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Doctors of Optometry | Course Notes

OD2 – 1CE – COPE: 48272-AS

Straight Outta Tears – Treating & Managing MGD, Lid Bugs & Other Lid Thugs

Saturday, February 25, 2017

8:40 am – 9:35 am Plaza A/B – 2nd Floor

Presenter: Marc Bloomenstein, OD, FAAO

Dr. Marc Bloomenstein is an accomplished optometrist who lectures and publishes extensively in the fields of anterior segment disease and refractive surgery. Dr. Bloomenstein is at the Schwartz Laser Eye Center and is on the editorial board of Primary Care of Optometry and Contemporary Optometry. Dr. Bloomenstein served as the President of the Arizona Optometric Association, as well as an Optometric Advisor to STAAR Surgical and Medtronics Solan and is now the President of the Board of the Arizona Optometric Charitable Foundation. He graduated in 1990 from the University of California, Los Angeles with a degree in Biology, and received his optometric degree from the New England College of Optometry in 1994. After graduation, Dr. Bloomenstein finished a residency in secondary ophthalmic care at the Barnet Dulaney Eye Center in Phoenix, Arizona. He received his fellowship from the American Academy of Optometry in December 1998 and is a founding member of the Optometric Council on Refractive Technology. Moreover, Dr. Bloomenstein is an Adjunct Assistant Professor at the Southern California College of Optometry and New England College of Optometry.

Course Description

This course will focus on the eyelids and all the nasty and unsavory creatures that affect eye health. The advent of new diagnostic equipment has enabled clinicians to make point of service differentiating. Treatment options can range from over the counter management, to prescription medications, as well as office procedures. Getting the lids right will make the vision tight.

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Doctors of Optometry | Course Notes

NOTES:

Straight Out of Tears:Treating and Managing MGD,

Lid Bugs and Other Lid Thugs!

Marc R. Bloomenstein, OD, FAAO

Scottsdale, AZ

Disclosure

• Presenter is on speakers panel of: Akorn, Alcon, Allergan, AMO,

B+ L, BlephEX, Lunovas, OcuSOFT, Tear Lab

• President of MRB Eye Consultants

• AOA CE Chairman

• Past-President of the Optometric Council on Refractive Technology

(OCRT)

• OSSO Board Member

• Presenter has NO financial interest in any products mentioned

EyetubeOD.com

Incidence and Prevalence of “Dry Eye”

• 25% of teen-adults

• 28 million experience symptoms frequently

• 2015 Gallup Poll-

– 30 million Americans affected

Proactive and Preventive

• Risk Factors for Ocular Surface Inflammation

– Females

– Sjogren’s

– Aging

– Environmental Issuse

– Refractive Surgery

– Vitamin deficiency

– Medications

Sea Change• Managing the disease in the chair

– Insurance visits

• Glaucoma model

• 3-4 visits a year

– Compensation

• Vision “plan”

• Medical Insurance

• Cash pay-ABN

Sea Change

–Patient retention

–Patient referrals

–Cutting Edge Treatment

Symptoms

• #1 most important –

VISION CHANGES

– Blurred

– Fluctuating

– Hazy

– Refractive changes

• Pain

– Light sensitivity

– Gritty

• Redness

– Lid margin

– Conjunctival

• Itch

Signs, Signs, everywhere Signs!

• Lid Debris

– Frothy tears

– “collarettes”

Anterior Blepharitis

Seborrheic Blepharitis

Signs and Symptoms

Morning crusting

Foreign body

sensation

Recurrent hordeola

Loss of lashes

Conjunctival hyperemia

Collarretes

(scales that

encircle lash)

Staph

immune disease

• Phlyctenula

• Pannus

• Catarrhal infiltrates

• etc

Sequelae to Blepharitis

Blepharitis

Chalazia / hordeola

Dry eyesPunctate keratitis

Phlyctenules“Recurrent

conjunctivitis”Pannus

Corneal ulceration

Endophthalmitis

MGD

Pathophysiology ofMeibomian Gland Disease

• Normal meibomian gland secretions convert from

unsaturated lipids that melt at body temperature

to saturated fats that inspissate the meibomian

glands

• Lid bacteria secrete lipases that break down lipids

from soaps to fatty acids

Bacterial Lipases BreakDown Lipids to Soaps

NON-OBVIOUS MGD

Photos courtesy of Justin Webb, OD, Alcon Research Ltd., 2010.

