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Home , Dry eye syndrome, Keratitis, Lagophthalmos, Trichiasis

Optometric Study Center

2nd Annual Dry Report Dry Eye Management New for the Century The latest on causes and treatments. By Paul M. Karpecki, O.D. and J. James Thimons, O.D., Contributing Editors

reatment of ocular and treating dry eye and its related bomian glands.2 Experimental surface disease, includ- conditions. We’ll review some of evidence indicates that androgen ing dry eye, has become them here. hormones (primarily estrogen, but an important part of also pro­gesterone and testosterone) Toptometric practice. And, when Pre-Disposing Factors improve secretory you consider that 35% of the U.S. Treatment of dry eye begins with function and help maintain the anti- population has symptoms related an understanding of the factors inflammatory state for the ocular to dry —for example, 9.3 mil- that predispose the patient to this structures.3 Hormonal deficit, as lion patients were diagnosed with problem. Among them: with menopause, may remove this sicca alone in • Age and sex. Studies show protection; so as patients grow 1999— this condition will likely that androgen hormones regulate older, deficiencies in these circu- be an expanding segment of our homeostasis of many structures, lating hormones can more easily practices.1 including the lacrimal and mei- initiate of the ocular An individual who surface and lacri- complains of dry eye mal glands.4-6 symptoms is not sim- • Environment. ply the patient with Air conditioners, a routine “nuisance” heaters and ceiling complaint. Rather, fans all remove this patient may have moisture from significant ocular or the air. Patients systemic disease. Left who work in drier untreated, this can environments—for result in sight-threat- example, pilots ening sequelae such and flight atten- as bacterial dants—may be and sterile corneal more prone to dry melts. eyes. So are pa- We must stay tients who spend abreast of new devel- significant time

opments, findings and Courtesy: Joseph P. Shovlin, O.D. working at com- tools for diagnosing Poor ocular surface wetting in marginal dry eye patient. puters. Researchers

64 REVIEW OF february 15, 2001 have found a correlation between have regular exams for this type of of sensory input back to the lacri- smoking and significant caffeine in- malignancy.13 mal and accessory lacrimal glands; take and dry eye, and now consider Another systemic disease, acne that the suction ring used during these the top two environmental or , is perhaps one of the most LASIK disrupts the high concentra- intake sources, though they have misdiagnosed causes of dry eye. tion of goblet cells at the limbus, not determined the cause.7 Rosacea also involves meibomian decreasing mucin production; and • Anterior segment disease gland dysfunction, and tear flow alteration, which results (primar- dry eyes, and can from the alteration of the corneal ily blepharitis lead to rosacea surface—a temporary condition and posterior keratitis.14 because the iron deposits that ap- meibomianitis). • Medica- pear centrally in long-term LASIK Patients with tions. Antihis- patients support tear flow.19 blepharitis are tamines, anti- approximately hypertensives, Patient Workup twice as likely anticholinergics, We can probably diagnose many to experience dry eye cases by the initial present- dry eye symp- and even oral ing symptoms: burning, stinging, toms than pa- contraceptives transient blur, , injec- tients without Inferior SPK may indicate , can all contribute tion and foreign body sensation. blepharitis.8 , blepharitis, meibomianitis or to dry eye. So, Even so, you must thoroughly Blepharitis and other lid conditions. too, can topi- examine the patient to arrive at meibomianitis cal ophthalmic a proper diagnosis, especially in may also indicate a systemic prob- and their preservatives. determining the underlying cause. lem such as acne rosacea.9 These include medica- Include the following in your work- • Systemic disease. This is a tions and any chronic up: strong contributing factor to dry with preservatives. • , lid margins and eye- eye, especially among patients with • Contact wear. Because the lashes. Look for anterior segment and rheumatoid arthri- pre-lens tear film is thinner than disease such as blepharitis and tis.7,10 Also, due to slow and/or the pre-ocular tear film, contact posterior dys- abnormal healing in many diabet- lens wear is likely to exacerbate function. Also look for , ics, this condition poses a risk of dry eye symptoms.15,16 The Canada en­- tropion and trichiasis. significant sequelae such as bacte- Dry Eye Epide- Dermato­ rial kera­titis and persistent corneal miology study chalasis may erosion or epithelial defects. found that half also contribute Sjögren’s syndrome, an autoim- of significantly to mune and arthritis-type condition, wearers reported dry eye-type involves a triad of dry mouth, dry dry eye symp- symp­toms. In eye and systemic immune dysfunc- toms vs. less fact, one study tion, such as polyarteritis. Recent than one-fourth shows that research into Sjögren’s syndrome of non-wearers this condition suggests a lymphocytic infiltration (see “The CLIDE Courtesy: Joseph P. Shovlin, O.D. existed in more of the lacrimal and salivary glands. Files,” page Significant meibomian gland dysfunc- than 86% of Sjögren’s has a prevalence of 4 in 59).17 tion causes dry eye symptoms. cases following 1,000, and 95-98% of patients with • LASIK. Re- a blepharoplas- Sjögren’s are women.11,12 Again, fractive ty.20 lower androgen counts, especially has also been shown to contribute • The and . in post-meno­pausal women, may to dry eye, primarily in the first 3-6 Evaluate the quality and size of the contribute to a breakdown of the months post-op.18,19 There are three tear film on every patient.21 This salivary and lacrimal glands. One theories on this: the neurotrophic can be noted by looking at the size study found that patients with theory, which suggests that a sever- of the tear meniscus as well as the Sjögren’s are 46.3 times more likely ing of nerves in the corneal stroma, quality based on debris in the tear to develop a non-Hodgkin’s lym- which takes some 3 months to film. phoma. Sjögren’s patients should regenerate, may contribute to lack Look for staining. Using Lis-

