powerpoint presentation to avenova bid ou in 2 weeks 27 demodex ... ocular surface discomfort and...

3/17/2017

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Ocular Surface Disease: The Medical Business of Dry Eye: A Comprehensive Course on OSD Evaluation, Diagnosis, and Treatmetn Strategies

Jack Schaeffer OD FAAO

Doug Devries OD FAAO

Milton Hom OD FAAO

Dr Jack L. Schaeffer

financial disclosure form

Alcon

Allergan AMO / Abbott

Bausch and Lomb Ciba Vision

Cooper Vision Essilor Hoya

Inspire Optos

Optovue Zeis Vision

Disclosures

Last 12 months: Dr Milton Hom

Allergan

Bausch/Valeant

Shire

Sun

Disclosures

Douglas K. Devries

Consultant or Speakers Bureau for

Allergan

AMO

TearLab

NicOx

BVI

B&L

DEWS

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.

Dry eye is not just a

disease,

it’s a complex, multi-

factorial disorder.

Dry Eye Evaluation

Vision care Exam

CONVERSION

Medical Exam

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DIAGNOSTIC TESTS

TEAR EVALUATION

Tear Meniscus

TFBUT

Osmolarity

Evidence of Fluorescein Staining

Tear Consistency-i.e. thickness, debris, evidence of meibomian gland oil and sebaceous secretions

Shirmers

DIAGNOSTIC TESTS

Schirmer--w/ or w/o anesthetic

Phenol Red Thread Test

Zone Quick-represents fluid present in the conjunctival sac

Fluorescein Staining

Rose Bengal Staining

Lissamine Green Staining

Tear Osmolarity

Collagen Plugs

Schaeffer Shirmer

Always do this as the last test

Place strip in any part of the eye

Count to three

remove

Tear Osmolarity

Osmolarity Provides

Improved Standard of Care Tear osmolarity is the most accurate diagnostic test for dry

eye disease

Elevated osmolarity is the central mechanism causing

ocular surface damage

Allows a physician to rapidly diagnose & classify patients with

a global assessment

In combination with a slit lamp exam, physicians can select

therapies based on mechanism of disease and severity

Modulate therapy using a quantitative endpoint

Tomlinson A, IOVS 2006. DEWS Ocular Surf 2007

Dry Eye Disease and MMP-9

Matrix metalloproteinases (MMP) are proteolytic enzymes that are produced by stressed epithelial cells on the ocular surface1

MMP-9 in Tears Non-specific inflammatory marker Normal range between 3-41 ng/ml More sensitive diagnostic marker than clinical

signs1 Correlates with clinical exam findings1 Ocular surface disease (dry eye) demonstrates

elevated levels of MMP-9 in tears1

[1] Chotiakavanich S, de Paiva CS, Li de Quan, et al. Invest Ophthalmol Vis Sci 2009; 50(7): 3203-3209.

Dry Eye Disease and MMP-9

Increased concentrations of MMP-9 can be found in other diseases or conditions, including:

Ocular rosacea

Meibomian gland disease

Sjögren’s syndrome

Corneal ulcers

Corneal erosions

Patient /Busy Doctor

64 YOM

History of Dry eye with all signs and symptoms

Restasis

UNG PM

PP

PFAT

Signs / symptoms vary at each visit over a year

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Systemic Disease

Diabetes

Rheumatoid Arthritis

Sjogren’s syndrome

Thyroid Eye Disease

Rosacea

Sleep Apnea

Graft Vs Host Disease

Many others

TBUT vs ABMD Causes of Clinical Dry Eye

Mucin deficiency

Goblet cell dysfunction

Epithelial surface disease

Aqueous deficiency

Lacrimal gland dysfunction

Keratoconjunctivitis sicca

Meibum deficiency

Meibomian gland disease

Evaporative dry eye

Lid Disease

We cannot treat the dry eye until we understand and treat

LWE

MGD

Blepharitis

Epihora

IT IS ALL ABOUT THE LIDS

Case #2

52 year old, white female

Occupation: Web designer

Hobbies: Pinterest on her iPad, reading, yoga

Ocular history: Dry Eye Disease, mild cataracts

Medical history: Occasional migraine headaches, mild hypertension

Meds: Lorazepam, Cymbalta, flax seed oil

Case #2

Complaint Dry symptoms worsening, “OTC’s don’t work,”

