shield of Vectored Thermal Pulsation protects surface o (VTPTM) technology, the LipiFlow f the eye treatment utilizes a patented algorithm of heat applied to the Meibomian Gland inner eyelids and massage to remove the obstructions in your LipiFlow Treatment Cross Section meibomian glands.

Breakthrough Performance for Dry Eye Sufferers! ROHTO® DRY-AIDTM LUBRICANT EYE DROPS ROHTO® DRY-AIDTM works uniquely on the 3 layers of the tear to provide continuous relief by: • Non-blurring lubricant eye drop clinically shown to improve key symptoms of dry eye. (1)Enhancing tear adhesion to the surface of the eye • Designed for patients who need a long-lasting advanced artificial tear option to help relieve their dry eye symptoms; Complements Rx treatments. (2)Providing dual lubricants for instant relief and moisture to the aqueous layer • Developed by Rohto, the #1 Global OTC Eye Care Brand* (3)Replicating a uniform lipid layer with unique • Available in 10-Ml multi dose bottle with single-drop nozzle where OTC eye drops are sold. TM Patients can download discount coupons at http://bit.ly/2qBaYlv. Liquidshield technology, for long lasting protection and relief without blur. • For further information, visit www.rohtoeyedrops.com/professionals/ Rohto® Dry-Aid brings tears back to their natural *Euromonitor International Limited Consumer Health Eye Care definition, retail value share, 2016 data state over time.

Clinically Shown* to improve of Dry Eye Disease BEFORE YOU BUY EYE DROPS: WHAT YOU SHOULD KNOW • Single center, parallel group study evaluated ROHTO® DRY-AIDTM vs. leading OTC artificial tear product over approximately 30 days in a real-life, real-time setting. • New educational resource developed by ROHTO® DRY-AIDTM in conjunction • Patients using ROHTO® DRY-AID™ reported longer lasting relief of the ocular signs, with two leading groups -- CEDARS/ASPENS and symptoms, and visual function issues associated with DED versus comparator. Intrepid Eye Society. • Only the ROHTO® DRY-AID™ group reported significant improvements in • Developed to assist ECPs and other health care professionals in helping comfort scores during visual tasking activities such as watching television consumers better understand when and how to properly use OTC eye drops. and driving at night. • Offers important information about • Different types of eye drops and what they are most commonly used for • Helpful “Do’s and Don’ts” to follow when using eye drops • Step-by-step instructions on how to properly instill eye drops • Links to additional eye health information resources • Download at www.rohtoeyedrops.com/professionals/resources

*Torkildsen G, Brujic M, Cooper MS, Karpecki P, Majmudar P, Trattler W, Reis M, Ciolino J, Evaluation of a new Artificial Tear Formulation for the Management of Tear Film Stability and Visual Function in Patients with Dry Eye, Clinical https://www.dovepress.com/evaluation-of-a-new-artificial-tear-formulation-for-the-management-of--peer-reviewed-article-OPTH

9 1/30/2021

Meibomian Gland Evaluator • Stick with the prescribed drops until the doctor tells them to change • Follow the manufactures recommendations for use and storage Things to tell • Read the label to ensure contact friendly or not Temporal Nasal your patients • Stop using the product if they begin Central having irritation Meibomian gland function is evaluated by assessing how glands respond to about drops gentle force, imitating that of a deliberate blink. • Wait 5 minutes between drops and 15 minutes after medications • Don’t share your drops with others • Don’t use drops if they change color or

CLEAR OIL SECRETION NO OIL SECRETION (BLOCKED) OPAQUE SOLID SECRETION become cloudy Glands are functioning using the No oil is expressed using the MGE Glands not functional; requires more MGE force than the MGE

Eye Anatomy Eyelid Positions • Eye anatomy is critical for the eye to sustain its ability to remain Disease: properly saturated • • • The anatomical structure of the • is vital for proper tear production • Tear deficiency / instability and drainage • (5th CN) irritation • New developments in cornea

https://www.independent.co.uk/news/science/cornea-3d-printing-eye-transplant-blindness-cure- scientists-newcastle-university-research-a8377206.html