REVIEW OF OPTOMETRY february 15, 2001 65 Optometric Study Center

samine Green dye, the conjunctiva thritis is the contributing cause (see temic causes. Otherwise, the signs will stain at 3 and 9 o’clock in dry “Case Report: Octogenarian with and symptoms of dry eye and ocular eye patients. Using dye, Keratoconjunctivitis Sicca,” below). surface disease usually will not it is the cornea that is examined Making Changes clear. for staining. Its location helps you The first step in your treatment: Treatment of blepharitis depends determine how to proceed with Educate these patients that their upon severity. Patients can treat treatment. Inferior superficial condition is chronic and that there mild, non-symptomatic conditions punctate keratitis clearly indicates is no current cure available. If they with hot compresses for 10 minutes incomplete blink, lagophthalmos, understand this, they’re more likely a day and lid hygiene. Diluted baby or blepharitis and posterior meibo- to comply with treatment. shampoo application may be effec- mian gland dysfunction. Next, try to reduce or eliminate tive for acute cases and short-term • Cranial nerve function. Prob- any underlying, exacerbating fac- treatment, although longer-term lems in this area, especially a tors. Encourage patients to con- use results in chafing and chronic seventh nerve palsy, may result in sume less caffeine and quit smok­ dryness of the lids, causing irrita- an incomplete blink and/or chronic - ing, increase their water intake tion.22 Fortunately, there are now exposure. (at least 6-8 cups a day) and use a commercial lid scrubs available that • Skin. Check for erythema, humidifier. appear to be effective. telangiectasia, pustules, prominent Also, the patient may need to More advanced cases of blepha- sebaceous glands and rhinophy- reduce the dosage or switch certain ritis and meibomianitis warrant the ma—the characteristic findings of medications such as . use of medications, including: rosacea. Systemic rosacea usually Involve other doctors who are treat- • Anti-infectives such as bacitra- presents in the cheek region in ing the patient in this decision. cin and . Bacitracin is a women, and on the nose and fore- good ointment in mild, inflamma- head in men. Medications tory cases of blepharitis because • Hands. Be sure to look at the Your first target of treatment: of its effectiveness against gram- patient’s hands to determine if ar- blepharitis, meibomiantis or sys- positive such as Staphy- lococcus, the primary pathogen Case Report: Octogenarian with Keratoconjunctivitis Sicca of blepharitis and meibomianitis. An 82-year-old white female with a longstanding history of keratoconjunctivitis sicca Secondly, bacitracin is topical, so presented to her primary eye-care provider about 2 months before we saw her. She bacterial resistance to this drug is said her symptoms had become more severe. The clinician diagnosed severe dry fairly limited. eye and prescribed numerous lubricants and • / artificial . combinations. Patients Four weeks later, the patient showed no who experience significant improvement, so the doctor referred her to our inflammation with ery- center. We noted significant corneal thinning thema and edema of the on examination. lid margins may require When we looked at the patient’s hands, we a combination such as realized that arthritis was an underlying sys- Blepha­mide (sulfaceta­mide/ temic cause of her dry eye. The patient said pred­- nisolone) or Tobra- she was aware of her arthritic condition but Dex (tobramycin/dexa- had never seen a rheumatologist or internist; methasone). Blepha­mide rather, she simply took ibuprofen daily. had fallen out of favor This patient eventually experienced a neu- This 82-year-old female with a his- because of the relatively rotrophic or arthritic corneal melt with uveal tory of eventu- high bacterial resistance (60-70%) prolapse, and lost her eye. Earlier referral to ally experienced a corneal melt. to sulfa­­- cetamide and the high level a rheumatologist and treatment with systemic of allergic response.23 Although only immunosuppressants may have saved the anecdotal evidence exists, since so patient’s eye; without oral immunosuppressants, her condition advanced to a com- many eye doctors have avoided it, plete corneal perforation.39 bacteria may be increasingly suscep- This patient demonstrates why we must consider systemic causes of dry eye tible to this medication. The steroid and, in patients such as this one, look at their hands when they present with dry eye combination will certainly regress symptoms.—P.M.K. the inflammation and edema and

