How Many People With · 2018-02-09 · Modern Management of Dry Eye February 17, 2018 Greg A....
Transcript of How Many People With · 2018-02-09 · Modern Management of Dry Eye February 17, 2018 Greg A....
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 1
Modern Management of Dry Eye Disease
Greg Caldwell OD, FAAOOptometric Education Consultants
February 17, 2018
Disclosure Statement(next slide)
Disclosures- Greg Caldwell, OD, FAAO
$ Will mention many products, instruments and companies during our discussion
¬ I don�t have any financial interest in any of these products, instruments or companies
$ Pennsylvania Optometric Association –President 2010
2 POA Board of Directors 2006-2011 $ American Optometric Association, Trustee 2013-2016
¬ Thank you to the members and those who join $ I never used or will use my volunteer positions to further my lecturing
career$ Lectured for: Shire, BioTissue, Optovue
$ Advisory Board: Allergan
$ Envolve: PA Medical Director, Credential Committee $ Optometric Education Consultants- Scottsdale and Quebec City, Owner
Course Description and Learning Objectives
Dry eye is a common yet under diagnosed cause of ocular morbidity such as decreased vision and ocular discomfort. This course will view the modern management of dry eye disease including pharmaceuticals, nutraceuticals, and devices. This case based presentation will aid in the diagnosis, treatment, and guidance around pitfalls.
$Review aqueous deficient and evaporative dry eye
$Review the diagnostic techniques to help diagnose aqueous deficient versus evaporative dry eye
$Discuss current and modern treatment of dry eye disease$Discuss current pharmaceutical and nutraceutical therapies
$Review the current devices available for the treatment of dry eye disease
How Many People With
$Diabetes$Thyroid
$Glaucoma$Dry Eye
Vital Dyes $ Fluorescein
¬ Detects disruption of intercellular junctions¬ Positive (stain)-pooling¬ Negative (stain)-high or elevated areas
$ Rose bengal and Lissamine green ¬ Stains devitalized cells and cells that have
lost normal mucin surface¬ Detects abnormal epithelial cells
Why is Conjunctival Staining and SPK Often Missed or Under Scored ?
Wratten Filter
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 2
Aqueous Deficient vs Evaporative
$What’s the common denominator?
$What’s the next question?
48 year old manOU red, gritty, sandy and dry feeling
Va 20 20 20cc 20
Current CorrectionR -2.00 sphereL -3.00 sphere
EOMS: full, unrestricted PERRL (-)APDCT: ortho D/N CF: full by FC OU
$Diagnosis¬ Rosacea
$What findings support your diagnosis?¬ Telangiectasias
¬ Erythema of the cheeks, forehead and nose
¬ Rhinophyma2 Indicates chronic
$Let us get a closer look
A Closer LookMeibomian Gland Dysfunction
Exacerbated by Rosacea Evaporative
$Treatment?¬ In my opinion, most under treated condition¬ Warm compresses¬ Lid hygiene
¬ Artificial tears¬ Omega 3 fatty acid
2 EPA and DHA total 1500 mg (1000 mg minimum) ¬ Dermatological consult (Acne Rosacea)¬ Oral antibiotics…???
2 Which one and why??
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 3
Minocycline
Leukotrienes
Arachidonic Acid
Staph AureusStaph Epidermidis Lipase
Meibomian Gland Secretions(Lipid)
ProstaglandinsThromboxines
Marginal Foam(Soap)
TurbidInspissated MG
How About Steroids?
