AAddvvaanncceess iinn MMeeddiiccaall && SSuurrggiiccaall AAnntteerriioorr SSeeggmmeenntt TThheerraappyy J. James Thimons, O.D.,FAAO Optometric Medical Director Ophthalmic Consultants of Connecticut CCrroossss LLiinnkkiinngg:: NNeeww TTeecchhnnoollooggyy ffoorr aanndd OOlldd DDiisseeaassee KCN Diagnosis Corneal Collagen Cross-Linking Creates chemical bonds between fibers Floppy Eyelid Syndrome Cross-Linking is Not New Hardening of polymers in materials science since 1930s (silicone oil→rubber ball) Dentists X-linked for decades Normal aging of connective tissue involves cross-linking and stiffening Progression of KCN↓ with age as XL↑ We All “Crosslink” as we Grow Up Transplant Risks Before and After Crosslinking CCXXLL iinn KKeerraattooccoonnuuss Shown safe and effective worldwide Arrest progress of KCN Improvement in UCV, BCSVA, CLs Ideal candidates ≤ 45 y/o, corneal thickness ≥ 400 µm, limited scarring Minimum age in Europe now 10 y/o CXL and Ectasia Kannalopoulos, J Review of CXL post LASIK with ectasia Analysis at one year – Corneas stable – Mild refractive error shift No PK required at two years CXL and PRK Requires wavefront scan at level 4 reliability Predictability is less than standard PRK Contraindicated with apical scar Post-op similar to standard PRK CL’s same algorithm Radial Keratotomy CXL Technique UV-A Light 370 CXL Post-operative Care – 1 day, 1 week, & 1 month recommended visits – 4th generation fluoroquinolone qid x 4 days – Durezol or PF taper x 3 weeks – BCL – NPATS Haze? CXL Post Epi-On CXL Contact Lens Tx – Soft lens several days – HCL 1 week – Hybrid 2 weeks Topo’s at 3M/ 6M Crosslinking can continue up to 6M Indications for Intacs Step 1: Intralase Intacs Channel Creation Post-Operative Management Issues Managing MGD in the Primary Care Setting OM3’s Cycline’s Hot compresses Lid Hygiene Meibomian Gland Expression Lipiflow Because Not All MGD Is Obvious, Active Disease Identifiication Is Crucial Meibomian Glands Meibomian Gland Expression Arita Meibomian Gland Expression System With or without anesthesia Grade I-IV Non- billable More difficult at the punctal region. LLiippiiFFllooww // LLiippiiVViieeww AA NNeeww PPaarraaddiiggmm iinn MMeeiibboommiiaann GGllaanndd DDiisseeaassee TTrreeaattmmeenntt Meibomian Gland Expression and Gland Functionality MGD and Lipid Layer Thickness TTeeaarrSScciieennccee®® SSoolluuttiioonn LipiView® Output Because Not All MGD Is Obvious, Active Disease Identification Is Crucial Normal Meibomiian Glands Posterior Lid Margin Disease Clinical Findings – Posterior Lid margin – Inspissation of glands Erythema & telangiectasia – Pouting of oil – Gland drop out – Rapid tear break up time Bacterial Lipases Breakdown Lipids to Soap Meibomian Glands LipiFlow® Thermal Pulsation System LipiFlow® Thermal Pulsation System LipiView/ LipiFlow LipiView – Reimbursement: $ 125.00 Lipiflow – Reimbursement: $1000.00-1,500.00 Point of Care Diagnostic Systems: The Next Step in Anterior Segment Care RPS Adenodetector Tear Lab Inflamma-Dry LacriPen Laboratory Testing Primary Care: A Paradigm Shift Laboratory Testing Acute Conjunctivitis Adenoviral Conjunctivitis Clinical Accuracy AdenoPlus How to Use AdenoPlus: Four-step Process RPS Adeno Detector Plus InflammaDry InflammaDry: Defining the Role of MMP-9 in Dry Eye? MMP-9 and Dry Eye Severity1 Limit of Detection How to Use InflammaDry: Four-step Process Future Advances in Tear Marker Assessment Tear markers that currently exist: – Osmolarity – Adenovirus – MMP-9 IgE, HSV Alzheimer's Diabetes Parkinsons? Tear Function Screening Questionnaire Gritty or sandy sensation? Pain or soreness? Fluctuating vision? Occasional Tearing? Blurred vision while reading? Discomfort in windy conditions? Discomfort in air conditioned areas? Itching? Possible Testing During Dry Eye Evaluation Tear Break Up Time CCoonnjjuunnccttiivvaall SSttaaiinniinngg SScchhiirrmmeerr SSttrriippss Summary Statistics on Tear Osmolarity Normal subject average: – 296 ± 8 mOsm/L Dry Eye subject average: – 323 ± 16 mOsm/L Normal subject inter-eye difference: – 7 ± 6 mOsm/L Dry Eye subject inter-eye difference: – 17 ± 15 mOsm/L – Inter-eye difference is the hallmark of DED ( > 8 mOsm/L between eyes)1 Osmollariity iin the Diiagnosiis of Dry Eye Diisease Osmolarity is the “gold standard” test for Dry Eye – 45 years peer reviewed research – Osmolarity has been added to definition of Dry Eye – Global marker of Dry Eye, indicating a concentrated tear film Tear Osmolarity (Tomlliinson 2006) KEEP IT SIMPLE AND TAKE ADVANTAGE OF PPV Osmolarity & Tear Film Instability in DED Two Numbers Crucial to Understand Osmolarity The DIFFERENCE b/w two eyes: 24 This tells you how stable the tear film is. Normal tears are stable and < 300 