Associated symptoms

Eye fatigue, discomfort, worsening in the evening, often matted

Effect to ADL’s Effects work, limits reading

Medications for DED

Similasan “Dry Eye Relief” (has used “all” artificial tears), warm compresses, cold packs

Case #2

cc DVA 20/20 OD 20/20 OS

EOMs FROM OU

Pupils ERRL(-)APD

SPEED 14/28

OSDI 54/100

Inflammadry

Negative

NIKBUT (initial)

4.72 OD 4.33 OS

Osm 294 OD 277 OS

Case #2

Visit 3:

Patient reports significant improvement and relief

ADL’s not effected at the end of the day

Continuing Cliradex qhs OU and Systane Balance QID OU

Switching to Avenova BID OU in 2 weeks

27

Demodex

Ubiquitous obligatory ectoparasites of man

Two forms: D. brevis and D. folliculorum

Lifecycle of 14.5 days

Negatively phototaxic

Move in dark environment, stop with bright ones

Lacey N et al. Demodex Mites – Commensals, Parasites or

Mutualistic Organisms? Dermatology 2011;222:128–130

3/17/2017

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28

Demodex

84% of patients at 60, 100% over 70

Increased incidence with:

Age

Immunocompromised

Skin disorders (Rosacea)

Eye environment- increased pH and amino acids

Lacey N et al. Demodex Mites – Commensals, Parasites or

Mutualistic Organisms? Dermatology 2011;222:128–130 29

Demodex

Blepharitis secondary to demodex consuming epithelial cells

Micro-abrasions causes reactive hyper-keratinization which leads to cylindrical dandruff

Liu J et al. Pathogenic role of Demodex mites in blepharitis

Curr Opin Allergy Clin Immunol. Oct 2010; 10(5): 505–510. 30

Demodex Treatment

50% TTO in-office weekly, 10% TTO wipes bid OU

5% TTO ointment massage

Gao YY et al. Treatment of Ocular Itching Associated With Ocular Demodicosis

by 5% Tea Tree Oil Ointment. Cornea. Jan 2012: 31(1), 14-17.

Ocular Surface Discomfort and Demodex: Effect of Tea Tree Oil Eyelid Scrub in

Demodex Blepharitis J Korean Med Sci. Dec 2012 27(12), 1574-9.

31

Demodex Treatment

Commercially available:

Cliradex- 25% TTO wipe

OcuSoft Demodex kit (for in-office)

MGD

Treatments

Age and Gender

Cosmetics

Inflammation vs. Obstruction

Cosmetics

“Volatile organic compounds (VOCs) are emitted as gases from certain solids or liquids.”

-EPA https://www.epa.gov/indoor-air-quality-iaq/volatile-organic-compounds-

impact-indoor-air-quality

“VOCs include a variety of

chemicals, some of which may

have short- and long-term

adverse health effects.”

-EPA

https://www.epa.gov/indoor-air-quality-iaq/volatile-organic-compounds-

impact-indoor-air-quality https://www.epa.gov/indoor-air-quality-iaq/volatile-organic-compounds-

impact-indoor-air-quality

https://www.epa.gov/indoor-air-quality-iaq/volatile-organic-compounds-impact-indoor-air-quality




























































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https://www.epa.gov/indoor-air-quality-iaq/volatile-organic-compounds-

impact-indoor-air-quality https://www.google.com/patents/EP1257813A4?cl=en https://www.google.com/patents/EP1257813A4?cl=en

“Only 11% of patients have had a

conversation with their eye care

provider about makeup”

O’Dell LE. Periman LM. Sullivan AG. Hom MM. Cosmetics Can Compromise Eye Health: Clinical Awareness

Necessary Optom Vis Sci 2016 American Academy of Optometry, Anaheim, CA, DOI: 10.13140/RG.2.2.28180.09602



Do your eyes feel more comfortable

without makeup use?

YES 41.4%

(99/169)



Do your eyes itch with cosmetic use?

YES 22.5%

(38/169)



Are your eyes red with cosmetic use?

YES 17.1%

(29/169)



Have you ever discontinued use of

makeup due to eye irritation?

YES 15.3%

(26/169)



92.2% No





















3/17/2017

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71% No



64.5% No

http://healthy-family.org/eyelid-rash-dry-red-itchy-skin/2/

https://hpd.nlm.nih.gov/index.htm

Aizawa, A., Ito, A., Masui, Y., & Ito, M. (2014). Case of allergic contact dermatitis due to 1, 3‐butylene glycol. The Journal of dermatology, 41(9), 815-816.

SUGIURA, Mariko, et al. "Results of patch testing with 1, 3-butylene glycol from 1994 to 1999." Environmental

dermatology: the official journal of the Japanese Society for Contact Dermatitis 8.1 (2001): 1-5.

IKEZAWA, Yuko, et al. "Two cases of contact dermatitis due to 1, 3-butylene glycol." Journal of environmental

dermatology: the official journal of the Japanese Society for Contact Dermatitis 11.3 (2002): 59-64.

Oiso, Naoki, Kazuyoshi Fukai, and Masamitsu Ishii. "Allergic contact dermatitis due to 1, 3‐butylene glycol in

medicaments." Contact dermatitis 51.1 (2004): 40-41.

YASHIRO, Kyoko, and Masayoshi NISHIMOTO. "A case of contact dermatitis due to 1, 3-butylene glycol and trisodium hydroxyethyl ethylenediamine triacetate." Environmental dermatology: the official journal of the Japanese Society for

Contact Dermatitis 10.1 (2003): 14-20.

Matsunaga, K., et al. "Allergic contact dermatitis from 1, 3-butylene glycol." Allergy Pract 14 (1994): 492-495.

Thorén, Sara. "Contact allergens in ‘natural’hair dyes." Contact dermatitis 74.5 (2016): 302-304.

Scognamiglio, J., et al. "Fragrance material review on 2-phenoxyethanol." Food and chemical toxicology 50

(2012): S244-S255.

Travassos, Ana Rita, et al. "Non‐fragrance allergens in specific cosmetic products." Contact Dermatitis 65.5

(2011): 276-285.

Birnie, Andrew J., and John S. English. "2‐phenoxyethanol‐induced contact urticaria." Contact dermatitis 54.6

(2006): 349-349.

Baylor, Peter A., Juan R. Sobenes, and Val Vallyathan. "Interstitial pulmonary

fibrosis and progressive massive fibrosis related to smoking

methamphetamine with talc as filler." Respiratory care 58.5 (2013): e53-e55.

Cruthirds, Terry P., Francis H. Cole, and Raphael N. Paul. "Pulmonary

talcosis as a result of massive aspiration of baby powder." Southern medical

journal 70.5 (1977): 626-628.

Inhalational talc pneumoconiosis: radiographic and CT findings in 14 patients

"Samosa" pneumoconiosis: a case of pulmonary talcosis uncovered during a

medicolegal autopsy

http://healthy-family.org/eyelid-rash-dry-red-itchy-skin/

“Bismuth Oxychloride is very

much like arsenic chemically,

which is a poison if you ingest it.”


“If your skin becomes itchy and

pink after wearing mineral makeup

with bismuth oxychloride you may

develop a severe rash or acne

over time.”



3/17/2017

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“Why do cosmetic companies use bismuth

oxychloride? It hides flaws, and is an

inexpensive filler that helps keep the

makeup sticking to your skin over the

course of the day.”


Bare Minerals

Jane Iredale

Philosophy

La Bella Donna

Youngblood


“Mica is

colorless but has

sharp edges

when you see it

under a

microscope.”


“rubbing mica on their skin can

cause inflammation, redness, and

itching.”

253 people Wearing makeup 4.99 days/wk SPEED 8.19 (0 to 28) UNC = 3.28 (0 to 10) O’Dell LE. et. al. Accepted for publication ARVO 2017

No eye make up remover

SPEED 10.5

Use eye make up removers

SPEED 7.6

P=0.0004 O’Dell LE. et. al. Accepted for publication ARVO 2017

SPEED Asymptomatic 2.2

Mild 5.0

Moderate 6.6

Severe 9.9

Asiedu, Kofi, et al. "Ocular surface disease Index (OSDI) versus the

standard patient evaluation of eye dryness (SPEED): a study of a

nonclinical sample." Cornea 35.2 (2016): 175-180.

Tips Read the label

Look up at US. Department HHS site (https://hpd.nlm.nih.gov/index.htm)

Not all VOCs will irritate; patient dependent

Look at order of ingredients

Concentrations matter

Rotate make-up if possible (decrease hypersensitivity risk)

Remove make-up nightly for greatest comfort

Eyelid cleansers

Avoid exfoliation beads (Leslie Gallagher)

Baby oil (Louise Sclafani)

Avoid fiber-based mascaras

Use water soluble cosmetics (Glenda Secor)

Disclosures

Last 12 months:

Allergan

Bausch/Valeant

Shire

Sun


3/17/2017

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MGD

Treatments

Age and Gender

Cosmetics

Inflammation vs. Obstruction

Lid margin disease

Meibomian gland

dysfunction (MGD)

Evaporative dry eye

Blackie, Caroline A., and Donald R. Korb. "MGD: getting to the root cause of dry eye: Review of Optometry

149.6 (2012): 30-37. Nelson JD, Shimazaki J, Benitez-del-Castillo JM, et al. The international workshop on meibomian gland

dysfunction: report of the definition and classification subcommittee. Invest Ophthalmol Vis Sci. 2011 Mar 30;52(4):1930-7.

“MGD is currently thought to

be the leading cause of dry

eye.” Caroline Blackie

Donald Korb




“MGD is currently thought to

be the leading cause of dry

eye.” Caroline Blackie

Donald Korb

Lemp, Michael A., et al. "Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient

cohort: a retrospective study." Cornea 31.5 (2012): 472-478.

299 normal

DED patients (M:81 F:218)

10 sites European Union & US

Lemp, Michael A., et al. "Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient

cohort: a retrospective study." Cornea 31.5 (2012): 472-478.

“Overall, 86% of these qualified

DED patients demonstrated

signs of MGD.” Michael Lemp

What triggers you to perform a

dry eye evaluation?

A. Symptoms

B. Signs

C. Both

Schachter A. Schachter S. Hom MM. Asymptomatic Meibomian Gland

Dysfunction Invest Ophthalmol Vis Sci 2016;57:ARVO E-Abstract:5672.

DOI: 10.13140/RG.2.1.2032.2161

“Of patients with meibomian

gland atrophy…60%…were

asymptomatic”

Schachter S. Schachter A. O’Dell LE. Hom MM. A Dry Eye Survey of

Practicing Optometrists. Optom Vis Sci 2016 American Academy of

Optometry, Anaheim, CA, DOI: 10.13140/RG.2.2.22026.26565

“Only 30% of respondents

routinely test for MGD in

their comprehensive

examinations”

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Obstruction vs inflammation Two camps: Obstruction

Inflammatory

Obstruction




“Obstructive MGD is the

most common form of MGD

resulting in dry eye.” Caroline Blackie

Donald Korb

Knop, Erich, et al. "The international workshop on meibomian gland dysfunction: report of the subcommittee on anatomy, physiology, and pathophysiology of the meibomian gland." Investigative ophthalmology & visual

science 52.4 (2011): 1938.

“hyperkeratinization is one

of the primary

components…of obstructive

MGD.”

Hyperkeratinization…disord

er of the cells lining the

inside of a hair follicle.”


science 52.4 (2011): 1938.

“normal function of these cells [is] to..slough off (desquamate)…this process is interrupted…dead skin cells do not leave the follicle…[due to] excess of keratin”


science 52.4 (2011): 1938.

“cohesion of cells

will block or

“cap”…or clog

the sebaceous/oil

duct.”

3/17/2017

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science 52.4 (2011): 1938.

“changes in the composition of

meibum…increase its viscosity or…can

reinforce keratinization.”

Inflammation

Obata H, et al. IOVS 2002;43:ARVO E-Abstract 60.


science 52.4 (2011): 1938.

“The definition and involvement

of inflammation in MGD have

been unclear in the past for

several reasons.”



science 52.4 (2011): 1938.

“Inflammatory leukocytes

are not apparent [in

atrophied glands]”



science 52.4 (2011): 1938.

“inflammation…does not

represent a major etiologic

factor in obstructive MGD”


science 52.4 (2011): 1938.

“inflammatory events [promoted] inside

the gland, in the periglandular

conjunctiva, on the lid margin, and on the ocular surface”

Inflammation: Heat (calor) Pain (dolor) Redness (rubor) Swelling (tumor) Celsus, 1st Century Rome

Inflammation: Heat (calor) Pain (dolor) Redness (rubor) Swelling (tumor) Celsus, 1st Century Rome

Meibomian Gland Dysfunction

Level one Treatment: Available to all Doctors

Medical :

In office and home Procedures

Level two Treatment: Specialized equipment needed

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1 Manual Expression

2 Miboflow

3 Lipiflow


and Management

Kelly K. Nichols, OD, MPH, PhD

FERV Professor

University of Houston College of Optometry

Chair, TFOS International Meibomian Gland Workshop

©KNichols 2012


• The TFOS Report of the International

Meibomian Gland Dysfunction Workshop

– Etiologies

– Definition/ Classification

– Epidemiology

– Clinical characteristics

– Diagnosis/ Management

– Contact lenses, surgical implications

©KNichols 2012

Current Dry Eye Definition

“Dry eye is a multifactorial

disease of the tears and

ocular surface that results in

symptoms of discomfort,

visual disturbance, and tear

instability with potential

damage to the ocular surface.

It is accompanied by

increased osmolarity of the

tear film and inflammation of

the ocular surface.”

©KNichols 2012

DEWS—Classification of Dry Eye

80% 20% 5% 65% 35%

©KNichols 2012

TFOS International MGD Workshop

• Over 65 International clinicians,

scientists, and industry participants

• 2+ year process

• Published in March 2011, IOVS

• #1 Most downloaded IOVS article for

the last 12 months

• Downloaded over 5500 times

• All MGD workshop reports are in the

“top 10”

• Translation into 12 languages

• www.tearfilm.org

The 65 Most-Frequently Read Articles in Invest. Ophthalmol. Vis. Sci. during October 2010 thru September 2011 -- updated monthly

Most-read rankings are recalculated at the beginning of the month and are based on full-text and pdf views.

1. Kelly K. Nichols, Gary N. Foulks, Anthony J. Bron, Ben J. Glasgow, Murat Dogru, Kazuo Tsubota, Michael A. Lemp, David A. Sullivan

The International Workshop on Meibomian Gland Dysfunction: Executive Summary

Invest Ophthalmol Vis Sci Mar 30, 2011; 52: 1922-1929. (In "Special Issue") [Full Text] [PDF]

(Read 5554 times)

2. Kelly K. Nichols

The International Workshop on Meibomian Gland Dysfunction: Introduction


(Read 5318 times)

3. Erich Knop, Nadja Knop, Thomas Millar, Hiroto Obata, David A. Sullivan

The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Anatomy, Physiology, and Pathophysiology of the Meibomian Gland


(Read 4663 times)

4. Alan Tomlinson, Anthony J. Bron, Donald R. Korb, Shiro Amano, Jerry R. Paugh, E. Ian Pearce, Richard Yee, Norihiko Yokoi, Reiko Arita,

Murat Dogru

The International Workshop on Meibomian Gland Dysfunction: Report of the Diagnosis Subcommittee