66 REVIEW OF OPTOMETRY february 15, 2001 Optometric Study Center

relieve symptoms much faster than dizziness. Of course, Doxycyline condition, location of staining, a non-steroid. is contraindicated in children, systemic involvement and the cause • Oral tetracyclines. These are pregnant women and nursing of symptoms (e.g., lagophthalmos). especially effective in severe or women due to possible teratogenic You may need to experiment to chronic cases of blepharitis and effects and the possibility of tooth determine which brand works best. meibomi­- an gland dysfunction and bone deformities in children.27 For patients with severe dry eye because they accumulate in oil Pseudotumor cerebri is a rare but and little or no tear production glands and limit lipase possible ocular side effect, so moni- (less than 5mm over 5 minutes on activity.24 Also, tetracyclines help tor patients for this condition.28 Schirmer test), a preservative-free reduce inflammation resulting from artificial tear is warranted to reduce anterior segment disease and sys- Tears and Lubricants the risk of preservative toxicity.29 temic inflammatory conditions such The artificial tear supplement Preservatives will exacerbate symp- as arthritis.24,25 For these patients, you choose should depend, in part, toms in patients with conditions consider Doxycycline 100mg bid on the severity of the patient’s such as rheumatoid arthritis, in for 4 weeks, then taper which they have little to to qd as a maintenance Diagnostic Testing no tear production.29 dose. Many diagnostic tests that aid us in positively diagnosing dry eye The same may hap- Doxycycline is also have been developed over the years. Most clinicians rely on tradi- pen with the “disap- recommended for tional tests, such as tear breakup time, Schirmer’s and ocular sur- pearing” preservative treating acne rosacea. face staining for proper diagnosis of dry . found in many brands The recommended However, using several diagnostic aides is better for identifying a of artificial tears. The dosage is 100mg bid patient’s dry eye condition than a single test alone.40 For example, disappearing preserva- for 4-6 weeks, then patient questionnaires about symptoms and risk factors give some tive, often borate or qd until fully resolved. credibility to the diagnosis; however, many patients experience hydrogen peroxide, Other effective treat- many of the common symptoms related to dry eye.41 dissolves from H2O2 to ments for rosacea Some additional tests: H2O when it comes in include Metro­Gel • Tear break-up time. This is an effective test, but proper test- contact with tears, but (metronidazole) or ing and proper administration of the dye is important. This includes many patients lack suf- MetroCream (metroni- instilling an ample amount of sodium fluorescein dye, performing the ficient tears to dissolve dazole) in the involved test prior to instillation of other drops, and waiting 1 full minute for the preservative. H2O2 regions.26 Also educate fluorescein and tears to become uniform. can be toxic to an the patient on com- Tests such as the Dry Eye Test (DET) and Zone-Quick cotton already compromised mon triggers of thread tests provide quicker, repeatable ways to assess tear film- cornea. rosacea such as spicy breakup time. Schirmer’s tear testing is also of value. However, tears with foods, alcohol and, in • Staining. Both sodium fluorescein or lissamine green are good the disappearing pre- some cases, heat. indicators of this condition. servative are ideal for Of course, you must Lissamine green has at least three advantages over : patients without signifi­- use caution when pre- it’s less toxic to the cells, does not last as long in cosmetically con- cant keratoconjunc- scribing tetracyclines. scious patients and does not sting as much.42 As with rose Bengal, tivitis sicca and who Don’t forget the usual lissamine green stains devitalized cells, but is not as effective in have moderate tear warnings: the risk of staining cells unprotected by a deficient mucin layer.43 When exam- production sufficient phototoxic reactions ining a patient with lissamine green dye, first look at the conjunctiva, to dissolve the preser- (patients should wear not the cornea, as dry eye signs will be most evident in the exposure vative. These brands sunscreen or protective areas of 3 and 9 o’clock. If the cornea stains with lissamine green, combine convenience clothing); chelation you probably have a significantly dry eye. and cost-savings, two with dairy products The location of the corneal staining can vastly affect treatment for factors that usually and antacids, which dry eye patients. Significant inferior staining alone would suggest increase compliance. may render them inef- lagophthalmos or blepharitis and posterior meibomianitis. Superior Clinically, they appear fective; and the risk staining alone might suggest superior limbic keratoconjunctivitis. to be a better choice of gastric inflamma- There are numerous other tests—lactoferrin microassay and than preserved tears in tion.27 Patients who impression cytology among them—although you might be able to regards to preservative use Minocycline may make a proper diagnosis with those mentioned earlier. They’re most build-up and toxicity, experience vertigo or appropriate for an optometric practice.44—P.M.K., J.J.T. so long as the patient

