6/3/2019

1

Ocular Surface Disease Prevention:

Shifting Spectrum

Paradigms and Protocols

Michael S. Cooper, OD

Solinsky EyeCare

West Hartford, CT

coopadre@gmail.com

Disclosures

• The content of this presentation was prepared

independently by Michael Cooper, OD without input from

members of the ophthalmic community.

• Dr. Cooper is affiliated with Allergan, Alcon Surgical,

BioTissue, Shire, JJVC, TearScience, Glaukos, Bausch +

Lomb/Valeant, Mentholatum, and TearLab as a

consultant/speaker in the past 12 months.

• There is no direct financial or proprietary interest in any

companies, products or services mentioned in this

presentation.

• The content and format of this course is presented without

commercial bias and does not claim superiority of any

commercial product or service.

2

Live and Let Die? Glaucoma Analogous

Testing

• Structure + Function of the Meibomian

Glands and ocular surface

Multiple testing:

• IOP/ORA = Osmolarity

• VF = Corneal staining

• Gonioscopy = TBUT/Tear Meniscus

• OCT = Meibomography/LipiView/Meibox

• ONH examination = Meibomian Gland

expression 4

The Dental Transformation

The Dental Model

– It works

– Patients understand it easily

Efficient Analogies:

• Tooth Brush = Warm compress

• Floss = Lid Massage and lid hygiene products

• Scaling = Debridement of keratin with Golf Club Spud

• Dental cleaning = Mechanical pulsation or cleaning

– LipiFlow, MiBo, BlephEx etc.

• Dental X-rays = Meibography/LipiView/Meibox

5

How Do We Change?

• Alter the terminology:

Ophthalmic Tech = Ocular Hygienist

• Empower staff to actively educate

• Embrace technology to bring you

into the patient’s virtual home

(Telemedicine/AI)

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2

Monday Morning…

Let’s fill this in later!

Some Hints!

The 1-2-3 Rules for Identifying, Diagnosing, &

Treating.

• Rule #1: Similar to the subjective 20/20, never

underestimate the patient’s level of discomfort.

• Rule #2: Use that noodle and sleuth in office

clues.

• Rule #3: Create a protocol and invest in 1 Point

of Care test that you will use consistently as a

metric. 8

Case #1: Museum Stroll

• 35 year old Caucasian male

– presents on an emergency basis for recurrent

sticky lids in the morning and increased

dryness at night.

– The patient is rather concerned since it has

affected his communication skills with clients

as he is constantly hard blinking to both see

and “prevent” excessive watering.

– He is currently being treated with a variety of

systemic and topical medications.

Rapid Fire!

i) What other questions would you ask?

ii) Are we the only providers he has seen?

iii) What ophthalmological information is

pertinent to collect?

iv) How would you manage and treat this

patient?

Stats

• VAcc: 20/40 OD, 20/30 OS

• TBUT: 2 OU

• 1+ SPK confined mostly inf OU

• Tr-1+ Lissamine stain, +ULMS

• Tear Meniscus= .2 OU

• TearLab: 305 OD, 316 OS

• InflammaDry: Moderate Pink OU

• What about his lids????

Floppy Eyelid Syndrome

• Rubbery lids

• Papillary Conjunctivitis

• Chronic irritation worse in the morning

• Obese patient

• Eyelash ptosis with loss of parrallelism

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3

Management & Tx

• Beauty Mask for overnight wear

• Lubrication (Pick your favorite)

• Steroid (In this case, Lotemax Gel tid OU)

– 2 weeks with a modified taper

• Plugs (Lacrisolve 180 Absorbable)

• Omega 3’s

• RTC for Scleral CL Fit w/ OD colleague

**Patient advised on seeking nutrition

counselor to help balance work/life

Outcome

• VA w/ Sclerals: 20/25 OD/OS/OU

• Rare SPK OU

• TBUT: 7 OU; tear meniscus= .35 OU

• Patient lost 40 lbs in 5 months due

to change in dietary/sleep habits

• Better lid apposition, reduced floppy

nature

Plugs, Goggles, and

Masks

• Plugs – Silicone Permanent

– Collagen 3 to 180 days

• Moisture Goggles – Customizable

• Masks – Bruder

– Rhein Medical

15

The Cost of Non-adherence

• In the United States, avoidable healthcare costs add up to $213 billion, of which $105 billion is due to medication non-adherence, according to the Express Scripts 2013 Drug Trend Report.