Remove those pesky caps:

MacGruber!

Examples of meibum stagnation and changes that correspond to MGD

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Clear liquid secretion (glands are functional using the MGE)

Cloudy liquid secretion(glands are functional using the MGE)

Opaque solid secretion (glands not functional;

requires more force than the MGE)

Opaque solid secretion (glands not functional;

requires more force than the MGE)

Absence of secretion(glands not functional; even significant force does not yield

secretion)

Notching at gland orifice (indicates

atrophy/drop out)

Blepharitis

Blepharitis

Anterior

Posterior

Inflammation

mainly

centered

around the

eyelash and

follicles

Inflammation

that involves

the meibomian

gland orifices

Is the most common and arguably the most important diagnosis presenting to the optometry

BIOFILM

The Biofilm

• Biofilm: A biofilm community can be formed by a single

bacterial species, but in nature biofilms almost always

consist of rich mixtures of many species of bacteria in a

polysaccharide matrix

– Thrives in moisture

– Smooth surface

– Bacteria

BlephEx Treatment

3

2

BlephEx Treatment

3

3

Treatment

Blepharitis….MGD

ADJUNCTIVE THERAPY

FOR MGD

Lipid/Oil-Based Lubricant Eye Drops

Palliative – None treat the causeDownside can be blurring & stinging with castor oil emulsions

Retaine® MGDTM

• A main issue is the loss of product while

blinking

• A unique cationic oil-in-water

nanoemulsion addresses unmet needs

– Lipid compound + innovative cationic

(positively charged) technology

• Better attraction to the ocular surface

→ Improvement of the residence time

• Better spreading on the ocular surface

→ Better adsorption

• Enhanced tear film and corneal

epithelium1,2

Introducing the cationic

emulsion

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1. Lallemand F, et al. J Drug Deliv. 2012;2012:604204.2. Daull P, et al., Benefits of cetalkonium chloride cationic oil-in-water nanoemulsions for topical ophthalmic drug delivery. Draft for publication, 2013.

OILY CORE

SURFACTANT

CATIONIC AGENT

Solubilizes the drugs

Stabilizes the interface

Brings the positive charges

Seborrheic Blepharitis

Seborrheic blepharitis is caused by

seborrheic dermatitis, a skin condition that

creates flaking and scaling — including on the

eyelids. Regular cleansing with eyelid scrubs

can provide significant relief and improve the

appearance of eyelids.

Signs and Symptoms

Red, irritated, itchy eyelids and the formation

of dandruff-like scales on the eyelashes.

Seborrheic Blepharitis (continued)

Take Home Recommendation

OCuSOFT ® Lid Scrub ® Eyelid Cleanser

Original Formula

OCuSOFT ® Lid Scrub ® removes oil, debris,

and desquamated skin from the eyelids and

is non-irritating to the eyes.

41M15-056 12/15

TheraTears® SteriLid®

Soothes and Cleanses Away External IrritantsTheraTears® Sterilid® removes oil, debris and other contaminants that can accumulate on eyelids and eyelashes.

Need More Eyelid Relief

The root cause of anterior blephartitis is the

overproduction of oils. Mild surfactants in

OCuSOFT® Lid Scrub® PLUS eyelid

cleanser act to dissolve and remove oil,

debris, and desquamated skin. Other

formulas do not.

Hypochlorous Acid is produced by white

blood cells as part of the body’s natural

defense mechanism against pathogens.

What Is Hypochlorous Acid?

Hypochlorous acid is a weak acid that is

formed when chlorine dissolves in water.

Its chemical formula is HOCL. An acid is

a pH below 7 (neutral). Above 7 is

considered base/basic or alkaline. Tap

water is generally a pH of 7 whereas

citric acid from lemons is highly acidic at

around a 2. The pH of HOCL is between

6-7.

Hypochlorous Acid

HypoChlor

OCuSOFT® HypoChlor™ is a

0.02% concentration of

Hypochlorous acid in both

Spray and Gel formulation

Avenova

NovaBay Avenova with Neutrox

is a 0.01% concentration of

Hypochlorous acid

Best MGD Treatment

• Warm up the lids

• In office expression

• Retaine MGD/RESTASIS (cyclosporine

0.05%)

• Low dose tetracycline derivatives

• LipiFlow for Severe Cases

• Omega fatty acids

• Get the patient early!

Inflammatory Dry Eye Alters the Tear Film

Dry Eye Disease reduces mucins, and alters concentrations of growth factors and tear proteins1,2. Fewer tears can lead to increased inflammatory output from the lacrimal gland, which can cause ocular surface damage and altered tear production. The resulting chronic inflammatory stimuli can then lead to further decreased tear production3-5

Image used with permission.

Treating The Inflammation• Restasis (Allergan)

– Primary treatment option

– Multiple mediators of inflammatory

cascade

– Increase goblet cells density and

emulsion vehicle

– Proven

• Steroids

• Amniotic Membrane

Demodex

That other Thug!

HANDBOOK OF MEDICAL

ENTOMOLOGY

Dr. WM. A. RILEY, Professor of Insect

Morphology and Parasitology,

Cornell University

Dr. O. A. JOHANNSEN, Professor of

Biology, Cornell University

1915

Rosacea and Demodex?• Rosacea and demodex

– Meta-analysis of 48 studies

– 10 different countries

– 28,527 subjects

– Rosacea patients 7-8x chance have Demodex

Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the

association between Demodex infestation and rosacea. Arch

Dermatol 2010;146:896Y902.

Remember Biofilm….

Biofilm is a polysacharride

Perfect food source for a Demodex infestation

MICROBLEPHAROEXFOLIATION (MBE) Doctor centered approach to lid health

Spins a micro-sponge 2,500 RPM along margin

Results in completely clean lids

Repeated every 4-6 monthsPrivate pay procedure,

typically $150-$250

In Office Treatment

• Patients with heavy scruff may need an in office

treatment to remove scruff (Blephex) or TTO will never

get to the target.

• I use of Cliradex/ Oust for those recalcitrant cases

• Typically doing 2 different in office TTO, rarely third

• Maintenance on: Cliradex, Oust, BlephaDex

Demodex Infestation of the Eyelids

Recommended Treatment

In-office procedure: Cleanse eyelids and

eyelashes in-office utilizing OCuSOFT® Lid

Scrub® PLUS Swabstix™ and Oust™

Demodex® Swabstix™.

Oust™ Demodex® Swabstix™ contain 50%

Tea Tree Oil, 40% Sea Buckthorn Oil, and

10% Caprylic Acid. These single-use,

disposable, self-saturating Swabstix™

provide convenient in-office use to effectively

eradicate demodex and remove oil, debris,

and other contaminants on the eyelids in-

office. A complete Demodex Kit is available

for in-office use.

BlephaDex

• Aqua

• Coconut Oil

• Glycerol

• Aloe Barbadensis Gel

• Sodium Lauryl Sulfate

• Cocoamidopropyl Betaine

• DMDM Hydantoin

• Laurel Glucoside

• Melaleuca Alternifolia( Tea Tree) Leaf

Oil

Easier Way To Start In-Office

• Regular Maintenance-Like teeth cleaning

– Use Blephadex swab, with BlephEx, for annual

(bi-annual) in office treatment

– At-home treatment with Blephadex pads or foam

• Continue to use everyday for maintenance

Treatment Goal:

• NOT to eradicate 100%

• Want to knock down the “load” and reduce symptoms

– Watering

– Crusting

– Itching of lids

• Like to see some visible reduction in cylindrical

dandruff

• Improve redness profile of eye, lid and face

Conclusion

• Differentiate the condition in your practice

• Think Biofilm

– Remove the debris

– In-office treatments

• Have the options in your practice

– Provide options

– Utilize the products

• New comfortable Demodex treatments