68 REVIEW OF OPTOMETRY february 15, 2001 Optometric Study Center

has sufficient tears to dissolve the Many patients report much term use of carries with preservative. greater comfort when using these it potential risks such as posterior Any patient who uses more than devices. Collagen plugs that last 3-7 subcapsular , IOP rise and 8-10 drops a day should switch days are certainly easier to insert, possible glaucoma, and secondary to true preservative-free tears or but usually yield little change in such as bacterial or HSV consider punctal occlusion. (Punctal symptoms over a 3-day period. The keratitis.32 occlusion is an excellent option for advent of new 2-week dissolving • Cyclosporin A. Although now plugs may be a signifi- under investigation, cyclosporin cant improvement and a A may eventually allow longer- great consideration for term use without the potential side post-LASIK patients. Sili- effects of steroids. Studies have cone plugs appear to be shown topical cyclosporin to sig- the most effective punctal nificantly improve signs of kerato- occlusion device because sicca in dogs, and it they block a greater has been approved by the Food and amount of outflow tears Drug Administration for treatment and do not dissolve.30 of veterinary dry eye disease.33 Some clinicians recom- Cyclosporin inhibits inflammato- mend upper punctal ry cytokine production. Cytokines Cyclosporin inhibits inflammatory cytokine produc- occlusion in patients with lead to tissue damage, activation of tion and may one day allow longer-term use without chronic blepharitis or more T lymphocytes and produc- the potential side effects of steroids. significant inflammation, tion of additional inflammatory such as with rheumatoid substances that result in breakdown arthritis. These clinicians of the lacrimal and ocular surface.34 elderly, arthritic patients who lack postulate that patients with blepha- Studies show a significant increase the dexterity to instill artificial tears ritis, upper occlusion allows the of cytokines and T-lymphocytes of regularly.) Staphylo­ coc­cus to accumulate in the conjunctiva and lacrimal gland Patients who use less than 4 the lower lid margin to wash away in individuals with keratoconjuncti- drops a day or experience occa- more easily through an open lower vitis sicca.35 sional dryness in their eyes should punctum. probably use preserved tears be- cause these patients are more likely Alternative Treatments to leave the bottle around for long Besides some of these traditional periods of time. dry eye treatments, many alterna- Ointments are better suited as a tive therapies are in the pipeline. nighttime lubricant or for patients Among them: with significant vision loss. Of • . Many clini- course, because ointments com- cians are starting to consider promise vision, their daytime use is corticosteroids effective treatments limited. for dry eye because corticoste- Gels offer greater contact time roids can inhibit most inflamma- Silicone punctal occlusion of the up­per than drops without the visual com- tory pathways, including cytokine puncta may be an effective treatment promise of ointments. However, production, cell adhesion molecules in some cases. they also don’t have the contact and vascular permeability. In fact a time of an ointment. Again, we cau- study by P. Prabhasawat and S.C. So, we are now starting to see a tion their use in patients with severe Tseng showed an 83% subjective shift in thinking; dry eye is not only dry eye because the disappearing improvement in symptoms and a disease of evaporation or insuf- preservative has the rare chance to an 80% improvement in certain ficient tear production, but rather cause mild toxicity in this type of clinical observations with a 2-week a localized, immune-mediated patient, particularly one atopic in regimen of 1% qid.31 inflammatory response affecting the nature.29 While steroids are generally good lacrimal gland and ocular surface. for short-term use, dry eye is a Clinical trials involving cyclospo­ Punctal Occlusion chronic condition. Remember, long- rine ophthalmic emulsion 0.05%