• Non-adherence causes 30-50 percent of treatment failures and 125,000 deaths annually.1

• Medications are not continued as prescribed in about 50 percent of cases, according to a 2013 Centers for Disease Control and Prevention (CDC) presentation.

• Nearly 50 percent of Americans have one or more chronic conditions that require prescription medications, according to the CDC.

• Medication adherence is higher among patients who see the same healthcare provider each time they have a medical appointment. In this group, the average adherence is 81 percent, according to "Medication Adherence in America: A National Report Card," a recent report from the National Community Pharmacists Association.

16 1Smith D, Compliance Packaging; a patient education tool, American Pharmacy, Vol. NS29, No 2, February 1989.

http://www.fda.gov/Drugs/ResourcesForYou/HealthProfessionals/ucm470165.htm

So, What is Dry Eye Disease?

• Dry eye is a multifactorial disease of the tears

and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface

The Ocular Surface / April 2007, Vol. 5, No. 2 / www.theocularsurface.com (DEWS I)

17

Dry Eye Disease: DEWS II

• “Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.”

ARVO 2017 Baltimore Special Session, Dr. Jennifer P. Craig, the Workshop Vice-Chair 18

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Inflammation in Dry Eye

19

Healthy tear film Dry eye

Pro-inflammatory Mediators in tears are the

the main actors of DED-related events

Two Types of Dry Eye

• Aqueous Deficient dry eye is a disorder in which the lacrimal glands fail to produce enough of the watery component of tears to maintain a healthy eye surface

• Evaporative dry eye may result from inflammation of the meibomian glands. These glands make the lipid of tears that slows evaporation and keeps the tears stable

*The National Eye Institute (NEI)

20

Or is it 3 Types?

• Between signs and symptoms, there are both literature and clinical experience suggesting the 2 recognized types are blended in many cases.

• In my practice, we make our best effort to label the cases with a support reason(s) for DED

– ie. Aqueous Deficient Dry Eye OU due to Medication

(Beta Blocker/SSRI/Antihistamines)

– ie. Evaporative Dry Eye OU due to Blepharitis/MGD

– ie. Aqueous Deficient/Evaporative Dry Eye OU due to early menopause/Blepharitis/MGD/CChal

21

What if there was a 4th

Type?

Inflammation…… Chronic Pain

22

Substance P (SP)

23

• Is present in the

cornea in

physiologically

relevant

concentrations

• Its is a 11 amino acids

peptide generally

associated with

intense, persistent, or

chronic pain.

Substance P (SP) positive nerve fibers

Dry Eye is a Chronic Pain

Disorder

24

CGRP positive nerve fibers in the subbasal plexus

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Lids and Tear Chemistry

• Play a significant role in clinical

decisions

• Similar to IOP measurements,

create a consistent paradigm you

will do on each visit

– Point of Care Diagnostic

– Imaging

Meibox Imagery

Keratograph Imagery

Visiometrics

Tear Film Analyzer

The Ocular Surface

30

Lacrimal glands

Conjunctival epithelium with goblet cells

Meibomian glands

Corneal epithelium

Tear Film

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What’s Wrong With

These Pictures Pre-Op?

31

Classification for

Treatment

32

Lissamine Green

33

Gender Roles

• Sjögren’s: Dry eye is characterized by a triad

of dry eye, dry mouth, and associated

autoimmune disorders.

• Prevalence

– 0.4%

– 85% women

– Strong relationship (46%) to non-Hodgkin’s

Lymphoma

• Sjö Test (Valeant/B+L)

– In Office or QuestDx/LabCorp 35

A Simple Question…

• Can you chew and swallow a

saltine?

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Sjö Test Diagnostics

37

Environment

• Air conditioners or heaters

• Airline travel

• Winter months, allergy season

• Ceiling or Oscillating Fans

• Exogenous irritants (smoking or

general pollution)

• Reading time

• Digital device use (That’s right, the

device you are texting on right now!) 38

Symptoms of Dry Eye

• Burning

• Stinging

• Transient blur

• Dryness

• Photophobia

• Epiphora

• Blurred vision

• Contact lens intolerance

• Redness

• Foreign body sensation

• Grittiness

• Increased blink rate

39

Role of AT’s

• Osmolarity lowering

– Refresh Optive, Blink Tears & TheraTears

• ABMD/corneal staining

–FreshKote

• Lipid Deficient

–Systane Balance, Rohto Dry Aid, Soothe XP, Retaine MGD, Refresh Optive Advanced, Refresh Optive Mega