Phospholipids
Tetracycline Analog Clinical PearlTreatment Failure
$If you continue to think of doxycycline and minocycline as antibiotics, treatment failure will be the result
$From this point on consider them a steroid
Minocycline / Doxycycline$Drug of choice for marginal inflammatory
blepharitis (posterior blepharitis)$AB, anti-inflammatory and anti-collagenase$Inhibits lipase enzyme
$No renal adjustment$50-100 mg qd-bid 2-12 weeks (pulse)
¬Lower maintenance dose
$20 mg Periostat (Doxycycline)¬Helpful in those with stomach or GI sensitivity¬Excellent for those requiring long maintenance dose
My Paradigm for Minocycline / Doxycycline
$Status of MG
¬Inspissated
¬Turbid
¬Clear
$Minocycline / Doxycycline Paradigm
¬Maximum dosage for 2-12 weeks (pulse)2 100 mg BID, QD
¬50-100mg qd while turbid¬20 mg longer treatments
2 Periostat (Doxycycline)
¬20 mg if maintenance dose needed
Precautions With Oral Tetracycline Analogs
$ Enhanced photosensitivity$ Avoid in children and pregnancy
(Category D)$ Can enhance Coumadin$ Can enhance the action of digoxin$ ?Long term use with increase risk
of breast cancer?¬ 1 paper/study, not regarded as
highly reliable study¬ Further investigation discredited
the association$ Benign intracranial hypertension,
reported cases¬ 17 cases from 1978-2002
Benign intracranial hypertension�It�s not rare if it�s in your chair�
8-19-2010
8-31-2010
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 4
9-13-2010
10-6-2010
8-19-2010
Successfully Treated
$ Warm Compresses
$ Lid Scrubs$ Artificial Tears, Systane Balance
$ Omega 3 (1500 EPA and DHA)
$ Mino 100 mg PO 6 weeks, 50 mg 3 months, 20 mg maintenance (Doxy)
$ Steroids, Tobradex qid (5 weeks with taper)¬ Moderately red and thickened lid margins¬ Marginal infiltrates
What is an Inspissated MG? I Can�t Believe It�s Not Butter!® Squeeze
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 5
6 Month Later 1 Year Later
What Has Changed?
Bruder Moist Heat Eye Compress
Bruder Moist Heat Eye Compress
$ Moist heat treatment ¬ Stabilize the tear film, improve oil gland function, slow tear evaporation
$ Ready in seconds, easy to use¬ Patient compliance increases
$ Patented MediBeads¬ Self-hydrating (no need to add water)¬ Anti-bacterial and non-allergenic¬ Washable and reusable
$ Safe for frequent use ¬ Microwave for 20-25 seconds ¬ Apply for 10 minutes
$ Unique pod design provides improved fit and performance
Dry Eye Relief andDaily Eyelid Hygiene
Micro-fine sheets are designed to cleanse the eyelids
Bruder Cold Therapy Eye Compress
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 6
XiidraWhat Have I Learned?
$How many did you write before you called failure?$Only pharmaceutical indicated for the signs and
symptoms of dry eye¬ Prior authorizations
2 CoverMyMeds
2 ParRx
$BID means 11-12 hours apart
$It’s safe, safe, safe… 5-25% report site irritation, blurred vision, or dysgeusia¬ Tell the patients they may taste it
$Use it as a diagnostic
XiidraWhat Have I Learned?
$Restasis when prescribed- how long until you see improvement?
$Xiidra¬ 2 weeks- symptom relief in moderate patient¬ 6 weeks- symptom relief in mild patient
¬ 12 weeks/3months- cornea improvement
$Restasis or Xiidra?
$Use on GPC patient with steroid (Lotemax gel)¬ Then as maintenance
$Seasonal allergic conjunctivitis patient¬ ”need something for 2-3 weeks in spring and fall”
$Superior Limbic Keratoconjunctivitis (SLK)$Rheumatology patients (RA, SLE, Mixed Connective…)
$After cataract surgery patients usually will complain of what at that 2-3 month post-op?
$Use if thinking a specialty IOL, discussing IOL and refractive outcome, monovision
$Take advantage of the free 30 day trial and $10 refill
XiidraWhat Have I Learned?
Nutraceutical Therapies in Dry Eye
$Looking for anti-inflammatory fatty acids¬ Dry eye efficacy
$”Fish oil” will provide nice hair, nails, and skin$Gamma-Linolenic Acid GLA
¬ Specific action that ”fish oil” omegas lack
¬ 7 randomized controlled trials for dry eye2 Aqueous-deficient (Barabino S et al. Cornea 22: 97–101, 2003.)2 PRK (Macri A et al. Graefes Arch Clin Exp Ophthalmol 241:561-6, 2003.)2 Sjögren's (Aragona P, et al. Ophthalmol Vis Sci 46:4474-9, 2005.)
2 Contact lens (Kokke KH et al. Contact Lens Ant. Eye 31:141-6, 2008.) 2 MGD (Pinna et al. Cornea 26:260-264, 2007.)2 Mild-moderate DE (Brignole-Baudouin et al. Acta Ophthalmologica 89:e591-7, 2007.)2 Post-menopausal women (HydroEye) (Sheppard JD, Pflugfelder SC, et al. Cornea 32
:1297-1304, 2013.)