70 REVIEW OF OPTOMETRY february 15, 2001 Optometric Study Center Examination Answer Sheet 2 CE Credits Valid for credit through February 28, 2002 DRY EYE Directions: Select one answer for each question in the exam and completely darken the appropriate bid for 6 months showed a significant increase in circle. A minimum score of 70% is required to earn credit. Social security number is density, a decrease of T-lymphocytes required to process your exam. This is used for internal processing purposes only. and a corresponding improvement in patient Mail to: Payment: Optometric CE Remit $30 with this exam. symptoms, im­proved rose Bengal staining and PO Box 488 Make check payable to superficial punctate keratitis.36 Canal Street Station Jobson Publishing. New York, NY 10013 • Androgen medications. As we mentioned, There is an eight to ten week processing time for this exam. androgen hormones appear to improve lacrimal 1. A B C D 21. The CE goals and objectives were achieved: gland secretory function and help maintain the 2. A B C D Very Well Adequately Poorly anti-inflammatory state for the ocular structures. 3. A B C D 22. The information presented was: Over the next few years, we may begin to see 4. A B C D Very Useful Useful Not Very Useful 5. A B C D treatments that focus on hormonal regulation. 6. A B C D 23. The difficulty of the program was: • Nutrition. Research suggests that dietary 7. A B C D Complex Appropriate Basic supplementation with omega-3 and other poly- 8. A B C D unsaturated fatty acids may help decrease pro- 9. A B C D 24. Your knowledge of the subject was increased: 10. A B C D Greatly Somewhat Hardly inflam­- matory cytokines and lessen the severity of A B C D 11. 25. The quality of the program was: Sjögren’s syndrome, but more research is probably 12. A B C D 37 Excellent Fair Poor needed. N.A. Brown and colleagues believe that 13. A B C D 14. A B C D How long did it take to complete this program: gamma-linolenic acid, one of the essential fatty ac- 15. A B C D ids, may relieve symptoms of Sjögren’s syndrome A B C D 16. Comments on this program: and other dry eye conditions.38 17. A B C D 18. A B C D Topics you would like in future CE articles: 19. A B C D The newest research in dry eye pathology fo- 20. A B C D cuses on the underlying causes, multiple tests and Please retain a copy for your records - Please print clearly new treatments. Armed with this information, , one of the most common diseases SS # - - we see in optometric practice, will become easier First Name to diagnose and treat. Proper diagnosis assists the

Last Name chronic dry eye patient and will prevent severe sight-threatening pathology such as bacterial kera- Home titis and corneal melts. n Address Dr. Karpecki is the medical director for cata- ract, and anterior segment City State disease at Hunkeler Eye Centers, a NovaMed Zip - EyeCare Management practice, in Kansas City, Home # Mo. Dr. Thimons is executive director of TLC - - and Ophthalmic Consultants of Connecticut. Both Business Address are regular columnists for Review of Optometry.

1. Lemp MA. Epidemiology and classification of dry eye. Adv Esp Med Biol. City State 1998;438:791-803. 2. Sullivan DA, Wickham LA, Rocha EM, et al. Androgens and dry eye in Sjögren’s Zip syndrome. Ann N Y Acad Sci 1999;876:312-24. - 3. Sullivan DA, Block L, Pena JD. Influence of androgens and pituitary hormones on the structural profile and secretory activity of the lacrimal gland. Acta Ophthalmolo Business # - - Scand 1996;74:421-35. 4. Pfugfelder SC, Whitcher J, Daniels T. Sjögren’s syndrome. Ocular and Fax # immunity. St Louis: Mosby 1996:1043-7. - - 5. Azarollo AM, Wood RL. Mircheff A, et al. Androgen Influence on lacrimal gland E Mail apoptosis, necrosis and lymphocytic infiltration. Invest Ophthalmolo Vis Sci 1999;40:59-2602. Preferred Address: Home Address Business Address 6. Sullivan DA, Krenzer KL, Sullivan BD, et al. Does androgen insufficiency cause By submitting this answer sheet, I certify that I have read the lesson in its entirety and lacrimal gland inflammation and aqueous tear deficiency? Inves Ophthalmol Vis Sci completed the self-assessment exam personally based on the material presented. I have 1999;40:1251-5. not obtained the answers to this exam by any fraudulent or improper means. 7. Moss SE, Klein R, Klein BE. Prevalence of and risk factors for dry eye syndrome. Arch Ophthalmol 2000 Sep; 118(9):1264-8. Signature: Date: 8. Mathers WD, Lane JA, Zimmerman MB. Assessment of the tear film with tandem scanning confocal microscopy. Cornea 1997 Mar;16 (2): 162-8. 9. Kiratli H, Irkec M, Orham M. Tear lactoferrin levels in chronic meibomitis associ- ated with acne rosacea. Eur J Ophthalmol 2000 Jan-Mar;10(1):11-4. 10. Nepp J, Abela C, Polzer I, et al. Is there a correlation between the severity of diabetic and keratoconjunctivitis sicca? Cornea 2000 Jul;19(4):487-91. Lesson 1783 40420 11. Cervera R, Font J, Ramos Casals M, et al. Primary Sjögren’s Syndrome in men: PCO-OSC-0201 clinical and immunological characteristics. 2000;9(1):61-4. Optometric Study Center