mOsm/L bilaterally. A difference of > 8 mOsm/L is a hallmark of tear instability. Tear Lab Reimbursement – NGS:$ 44.50 – Medicaid: $ 43.50 – Commercials: $ 29-40 Code: 92071 Card cost: $10 Symptoms of Dry Eye Signs of Dry Eye PPootteennttiiaall CChhrroonniicc CChhaannggeess Telangiectasia Dislocation of meibomian glands/ gland atrophy Scarring Treatment Recommendations by Severity Levels Treatment Recommendations by Severity Levels EXTEND™ Synthetic Absorbable Implant Billing for Punctal Occlusion 68761 Punctal Occlusion Permanent or Temporary – E Codes E1 Superior Left E2 Inferior Left E3 Superior Right E4 Inferior Right – NGS reimbursement: $168.64 – Silicon Plug cost: $40-50 – Extended Collagen: $7-8 Developing Treatment Protocols Nutritional Supplements – Omega 3 fatty acid Fish Oil (EPA and DHA) Flaxseed – GLA – Vitamins The Hypothesis behind “The Root Cause” of Dry Eye Omega Imbalance (excess Omega-6:Omega-3) – causes the meibum to become thick, viscous and inflamed – causes the Meibomian Glands to become blocked – prevents the production of the lipid layer Without the lipid layer, the aqueous layer evaporates, causing the ocular surface to become irritated (red, dry, scratchy) Dosing Protocol – Dry Eye Omega Benefit Therapeutic Dose -Four capsules daily with meals Treatment Recommendations by Severity Levels Treatment Recommendations by Severity Levels Moderate to Severe Treatment Recommendations by Severity Levels Persistent Epithelial Defects Treatment cyanoacrylate tarsorrhaphy – Indications lagophthalmos exposure keratitis neurotrophic keratitis dry eyes persistent epithelial defects Persistent Epithelial Defects Treatment cyanoacrylate tarsorrhaphy – Indications lagophthalmos exposure keratitis neurotrophic keratitis dry eyes persistent epithelial defects Temporary Cyanoacrylate Tarsorrhaphies Age (27-85) 62 Dx: – Persistent epithelial defects – Neurotrophic keratitis – Exposure keratitis – Lagophthalmos Product Specifications PROKERA® PLUS PROKERA® SLIM Amniotic Membrane ProKera ( Biotissue) IOP Ocular Surface Disease Pathology Inflammation’s Effect on Healing . Inflammation: the first sign of wound healing & is also the hallmark symptom of all ocular surface diseases . Uncontrolled inflammation leads to: . Chronic pain and discomfort/irritation . Delayed healing, more tissue damage . Vision-threatening complication, e.g., scar/haze . Effective control of inflammation is an important strategy to promote healing and minimize the risk of scar/haze Different Outcomes to Tissue Injury Scarring is more than just the risk of vision loss… Ophthalmologists Are Aware of the Importance & Challenges of treating Ocular Surface Inflammation Emerging Treatment Paradigm Emerging Therapeutic Options Amniotic Membrane Power of the Amnion KEY Amniotic Membrane Components Recommended Pre-Treatment Tips Published Case Review Published Case Review Case Study 3: Acute Chemical Burn Recommended Post Treatment Tips ProKera Reimbursement – $1,628.38 Code: 65778 OOccuullooppllaassttiicc PPrroocceedduurreess ffoorr tthhee PPrriimmaarryy CCaarree CClliinniicciiaann J. James Thimons, O.D., FAAO Comprehensive Lacrimology Therapy Includes Therapeutics – Topical – Oral Includes Punctal Occlusion Dilation & Irrigation Nasolacrimal Probed Multiple Medical Visits PPrreeddiissppoossiinngg ffaaccttoorrss Age Gender Environment Anterior Segment Disease Medications CL Wear Refractive surgery Systemic Disease Pathophysiology of Epiphora Increased Reflex Tear Production – Rapid tear break up time – OSDI – Ocular surface irritation – Corneal changes: Punctate epithelial erosions Infiltrates related to staph hypersensitivity Decreased Outflow – Punctal Stenosis – Naso-Lacrimal obstruction – Anatomic Abnormality Floppy Lid Ectropian/Entropian Trichiasis – Dacryocystitis Managing Dacryocystitis Antibiotic Therapy Important Penicillins Ampicillin: Broad spectrum oral-QID dosing Amoxicillin: Pro-drug of Ampicillin, improved absorption with lower GI side-effects Cloxacillin/Dicloxacillin: Intrinsic beta-lactamase resistance Augmentin: Amox + Clavulanate Methicillin: IV prep for penicillinase producers Amp + Sulbactam: Unasyn: IV Ticarcillin + Clavulonic acid: IV better penicillinase protection than methacillin Augmentiin Indiicatiions/Dosage forms Indications: Preseptal cellulitis Dacryocystitis Pediatric Hemophilus Amoxicillin + Clavulanate@@@@ Dosage forms: 500 or 875mg tablets BID 125 or 250mg/5cc pediatric suspension Plan B: The Cephalosporins Mechanism: Same as penicillin Bacteriostatic Low toxicity 3% allergic to pen are allergic to Ceph. Better penicillinase resistance than penicillins Second Generation: Greater Gram (-) activity, especially Hemophilus Cefaclor: PO-Ceclor Cefuroxime: