Part 2: Dry Eye - MedEdicus€¦ · 2-part series: this is Part 2, Dry Eye. Part 1, Ocular Allergy,...

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Proceedings From an Expert Roundtable Discussion Mile Brujic, OD, FAAO—Program Chair and Moderator Alan Kabat, OD, FAAO David Kading, OD, FAAO Christine Sindt, OD, FAAO Loretta Szczotka-Flynn, OD, PhD, FAAO Original Release: May 1, 2014 Expiration: March 27, 2017 faculty U p d a t e s i n O c u l a r S u r f a c e W e l l n e s s A supplement to This course is COPE approved for 2 hours of CE credit for optometrists. COPE Course ID: 40944-AS This continuing education activity is supported through an unrestricted educational grant from Administrator Sponsored by CE Monograph Part 2: Dry Eye Online Testing and Instant Certificate Processing http://tinyurl.com/OcularSurface2

Transcript of Part 2: Dry Eye - MedEdicus€¦ · 2-part series: this is Part 2, Dry Eye. Part 1, Ocular Allergy,...

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Proceedings From an Expert Roundtable Discussion

Mile Brujic, OD, FAAO—Program Chair and ModeratorAlan Kabat, OD, FAAO

David Kading, OD, FAAOChristine Sindt, OD, FAAO

Loretta Szczotka-Flynn, OD, PhD, FAAO

Original Release: May 1, 2014

Expiration: March 27, 2017

faculty

Updat

es in Oc

ular Surface Wellness

A supplement to

This course is COPE approved for 2 hours

of CE credit for optometrists.

COPE Course ID: 40944-AS

This continuing education activity is supportedthrough an unrestricted educational grant from

Administrator

Sponsored by

CE Monograph

Part 2: Dry Eye

Online Testing and Instant Certificate Processing

http://tinyurl.com/OcularSurface2

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Learning Method and MediumThis educational activity consists of a case reportand twenty (20) study questions. The participantshould, in order, read the Learning Objectivescontained at the beginning of this activity, read thematerial, answer all questions in the post test, andcomplete the Activity Evaluation/Credit Requestform. To receive credit for this activity, please followthe instructions provided below in the section titledTo Obtain CE Credit. This educational activity shouldtake a maximum of 2.0 hours to complete.

Content SourceThis continuing education (CE) activity capturescontent from a roundtable discussion.

Activity DescriptionEye care providers face multiple challenges inmanaging ocular surface disorders, such as ocularallergy and dry eye. Recently, experts met todiscuss new and practical approaches to improvingthe management of these patients. This CE activitybrings you highlights from these discussions in a 2-part series: this is Part 2, Dry Eye. Part 1, OcularAllergy, was published in March 2014 and isavailable on www.mededicus.com.

Target AudienceThis educational activity is intended for optometrists.

Learning Objectives Upon completion of this activity, participants willbe better able to:

• Make a differential diagnosis in patients withdry eye• Select the therapy that is most appropriate forthe patient’s diagnosis and severity of dry eye• Incorporate current approaches to successfullymanage more contact lens wearing patientswho also have dry eye• Counsel patients on proactive measures formanaging dry eye

Accreditation Designation StatementThis course is COPE approved for 2 hours of CEcredit for optometrists.COPE Course ID: 40944-AS

DisclosuresMile Brujic, OD, FAAO, had a financial agreement oraffiliation during the past year with the followingcommercial interests in the form of Consultant/Advisory Board: Alcon, Inc; Allergan, Inc; Bio-Tissue,Inc; NicOx SA; TelScreen; Transitions Optical, Inc;Valeant Pharmaceuticals International, Inc; and Vmax Vision, Inc; Contracted Research: Alcon, Inc;Honoraria from promotional, advertising or non-CEservices received directly from commercial interestsor their Agents (eg, Speakers Bureaus): Alcon, Inc;Allergan, Inc; Optovue, Inc; Paragon Pharmaceuticals,LLC, Valley Contax; and Vmax Vision, Inc.

Alan G. Kabat, OD, FAAO, had a financialagreement or affiliation during the past year withthe following commercial interests in the form ofConsultant/Advisory Board: Alcon, Inc; Allergan,Inc; Bio-Tissue, Inc; NicOx SA; TearScience; andValeant Pharmaceuticals Inc; Honoraria frompromotional, advertising or non-CE servicesreceived directly from commercial interests or theirAgents (eg, Speakers Bureaus): Alcon, Inc; andValeant Pharmaceuticals Inc.

David L. Kading, OD, FAAO, had a financialagreement or affiliation during the past year with the following commercial interests in the form of Consultant/Advisory Board/SpeakerBureau/Contracted Writing: Alcon, Inc; Bausch +Lomb Incorporated; Bio-Tissue, Inc; EssilorLaboratories of America; NicOx SA; ValeantPharmaceuticals Inc; and Valley Contax; Contracted Research: Alcon, Inc.

Christine Sindt, OD, FAAO, had a financialagreement or affiliation during the past year withthe following commercial interests in the form ofConsultant/Advisory Board: Alcon Vision Care;Contracted Research: Alcon Vision Care;Ownership Interest: EyePrint Prosthetics LLC.

Loretta Szczotka-Flynn, OD, PhD, FAAO, had afinancial agreement or affiliation during the pastyear with the following commercial interests in theform of Consultant/Advisory Board: Alcon, Inc;Contracted Research: Alcon Laboratories; andJohnson & Johnson Vision Care, Inc.

Disclosure AttestationEach of the contributing physicians listed abovehas attested to the following:1. that the relationships/affiliations noted will not

bias or otherwise influence his or herinvolvement in this activity;

2. that practice recommendations given relevant tothe companies with whom he or she hasrelationships/affiliations will be supported bythe best available evidence or, absent evidence,will be consistent with generally acceptedmedical practice; and

3. that all reasonable clinical alternatives will bediscussed when making practicerecommendations.

Product Usage in Accordance With Labeling Please refer to the official prescribing informationfor each product for discussion of approvedindications, contraindications, and warnings.

Grantor StatementThis CE activity is supported through anunrestricted educational grant from Alcon, Inc.

To Obtain CE CreditWe offer instant certificate processing and supportGreen CE. Please take this post test and evaluationonline by going to http://tinyurl.com/OcularSurface2.Upon passing, you will receive your certificateimmediately. You must answer 14 out of 20questions correctly in order to pass, and may takethe test up to 2 times. Upon registering andsuccessfully completing the post test, your certificatewill be made available online and you can print it orfile it. Please make sure you take the online posttest and evaluation on a device that has printingcapabilities. There are no fees for participating inand receiving CE credit for this activity.

DisclaimerThe views and opinions expressed in thiseducational activity are those of the faculty and donot necessarily represent the views of the StateUniversity of New York College of Optometry;MedEdicus LLC; Alcon, Inc; or Review of Optometry.

This CE activity is copyrighted to MedEdicus LLC ©2014. All rights reserved.

Mile Brujic, OD, FAAO (Program Chair and Moderator)Premier Vision GroupBowling Green, Ohio

Alan Kabat, OD, FAAOProfessorSouthern College of OptometryMemphis, Tennessee

David Kading, OD, FAAOAdjunct Faculty Pacific University College of Optometry

Forest Grove, OregonSpecialty Eyecare GroupSeattle, Washington

Christine Sindt, OD, FAAODirector, Contact Lens ServiceClinical Associate Professor ofOphthalmology and Visual Sciences

University of IowaCarver College of MedicineIowa City, Iowa

Loretta Szczotka-Flynn, OD, PhD, FAAO

Director, Contact Lens ServiceUniversity HospitalsCase Medical Center

Professor of OphthalmologyCase Western Reserve University School of Medicine

Cleveland, Ohio

faculty

Erratum: Table 2 in Updates in Ocular Surface Wellness, Part 1: Ocular Allergy. The dosing for alcaftadine incorrectlystated “4 times a day”; the correct dosing is “once a day”. The dosing for olopatadine should be clarified from “everyday” to “once a day”.

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Dear Reader: This is the second part of a CE activity onOcular Surface Wellness. Part 1, which can be found onwww.mededicus.com, covered Ocular Allergy.

introductionDry eye is a common ocular problem, with an estimatedprevalence ranging from approximately 5% to more than35%, according to various studies1; it also is a commoncause of visits for optometric care because it can beassociated with bothersome ocular symptoms, fluctuatingvision, and contact lens discomfort. Appropriate treatmentcan address these issues and is important because dry eyecan be a chronic disease that can lead to abandonment of contact lens wear and progress to the degree that itbecomes sight-threatening in some patients. Establishing thediagnosis is the first step in providing effective care for dryeye, but there are many challenges to making the diagnosis.

This continuing education program aims to increase theclinician’s ability to accurately detect dry eye and effectivelymanage it by taking into account both its etiology andseverity in individual patients.

DiagnosisDry eye was defined by the International Dry Eye Workshop(DEWS) as “…a multifactorial disease of the tears and ocularsurface that results in symptoms of discomfort, visualdisturbance, and tear film instability with potential damageto the ocular surface. It is accompanied by increasedosmolarity of the tear film and inflammation of the ocularsurface.”2 DEWS also identified 2 major classes of dry eyedisease—aqueous-deficient and evaporative.

The DEWS definition and classification of dry eye diseaseprovides a foundation for conducting a proper diagnosticevaluation that should include a detailed patient history to characterize symptomatology and to identify etiologicalcauses, combined with a comprehensive evaluation of theperiocular skin and lids, ocular surface, and tear film. Athorough examination will also lessen the potential for dryeye to be overlooked or overdiagnosed. Misdiagnosis of dryeye is a real possibility because its most common signs andsymptoms—irritation, dryness, redness, burning, itching,tearing, and crusting—are nonspecific and overlap with thoseof other common ocular surface conditions, such as ocularallergy, contact lens-related discomfort, and infectious(kerato)conjunctivitis. A lack of concordance between dry eye signs and symptoms also contributes to the diagnosticdilemma.3 Patients with significant bother may have no tominimal clinical findings of dry eye on examination. Evenindividuals with confirmed Sjögren disease and an extremelylow Schirmer test result may have minimal to no otherobjective evidence of dry eye, while some patients who haveonly mild complaints may have significant signs of dry eye ondiagnostic testing. Therefore, attention to both subjective and objective measures of dry eye is critical for accuratediagnosis. It is particularly important to look for signs of

dry eye in patients wearing contact lenses, even though they,too, have been found to be asymptomatic upon questioning.

History“Symptoms of discomfort” is a defining feature of dry eye,and therefore the identification of symptoms should be partof the diagnostic evaluation. Although symptom severity may not correspond to the level of inflammation and ocularsurface damage associated with dry eye disease, it is stillimportant to gauge the intensity and effect of a patient’ssymptoms because one of the goals of treatment is toprovide relief of the associated bother.

The Ocular Surface Disease Index© (OSDI©) and the Standard Patient Evaluation of Eye Dryness™ (SPEED™)questionnaire represent 2 relatively quick, structured,validated questionnaires for assessing dry eye diseasesymptoms. OSDI also assesses effect on vision-relatedactivities.4,5 The OSDI and SPEED documents can bedownloaded from their respective Web sites:http://dryeyezone.com/encyclopedia/documents/OSDI.pdf;http://korbassociates.com/assets/SPEED_Questionnaire.pdf.

Alternatively, patients may be asked about the presence andseverity of symptoms using informal questioning and simplegrading scales. A history, however, should include specificqueries to uncover functional or quality-of-life consequencesof dry eye because this information can help guide theaggressiveness of treatment and provides a measure forassessing therapeutic response. Sometimes, patients whodescribe themselves as very symptomatic are found, throughspecific questioning, to suffer minimal to no effects. Otherpatients who complain little, if at all, may admit to havingtrouble when asked specifically about certain situations, forexample, when performing vision-intensive tasks such asreading or working at the computer, or when in certainenvironments, such as in a room where there is a ceiling fan.Given that individual patients are affected in different waysby dry eye, depending on their usual activities and accordingto what they value, these types of questions provide a usefulway to assess the severity of dry eye in order to establishindividualized goals for intervention.

A history also should identify factors associated with dry eye(Table 1) because such information can reveal contributingcauses of the condition and so lead the clinician to deduceappropriate patient management.2,6

Clinical ExaminationThe clinical examination for dry eye should includeassessments of lid morphology, the meibomian glands,meibum secretion, tear meniscus height, tear film break-uptime (TBUT), and vital dye staining of the ocular surface.7

New diagnostic technologies also allow assessment of tearosmolarity, thickness of the tear film lipid layer, and aninflammatory marker of dry eye. Table 2 lists normal values for many of the tests performed to assess for dry eye disease.

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External evaluation. Lid evaluation is a critical componentof dry eye diagnosis because it is now recognized that mostdry eye disease is evaporative and that meibomian glanddysfunction (MGD) is the most common cause ofevaporative dry eye disease.8 Lid evaluation also allows foridentification of other causes of the patient’s complaints,such as eyelid contact dermatitis and comorbid conditionsthat can be contributing to MGD and dry eye, includinganterior blepharitis and various dermatologic diseases. As part of the external examination, patients also should bechecked for lagophthalmos and observed for blink rate; theseissues can be etiological factors in dry eye.

The lid examination should check for missing eyelashes,debris or collarettes, redness, thickening, telangiectasia, andevidence of Demodex infestation (Figures 1 and 2).

Notably, telangiectasia may be found even in teenaged andyoung adults who have no signs or symptoms of dry eye. Thepresence of these small, irregular vessels at the lid margin isindicative of an inflammatory state and the likelihood thatproblems will develop in the future.

Evaluation of meibomian gland obstruction and meibumcharacteristics should be performed by gland expressionthrough gentle pressure that is applied to the eyelid and lidmargins. Gland expression can be done manually with thethumb or a cotton-tipped applicator, or using handheldinstruments designed to apply a standardized level of lightpressure. Normal meibum is a clear oily liquid. As the quality

Table 1. Factors Associated With Dry Eye2,6

Dermatologic diseasesAtopic dermatitisPsoriasisRosaceaSeborrheic dermatitis

Environmental factorsLow humidityExposure to wind, dry air, ceiling fans

Medications/SupplementsAntiandrogensAntihistaminesAntimuscarinics for overactive bladderAntipsychoticsBeta-blockersDiureticsEchinaceaKavaNiacinPostmenopausal hormone therapy (estrogens and progestins)RetinoidsTricyclic antidepressants

OphthalmicContact lens wearCorneal surgeryEyelid/Eyelid margin issues (anterior blepharitis, blinking defects, Demodex infestation, entropion/ectropion, lagophthalmos)

Topical medications (effects of preservative)Vision-intensive tasks (working at a computer, driving, reading)

Systemic diseasesAutoimmune diseases (rheumatoid arthritis, lupus, scleroderma,Sjögren syndrome)

DiabetesThyroid disordersVitamin A deficiency

Table 2. Diagnostic Tests for Dry Eye Disease – Normal Values*

Test Normal Values

TBUT >10 seconds

Schirmer test with anesthesia >5 mm in 5 minutes

Phenol red thread test >10 mma

Tear meniscus height 0.1 to 0.6 mm

Tear film osmolarity <312 mOsms/L; ≤316 mOsms/Lb

Tear film matrix metalloproteinase-9concentration

<40 ng/mLc

*Reference No. 7, unless otherwise noted.aZONE QUICK from FCI Ophthalmics. Phenol Red Thread (PRT) Tear Test. www.fci-ophthalmics.com/files/pdf/zone_quick_web.pdf. Accessed March 23, 2014.bTearLab Osmolarity System User Manual. TearLab Corporation. San Diego, CA.cRPS InflammaDry Detector [package insert]. Sarasota, FL: Rapid Pathogen Screening, Inc; 2011.

Figure 2. Epilation of an eyelash with cylindrical dandruff reveals infestationby several Demodex mites at the lash root when examined under themicroscope (magnification 100X).

Image courtesy of Alan Kabat, OD

Figure 1. Cylindrical dandruff encircling the eyelash follicle in a patient withdemodicosis. The debris represents scales that form clear cuffs collaring the lashroot and have been shown to be prevalent in cases of Demodex infestation.

Image courtesy of Alan Kabat, OD

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worsens, the meibum becomes increasingly opaque andthicker (Figure 3), so that expressibility necessitates increasedpressure.

The lid margin also can be assessed for meibomian glanddropout by using transillumination. This is done by flippingthe skin side of the lid over a transilluminating light sourceand viewing the meibomian glands on the everted mucosalsurface. Transillumination enables identification of glandarchitecture and also reveals inspissation of the orifices.Noncontact infrared meibography, which is commerciallyavailable from a number of sources, is another method forevaluating meibomian gland morphology.

Assessing the degree of meibomian gland atrophy isimportant for guiding treatment decisions. As more atrophiedglands are noted, it is incumbent upon the clinician toappreciate that atrophied glands will be much more difficultand often impossible to rehabilitate with standard lidhygiene measures that are a mainstay for the managementof obstructive MGD. It is critical, thus, to work to regainfunctionality to those glands that are still functioning.

Ocular surface staining and TBUT. Staining of the ocularsurface can be done using fluorescein alone or bothfluorescein and lissamine green to identify damage to thecornea and conjunctiva. Fluorescein also is used to fluorescethe tear film in order to measure TBUT and tear filmmeniscus height.

Proper technique and consistency in methodology isimportant when using the vital dyes in order to obtainaccurate and reproducible results. In research studies, apipette is used to precisely measure and instill a fixedvolume of a preservative-free dye solution. In clinical practice,dye-impregnated strips are used instead. The strip should becompletely wetted with a few drops of nonpreserved sterilesaline and then shaken firmly to remove excess liquid. Thistechnique will minimize variability in dye concentration andvolume applied to the ocular surface, assuring that sufficientdye is transferred, but not in an excessive amount that willlead to quenching of fluorescence.

After pulling down the lower lid and directing the patient to gaze up, the strip can be applied to either the bulbar orpalpebral conjunctiva. Clinical experience suggests thatplacement on the lower palpebral conjunctiva provides

accurate TBUT measurements and is less likely to stimulatereflex tearing than placement of the strip on the bulbarconjunctiva. Tear film assessments should be performed prior to staining assessments and before expressing themeibomian glands. Because it can take some time for thetear film to stabilize, it might be helpful to measure TBUT 3 times, allowing patients to blink between measurements,and then to average the results. Alternatively, patients maybe instructed to blink completely a few times beforemeasuring TBUT. Since contact lens wear destabilizes TBUT,clinicians are advised to wait at least 5 minutes after lensremoval before measuring TBUT.

In assessing TBUT, clinicians should determine the time forbreak-up as well as the position and pattern. For example,rapid tear break-up localized to the inferior cornea is atelltale sign of lagophthalmos (Figure 4).

The interval between dye instillation and staining evaluationshould be standardized, and a wait time of 2 minutes isgenerally recommended for lissamine green and fluorescein.9

The ocular surface staining pattern also provides diagnosticclues, and its severity should be recorded using the OxfordScheme or some other type of grading scale. Interpalpebralconjunctival lissamine green staining in the nasal andtemporal regions is indicative of dry eye (Figure 5).10

A negative corneal staining pattern with a vague mosaicpattern is diagnostic of anterior basement membranedystrophy, which is sometimes misdiagnosed as dry eye.

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Figure 3. Image taken during manual meibomian gland expression showsthick, turbid secretions indicative of MGD.

Image courtesy of Alan Kabat, OD

Figure 4. Rapid TBUT and fluorescein staining of the inferior cornea thatcorresponds to the area of exposure in a patient with lagophthalmos.

Photo courtesy of Christine Sindt, OD

Figure 5. Lissamine green staining of the nasal bulbar conjunctiva in a patientwith dry eye.

Photo courtesy of Mile Brujic, OD

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When using vital dyes in contact lens wearers, conjunctivalstaining associated with dry eye should not be confused withthe circumlimbal staining that is associated with indentation ofthe lens edge into the conjunctiva (Figure 6).

Lid wiper epitheliopathy. The lid wiper is the area justposterior to the meibomian glands on the superior lid thatwipes along the ocular surface during the blink. Dry eyepatients often show lid wiper epitheliopathy (LWE), identifiedby staining of the lid wiper area using rose bengal, lissaminegreen, or fluorescein. The severity of LWE is graded accordingto both the length and the width of the area of staining.

Tear volume. The Schirmer test with anesthesia remains thestandard method for evaluating aqueous tear production. It should be performed after TBUT and ocular surface dyestaining—waiting for several minutes after the dye testing—because the Schirmer test can disrupt tear film stability.Excess fluid from instillation of topical anesthesia should beremoved from the cul-de-sac prior to inserting the filterpaper. The results are measured after 5 minutes.

Phenol red thread testing is a practical alternative to theSchirmer test because it takes only 15 seconds to complete.Phenol red thread testing also affords greater patient comfortand avoids reflex tearing. Measurement of tear meniscusheight can be done using some optical coherencetomography platforms and is another method for estimatingthe volume of tears.

Instrumental diagnostic measures. Point-of-carediagnostic testing for dry eye has been emerging, and adevice for measuring tear osmolarity was the first to becomeavailable. The test analyzes osmolarity in a 50-nL samplecollected from the inferior tear meniscus; a result of >316mOsms/L is considered indicative of dry eye disease.11 Someresearch supports tear osmolarity testing as superior to other diagnostic tests for identifying dry eye and grading itsseverity.12,13 Other studies, however, raise questions about its utility.14,15 It is unclear whether the latter results reflectlimitations of the test itself or illustrate the fact that dry eyedisease manifests with a complex and variable plethora ofsigns and symptoms. Therefore, clinicians may consider tearosmolarity testing to supplement other diagnostic testing, butshould not rely on it as the sole measure for detecting andmonitoring dry eye.

A semiquantitative immunoassay for detecting elevatedlevels of matrix metalloproteinase-9 (MMP-9) in the tears isa new point-of-care test for dry eye that was approved by theUS Food and Drug Administration (FDA) in November 2013.MMP-9 is an inflammatory marker, and the test yields apositive result if the level of MMP-9 is >40 ng/mL. The roleof this new assay in clinical practice for diagnosing andmanaging dry eye is yet to be determined.

An ocular surface interferometer provides information on the absolute thickness of the lipid layer of the tear film and allows clinicians to evaluate blinking frequency andcompleteness. Studies have shown that lipid layer thicknesscorrelates with expressible meibomian glands and is lower inpatients with obstructive MGD than in controls.16,17 However,further research is needed to determine the role of theocular surface interferometer in screening for MGD.

Sjögren disease evaluation. Sjögren disease is amultisystem autoimmune disease that can lead to significantmorbidity and even mortality. It is one of the most commonautoimmune diseases, but its prevalence is underappreciatedand the disease is underdiagnosed.18

Given that dry eye is often one of the earliest manifestationsof this condition, the possibility of Sjögren disease should beconsidered in any patient with clinically significant dry eye.19

Patients should be asked about dry mouth and about signsand symptoms of other tissue damage, particularly joint pain; they should be asked to provide family history ofautoimmune disease because such findings further supportthe diagnosis of Sjögren disease and are an indication forconfirmatory laboratory testing.

A relatively new laboratory blood test for Sjögren diseasedetects additional autoantibodies, thus improving theidentification of patients with disease.20 Maintaining an indexof suspicion for Sjögren disease, combined with use of this blood test, should increase early detection of affectedpatients and allow them to receive appropriate care throughcollaboration with a rheumatologist.

TreatmentsTreatments for dry eye encompass a range of modalities thatinclude medical therapies, surgical techniques, and a varietyof other interventions (Table 3).21 Specific strategies for use inpatients wearing contact lenses will be discussed later.

Management decisions for patients with dry eye should take into account the severity of the disease and anymodifiable contributing causes identified in a patient’spersonal history.21 The goals of treatment are to provide relieffrom disease-related signs and symptoms and to preventpermanent tissue damage.

Ocular lubricants/Tear supplements Artificial tears continue to be a mainstay in the management of dry eye, and there are a myriad of products from which tochoose. Because MGD may be the cause or a contributing factorin as many as 85% of patients with dry eye,22 there is a role for

Figure 6. Staining on the superior limbus from indentation by a contact lens edge.

Photo courtesy of Christine Sindt, OD

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using a lipid-based artificial tear that will help supplement thedeficient lipid component of the tears and stabilize the tear film.Studies evaluating lipid-based artificial tears show their efficacyin improving signs and symptoms of dry eye in patients withMGD, but also in those without lipid deficiency.23-25

Patients should understand why a lipid-based product ispreferable to one of another formulation, thus reducing thepossibility that they will decide to purchase a product solelyon the basis of cost. Treatment of chapped lips provides auseful analogy for helping patients understand the differencebetween lipid-based and aqueous-based artificial tears. Theexplanation compares use of the aqueous-based artificialtear products for treatment of dry eye with licking the lips fortreatment of chapped lips: the aqueous saliva evaporatesquickly, and so it exacerbates the chapping rather thanrelieving it; in contrast, a wax- or ointment-based productspecific for treating chapped lips has better retention and cancover and protect the surface.

There are several lipid-based artificial tear products available(Table 4). It is better to make a specific recommendation andto reinforce the underlying reason for that recommendationrather than to allow the patient to choose from among thevarious options. Giving a sample of the particular productbeing recommended, or a money-saving coupon, can helpreinforce the recommendation, although it is not advisable to give patients samples of several different products, with a suggestion to try them all and select their preference,because this approach may leave patients with theperception that all the products are interchangeable.

Consumers will find an array of generic/store-brand artificialtear products on the shelves. Although the active ingredientsin store-brand artificial tears may at times be similar to thosein their brand-name counterparts, the inactive ingredientsmay be very different in the 2 formulations. In particular, with respect to preservative-containing formulations, thepreservative in store-brand products is usually BAK

(benzalkonium chloride), whereas the brand-name productsare generally formulated with a preservative that is gentler tothe ocular surface than is BAK.

Preservative-free artificial tears may be preferred when therequired dosing frequency exceeds 4 times a day or inpatients with more severe dry eye who have greater ocularsurface damage, or who have sensitivities to any of thepreservatives found in popular artificial tears. Gel or ointmentformulations may be used in patients with severe dry eye.

Anti-inflammatory TreatmentCorticosteroids. Topical corticosteroids alone provide an effective anti-inflammatory treatment for dry eye.26-28

But dry eye is a chronic disease, often requiring ongoingtherapy, and the potential for cataract and IOP elevation with corticosteroid use is a limitation to the long-term use of these agents.

Cyclosporine. Cyclosporine, 0.05%, ophthalmic emulsion isthe only prescription medication that has an FDA-approvedspecific indication for the treatment of dry eye. It acts tomodulate inflammation, increase tear production, and hasbeen shown to be safe and effective when used consecutivelyfor up to 3 years.29 Time to onset of symptomatic relief withcyclosporine treatment is variable and may be delayed insome patients, especially those with more severe disease.30

Treatment benefit increases, however, with ongoing use andmay continue to accrue over a period of at least 2 years.31 Themost common side effects of cyclosporine use—and thus acommon cause of premature treatment discontinuation32—arestinging and burning with instillation29

Proper education is helpful for improving patient adherence tocyclosporine therapy32 (see Sidebar, next page). In addition, ashort course of a topical corticosteroid started prior to orconcurrent with cyclosporine therapy has been reported to

Table 4. Lipid-based Artificial Tears

Product NameActive and Lipid Layer-supportingIngredients Preservatives

FreshKotea polyvinyl alcohol, polyvinylpyrrolidone, Amisol CLEAR(proprietary phospholipid)

Polixetonium

Refresh Optive Advanced b

carboxymethylcellulose sodium,glycerin, polysorbate 80, castor oil

Purite (stabilizedoxychloro complex);also availablepreservative-free insingle-dose vials

Retaine MGDc light mineral oil, mineral oil Preservative-free

SystaneBalanced

propylene glycol, dimyristoylphosphatidylglycerol, mineral oil

Polyquaternium-1

ahttp://www.freshkote.com/about-freshkote_5000_ct.aspxbhttp://www.allergan.com/products/eye_care/refresh.htm. Product Packagingchttp://www.ocusoft.com/Featured-Products-RETAINE-MGD-OPHTHALMIC-EMULSION-30-SINGLE-DOSE-VIALS-P5279.aspxdhttp://www.systane.com/Systane-Balance-Lubricant-Eye-Drops.aspx

Table 3. Severity-based Treatments for Dry Eye21

MildOcular lubricants/Tear supplementsEyelid therapy (for MGD)

Moderate Add to above: Punctal plugsTopical anti-inflammatories (short-term corticosteroid, cyclosporine)Tetracyclines (for MGD, rosacea)Moisture-retaining/-releasing eyewear

SevereAdd to above:Amniotic membraneAutologous serumLid surgeryPermanent punctal occlusionScleral contact lensesSystemic anti-inflammatory medicationsTestosterone cream

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hasten control of inflammation and to minimize discomfortassociated with cyclosporine.32-35 Loteprednol etabonate,which has been studied as an adjunct to cyclosporine,33,34

was found in a recent claims analysis to be the most oftenprescribed corticosteroid for patients with dry eye.36 Althoughloteprednol has a lower propensity to increase intraocularpressure (IOP) than do some other corticosteroids,37 IOPshould be monitored in all patients receiving corticosteroidtreatment.

Nutritional supplements. Evidence that essential fatty acidshave anti-inflammatory activity provides a rationale for their usein the management of dry eye disease and MGD. In addition,there are an increasing number of reports from randomized,double-blind/double-masked controlled trials showing thattreatment with nutritional supplements containing omega-3and/or omega-6 fatty acids provides objective and subjectiveimprovements in patients with aqueous-deficient, evaporative,and contact lens-associated dry eye.38-41

Punctal OcclusionThe rationale for punctal occlusion using absorbable ornonabsorbable punctal plugs is to increase tear retention on the ocular surface. It should not be used, however, whenthere is acute inflammation, lest the ocular surface becomesexposed to an increased pool of inflammatory cytokines inthe tear film.21 Currently there are no good measures fordetermining when it would be appropriate to occlude thepuncta after initiating anti-inflammatory treatment for dryeye. In the future, measuring MMP-9 levels in the tear filmmay be helpful to better understand the inflammationpresent on the ocular surface. But, for now, clinicians shouldrely on subjective assessments of inflammation and mightconsider waiting 3 months after initiating anti-inflammatorytreatment before punctal occlusion treatment.

Punctal plugs also may have a specific role in managing dry eye that is considered contact lens-induced, that is,noninflammatory cases in which the primary underlyingcause of dry eye is believed to be absorption of tears into the lens. Patients who are likely to fit this description may be young, healthy contact lens wearers with a chiefcomplaint of end-of-day dryness as opposed to olderindividuals in whom inflammation and MGD are more likelyto be present. Nevertheless, while use of punctal plugs inpatients with dry eye suspected to be related to contact lenswear would intuitively seem beneficial, it may temporarilydecrease lacrimal function in patients with normal tearproduction,42 and there are conflicting reports in theliterature regarding its efficacy.43,44

Strategies for Severe Dry EyePatients with very severe dry eye disease may needintervention to rehabilitate the ocular surface. Thesemodalities may include amniotic membrane, which helpsreduce inflammation and facilitates regenerative healing;autologous serum, which has a composition similar to that ofhealthy tear film in terms of the protein components, growthfactors, and pH; and 3% testosterone cream.21 Use ofautologous serum and of 3% testosterone cream each callsfor the optometrist to utilize a compounding pharmacy.

Meibomian Gland Dysfunction ManagementAside from the use of lipid-based artificial tears, there arespecific interventions for patients with dry eye secondary toMGD that are designed to reduce inflammation, eliminatemeibomian gland obstruction, and improve meibum quality.

Lid hygiene and measures for relieving meibomiangland obstruction. Traditionally, lid hygiene has involvedapplication of heat and manual massage of the eyelids inorder to soften and extrude thickened meibum. Forcefulblinking exercises also can help keep the glands open,8 andcommercially available lid scrubs can be used to clear debris from meibomian gland orifices and control bacterialovergrowth, which may be important, considering evidencesuggesting that bacterial burden plays a role in dry eye evenin the absence of frank blepharitis. According to the results of 1 study, bacterial colonization of the lid margin wassignificantly higher in patients with dry eye compared withunaffected controls.45 A tea tree oil-based lid scrub caneradicate Demodex mites and reduce inflammation.46 Thetea tree oil-based lid scrub also has been shown to haveactivity against normal bacterial flora colonizing the lids.47

Various products and techniques to facilitate meibomiangland expression and to relieve obstruction have beenintroduced for in-office use. Among these is thermal pulsationtherapy that delivers heat and pulsatile pressure to the lids.48

Forceful expression also can be performed using acommercially available paddle and gland expressor. And, Korband Blackie have reported on their use of a golf club spud tomechanically debride the keratinized cells from the lid marginover the meibomian gland orifices in order to enableexpression of meibum from the glands.49 Intraductal probing

Counseling for Cyclosporine TreatmentInitiation32

Make sure patients understand that dry eye is achronic disease requiring long-term treatment.

Explain that cyclosporine reduces inflammation andincreases natural tear production. While the time toonset of benefit is variable, the level of improvementincreases with ongoing treatment.

Caution patients that they may experience stingingand burning with cyclosporine instillation, but thatthose side effects generally dissipate as treatmentcontinues.

Suggest keeping the cyclosporine refrigerated toimprove instillation comfort.

If prescribing a corticosteroid along with cyclosporine,instruct patients to wait 10 to 15 minutes betweendrop instillations.

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of obstructed meibomian glands and intense pulsed lighttherapy also have been reported to improve symptoms.50,51

Topical antibiotics and tetracyclines. Lid scrubs andtopical antibiotics are more effective and safer than oralantibiotics for addressing excessive bacterial burden on thelid margin. Bacitracin has retained good activity against thegram-positive organisms found on the lids and has a low riskfor causing allergic or contact dermatitis. Topical azithromycinprovides both anti-inflammatory and antimicrobial activityand has been reported effective for treating anterior andposterior blepharitis.52 Treatment of MGD with azithromycinis off-label. One approach is to continue its use until thecondition appears improved and then to maintain treatmentusing a pulse regimen of 1 week per month.

A fixed-combination topical antibiotic-corticosteroid can beused in patients with more significant evidence of lid margininflammation, but should be prescribed for short-course useonly because of safety concerns with the corticosteroid.

Tetracyclines have multiple actions that may be beneficial intreating MGD, including anti-inflammatory properties andeffects on bacterial lipase production, the composition and quality of meibomian gland secretions, and MMPexpression.21 A low, subantimicrobial dose provides anti-inflammatory action with good tolerability, and may beparticularly indicated in patients with concurrent rosacea.Results from a randomized study conducted by Koreaninvestigators showed doxycycline 20 mg twice a day and 200 mg twice a day were similarly effective for treatingpatients with MGD refractory to conventional therapy.53

Managing Dry Eye in Patients Wearing Contact LensesContact lens-related dry eye has been reported to affect asmany as 50% of lens wearers and is a leading cause ofcontact lens intolerance and dropout.54 The presence of acontact lens on the eye can lead to dry eye via multiplepossible mechanisms. The lens itself can absorb moisturefrom the tear film and alter the tear film, creating a prelenslayer with reduced stability and a higher evaporation ratethan normal. Deposits on the lens surface also can perturbthe prelens tear film as well as reduce lens wettability andcause irritation to the palpebral tissues that are constantlywiping over its surface.

Evidence also is accumulating to support the idea thatcontact lens wear causes dry eye by adversely affectingmeibomian gland function and the lid wiper area.55 However,it is believed that LWE in contact lens wearers and LWE innon-contact lens wearers are different conditions, and theclinical significance of the findings in relation to contact lenswear and the potential of LWE to affect management of dryeye in contact lens wearers has yet to be determined.

A thorough history and examination will help to sort out if apatient’s report of contact lens discomfort is due to dry eyeor to contact lens-related issues (eg, improper fit, physicaldefects, surface deposits), or both. The information obtainedwill allow a targeted approach to intervention that willenable patients to continue with contact lens wear.

In patients who are generally able to maintain their usualwear schedule but are complaining of end-of-the-daydryness, it is worth probing whether there have been anychanges in their environment that can cause dry eye. Anotherissue to consider: Is the patient using cosmetics or personalcare products on the lids and skin around the eyes that canbe adhering to the lens surface and causing problems withdry eye or irritation? MGD or Demodex infestation of the lash follicles also should be identified and treated becausethe problems associated with these conditions can beexacerbated by contact lens wear in that the lens provides a reservoir for adherence of foreign materials and antigens.In addition, patients should be queried to determine theirlens wear and care habits, including daily duration of wear,adherence to the recommended replacement schedule, and methods and specific products used for cleaning and disinfection.

If the patient has dry eye and is wearing a lens that has been functioning well optically, it may be reasonable tochange care solutions. Multipurpose disinfecting solutionsare formulated with various combinations of disinfectants,surfactants, moisturizing agents, and buffering agents.Contemporary care systems are unique in that they havebeen developed in the era of silicone hydrogel contact lenses and have been specifically formulated to optimize the comfort of both silicone hydrogel and hydrogel lenses(Table 5). Practitioners should query patients about their use of store-brand products that often do not contain the sameingredients as the innovator brand they aim to mimic. Inparticular, the store-brand product may be lacking in theoptimal moisturizing agents that are found in recentlydeveloped multipurpose disinfecting solution products,agents that may be especially beneficial in patients with dry eye; also, store-brand products may change ingredientswithout any notification.