• Aqueous deficient

–Optive Gel/Refresh, Systane Ultra

• Severe

–Systane/Genteal Gel or Ointment

40

Medical Therapies

• Restasis

• Xiidra

• Steroids

• NSAIDs

• Plugs

• Autologous Serum (NEW: Vital Tears)

• Compounding Biologics (Cyclosporin, Tacrolimus)

• PROKERA

• Fish Oil (EPA/DHA, Ester v. TG, GLA/ALA Importance)

• Krill Oil

• Flaxseed Oil

• Vitamin C

• Scleral Contact Lenses

• TrueTear

• Cequa (Just approved by Sun Ophthalmics)

41

Topical Steroids and

NSAIDs

• Lotemax Gel/Suspension/Ointment

• Prednisolone Acetate 1%/.12%

• Fluorometholone Acetate

• Loteprednol

• Prolensa

• Ilevro

• Ketorolac

• Bromsite (now commercially available)

***All Off-label use, but we all know extremely effective when paired simultaneously with Restasis and now Xiidra***

42

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Future Therapeutic Target:

Cannabinoid Receptors

• Novaliq has developed in a proof-tested environment, Nov-07 for Neuropathic Pain – Targeting the cannabinoid receptor system using

Novaliq’s proprietary EyeSol® drug delivery technology

– Will become a Phase I Study in the near future

News Release May 8, 2017: Joint statement from Novaliq/University of Cologne, Germany

43

Compounding Biologics

• Autologous Serum – 20 to 50% (I prefer 20%)

– Work closely with compounder to tailor the product to your specifications

– *UPDATE: Vital Tears*

• Ciclosporin-A – .05 to 2%

– Solution vs. Emulsion (Corn or Olive Oil)

• Tacrolimus – .03%

– Olive Oil

44 **Ciclosporin and Tacrolimus both require baseline & quarterly liver panels**

Nutritional Supplementation

• Vitamin C (2 g)

• Fish Oil = Omega 3 – EPA/DHA

– Ester v. TG

– GLA (Black Currant Seed Oil)

• Krill Oil = Omega 3 – Questionable efficiency due to increased endogenous

digestive absorption. Ecologic food chain dilemma too.

• Flaxseed Oil = ALA – Must be crushed to increase bioavailability

45

The Importance of GLA

• GLA: more compelling array of evidence (vs. Fish oil – with fewer DED studies, often small doses in non-representative populations, e.g. Northern India, Iran)

• GLA has specificity for DED that fish oil omegas lack.

• Combining GLA + modest level EPA from fish oil, other nutrients / cofactors. GLA + EPA has complimentary effect on inflammation

• HydroEye: Commercially available DTC or in office from a Texas based company (ScienceBased Health)

46

7 Controlled Clinical

Trials

• Aqueous-deficient (Barabino S et al. Cornea 22: 97–101,

2003.)

• PRK (Macri A et al. Graefes Arch Clin Exp Ophthalmol

241:561-6, 2003.)

• Sjögren's (Aragona P, et al. Ophthalmol Vis Sci 46:4474-9,

2005.)

• Contact lens (Kokke KH et al. Contact Lens Ant. Eye

31:141-6, 2008.)

• MGD (Pinna et al. Cornea 26:260-264, 2007.)

• Mild-moderate DED (Brignole-Baudouin et al. Acta

Ophthalmologica 89:e591-7, 2007.)

• Post-menopausal women (HydroEye) (Sheppard JD,

47

Amniotic Membranes

• Fetal Wound Healing

• Rapid uptake of nutrients and mobilization

of stem cells.

• Similar to therapeutics, earlier initiation of

membrane allows for better response.

• Cautionary Note

– Wet cryopreserved = Wound Healing

– Dry cryopreserved = Wound Coverage

48

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The Ocular Surface Landscape

Normal Adult

Healing

Regenerative

Healing with

HC-HA/PTX3

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

HC-HA

Stem Cell

HC-HA/PTX3 Improves the Quality of the Stem Cell Niche Environment

49

Case #2: The Angry One

• 49 year old Caucasian female

– presents for a 2nd opinion consultation for dry

eye.

– She explains that her previous 2 doctors

brushed off her complaints for which made

her rather upset and angry.