(Read 4074 times)

5. Gerd Geerling, Joseph Tauber, Christophe Baudouin, Eiki Goto, Yukihiro Matsumoto, Terrence O''Brien, Maurizio Rolando, Kazuo Tsubota, Kelly K. Nichols

The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Management and Treatment of Meibomian Gland Dysfunction


(Read 4027 times)

6. J. Daniel Nelson, Jun Shimazaki, Jose M. Benitez-del-Castillo, Jennifer P. Craig, James P. McCulley, Seika Den, Gary N. Foulks

The International Workshop on Meibomian Gland Dysfunction: Report of the Definition and Classification Subcommittee


(Read 3221 times)

7. Penny A. Asbell, Fiona J. Stapleton, Kerstin Wickström, Esen K. Akpek, Pasquale Aragona, Reza Dana, Michael A. Lemp, Kelly K. Nichols

The International Workshop on Meibomian Gland Dysfunction: Report of the Clinical Trials Subcommittee


(Read 2580 times)

8. Kari B. Green-Church, Igor Butovich, Mark Willcox, Douglas Borchman, Friedrich Paulsen, Stefano Barabino, Ben J. Glasgow

The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on Tear Film Lipids and Lipid–Protein Interactions in Health and Disease

Invest Ophthalmol Vis Sci Mar 30, 2011; 52: 1979-1993.

(In "Special Issue") [Full Text] [PDF]

(Read 2546 times)

9. Debra A. Schaumberg, Jason J. Nichols, Eric B. Papas, Louis Tong, Miki Uchino, Kelly K. Nichols

The International Workshop on Meibomian Gland Dysfunction: Report of the Subcommittee on the Epidemiology of, and

Associated Risk Factors for, MGD


(Read 2437 times)

©KNichols 2012

Lecture Description www.tearfilm.org

©KNichols 2012

Anatomy, Physiology and Pathophysiology of the

Meibomian Gland

Erich Knop, M.D., Ph.D. (Chair) Nadja Knop, M.D., Ph.D. Thomas J. Millar, Ph.D.

Hiroto Obata, M.D. David A. Sullivan, Ph.D.

©KNichols 2012

• Large sebaceous glands

• No direct contact to hair follicles

• Located in the tarsal plates

• Upper and lower eye lids

Meibomian Gland - ANATOMY

Modified and colored from Krstic H. Human microscopic anatomy. Springer Medizin Verlag 1991, (reproduced from Knop N & Knop E Ophthalmologe 2009; 106:872–883)

3/17/2017

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©KNichols 2012

• Length

• Follows the tarsus

• Number • More in upper lid (30-40) • Less in lower lid (20-30)

• Volume • Higher in upper lid (26µl vs. 13µl)

• Relative functional contribution (upper vs. lower) to the tear film lipid layer is unknown

Meibomian Gland - ANATOMY

Modified from Sobotta Atlas der Anatomie des Menschen. Urban & Schwarzenberg Verlag 1982, (reproduced from Knop N & Knop E. Ophthalmologe 2009; 106:872–883)

©KNichols 2012

Meibomian Gland – PATHOLOGY • Obstructive MGD leads to a progressive ductal

DILATATION and acinar ATROPHY

Fom Knop E & Knop N. Meibom-Drüsen Teil IV. Funktionelle Interaktionen in der Pathogenese der Dysfunktion (MGD). Ophthalmologe.2009;106:980–987

©KNichols 2012

Meibomian Gland Dysfunction Definition & Classification

J. Daniel Nelson, M.D. (Co-Chair)

Jun Shimazaki, M.D., Ph.D. (Co-Chair)

Jose M. Benitez-del-Castillo, M.D., Ph.D.

Jennifer Craig, Ph.D., MCOptom

James P. McCulley, M.D.

Seika Den, M.D., Ph.D.

Gary N. Foulks, M.D.

