DRY EYE EDUCATION

8/9/2019 DRY EYE EDUCATION

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earing

Dry vs. Wet vs. Both

Kimberly Cockerham, MD, FACSPlastics-Orbit-Neuro-Ophthalmology

www.CalEyes.com

http://www.caleyes.com/http://www.caleyes.com/


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Systematic Approach to

Tearing Dry

Wet

Other Ocular Surace

Eyeli!

Orbit


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Dry Eye is a Disease of the

Lacrimal Functional Unit

1

2

3

4


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Dry Eye "s Pre#alent $.% million people in the &nite! States'

A top reason or #isits to Eye(Ds an! O!s

Patients oten !issatis)e! with treatments *re+uent !rops incon#enient

,imite! symptomatic relie

*rustrate! Want new options

' (ulti-Sponsor Sur#eys "nc. The 2005 Gallup Study of Dry Eye Suerers. $%.


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Dry Eye Patient *actors Ol!er age

*emale gen!er

Post-menopausal

Tobacco smo/ing

Contact lens wear Prolonge! staring 0e.g. computer

wor/1


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En#ironmental *actors Air Pollution

Arti)cial orce! air

Allergens

,ow humi!ity


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(e!ications Antihistamines

Anti!epressants

Antispasmo!ics

Diruetics

Oral contracepti#es 2ormonal therapy


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Disease 3elate! *actors Systemic4

Autoimmune !isease 0TED1

Neurologic !isease that re!uces blin/ 5itamin A !e)ciency

,ocal4 ,acrimal glan! in)ltration Eyeli! malposition la6ity

lagophthalmos Ocular surace !isease


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Lacrimal Glands:Lacrimal Glands:• Chronic irritationChronic irritation

• T-cell activationT-cell activation

• Cytokine secretion intoCytokine secretion intotearstears

Interrupted SecretomotorInterrupted Secretomotor

Nerve ImpulsesNerve Impulses

Tears Damage OcularTears Damage Ocular

SurfaceSurfaceCytokinesCytokinesDisrupt Neural ArcDisrupt Neural Arc

Disruption o normalDisruption o normalneuronal control oneuronal control otearin!tearin!

Pathophysiology oChronic Dry Eye Disease

,acrimalDamage

Stern et al. Cornea. '778.Nelson et al. Adv Ther. $.


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2ealthy Tears

Comple6 (i6ture Antimicrobial proteins

9rowth actors

Cyto/ines suppress in:ammation

(ucin secrete! by goblet cells 5iscosity

Electrolytes Osmolarity

"mage a!apte! rom4 Dry Eye and Ocular Surface Disorders. $;.Stern et al. "n4 Dry Eye and Ocular SurfaceDisorders. $;.


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*unctions o a

2ealthy Tear *ilm Optical clarity reracti#e power

Ocular surace comort lubrication

Protection rom en#ironmental an! inectiousinsults

Antibacterial proteins antibo!ies complement

3e:e6 tears :ush away particles

Trophic en#ironment or corneal epithelium

Necessary electrolytes maintain p2

Protein actors or growth an! woun! healing

Antio6i!ants

3olan!o et al. Dry Eye and Ocular Surface Disorders. $;.Stern et al. "n4 Dry Eye and Ocular Surface Disorders. $;.


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Tears in Chronic Dry EyeDecrease! proteins

an! growth actors

Altere! cyto/inebalance promotesin:ammation

Proteases acti#ate! "ncrease! electrolytes

Altere! #iscositySolomon et al. nvest Ophthal!ol "is Sci. $'.


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E>ects o Altere! Tear

Composition in Chronic DryEye Ocular surace tissue en#ironment altere!

,ubrication compromise! !ue to poor

#iscosity "ncrease! osmolarity

"mbalance! growth actors an! cyto/inesail to promote normal epithelial growth

Ocular surace !amage

,oss o corneal epithelial integrity

S+uamous metaplasia o con?uncti#al

epithelium

P:ugel!er. A! $ Ophthal!ol. $;.