Pinguecula vs

14% of ocular surface disease is caused by a.Lipid layer b.Aqueous layer c.Mucin later d.Oil layer

Little Penguin Big Pterodactyl

10 1/30/2021

Clinical Evaluation • Normal corneal in a 21-year-old woman Stage 2 Fuch’s Endothelial Dystrophy

• Normal endothelial cell density

• Normal rate of polymegethism

• No pleomorphism

• No corneal guttata Specular Photomicrograph

Contact Lens-Induced Endotheliopathy

Temperature Maximum Eyelid Tissue Temperature Mode minutes Post Treatment Designed for Medical Professionals High 10 43~44C (~110F) Medium 15 41~42C (~108F) Anthropomorphically perfect. Low 30 39~40C (~103F) Fits any face...

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FDA Cleared via 510(k)

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MiBo Thermoflo / LidPro What makes The Eye Doctor Plus® the Best? • New Antimicrobial Material (Germ Free). • Has a removable cover for easy washing. • Supplies continuous controlled • The shape of the mask is designed to fit any size face comfortably. heat to the outer skin of the • This is the only moist heat mask that can be heated in the microwave and oven. • 35 seconds on “high” in the microwave gives off 10 to 12 minutes of soothing moist heat. eyelid using ultrasound gel for • Makes use of a comfortable elastic band to keep it in place. conduction of heat to the • Oven + Microwave + Freezer • Can be used for heat or cold. posterior lid where the • Inner beads are purposely loose, so you can shake after heating to prevent any “hot or cold Meibomian glands reside spots”. • Mask comes with its own storage pouch and 6 disposable Lid Wipes. • Clearing the scurf (staph) is • The mask can be used over and over. Guaranteed for one year. important

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• Foreign body sensation • Hypersecretion • Lacrimal secretion and drainage imbalance • Primary or reflex tearing (reflex tearing is more common with ocular surface irritation) • Epiphora • Lacrimal pump failure • Lacrimal drainage obstruction LipiView/LipiFlow • Medication / OTC / cosmetic Causes of Tearing Cont… • S/P Surgery

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Common Causes • Anatomy • Insufficient tear production Contributing • Clean house • Iphones • Ocular surface disease Environmental • Bedding • Computers • Demodex • Wood floors • TVs • Meibomian Gland Dysfunction Factors • Pollen • Reading • Improper blink rate • Animal dander • Video games • Smoking • Dust mites • Sports • Ceiling fans • Ceiling fans • Air conditioner • Medications (OTCs too) vents • Chronic Diseases (thyroid, diabetes, Steven-Johnson Syndrome, etc…) • Yard work • Contact Lens Wear

• Ocular Surgery (CRS)

Currently banned substances The FDA has banned the use of the following substances in cosmetics:1 Article on make-up • Bithionol: Screening Questions • Chlorofluorocarbon propellants: • Chloroform: Carcinogenic to animals; damaging to human tissues. • Halogenated salicylanilides (di-, tri-, metabromsalan and • Do activities like watching TV, • Do you sleep under a ceiling fan tetrachlorosalicylanilide): looking at computers, reading a or work/ sit under a ceiling fan? • Hexachlorophene: book make you eyes • Mercury compounds uncomfortable or hurt? Related: 7 tips for safer lens wear with cosmetics • Do your eyes ever feel • Methylene chloride: uncomfortable? • Prohibited cattle materials: • Dry your eyes feel dry ever? In • Latisse • Vinyl chloride: the morning or late evening? • Do you ever find yourself • Lash glue • Zirconium-containing complexes Ingredients not banned but questionable rubbing your eyes Eye Facts: Lash Extensions May Cause Dry • Are your eyes ever red? Eye (discovericl.com) • Alpha hydroxy acids (AHA): Side Effects of Latisse On Eyelashes. 5 Stories from • Beta hydroxy acids: Real Users (eyelash-growth.com) • Do you ever use eye drops? • Color additives: • Make-up / lash extensions http://optometrytimes.modernmedicine.com/optometrytimes/news/cosmetic-dangers-part-2-products-banned-fda-worsen-ocular-surface- disease?utm_campaign=OD%20Newsflash%20Enewsletter&utm_source=hs_email&utm_medium=email&utm_content=61595571&_hsenc=p2ANqtz-9lcDgezbeEhlC-pbrOT2GhTCTuZzUnKPVkH2ZP6iAmjmdSrxszG0RKP5op- ffJ5s8mWylcX_jurSmfSxaVDNXjfkJQ0w&_hsmi=61595572