12. Manthorpe R, Frost-Larsen K, Isager H, et al. Sjögren’s 24. Dougherty JM, McCulley JP, Silvany RE, et al. The role syndrome keratoconjunctivitis sicca. Curr Eye Res 1999 syndrome. A review with emphasis on immunological of tetracycline in chronic blepharitis. Inhibition of lipase Sep;19(3):201-11. features Allergy 1981 Apr;36(3):139-53. production in staphylococci. Invest Ophthalmol Vis Sci 1991 36. Stevenson D, Tauber J, Reis BL. Efficacy and safety of 13. Voulgarelis M, Dafni UG, Isenberg DA, Moutsopoulos Oct; 32 (11): 2970-5. cyclosporin A ophthalmic emulsion in the treatment of mod- HM. Malignant lymphoma in primary Sjögren’s syndrome. 25. Solomon A, Rosenblatt M, Li DQ et al. Doxycycline erate to severe dry eye disease: a dose-ranging, randomized Arthritis Rheum 1999 Aug;42(8):1765-72. inhibition of interleukin-1 in the corneal . Am J trial. The Cyclosporin A Phase 2 Study Group. Ophthalmol- 14. Chalmers DA, Rosacea: recognition and management Ophthalmol 2000 Nov;130(5):688. ogy 2000 May;107(5):967-74. for the primary care provider. Nurse Practitioner 1997 26. Barnhorst DA, Foster JA, Chern KC, et al. The efficacy 37. Sullivan BD, Cermak JM, Sullivan RM, et al. Correlations Oct;22(10):18-30. of topical metronidazole in the treatment of ocular rosacea. between nutrient intake and the polar lipid profiles of meibo- 15. Guillon J-P. Dry eye in contact lens wear. Optician 1996 Nov;103 (11):1880-3. mian gland secretions in women with Sjögren’s syndrome. 1997;214(5622):18-25. 27. Salamon SM. Tetracyclines in ophthalmology. Surv Third International Conference on the Lacrimal Gland, Tear 16. Lemp MA, Caffery B, Lebow K, et al. Omafilcon A Ophthalmol 1985 Jan-Feb;29(4):265-75. Film and Dry Eye Syndromes: Basic Science and Clinical (Proclear) soft contact lenses in a dry eye population. CLAO 28. Chiu AM, Chuenkongkaew Wl, Cornblath WT, et al. Relevance (abstracts). Cornea 2000;19(Suppl. 2): S127. J 1999;25(1):40-7. Minocycline treatment and pseudotumor cerebri syndrome. 38. Brown NA, Bron AJ, Harding JJ, Dewar HM. Nutrition 17. Dougherty MJ, Fonn D, Richter D, et al. A patient Am J Ophthalmology 1998 Jul;126(1):116-21. supplements and the eye. Eye 1998;12(Pt. 1):127-33. questionnaire approach to estimating the prevalence of dry 29. Palmer Rm, Kaufman HE. Tear film, pharmacology of 39. Bernauer W, Ficker LA, Watson PG, et al. The manage- eye symptoms in patients presenting to optometric practices eye drops, and toxicity. Current Opinions in Ophthalmology. ment of corneal perforations associated with rheumatoid across Canada. Optom Vis Sci 1997;74:624-31. 1995 Aug;6(4):11-6. arthritis: An analysis of 32 eyes. Ophthalmology. 1995 18. Yu EY, Leung A, Rao S ,et al. Effect of laser in situ 30. Slusser TG, Lowther GE. Effects of lacrimal drainage Sep;102(9):1325-37 keratomileusis on tear stability. Ophthalmology 2000 Dec; occlusion with nondissolvable intracanalicular plugs on 40. Pflugfelder SC, Tseng SCG, Sanabria O, et al. Evaluation 107(12):2131-5. hydrogel contact lens wear. Optometry and Visual Science. of subjective assessments and objective diagnostic tests for 19. Lee JG, Ryu CH, Kim J, et al. Comparison of tear 1998 May;75(5):330-8. diagnosing tear-film disorders known to cause ocular irrita- secretion and tear film instability after PRK and laser in situ 31. Prabhasawat P, Tseng SC. Frequent association of tion. Cornea 1998;17:38-56. keratomileusis. J Refract Surg 2000 Sept;26(9): delayed tear clearance in ocular irritation. British Journal of 41. Oden NL, Lilienfel DS, Lemp MA, et al. Sensitivity and 1326-31. Ophthalmology 1998 Jun;82(6):666-75. specificity of a screening questionnaire for dry eye. Adv Exp 20. Vold SD, Carroll RP, Nelson JD. Dermatochalasis and 32. Rennie IG. Clinically important ocular reactions to Med Biol 1998; 438:807-20. dry eye. Am J Ophthalmology. 1993 Feb 15;115(2):216-20. systemic drug therapy. Drug Safety 1993 Sep;9(3):196-211. 42. Kim J. The use of vital dyes in corneal disease. Current 21. Oguz H, Yokoi N, Kinoshita S. The height and radius 33. Kazwan RI, Salisbury MA, War DA. Spontaneous canine Opinion Ophthalmology 2000 Aug;11(4):241-7. of the tear meniscus and methods for examining these keratoconjunctivitis sicca: a useful model for human kerato- 43. Tseng SC, Zhang SH. Interaction between rose parameters. Cornea. 2000 Jul;19(4):497-500. conjunctivitis sicca. Treatment with cyclosporin eye drops. Bengal and different protein components. Cornea 1995 22. Key JE. A comparative study of cleaning regimens Arch Ophthalmol 1988; 106:631-9. Jul;14(4):427-35. in chronic blepharitis. CLAO J 1996 Jul;22(3): 209-12. 34. Mathers WD. Why the eye becomes dry: a cornea and lacri­ 44. Nichols KK, Nichols JJ, Zadnik K. Frequency of dry 23. Genvert GI, Cohen EJ, Donnenfeld ED, Blecher MH. mal gland feedback model. CLAO J. 2000 Jul;26(3):159-65. eye diagnostic test procedures used in various modes of Erythema multiforme after use of topical sulfacetamide. Am J 35. Pflugfelder SC, Jones D, et al. Altered cytokine balance ophthalmic practice. Cornea 2000 Jul;19(4):477-82. Ophthalmol 1985 Apr 15;99(4):465-8. in the tear fluid and conjunctiva of patients with Sjögren’s