– Although she had multiple symptoms, the

common thread always returned to a chronic

state of pain that she experienced from the

time she awoke until she went to bed.

Rapid Fire!

i) What other questions would you ask?

ii) How would you handle her frustration

from her commentary?

iii) What ophthalmological information is

pertinent to collect?

iv) How would you manage and treat this

patient?

Verbal/Nonverbal Cues

• Sizing Up

• The Handshake

• Salutation

• Eye Contact

• Down to Earth

Analogies

• Closing the Loop

• Call to Action 52

Deductive vs. Inductive

Are You Here? Or There?

53

Are You Open or Closed?

• Are you feeling better today?

• Can I help you?

• Should I date him?

• Is Optometry your favorite job?

• Is that your final answer?

How did you and your

best friend meet?

What is your favorite

memory as a child?

How did you book

those tickets?

What did you learn by

the end of this

meeting?

54

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The Power of “Because”

• Harvard Research Study by Ellen Langer in 1978

• Syntax matters and Quantity does make a difference!

Langer, E., Blank, A., & Chanowitz, B. (1978). The mindlessness of Ostensibly Thoughtful Action: The Role of “Placebic” Information in Interpersonal Interaction.

Journal of Personality and Social Psychology, 36(6), 635-642.

55

Because = Compliance

• 1. Always give a reason. Human brain is

wired to react when it hears because. It is a

magical word. It is an automatic trigger for

compliance, and in many cases a person stops

paying attention to what comes after they

hear because.

• 2. Share your mission – add what is the bigger

reason why you do what you do. Doing so will

make people feel like they are contributing to

that mission and doing more for the greater

good. 56

Stats

• VAcc: 20/20 OD/OS

• TBUT: 5-6 OU

• Tear meniscus= .3 OU

• Tr SPK inf and nas OD, sup OS

• 1+ papillary rxn

• 1+ Lissamine stain nas and temp, +ULMS

• TearLab: 301 OU

• InflammaDry: Very subtle pink

• 1+-2 MGD, tr toothpaste expression

So, What’s Next?

• She had tried multiple medications and

lubricants, warm compresses, etc

• She mentioned always feeling cold, her

nails became more brittle, fatigue

• I decided to order lab work

– Sjo

– Thyroid immunoglobulins, Thyroid panel

– Lyme

– Bartonella

Hypothyroidism

• Hypothyroidism is an underactive thyroid gland.

• Hypothyroidism is a condition where the thyroid

gland can’t make enough thyroid hormone to

keep the body running normally. People are

hypothyroid if they have too little thyroid

hormone in the blood.

• Common causes are autoimmune disease, such

as Hashimoto’s thyroiditis, surgical removal of

the thyroid, and radiation treatment.

Outcome

• Referred to Endocrinology for further

management

• Since starting Synthroid 112 mcg,

most of her symptoms have

decreased to a neglible level.

• Recommended lubrication

• Made aware of punctal plugs for

winter months

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Outcome: Part 2

• She was appreciative that we

actively listened to her complaint

• After 3 months, she read about

LipiFlow for Dry Eye and saw we

had a unit

– The conversation began…

Blepharitis & MGD

Has anyone heard of these before?

62

Classification

Anterior

• affects the eyelid epidermis

• base of the eyelashes

• eyelash follicles

– Staphylococcal

– Seborrheic blepharitis (scurf)

• AAO Preferred Practice Guideline:

Anterior to Gray Line

63

Classification

Posterior

• Inflammation affecting back portion of

eyelid margin in relation to the meibomian

glands.

• AAO Preferred Practice Pattern:

Posterior to Gray Line

64

Classification

Meibomian Gland Dysfunction (MGD)

• Chronic

• Diffuse abnormality of the meibomian gland characterized

by terminal duct obstruction and qualitative or quantitative

changes in glandular secretion

• Decrease tear film evaporation and deliver an optically

stable tear film surface

– Increased Vulnerability

65

Case #3: The Law

• 46 year old Hispanic female

– presents for LASIK pre-op consultation with surgery

already booked out 10 days from this appointment.

– She has worn contact lenses for 15+ years and has

been uncomfortable for the past 5 years with itchy,

dry eyes. Although she has worn several different

brands of single use contacts, none have been

manageable for her work environment

– Her work: insurance lawyer. She states several

times that she is rather nervous to have the surgery.

