Dry eye management ppt
- 2. Chairman : Dr. Md. Saifullah Professor & Head Of Department Of Cornea, NIO&H Moderator : Dr. Farhat Jahan Assistant professor, Department Of Cornea, NIO&H Presenter : Dr. Navid Rahman DO resident, NIO&H
- 3. Definition A multifactorial disease of tears and ocular surface that results in symptoms of discomfort,visual disturbence and tear film instability with potential damage of oculer surface.
- 4. DRY EYE -INFLAMMATION MODEL
- 5. Dry eye etiology Tear deficient Sjogrens Non-sjogrens Lacrimal deficiency Lacrimal obctruction Reflex hyposecretion Evaporative Oil deficient Lid related Contact lens Surface change
- 6. Influential Factors of Dry Eye • Age • Gender • Arthritis • Gout • Lens Surgery • Contact Lens wear • Nutritional problem • Rheumatoid arthritis • Thyroid problem • Time of day • Blink disorder • Disorder of lid aperture
- 7. • LASIK Surgery • Cosmetic Surgery • Mechanical Disturbence • Exposure keratitis • Ectropion • Entropion • Symblepheron formation • Large lid notches • Lagophthalmos • Incomplete blinkig • Dellen formation • Illumination
- 8. Cont.. • Temperature • Humidity • Air movement • Allergies • Change in environment • Reading • Long time working on computer screen,watching movies • Sleep Prause JU, Norn M. Relation Between Blink Frequency and Break-Up Time. Acta Ophthalmol. 1983 61: 108-116. Cho P, Cheung P, Leung K, Ma V, Lee V. Effect of Reading on Non-Invasive Tear Break-Up Time and Inter-Blink Interval. Clin. Exp. Optom. 1997 80: 62-8. Tsubota K, Seiichiro H, Okusawa Y, Egami F, Ohtsuki T, Nakamori K. Quantitative Videographic Analysis of Blinking in Normal Subjects and Patients with Dry Eye. Arch. Ophthalmol. 1996 114(6): 715-720. Nally L, Ousler GW, Abelson MB. Ocular discomfort and tear film break-up time in dry eye patients: a correlation. IOVS 2000 41(4): 1436. Collins M, Seeto R, Campbell L, Ross M. Blinking and Corneal Sensitivity. Acta Ophthalmologica 1989 67(5): 525-531. Abelson MB, Holly FJ. A tentative mechanism for inferior punctate keratopathy. Am. J. Ophthalmol. 1977 83: 866-869. Doane MG. Dynamics of the Human Blink. Ber. Disch. Ophthalmol. Ges. 1980 77: 13-17. Kaneko K, Sakamoto K. Spontaneous Blinks as a Criterion of Visual Fatigue During Prolonged Work on Visual Display Terminals. Perceptual and Motor Skills 2001 92(1): 234-250.
- 9. Conditons associated with Dry eye • Chronic systemic inflammation: Sjogren's syndrome,Rhematoid arthritis,lupus • Ocular surface inflammation: Meibomian gland dysfunction,keratitis,inflammation,Blepharitis • Hormonal change: Menopause,OCP,prenancy • Systemic disease: DM,Thyroid dysfunction • Steven Johnson's syndrome:severe dry eye
- 10. Cont.. • Environmental factors: Smoke,Air pollution,Air conditioning,Air travelling,Light,Dry climet • Blink disorder • Medications: Systemic Topical Anti-depressants decongestants Antihistamines preservatives Antihypertensives anesthetics diuretics B-blocker Antimuscarinics anesthesia phenothiazines Atropine oral contraceptives anxiolytics antiparkinsonian Anticholinergics antiarrhythmics isotretinoin
- 11. Dry eye is not a disease, it is a complex multifactorial disorder. It is an iceberg phenomena...