Steps for treatment Nasal Lacrimal Duct Obstruction • Speed questionnaires • Other Rx medications are Xiidra, • Patient education Restasis, and Cequa which requires patient education as well. • • Osmolarity testing Corrected through surgery • Each of these can and should be called a DCR • Inflammation testing (InflammaDry) customized according to the level • Meibography of the disease in which the patient • Artificial Tears education is experiencing. • Stones in the lacrimal sac • Lid maintenance - scrubs and sprays • The are options for further treatment and procedures • Omega fatty acids education • Stenosis of the punctum • Moist Heat for meibomian glands

13 1/30/2021

Conjunctivitis NLDO Test: Lacrimal Irrigation • The “infamous” pink-eye • Numerous causes: • Nose inspections • Bacteria • Viruses • S-Tubes 3-4 months • Allergies • Toxic Reactions (chemicals) • Jones Tubes • Often difficult to diagnose exact etiology

Call it Hypersecretion = Pump Failure - lid positions • Crocodile-tears Syndrome • Gustatory Hyperlacrimation or Gustatory epiphora or Gustolacrimal reflex (could be congenital) • Ocular Surface Irritation

The tear lake is really high What is a normal tear lake measurement?

Anatomical Functional Issues

• Entropion • Ectropion • Punctal Stenosis • NLDO • Floppy Eyelid Syndrome • Lid Trauma Check the neck size • Nerve Innervations – trigeminal nerve • Lid Disease •

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Demodex Demodex Story • Case history • Demodex can be found on the base of the eye lash and can be A 32-year-old female presented with bilateral worsening itchy eyes, intermittent seen by using a microscope blur, epiphora, and overall conjunctival • They live on the lash approximately for 4-6 weeks, so injection. Upon slit-lamp examination, it was obvious this patient had false lash treatment has to last for 8 weeks to destroy the mites and extensions capped on the ends of most of their eggs. Eliminate the food source and mites die. her upper lashes. • • The patient reported she had avoided Bolo for patient’s with Rosacea washing her eyelashes because she worried • Children have Demodex too the lash extensions would be ruined. Because of this lack of hygiene, the patient • Mites are more active a night, medicate BID created a perfect harbor for Demodex (D.) folliculorum to flourish.

https://www.optometrytimes.com/blog/blog-case-demodex-infestation-eyelash-extensions http://www.reviewofophthalmology.com/content/c/36411#.dpuf

14% of ocular surface disease is caused by Which is the oil or lipid producing gland? Demodex mites are microscopic ectoparasites found in human skin. They are extremely common, and their rate of infestation increases with a.Lacrimal age. The life span of demodex outside the living body is very limited. b.Meibomian Direct contact is thought to be required for transmission of the mites. c.Gland of Wolfring The lifecycle of demodex from egg/molt to an adult is quite short and no longer than two to three weeks. The adult stage is less than a week, d. and this is when mating occurs.

http://optometrytimes.modernmedicine.com/optometrytimes/news/what-s-all-craze-about- demodex?utm_campaign=Sponsored+Resource+Center&utm_source=hs_email&utm_medium=email&utm_content=2797580 4&_hsenc=p2ANqtz-9RsjbCo6ARW9K6ewHdPGSW9_GFvfzPrTVsnruZAxgW95Rtbq3l-20_X9FnLxABA9txzjnT- VaXg9qWKRNXkC_9dj1nUw&_hsmi=27975804