– Her treatment history in the chart states she has

used Visine redness reliever in the past, multiple

chalazia in both lids, and has refractive amblyopia

in her left eye.

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12

Rapid Fire!

i) What other questions would you ask?

ii) Are we the only providers she has seen?

iii) What ophthalmological information is

pertinent to collect?

iv) How would you manage and treat this

patient?

Stats

• VAcc: 20/25 OD, 20/60 OS

• TBUT: 7 OU

• Tear meniscus= .4 OD, .3-35 OS

• Rare SPK OU: mostly sup, few dots inf

• No Lissamine stain, sporadic ULMS

• TearLab: 303 OD, 300 OS

• InflammaDry: Negative OU

• 1+ MGD, caved glands RLL medial x1 and

LLL temp x1

• Toothpaste expression, Line of Marx behind

LipiScan

• Joe Boorady

(CEO of TearScience)

– He is an OD

Device Potential:

– Practice Differentiator

– Unmet need for our

peers

– More affordable than

purchasing LipiView

69

LipiView Imagery

70

Modest

Health to

Glands

Maximal

Dropout of

Glands

Management & Tx

• D/C Visine

• Start warm compresses/Avenova

• Start Blink Exercises

• Counseled on LipiFlow prior to

LASIK

• Made clear that she might need

repeat procedures in future to

maintain structural integrity

Treatment Options

Mechanical

• Warm Compresses/Lid Massage

• LipiFlow

• MiBo

• IPL

• BlephEx

• Cliradex/Cliradex Light

• Blephadex

• Avenova vs. OCuSOFT HypoChlor

• iLast

• Meibomian Intraductal Probe

• TrueTear

Medicinal

Azithromycin (Oral or Drop)

Doxycycline

Lipid based artificial tears

Omega 3’s

Ivermectin/Permethrin

Tea Tree Oil/Coconut Oil mix

Restasis (potentially)

72

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13

Outcome

• Excellent expression directly post

procedure

• 6 months post procedure, continued

toothpaste-free expression

• She was maintaining warm

compress/Avenova treatment

• VAsc: 20/20 OD, 20/50 OS

TearCare™

(Sight Sciences)

• It is a software-controlled, wearable eyelid

technology that provides targeted and

adjustable thermal energy to the

meibomian glands.

• Leveraging the full functionality of the

blinking eye, TearCare’s proprietary

iLid™ technology facilitates natural

meibum expression when meibum is in its

melted phase.

iLux

Case #4:

Kicking it up a Notch

• 51 year old Jordanian female

– presents for a lid evaluation.

– She claims that her eyes are infested

with Demodex and requests a BlephEx

procedure be performed immediately to

manage her condition.

– While in Jordan, she used a

homemade permethrin preparation on

her lashes daily to remove the “eggs”

she visualized on her lids.

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Hottest Topic Today:

Demodex

• Closely associated with Posterior Blepharitis and

MGD

• 2 parasitic species

– Demodex Folliculorum

– Demodex Brevis

• Beyond 70 years old, 95-100% chance of

infestation

• Term used is Cylindrical

Dandruff (CD)

95% in 71 to 96 year-old

87% in 51 to 70 year-old

69% in 31 to 50 year-old

34% in 19 to 25 year-old

13% in 3 to 15 year-

old

79

The Home of Demodex

• Visualizing the Ectoparasite

80

Progressive Demodex

Events

Demodex Mites

Blepharitis

Meibomian Gland Dysfunction

Rosacea

Chalazia

81

Fasten Your Seatbelt!

• Explanations for Anterior and

Posterior Blepharitis

– Lumped into 1 group

– Inefficient oil production and

relationship to zits

– Lifestyle implications with dry eye and

“styes”

• Gateway to Makeup discussion

– Waterproof

– Placement of mascara line

82

Demodex Patient

Conversation

• One of the few times I make a joke to break the ice – Start with bacterial portion and then follow that

there are some “friends” we all have present in some form or another

– The next layer of the conversation is why • Folliculorum = Lawnmowers for lashes

• Brevis = Mite Excess Oil Binge Eaters

• Close the loop by sharing the relationship is mostly mutual, but some times we have fights – Similar to marriage– we can all get along right?!