OSC QUIZ

ou may obtain transcript- (limits are noted): Alaska, 6 hrs/6 d. Premenstrual syndrome in women. quality continuing education yrs • Arizona • Arkansas, 4 hrs/yr • Ycredit through the Optometric California, 20 hrs/2 yrs • Delaware, 6 2. What may alleviate the type of dry Study Center. Just complete the test hrs/yr • Georgia, 5 hrs/2 yrs • Hawaii, eye that is caused by environmental form on page 94 and return it with the 8 hrs/2 yrs • Idaho, 6 hrs/yr • Illinois, factors? $30 fee to: Optometric CE, P.O. Box 2 hrs/2 yrs • Indiana, 6 hrs/2 yrs • a. Antihistamines. 488, Canal Street Station, New York, Kansas, 3 hrs/2 yrs • Maryland, 6 b. . NY 10013. To be eligible, please hrs/2 yrs • Massachusetts, 2 hrs/ c. Lid scrubs. return the card within 1 year of publi- yr • Michigan • Minnesota, 9 hrs/3 d. Humidifiers. cation. You may also access the test yrs • Mississippi, 4 hrs/yr • Missouri form, and submit your answers and • Montana, 6 hrs/yr • Nebraska, 2 3. Which one statement is true payment via credit card, at Review hrs/2 yrs • Nevada, 12 hrs/yr • New re­garding the treatment of blephari- of Optometry OnLine, www.revoptom.­ Hampshire • New Jersey, 12 hrs/2 tis? com. You must achieve a score of 70 yrs • New Mexico • New York, 12 a. It depends on the patient’s age and or higher to receive credit. Allow 8-10 hrs/3 yrs • North Carolina, 4 hrs/yr • gender. weeks for processing. Ohio, 10 hrs/yr • Oklahoma, 3 hrs/yr • b. It depends on the severity of the For each Optometric Study Center Oregon, 10 hrs/2 yrs • Pennsylvania, patient’s condition. course you pass, you earn 2 hours of 6 hrs/2 yrs • Rhode Island, 2 hrs/yr • c. It can’t be accomplished with warm transcript-quality credit from Pennsyl­ South Dakota, 4 hrs/3 yrs • Texas, 4 compresses and lid scrubs alone. vania College of Optometry, and dou- hrs/yr • Vermont, 1 hr/yr • Virginia • d. Doxycycline is always indicated. ble credit toward the AOA Optometric Washington, 10 hrs/2 yrs. Recognition Award-Category 1. 4. Oral tetracyclines are contraindi- Boards of Optometry in 35 states 1. Which one of the following is a pre- cated in patients with : have approved the Optometric Study disposing factor to keratoconjunctivitis a. Inflammation from anterior seg- Center for credit toward license sicca? ment disease. renewal. a. Race. b. Inflammation from arthritis. These states have approved the b. Anterior segment disease. c. Mild blepharitis or meibomianitis. Optometric Study Center for 2 credits c. Excess hormones. d. Severe blepharitis or meibomiani-