New Treatments ZEST – Zocular Eyelid Treatment System

• Eye Barriers/Masks Blepharitis (inflammation of the • Ocular Lid Scrubs eyelids) is an extremely common • Avenova with neutrox problem which can cause irritation • Hypochlorus acid has a killing to both the eyelids and the eyes. capacity Typically, under magnification, it • Everyday lid care appears like dandruff on the • Removes germs and bacteria eyelid margin. Most people • Stable for 3 years in glass cannot effectively treat this on bottle their own and require professional • Medvantx MO $35 or $60 help to most effectively manage Kills Demodex too! this problem.

https://www.youtube.com/watch?v=o96Js8H2vaY

15 1/30/2021

DEWS Report DEWS Report Table 3. Dry eye menu of treatments • Artificial tears substitutes • Sponsored by The Tear Film & Ocular Surface Society • Gels/Ointments • The Ocular Surface, April 2007 • Moisture chamber spectacles • Dry eye grading scale: Levels 1 - 4 • Anti-inflammatory agents (topical CSA and corticosteroids, omega-3 fatty acids) • Based on Ocular Surface Disease Index (OSDI) • Tetracyclines • Level 1 dry eye recommendations: Education and • Plugs environmental/dietary modifications, Elimination of offending systemic medications, Artificial tear substitutes, • Secretogogues gels/ointments, Eye lid therapy • Serum • Level 2 dry eye recommendations: If Level 1 treatments • Contact lenses are inadequate, add: Anti-inflammatories, Tetracyclines (for meibomianitis, rosacea), Punctal plugs, • Systemic immunosuppressives Secretogogues, Moisture chamber spectacles • Surgery (AMT, lid surgery. tarsorrhaphy, MM & SG transplant)

BOLO Non-Ocular Diseases MGD Workshop • RA rheumatoid Arthritis • Tear Film & Ocular Surface Society: Dr. Kelly Nichols, chairperson • HTN (high blood pressure) • International Workshop - 50 dry eye experts • Thyroid • Published in IOVS – 2011, volume 52, #4 • Diabetes • Dry eye grading scale: Stages 1 – 4 • Level 1 dry eye recommendations: Inform patient about MGD, the • Fuch’s Disease potential impact of diet and the effect of work/ home environments on • Lupus tear evaporation, and the possible drying effect of certain systemic medications. • Sjogren’s • Level 2 dry eye recommendations: Advise patient on improving ambient • Leukemia humidity; optimizing workstations and increasing dietary omega-3 fatty acid intake. • Vitamin A deficiency • Accutane

• OTC medications • Age is #1 • Antihistamines • Gender (Women) • Blood pressure meds • Chronic Systemic Disease • Medications • Thyroid meds • Environmental • More… • Anatomical • CPAP Machines • *ask patients if they • Contacts (CLIDE) have recently started any new medication Risk Factors Medications BOLO

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Symptoms Common Complaints • Burning • Stinging • Redness • Though is present, pt may not present with a chief complaint • Redness • Burning • Painful • Watering eyes • • It is best to ask the question Gritty • Reflex tearing • Foreign body sensation about dry eyes even if the • Itchy patient does not volunteer • Discharge • Foreign body sensation • Eyelid sticks • • Fluctuating vision • Hard to open eyes Discharge • Intense visual concentration • Early in the a.m. or late in the • Excessive blinking evening extra stress • Eye fatigue

Testing Contact Lens Wearers and Dry Eye • Florescein staining • Recent studies estimate that the frequency of contact • Schirmer Tear Quantity tests lens related dry eye is about 50%. (1) (paper in 1901) • Lissimine Green (conjunctival • Approximately 77% of patients discontinue contact lens staining) wear at one time or another due to discomfort. (2) • TBUT (tear quality test) • 16% of contact lens wearers stop wearing contact lenses, • Tear Lab representing an annual revenue loss of $275 per patient, $45,000 per year for the typical practice. (compliments • Lipi-flow of ZeaVision) • RPS • “SJO” Test (Sjogrens test)

1. Ramamoorthy P, Sinnott LT, Nichols JJ. Treatment, Material, Care, and Patient-Factors in Contact Lens-Related Dry Eye.. Optom Vis Sci. 2008; 85(8): 764-772. • Rose Bengal 2. Prichard N, Fonn D, Brazeau D. Discontinuation of contact lens wear: a survey. ICLC 1999; 26(6): 157-162.