83

Back to Our Case: Stats

• VAsc: 20/30 OD, 20/30-2 OS

• Significant Madarosis of Lash Lines

LL/UL OU

• Flaky Tear Debris OU

• TBUT: 3 OU

• Tear Meniscus= .1 OU

• Fine SPK scattered 360 OU

• Obvious Obstruction MGD OU

• Significant Toothpaste sleeving OU

• +Dense ULMS

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15

Management and Treatment

• Stop Permethrin preparation immediately

• I advised her BlephEx was not recommended

based on the lid appearance

• LipiScan illustrated reduced lipid layer thickness

OU and mild to moderate gland truncation LL

• Start Avenova qPM, Cliradex Light qAM, Optive

Advanced qid OU, alternate warm and cold

compresses to minimize lid inflammatory

response

• Counseled on LipiFlow to be done in 1 wk

Outcomes: Regrowth

• She mentioned

improvement

on her 2 week

follow up.

• By weeks 2

and 3, her lash

line showed

dramatic

regrowth.

Case #5: Family Matters

• 7 year old Caucasian female presents with chronic itchy

eyes that cause swelling of eyes.

• Her mother is concerned because she has sensitive skin

and there is a family history of significant allergies.

• The mother wants to know if there are any treatments

available.

Hannah

Pediatric Pearl:

Magic Beans and Potions

Medication,

Drop, or Pill =

Non-

adherence

90

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16

Signs

• Sneezing

• Thin watery discharge

• No pre-auricular nodes

• No corneal involvement

• Hyperemia

• Papillary Reaction– Stain with

Lissamine and NaFl to gauge uptake

91

Questions: For Kids and Adults

92

Prevalence of Allergic

Conjunctivitis

• Increasing incidence over the last 40 years

• Over 20% of the general population are affected by allergic

• conjunctivitis

• In a study of 5000 children with allergies, 32% of children

• had only ocular symptoms

• Of 509 patients studied with “hay fever,” approximately

• 93% had conjunctivitis symptoms – Ocular symptoms predominated in 22% of patients,

nasal symptoms in 25%, and both in 53%

• Ocular symptoms were mild in 25%, moderate in 53%, and severe in 22%

93

Patients

With O

cula

r A

llerg

y

Sym

pto

ms (

%)

Month

Ocular Allergy Symptoms by Month of Year

(Findings from NHANES III Survey)

94

Vernal Conjunctivitis

Features

• Young age (mostly boys)

• Seasonal/Perennial

• Perilimbal pigmentation

• Papillary reaction

• Horner Trantas dots

• Ropy discharge

• Intense itching

• Ptosis from lid swelling

• Runny nose

95

Palpebral

• Giant papillae

• Shield ulcers

96

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Limbal

• Limbitis (Trantas dots)

97

Atopic Conjunctivitis:

Features

• Males (Teens to 50’s) / No Seasonal Component

• Atopy Triad (Allergy, Eczema, Asthma)

• Red, thickened, macerated lids

• Infiltration of tarsal conjunctiva

98

Complications

• Persistent epithelial defects

• Corneal Scarring

• Superinfection

• Corneal neovascularization

• Pannus

• Cicatrization

• Keratoconus

• Cataract (ASC/PSC)

• Symblepharon

• Blepharitis

• Diathesis

99 100

Point of Care:

Diagnostic Systems

101

Treatment Methods

Straightforward/Early

• Antihistamine/Mast Cell Stabilizers • Pazeo, Bepreve, Lastacaft, Pataday, Epinastine, Zaditor

• Oral and Topical Antihistamine – Azelastine, Loratidine, Zyrtec, Xyzal, Allegra

• Mast Cell Stabilizers – Cromolyn Sodium 4%

• Steroids

• Cold Compresses/Preservative Free Tears

**Avoidance

102

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Treatment Methods

Advanced Stage (Vernal and Atopic)

• Cyclosporine A 0.05% eye drops (V&A)

• Tacrolimus 0.03% ointment to the eyelid skin (A)

• Topical corticosteroid 4-6x/day (A) – Shield Ulcers (V)

• Consultation with allergist and/or dermatologist for traditional, SLIT, EPIT

• Oral cyclosporine, tacrolimus, or corticosteroids (A)

• Boston Keratoprosthesis– if visual loss from corneal opacification has occurred (A)

103

Back to Hannah…

• Avoidance is key

• Showering is done twice daily to remove allergens

from her hair

• AC system is flushed semi-yearly

• Cold compresses are her best friend

• Pazeo is the most effective for her when symptoms

are heightened (she is pretreated 1 month prior to the

official season and then dosed intermittently

throughout)

Thank You!