$Prostaglandins¬ Myth buster- they are not all bad
$Prostaglandin E1 (PGE 1) -good¬ Shown to stimulate lacrimal production (Phalpramool, 1980, 1983)
¬ Supports mucin production 2 Conjunctiva, other membranes (Viau, 2009, Willemsen, 2003, Nygren, 1984)
¬ Experimental deprivation of vitamin C a required cofactor for PGE 1 2 Stops lacrimal production, produces Sjögren's-like signs & symptoms Wood,
1970
¬ Precursor GLA
$Prostaglandin E2 (PGE 2) – bad¬ Precursor AA
$Prostaglandin E3 (PGE 3)- good¬ Precursor Omega-3 “fish oil”
Nutraceutical TherapiesAnti-inflammatory Fatty Acids
EssentialFatty Acids
Delta-6desaturase
Elongase Delta-5Desaturase
COX
18:2w3Alpha linolenic
(ALA)
18:4w3SDA
20:4w3ETA
20:5w3
EPA
20:6w3DHA
Omega-618:2w6
Linoleic Acid (LA)
20:3w6DGLA
20:4w6Arachidonic
Acid
Series 2 (“bad”)Prostaglandins
Series 1 (“good”)Prostaglandins
Omega-3
(Parent)
(Parent)
Rate-Limiting
Delta
-4 D
esat
uras
e
18:3w6
GLA
Series 3 (“good”)Prostaglandins, LTB5, Resolvin E1
Series 1 (“good”)Prostaglandins
EPA & GLAare powerhouses of omegas – they are
effective precursors of anti-inflammatory
compounds(DHA is also precursor to a protectin, NPD1 – though no dry
eye role for NPD1 is established)
20:5w3
EPASeries 3 (“good”)Prostaglandins, LTB5, Resolvin E1
20:3w6DGLA
Series 1 (“good”)Prostaglandins15-HETE-rE
18:3w6
GLA
©2016, Zac Denning, ScienceBased Health, [email protected]
Omegas that are common in our diet (ALA from O-3
family, LA from O-6 family) are inefficiently
used, don’t directly affect inflammation
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 7
EssentialFatty Acids
Delta-6desaturase
Elongase Delta-5Desaturase
COX
18:2w3Alpha linolenic
(ALA)
18:4w3SDA
20:4w3ETA
20:5w3
EPA
20:6w3DHA
Omega-618:2w6
Linoleic Acid (LA)
20:3w6DGLA
20:4w6Arachidonic
Acid
Series 2 (“bad”)Prostaglandins
Series 1 (“good”)Prostaglandins
Omega-3
(Parent)
(Parent)
Rate-Limiting
Delta
-4 D
esat
uras
e
18:3w6
GLA
Series 3 (“good”)Prostaglandins, LTB5, Resolvin E1
Series 1 (“good”)Prostaglandins
Anti-inflammatory Fatty Acids
But GLA is an omega-6 …What about the pro-inflammatory aspects
of the omega-6s?
20:4w6Arachidonic
Acid
Series 2 (“bad”)Prostaglandins
©2016, Zac Denning, ScienceBased Health, [email protected]
American diet offers gross excess of arachidonic acid (e.g. from meat / dairy). Very little via conversion from other omega-6s.
EssentialFatty Acids
Delta-6desaturase
Elongase Delta-5Desaturase
COX
18:2w3Alpha linolenic
(ALA)
18:4w3SDA
20:4w3ETA
20:5w3
EPA
20:6w3DHA
Omega-618:2w6
Linoleic Acid (LA)
20:3w6DGLA
20:4w6Arachidonic
Acid
Series 2 (“bad”)Prostaglandins
Series 1 (“good”)Prostaglandins
Omega-3
(Parent)
(Parent)
Rate-Limiting
Delta
-4 D
esat
uras
e
18:3w6
GLA
Series 3 (“good”)Prostaglandins, LTB5, Resolvin E1
Series 1 (“good”)Prostaglandins
Anti-inflammatory Fatty Acids
20:4w6Arachidonic
Acid
Series 2 (“bad”)Prostaglandins
20:5w3
EPA
EPA blocks this step
1) GLA heavily favors the anti-inflammatory
pathway
2) As back up1, adding EPA to GLA in proper
balance, blocks production of pro-
inflammatory pathway
20:3w6DGLA
18:3w6
GLA
Reference: 1. Barham et al. 2000.