- 12. Goals of Management • Alleviate symptoms • Reduce ocular morbidity • Prevent complications • Improve quality of life • Improve productivity • Maximise benifit&relief • Minimise cost
- 13. Consultations Apart from Ophthalmologists... consultations may be needed from- Rheumatologists Internist & Dermatologists
- 15. Treatment Strategy Intervention Tear supplementation Lubricants Tear retention • Punctal occlusion • Moisture chamber spectacles •Contact lenses Tear stimulation Secretagogues Biologic tear substitutes • Serum • Salivary gland transplantation Anti-inflammatory therapy •Cyclosporine • Corticosteroids • Tetracyclines Essential fatty acids Omega-3 fatty acids Environmental strategies • Avoid low humidity • Avoid drafts • VDTlowered below eye level
- 16. Treatment is based on severity of disease
- 17. According to Intenational Dry Eye workshop(2007): Dry Eye Severity Leveled as 1,2,3,4;where Level 4 being most severe point. Severity level based upon these 9 conditions- 1.Discomfort,Severity&frequency 2.Visual symptoms 3.Conjunctival injection 4.Conjunctival staining 5.Conjunctival staining(severity/location)
- 18. 6.Corneal/Tear sign 7.Lid/meibomian gland condition 8.Tear film break up time(TUBT) 9.Schirmer score(mm/5min)
- 19. 1.Discomfort,Severity &frequency: 1 2 3 4 Mild and/or episodic,occur s under environmental stress Moderate episodic or chronic,Stress or no stress Severe frequent or constant without stress Severe and/or disabling &constant
- 20. 2.Visual symptoms: 1 2 3 4 None or episodic mild fatigue Annoying and/or activity limiting episodic Annoying,chr- onic and/or constant,limiti ng activity Constant and/or possibly disabling
- 21. 3.Conjunctival injection: 4.Conjunctival Staining: 1 2 3 4 None to mild None to mild +/_ +/++ 1 2 3 4 None to Mild Variable Moderate to marked Marked
- 22. 5.Conjunctival staining(severity/Location): 6.Corneal/Tear signs: 1 2 3 4 None to Mild Variable Marked central Severe punctate erosions 1 2 3 4 none to mild Mild debris,↓meni -scus Filamentary keratitis,mucus clumping,↑Tear debries Level 3+ulceratiion
- 23. 7.Lid/Meibomian glands: 8.TUBT(Sec.): 1 2 3 4 MGD variably present MGD variably present Frequent Trichiasis,Sy mblepheron, Keratinizatio n 1 2 3 4 Variable ≤10 ≤5 Immidiate
- 24. 9.Shirmer score(mm/5min): 1 2 3 4 Variable ≤10 ≤5 ≤2
- 25. Recomended treatment(AAO): Mild • Artificial tear with preservative upto 4X daily. • Lubricating ointment at bed time • Hot compresses and eye lid massage Moderate • Artificial tear without preservatives upto 4x daily to hourly. • Lubricating ointment at bed time. • Topical anti inflammatory treatment(closporin A) • Reversible lower punctul occlusion with plugs. Severe • All of the above • Punctul occlusion(lower &upper) • Topical serum drops4- 6x daily. • Topical corticosteroids • Moist environment(Humidifier, moisture shields) • Tarsorrhaphy(lateral&m edial)
- 26. Qualities of an ideal Dry eye product • Ability to spread evenly over the cornea quickly and efficiently. • Prolonged retention time for extened efficecy • Objective and subjective improvement in patient symptoms and signs *Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocular Surface 2007;5:165.
- 27. Anatomy of Artificial Tear
- 28. Varieties of Artificial TearsLubricants • Hydroxypropyl Methylcellulose • Hydroxypropyl cellulose • Hyaluronic acid • Carboxy Methylcellulose • Polyvinyl alcohol • Dextran • Glycerin • Eye Gels(Vit.A palmitate) • Polyethelyene Glycol:systane • Sodium Hyaluronates 0.1-0.3% • Povidon iodine
- 29. HYALUB (Sodium Hyaluronate 0.1%) • Lubricating,protecting • Powerful wetting agent • Long lasting • Reduced Ocular surface damage • Accelerate wound healing • Safe,well tolerated for long term use • Non preservative
- 30. SURGICAL OPTION Reserved for severe disease poor/non- complience. • Punctal plug • Surgical/Thermal/LASER occlusion. ADVANTAGES- • Prolong tear retention. • Reduces frequency of artificial tears needed for symptomatic relief.