Table 5. Contemporary Multipurpose Disinfecting Solutions

Product Preservatives/DisinfectantsSurfactant, Lubricant,and Wetting Agents

Biotruea polyquaternium,polyaminopropyl biguanide

hyaluronan; poloxamine

OPTI-FREEPureMoistb

polyquaternium-1,myristamidopropyldimethylamine

TETRONIC 1304,HydraGlyde MoistureMatrix

RevitaLensOcuTecc

polyquaternium-1, alexidinedihydrochloride

TETRONIC 904

ahttp://solution.biotrue.com/biotrue-packaging-insert.pdfbhttp://www.opti-free.com/pdfs/OFPureMoist_us_en.pdfchttp://www.yourhealthyeyes.com/instructions-for-use/revitalens-ocutec-multi-purpose-disinfecting-solution/

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In order to help patients reduce irritation from deposit build-up on the lens and to improve lens wetting in patientswith dry eye, practitioners might also recommend use of asurfactant cleaner. For those patients who seem to presentwith preservative sensitivities, a hydrogen peroxide-basedsystem would work well. Preservative sensitivity symptomscan be similar to dry eye symptoms, and removing thistrigger can increase comfort in individuals so affected.

The next step would be to switch lenses in an attempt tooptimize patient comfort. A daily disposable lens may be a logical choice if one is available that meets the patient’soptical needs, because it would minimize irritation andinflammation caused by deposits on the lens surface.56 Thereare a number of options in the realm of daily disposable lenses to offer patients. It is difficult to make definitiverecommendations about preferences for specific lensesbecause the interactions of the lens with the tear film and withthe ocular surface result in a complex issue mediated by avariety of factors (eg, surface treatment, propensity for build-up,water content), and because there are conflicting data in theliterature from studies evaluating the potential benefits ofswitching to different lens materials. Certainly many patientshave done well wearing daily disposable hydrogel lenses.Silicone hydrogel lenses are a newer introduction to the dailydisposable armamentarium that provide higher oxygenpermeability than the hydrogel materials.

A new water gradient contact lens made of delefilcon A isthe latest addition to the technology available in dailydisposable lenses. This lens has a high dK silicone hydrogelcore, but its outer layer, which makes up approximately 10%of the lens thickness, is a non-silicone hydrophilic polymer.The silicone hydrogel core material has a water content of33%, while the water content of the non-silicone hydrophilicpolymer is >80%, on average, and approaches 100% at itsoutermost surface, thus providing exceptional lubricity.57 Thedelefilcon A lens has been shown to have less effect on theprelens tear film surface quality than does a daily disposablehydrogel lens made of nelficon A.58 On the basis of itssurface characteristics, the water gradient technology lensmight be a good option for patients with dry eye.

Scleral contact lenses can work extremely well in patientswith severe dry eye because they provide an oxygenatedfluid reservoir over the damaged ocular surface that protectsthe cornea and helps to improve vision.59-61

Topical Treatment Issues Patients wearing soft contact lenses who are being treatedwith topical medications for dry eye need to be instructednot to instill the drops while wearing their contact lenses and to wait 10 to 15 minutes after dosing before lensinsertion. Only a few specific artificial tears are approved foruse while a contact lens is in the eye. Some practitioners arecomfortable recommending such use with certain otherproducts off-label.62 Considering the risks of IOP elevation,cataract formation, and secondary infection withcorticosteroid treatment, it is best that patients abstain fromcontact lens wear while using a topical corticosteroid.

Gas permeable lens materials do not absorb medications,and any medication that does adhere to the lens surface canbe effectively removed with proper cleaning. However, theimportance of meticulous cleaning must be reinforced aswell as instructions about not dosing the medication with thelens in the eye and waiting until after medication dosing toinsert the lens. Topical cyclosporine should not be used inpatients wearing scleral lenses because the emulsion vehicleaccumulates underneath the lens and causes cloudy vision.

conclusionDry eye is extremely common among patients seen inoptometric practices and is a leading reason for dropoutfrom contact lens wear. Dry eye is a multifactorial disease,and so a thorough history and examination are necessarynot only for diagnosis, but also to identify its underlyingcauses. Successful management to restore the normal tear film, rehabilitate the ocular surface, and mitigateinflammation will provide symptomatic relief, improve visualfunction, and prevent permanent tissue damage. A clearunderstanding of techniques for diagnosing dry eye and of current treatment modalities will enable optometrists to optimize patient care and outcomes.

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47. Gilbard JP, Douyon Y, Huson RB. Cornea. 2010;29(5):559-563.48. Lane SS, DuBiner HB, Epstein RJ, et al. A new system, the LipiFlow, for the

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59. Alipour F, Kheirkhah A, Jabarvand Behrouz M. Use of mini scleral contactlenses in moderate to severe dry eye. Cont Lens Anterior Eye. 2012;35(6):272-276.

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To Obtain COPE Credit Online and Instant CertificateTo obtain COPE CE Credit for this activity, read the material in its entirety and consult referenced sources as necessary. We offer instant certificate processing and support Green CE. Please take this post test and evaluation online by going tohttp://tinyurl.com/OcularSurface2. Upon passing, you will receive your certificate immediately. You must score 70% orhigher to receive credit for this activity, and may take the test up to 2 times.

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