©2016, Zac Denning, ScienceBased Health, [email protected]
EssentialFatty Acids
Delta-6desaturase
Elongase Delta-5Desaturase
COX
18:2w3Alpha linolenic
(ALA)
18:4w3SDA
20:4w3ETA
20:5w3
EPA
20:6w3DHA
Omega-618:2w6
Linoleic Acid (LA)
20:3w6DGLA
20:4w6Arachidonic
Acid
Series 2 (“bad”)Prostaglandins
Series 1 (“good”)Prostaglandins
Omega-3
(Parent)
(Parent)
Rate-Limiting
Delta
-4 D
esat
uras
e
18:3w6
GLA
Series 3 (“good”)Prostaglandins, LTB5, Resolvin E1
Series 1 (“good”)Prostaglandins
Anti-inflammatory Fatty Acids
This combo has added benefit of
delivering a 2 prong attack on
inflammation
20:5w3
EPA
20:3w6DGLA
Series 1 (“good”)Prostaglandins15-HETE-rE
18:3w6
GLA
Series 3 (“good”)Prostaglandins, LTB5, Resolvin E1
©2016, Zac Denning, ScienceBased Health, [email protected]
Gamma-Linolenic Acid GLA$Consistently shown improvement in markers of inflammation /
inflammatory mediators in dry eye$Shown promise in other inflammatory diseases, like
rheumatoid arthritis, IBD, dermatitis, and diabetic retinopathy$In Sjögren's increases tear production, raises PGE1 in tears
(Aragona, 2005)
$Supports meibomian glands ((Pinna, 2007)
¬ Probably through anti-inflammatory action
$2,000-3,000 mg omega-3s usually required to have significant effect¬ In contrast 235 mg of GLA significantly reduced 2 different
inflammatory markers (HLA-DR, CD11c) in the HydroEye trial (Sheppard, Pflugfelder, Whitley et al. Cornea, 2013)
$ Aren’t all Omega-6s Bad?
¬ Most assume omega-6 are bad / pro-inflammatory¬ Most people have also heard that we get too much omega-6 in our
diet and that we need more omega-3 ¬ The aka Omega-6 / omega-3 ratios
¬ This is based on studies that use dietary info – and therefore this info applies only to dietary omegas
$ GLA is not a dietary omega¬ except at trace levels
¬ It’s not valid to apply dietary info to GLA
$ GLA is a potent anti-inflammatory omega¬ Like EPA/DHA in the omega-3 family¬ Backed by a number of dry eye clinical trials
$ GLA has a unique dry eye specific action
Gamma-Linolenic Acid GLA Is GLA offered in the triglyceride (TG) form? aka “re-esterified”
$These forms of omegas triglyceride (TG) vs ethyl ester (EE) mainly apply only to fish oils
$ Fish oil when it’s purified is transformed from the natural TG form in fish to the EE form¬ Which allows the omegas to be concentrated & purified
$ Fish oil companies have heavily marketed re-esterified or TG fish oils as vastly more absorbable and bioavailable
$ GLA only comes as TG form¬ No other form
¬ TG vs EE discussion is purely about different fish oils
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 8
$Pick the right nutraceutical not “fish oil” ad get:¬ Improvement in irritation symptoms
¬ Better cornea smoothness¬ Significantly lower levels of inflammatory markers
Nutraceutical Therapies Amniotic Membrane
$To help reset the eye from a stage 3-4 back to something manageable
$Failure on multiple therapies$Sjogren’s and the rheumatological patient
Dry Eye and Amniotic Membrane
In-Office Lab Testing
In-Office Lab Testing
$Helps with:¬ Switching patient to dailies
¬ Starting nutraceuticals¬ Starting pharmaceuticals
¬ Following patients over time
TearLab Osmolarity Test
Modern Management of Dry Eye February 17, 2018
Greg A. Caldwell, OD, FAAO [email protected] 814-931-2030 cell 9
InflammaDry®InflammaDry®
For inflammatory dry eye detection
Normal levels of MMP-9 in human tears ranges from 3-41 ng/ml
NEGATIVE TEST RESULT
MMP-9 < 40 ng/ml
POSITIVE TEST RESULTMMP-9 ≥ 40 ng/ml
InflammaDry Sjö Diagnostic Test
$Uses proprietary biomarkers to create an advanced diagnostic panel
$ Early detection of Sjögren’s syndrome in your patients
Thank-Youand
Hope You Enjoyed
Greg Caldwell, OD, [email protected]