3. Rumpakis J. New data on contact lens dropouts: an international perspective. Rev . 2010;4:47-57

Schirmer Test Results Schirmer Testing • If your eyes are healthy, each test paper should contain • The maintains a stable level of more than 10 millimeters of moisture. Less than 10 moisture and eliminates foreign particles by millimeters of moisture indicates that your eyes are dry. producing tears. When your eyes are too dry or The diagnosis of dry eyes could mean that you have other too wet, you may be given Schirmer’s test. This health issues, such as rheumatoid arthritis or a bacterial test will show whether your eyes produce too few infection. More tests will likely be required to diagnose or too many tears to maintain optimal eye health. the specific cause of your dry eyes. If your eyes produce Schirmer’s test is primarily used to diagnose dry far more than 10 to 15mm of moisture, further tests may Schirmer 1 – dry strip eye conditions. also be required to determine the cause of your watery Schirmer 2 – anesthetic eyes. • Schirmer’s test is also known as a dry eye test, tear test, tearing test, or Basal secretion test.

17 1/30/2021

Lissimine Green Causes of Excess Tearing

• a strong emotional response (crying) • • climate (including cold and/or windy weather) Staining is a really great • allergies way to identify surface • infections defects • blocked tear ducts • complications from dry eyes • irritation of the eye (from stray eyelashes or other debris) • ingrown eyelashes • relaxation of eye muscles (limits the eye’s ability to drain) • the common cold • pink eye (conjunctivitis) • reactions to certain medications (antihistamines, eye drops, diuretics, sleeping pills, etc.)

Treatments Autologous Serum Drops from blood • Artificial tears Autologous serum eye drops (ASEDs) are • Medications (Restasis, used worldwide to treat dry eye disease doxycycline, …) pregnant!! (DED) • Cyclosporine

• Azithromycin (Azasite) $$$ Serum tears are made from the patient’s • Punctal Plugs own blood. The serum is created by taking • Ammino grafs (Bio-Tissue) blood and removing the red blood cells and • Lipi-flow any clotting tissue. The resulting serum is then diluted in a sterile and preservative • Supplements (start early) free solution that produces a tear • Humidifiers substitute • Lid scrubs https://www.reviewofoptometry.com/article/autologous-serum-helps-manage-ded

Options: Drops, Gels, Ung, Sprays New Intra-Nasal Device

Allergan Granted Marketing Authorization by the FDA for TrueTear™, the First Intranasal Neurostimulating Device Proven to Temporarily Increase Tear Production

Trigeminal nerve stimulation… impacts all three layers of tears

http://www.prnewswire.com/news-releases/allergan-granted-marketing-authorization-by-the-fda-for-truetear- the-first-intranasal-neurostimulating-device-proven-to-temporarily-increase-tear-production-300444980.html

18 1/30/2021

Supplements For The Eyes

Nasal Neurostimulator

What Are Omega-3 Fatty Acids? EyePromise EZ Tears Formulation Vitamin A -Retinyl Palmitate 1,000 IU • Considered essential fatty acids Vitamin D3 2,000 IU • We need them in our body for it to work Fish Oil EE 70% 1,480 mg Total Omega 3’s 1,100 mg • They are not made naturally in our body so we need to EPA 590 mg get it from our diet DHA 440 mg • All omega-3s are not the same Proprietary Blend (ingredients below) 220 mg Evening Primrose Oil 100 mg Health benefits: Turmeric Extract 50 mg Green Tea Extract 50 mg Reducing inflammation in blood vessels and joints Mixed Tocotrienols/Tocopherols 20 mg

