Post on 06-Mar-2016
description
Evidence Based Approach
Dry Eye
Meibomian Gland Dysfunction
Copenhagen 2012
Teifi James
MBBS DO FRCP FRCS FRCOphth
Consultant Ophthalmologist
Calderdale Royal Hospital
MGD — Symptoms
Declaration • Fees, Hospitality & expenses from
• Boots
• Allergan
• Specsavers
• EyeCare 3000
• Spectrum Thea
• Bausch & Lomb
• CIBA / Alcon / Novartis
• Rotho / Mentholatum / Sooft
• The EyeBag Company — patent and majority shareholding
Moll secretions
anterior to MGOs
Sjøgrens
Evaporative
The Dry Eye Pyramid - circa 20 million in UK Intrinsic
Meibomian Gland Dysfunction Lid Aperture disorders – eg GO Low blink rate – eg Parkinson's Drug action Ro-accutane effect on Meibomian Glands
Extrinsic
Vitamin A deficiency
Preservatives in Topical eye treatments
Contact lens wear
Ocular Surface Disease
Post Corneal / laser surgery
HES
Millions with dry eye
Dry Eye
• Lacrimal gland dysfunction, Sjogrens -
rare
• Evaporative dry eye very common
• MGD is the major cause of ‘Dry Eye’.
Onions
Tears?
MGD
Meibomian seborrhoea
MGD pseudo-
blisters with
capped
orifices
Transient blurred vision — Common in MGD
Blob of lipid in the tear film
Loss of lipid barrier
Loss of lid margin hydrophobicity
Macerated lid margin – water wettable
TFOS MGD Report
• Definition / Classification
• Anatomy, Physiology, Pathophysiology
• Tear Film Lipids & Lipid-Protein interactions
• Epidemiology & Risk Factors
• Diagnosis
• Management and Treatment
• Clinical Trials
MGD — Aetiology
• “Not clear”
• “More research required”
MGD is
The key underlying feature
of…
Dry Eye
Post Laser Ocular Dryness
Contact Lens Associated Dry Eye
Blepharitis
Chalazion
Stye
MGD
• Tear film has poor quality lipid layer
• Break Up Time is short.
• Strategies to restore it.
• Diagnosis is self-evident.
• Champagne bubbles on lid edge.
• Blepharitis & evaporative dry eye.
Temperature Dependent Phase Change
Lipid composition alters melting point
Unsaturated FAs — Increasing Saturation — Wax Esters
Omega 3 •Oily fish +++
•zero butter, red
meats
•or take a
supplement
•Lagad Lacrima
Omega 3
• GLA (Gamma Linolenic Acid)
• Anti-inflammatory Nutrient
• EPA (Eicosapentaenoic Acid)
• Omega 3 Anti-inflammatory Nutrient
Lipid chemistry
Meibum is a complex soup of variable lipids and lipid
derivatives. The melting point varies according to the exact
composition.
Properties of fatty acids and their derivative lipids depend on
chain length and being unsaturated
Unsaturated FAs have a lower melting point than saturated
FAs of same length
e.g.
C18 – Stearate ( zero double bonds) melts at 69.6ºC
C18 – Oleate ( one cis double bond) melts at 13.4ºC
Meibomian gland dysfunction and ocular
discomfort in video display terminal workers C Fenga1, P Aragona2, A Cacciola1, R Spinella2, C Di Nola1, F Ferreri2
and L Rania2 Eye (2008) 22, 91–95; doi:10.1038/sj.eye.6703025; published online 26 October 2007
• Results
• A total of 52 subjects out of 70 (74.3%) had MGD.
• A statistically significant correlation between the symptoms of ocular
discomfort and hours spent on VDT work was observed in the total
population (r=0.358; P=0.002; 95% CI 0.13–0.54) and in the group of
subjects with MGD (r=0.365; P=0.009; 95% CI 0.103–0.58). Such
correlation was not shown in subjects without MGD.
• Conclusions
• The high prevalence of MGD among the subjects with symptoms of ocular
discomfort suggests that this diagnosis should be considered when
occupational health practitioners encounter ocular complaints among VDT
operators. It appears that MGD can contribute to the development of
ocular discomfort in VDT operators.
Jackson Brown — Doctor my Eyes
3 blinks - 2 people
4 blinks - 4 people
118 Opticians
0 - 16
1 - 15
2 - 14
The near response...
• Convergence
• Miosis
• Accommodation
• ? Decreased blink rate
??
The 20-20-20-20 rule
&
Return / blink button
&
Gamers lose a life
or progress to next level
?
Melts at 39º C
Are you a squeezer?
Clinical Handbooks Moorfields Wills
Heat Wet Flannel
5mins od / bd
Warm
compresses
15 mins qid
Antibiotics Doxy 100mgs
od for 8/52
Tet 250 qid
for 6/52
Lubricants prn 4 to 8 x a day
The ideal warm
compress
• Must raise lid temperture above 39º C
• Stay above 39º C for a while
• Good compliance (nice and easy to
use)
• Affordable (inexpensive)
• No adverse effects
Blephasteam®
84
Temperature changes of the external and
internal eyelids using the MGDRx EyeBag
Paramdeep S Bilkhu, BSc (Hons) MCOptom. N,
Shehzad A Naroo, BSc (Hons) MSc PhD MCOptom FIACLE FAAO FBCLA
James S Wolffsohn, BSc (Hons) MBA PhD FSB MCOptom FAAO FBCLA
Aston University, Birmingham, UK
Corresponding Author: bilkhups@aston.ac.uk
Conclusions: Paramdeep Bilkhu et al
The MGDRx EyeBag does produce an increase in
external and internal eyelid temperature.
Based on the results, either surface of the MGDRx
EyeBag can be used but 5 minutes application
using the silk surface demonstrates greater
increases of eyelid temperature necessary for
optimal heating
Hot Compress
Survey
125 responses
Tear replacement!
Topical lubricant drops and gels • 4 million UK scripts annually for
Hypromellose
• Hyaluronate
• Polyvinyl alcohol
• Carbomer
• Guar
• Micelle mist / sprays
• Mucin mimetic agents
• Autologous Serum
£39.10 per 100 mls £30 per 100 mls
Generic Hypromellose 10 mls £ 2.99 from Amazon
No Recipe for hot spoon treatment!
Thank You