- 31. Punctul Plugs •Absorbable: -Made of collagen or polymer. -Occlusion duration ranges from 7- 180 days. -plugs dissolve by themselves or may be removed by salaine irrigation. •Non-absorbable: -Made of silicon -punctum plugs & Intracanalicular plugs(Cylindrecal smartplug)
- 32. Complications of plug • Too far insertion,unable to retrieve • Spontaneous loss into the canaliculus • Canalicular or NLD obstruction • Extrusion of plug • Scarring of punctum • Ocular surface irritation,epiphora • Papillomatous overgrowth of exubarent conjunctiva • Retains inflammatory mediator • Infection/discomfort • Costly
- 33. Surgical tretment • Parotid duct translocation: -Salivary gland may be affected in Sjogren syndrome. -Frequently secrete more fluid,increases during eating. • Tarsorrhaphy: -Narrowing of palpebral fissure reduces the rate of evaporation.
- 34. Evaporative Dry Eye Disease Meibomian Gland dysfunction(MGD)
- 35. Treatment is based on Staging of MGD
- 36. According to The International Workshop on MGD -Clinical summery of the MGD staging used to GUIDE treatment: Stage 1: MGD Grade Symptoms Corneal staining +Minimally altered expressibility & secretion quality None None
- 37. Stage 2: Stage 3: MGD Grade Symptoms Corneal staining ++Mildly altered expressibility and secretion quality Minimal to mild None to limited MGD Grade Symptoms Corneal staining +++Moderately altered epressibility & secretion quality Moderate Mild to moderate mainly peripheral
- 38. Stage 4: “Plus disease”: Coexisting or accompanying disorders of the ocular surface and/or eyelids. MGD Grading Symptoms Corneal staining ++++ severely altered expressibility & secretion quality Marked Marked ;central in addition
- 39. Treatment Stage 1: -Patient education about • MGD • Potential impact of diet & the effect of work/home environment on tear evaporation • Possible drying effect of certain systemic medication -Consider eyelid hygiene including Warming/expression. Stage 2: -Advise of improving • Ambient humidity • Optimizing Workstations • Increasing dietary omega-3 fatty acid intake(±)
- 40. -Institute eyelid hygiene with eylid warming. -All the above,plus • Artificial tear • Topical Azithromycin • Topical emmolient lubricant or liposomal sprey • Consider oral tetracycline derivetives. Stage 3: -All the above,plus • Oral tetracyclin derivetives(+) • Lubricant ointment at bedtime • Anti inflammatory therapy for dry eye.(±)
- 41. Stage 4: -all of the above plus -anti inflammatory therapy for dry eye(+) Plus disease: -Pulsed soft steroid -Bandage contact lens/scleral contact lens -Steroid therapy -Epilation,cryotherapy -Interlesional seroid or excision. -Topical antibiotic or antibiotic&steroid combination -Tea tree oil scrub
- 42. So,What's the Modern Technology in MGD LIPIFLOW A device having an insulated conformer that heats the inner surface of the lids. an inflatable pad applies a pulsatile pressure to the glands through the tarsal plate.
- 44. Intense Pulsed Light Therapy
- 45. Future casual therapy • Cyclosporine A0.05% drops in moderate and severe ocular surface inflammation • Essential Fatty acids Omega-3 in ocular surface irritation. • Secration stimulation,Mucin stabilizera(Sulglycotide),Mucolytic agents,local androgenic complexes. • Systemic immunomodulator/immunosupressive in severe cases. • Topical antiCD-4 monoclonal antibody to supress the activation of CD4+ T cells.
- 47. Carry Home Messsage • Symptoms & Signs don't always catch up with other in case of Dry Eye Disease,so- Do not miss subtle clinical conditions. • Methodical approach to Diagnosis. • Loads of conditions,Lots of options;so,careful plannig for treatment outline is must. • Irrespective of cause of dry eye- Immunomodulation+tear replacement. • All available options are only Symptom reliever,none of them curative. • Educate the patient & family members about the dillemas in management.
- 48. Thank you