REVIEW OF OPTOMETRY february 15, 2001 75 Optometric Study Center

OSC QUIZ

tis. 5. Medications likely to result in dry eye 11. What one statement is true about b. The severing of nerves in the corneal include: lissamine green staining? stroma may decrease mucin produc- a. Antidepressants and antihistamines. a. More toxic to the epithelial cells than tion. b. Antihistamines and insulin. rose Bengal. c. The severing of nerves in the corneal c. Antidepressants and insulin. b. Longer-lasting than rose Bengal. stroma may contribute to lack of sen- d. Beta-blockers and oral tetracyclines. c. More effective than rose Bengal at sory input to the lacrimal and acces- staining cells unprotected by a mucin sory lacrimal glands. 6. Which systemic disease is likely to layer. d. ­Increased pressure on the optic cause decreased tear secretion? d. Similar to rose Bengal in the way it nerve disrupts tear flow. a. Hypertension. stains devitalized epithelial cells. b. HIV. 17. Which treatment would you recom- c. Heart disease. 12. Circulating hormones, particularly mended for acne rosacea in a 45-year- d. Rheumatoid arthritis. estrogen, help: old male? a. Maintain a non-inflamed state in the a. Oral doxycycline 100mg bid for 4 7. The triad for Sjögren’s syndrome tissues. weeks, then taper. includes: b. Create an inflammatory state that b. Oral azithromycin 1,000mg once. a. Dry eye, dry mouth and dry skin. can cause a breakdown of the lacri- c. Oral erythromycin 250mg qid for 10 b. Dry eye, dry skin and arthritis (or mal glands and ocular surface. days. similar systemic immune dysfunc- c. Heal meibomian gland dysfunction d. Oral Augmentin (amoxicillin, clavula- tion). without resorting to drugs. nate potassium) qid for 10 days. c. Dry eye, dry mouth and arthritis (or d. Lead to the development of kera- similar systemic immune dysfunc- toconjunctivitis sicca in post-meno­ 18. Inferior staining alone may indicate: tion). pausal females. a. Lagophthalmos, blepharitis or supe- d. Dry eye, dry mouth and irregular rior limbic keratoconjunctivitis. heartbeat. 13. Sjögren’s syndrome increases the b. Superior limbic keratoconjunctivitis, patient’s chance of developing: meibomianitis or blepharitis. 8. Treatment for acne rosacea may a. Hormone deficiency. c. Superior limbic keratoconjunctivitis, involve: b. Non-Hodgkin’s lymphoma. Sjögren’s syndrome or post-LASIK a. Beta-blockers. c. Diabetes mellitus. dry eye. b. Topical antibiotics. d. Blepharitis or meibomianitis. d. Lagophthalmos, blepharitis or poste- c. Antihistamines. rior meibomianitis. d. Metronidazole or doxcycline. 14. Which are leading dietary contribu- tors to dry eye? 19. Which type of tear supplement is 9. Which one combination of symptoms a. Unsaturated fats and cholesterol. best for a patient with severe dry eye, is likely to present with dry eye? b. Sugars and carbohydrates. filamentary keratitis and Schirmer tear a. Flashes and . c. Smoking and caffeine. test measuring 2mm? b. Dry mouth and dry scalp. d. Carbonated beverages. a. Preservative-free artificial tears. c. Transient blur and stinging. b. Preserved artificial tears. d. Pain and elevated IOP. 15. Which lid disease will not lead to an c. Artificial tears with a “disappearing” increase in dry eye-type symptoms? preservative. 10. When examining a patient with dry a. Dermatochalasis. d. No tear supplements. eye, you look at the patient’s hands for b. Blepharitis. what reason? c. Distichiasis. 20. Treatment of a corneal melt in a a. To gauge the severity of dry skin d. Ectropion. patient with rheumatoid arthritis must present. involve which of the following? b. To determine if the patient may have 16. The neurotrophic theory of post- a. Artificial tears. arthritis. LASIK dry eye suggests that: b. Steroid drops. c. To look for any unusual discoloration. a. The suction ring used during LASIK c. Immunosuppressives prescribed by a d. To look for the presence of sclero- disrupts the high concentration of rheumatologist. derma. goblet cells at the limbus. d. Doxycycline.

76 REVIEW OF OPTOMETRY february 15, 2001