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The ,oo/ o Dry

NormalAbnormal


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Tear @rea/up Time 0T@&T1

Tear )lm instability is a hallmar/ o !ry eye Correlates with a+ueous an! e#aporati#e tear !e)ciency 0P:ugel!er

et al '7781

T@&T measures tear )lm +uality *luorescein intro!uce! rom strip yellow )lter increases

sensiti#ity

T@&T time rom complete! blin/ to 'st !ry spot 0B repetitions1

T@&T ' secon!s abnormal0,emp '77%1

Anesthesia decreases T%&T 'de (aiva et al) 200*+

A,nor!al corneal surface - ,rea/-up spots


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,issamine 9reen Staining

in Dry Eye

,issamine green !etects !ea! or!egenerate! con?uncti#al cells

E6posure one

staining withlimbal sparing

E6posure one

staining withlimbal staining

"ntense !i>use

staining oe6posureone limbalstaining

s rom Dry Eye and Ocular Surface Disorders. $;.


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5ital Stains

*luorescein 3ose @engal ,issamine9reen


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Schirmers Strips


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FDry EyesG are 5ery

Common $%H o oIce #isits in a general

practice

; in ' Americans su>er rom !ryeye symptoms 09allup Poll $;1

A>ects $ million Americans 0(ar/et

Scope $;1 Pre#alence4 ';H o a!ults ;8 J 7'

years ol!


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Dry Eye Patient *actors Ol!er age

*emale gen!er

Post-menopausal

Tobacco smo/ing

Contact lens wear Prolonge! staring 0e.g. computer

wor/1


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En#ironmental *actors Air Pollution

Arti)cial orce! air

Allergens

,ow humi!ity


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(e!ications Antihistamines

Anti!epressants

Antispasmo!ics

Diruetics

Oral contracepti#es 2ormonal therapy


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Disease 3elate! *actors Systemic4

Autoimmune !isease Neurologic !isease that re!uces blin/ 5itamin A !e)ciency

,ocal4

,acrimal glan! in)ltration Eyeli! malposition or la6ity Ocular surace !isease


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(il! to (o!erate

Symptoms (inimal signs Consi!er en#ironmentKinta/e

A!! tear replacement

Osmolarity

5iscosity

Combination


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(o!erate to Se#ere

Symptoms Abnormal tear )lm corneal an!

con?uncti#al staining #isual signs Essential atty aci!s 0E*A1

*la6see! oil 2y!roeyeL Topical anti-in:ammatory agents

Cyclosporine

Oral cholinergics Pilocarpine 0SalagenL1 Ce#imeline

C T t t


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"#@ehrens et al. Cornea. $=.

Consensus TreatmentAlgorithm 9ui!elines


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Dry Eye (anagement

ild to oderateSy!pto!s (inimal or no signs

A!! Essential atty aci!s 0E*A1 *la6see! oil 2y!roeyeL

A!! tear replacement

Osmolarity

5iscosity

Combination

3estasis


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Dry Eye (anagementoderate to SevereSy!pto!s Signs present4 Abnormal tear )lm corneal

an! con?uncti#al staining

Essential atty aci!s 0E*A1 *la6see! oil 2y!roeyeL Topical anti-in:ammatory agents

Cyclosporine

" !ry mouth also present4 consi!er oralcholinergics Pilocarpine 0SalagenL1 Ce#imeline


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"$

3estasis

Dosing an! A!ministration Not Fas nee!e!G li/e tra!itional eye !rops

One !rop-each eye in morning M e#ening

5ials shoul! be !iscar!e! ater each use Two #ials per !ay are re+uire! an! thats

why its important or patients to recei#e$ trays or B !ays

Arti)cial tears may be use! orconcomitant relie 0no preservatives!uch ,etter 1+


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%&

3ESTAS"SL increases tear pro!uction

in some patients

"n pi#otal trials the use o 3ESTAS"SL

twice a !ay or = months 0$1 "ncrease! goblet cell !ensity

"ncrease! tear pro!uction

Decrease! corneal staining 3e!uce! reliance on arti)cial tears


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Dry Eye

Surgical (anagement Punctal occlusion

Plugs Cautery


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Thank You!Thank You!

Kimberly Cockerham, MD, FACSKimberly Cockerham, MD, FACS

www.CalEyes.com www.CalEyes.com

Los Altos –Come Visit !!!Los Altos –Come Visit !!!
http://www.caleyes.com/http://www.caleyes.com/http://www.caleyes.com/

DRY EYE EDUCATION

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