Omega 3 Risks Vitamin A (as retinal palmitate) • Surgical risks are equated •A fat soluble vitamin that is essential omega-3s to Plavix (clopidogrel, Bristol-Myers Squibb), a for corneal surface health, as well as medication used to prevent platelets from clotting in mucosal, conjunctival, Meibomian, patients with a history of heart attack or stroke. Surgeons and lacrimal gland health. It is reported patients losing skin grafts and suffering excessive needed in genes and cells that express bruising due to fish oil supplementation—most often mucin (a polysaccharide) of major when patients did not report taking it preoperatively. importance in one of the three tear

http://optometrytimes.modernmedicine.com/optometrytimes/news/risks- layers. associated-omega-3-supplementation

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Vitamin D3 Vitamin E (d-alpha tocopheral) •A fat soluble vitamin, aka •A fat soluble vitamin that is cholecalciferol, which is the from of essential for reduction of systemic vitamin D that our bodies make from and ocular inflammation, also exposure to sunlight (UVB), it also important in stabilizing omega-3 usually comes from meat and fish. fatty acids Vitamin D3 aids in building up your immune system and aids in systemic inflammation

Dry Eye Patient Study EZ Tears Contact Lens Comfort Study • 56 Subjects • 90 Patients • 96% described symptoms as moderate to severe • Results: • 89% of patients reported improved contact lens comfort in 4 weeks • Results: • 32% saw improvement in hours per day of comfort (avg. 2.2 hours) • 86% reported symptomatic relief at 4 weeks • 45% reduction in contact lens removal • 93% reported no after • 11-13 day average onset of improved contact lens comfort • 89% reported little or no GI side effects • 85% of patients said they were likely to continue taking EZ Tears • All patients were able to take the softgels • 91% said they would recommend EZ Tears to others

EZ Tears Contact Lens Comfort Study ONIT Clinical Study Ocular Nutrition Impact on Tear Film Results: • IRB reviewed & approved • Significant improvement in comfortable wear • Extended hours of comfortable wear • FDA registered trial (clinicaltrials.gov) • Reduced artificial tear usage • Study Investigators • Dr. Bruce Koffler (Ophthalmologist) • Dr. Rob Davis (Optometrist) • Dr. Sean Mulqueeny (OD: Principal Investigator) • Currently enrolling patients

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ONIT Clinical Study Ocular Nutrition Impact on Tear Film Start-up Kit • 80 patients • Free to ECP’s • Objective: To determine whether EyePromise EZ Tears benefits • Coupons patients with dry eye. • Product Samples • Baseline, 1, 4, 8 week follow-up • Brochure holders • Patient Inclusion Criteria (Must Meet 4 of 7 criteria) • Staff Training Tear Osmolarity OSDI Survey • Patient Education Tear breakup time Corneal Staining materials Conjunctival Staining Tear Meniscus Height • Print & web Phenol red thread

Identify Patients Nutraceutical Support With Dry Eye

OSDI Survey Form • Dry Eye

• AMD Key Reminder: • Visual Performance Up to 50% of Contact Lens • Brand Specific Brochures Wearers experience

Contact Lens Induced Dry Eye (CLIDE)

Benefit To The Practice

• $700- $800 per pt per year

• Potential $200,000 per year

• Ophthalmology treating

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Reference Material Reference

• ZeaVision • Endoscopic Surgery of the and Lacrimal System 2006… Acquired • Allergan Nasolacrimal Duct Obstruction David M. Mills M.D., Dale R. Meyer M.D. FACS • Wikipedia Thank you to: • Images from Eye Imaginations • Reports: from ZeaVision • Images from TearScience • http://www.aoa.org/patients-and-public/eye-and-vision- problems/glossary-of-eye-and-vision-conditions/dry-eye?sso=y

Thank You [email protected]

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