Evaluation, Diagnosis and Grading of Severity of


Alan Tomlinson, MCOpt, Ph.D. (Chair) E. Ian Pearce, Ph.D. Anthony J. Bron, F.R.C.S. Richard Yee, M.D. Donald R. Korb, O.D. Norihiko Yokoi, M.D., Ph.D. Shiro Amano, M.D., Ph.D. Reiko Arita, M.D., Ph.D. Jerry R. Paugh, O.D. Murat Dogru, M.D.

©KNichols 2012

Management and Therapy of Meibomian Gland

Dysfunction

Gerd Geerling, M.D. (Chair) Terrence O’Brien, M.D. Joseph Tauber, M.D. Maurizio Rolando, M.D. Christophe Baudouin, M.D., Ph.D. Kazuo Tsubota, M.D. Eiki Goto, M.D. Kelly K. Nichols, O.D., M.P.H., Ph.D. Yukihiro Matsumoto, M.D.

MGD

105

Under-Treated


How treating MGD improves your

practice

040215

MGD Exposed

A new look at an old problem

107

1. Foulks GN1, Nichols KK, Bron AJ, Holland EJ, et al. Improving awareness, ident ificat ion, and management of meibomian gland dy sfunct ion. Ophthalmology. 2012 Oct ;119(10 S uppl):S1-12.

2. M urakami DK, Blackie CA and Korb DR. The Prevalence of M eibomian Gland Dysfunct ion in a Caucasian Clinical Populat ion. ARV O abstract 2015

3. Blackie et al. Nonobvious M GD. Cornea. 2010 Dec;29(12):1333-45.

4. M udgil P. Ant imicrobial role of human meibomian lipids at the ocular surface. Invest Ophthalmol V is S ci. 2014 Oct 14;55(11):7272-7.

5. Napoli PE, Coronella F, S at ta GM, et al. Evaluat ion of the adhesive propert ies of the cornea by means of opt ical coherence t omography in pat ients with meibomian gland dysfunct ion and lacrimal tear deficiency., PLoS One. 2014 Dec 23;9(12):e115762.

6. Jackson et al. Evaluat ion of Thermal Pulsat ion Treatment for M eibomian Gland Dysfunct ion in Cataract S urgery Pat ients AS CRS 2015

7. S uhalim JL, Parfit t GJ, X ie Y, et al. Effect of desiccat ing st ress on mouse meibomian gland funct ion. Ocul S urf. 2014 Jan;12(1):59-68.

8. Holland et al. Pat ient Characterist ics Associated with Improved M eibomian Gland Funct ion after Thermal Pulsat ion Treatment for M eibomian Gland Dysfunct ion. AS CRS 2015

9. Grenon, Liddle and Grenon et al. A Novel M eibographer with Dual M ode S tandard Noncontact S urface Infrared Illuminat ion and Infrared Transilluminat ion. ARV O 2014

The prevalence of MGD is as high as 60-70%1,2

MGD is frequently nonobvious and therefore missed3

Meibomian lipids are critical for innate tear film host defense4

MGD decreases corneal adhesiveness5

Pretreatment optimizes post-cataract surgery ocular comfort6

Evaporative stress causes MGD7 (Modern lifestyle, Contact lens wear and

Chronic use of topical medications all induce evaporative stress)

MGD is progressive: Early intervention optimizes outcomes8

Identify early compromise to MG function and structure with the MGE

and DMI9

An Unstable Tear Film Negatively Impacts Premium

Quality Vision Care

Fluctuating Vision

Ocular Discomfort

Compromised Barrier to Infection1

63%+ of Cataract Patients (PHACO study results)

Contact Lens Intolerance and LASIK

Candidates

Glaucoma and Retinal Patients

108

1Antimicrobial role of human meibomian lipids at the ocular surface. Mudgil P. Invest Ophthalmol Vis

Sci. 2014 Oct 14;55(11):7272-7.

3/17/2017

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Focus on the Gland

“Meibomian Gland Dysfunction (MGD) is a

chronic, diffuse abnormality of the Meibomian

Glands, commonly characterized by terminal

duct obstruction and/or

qualitative/quantitative changes in the

glandular secretion.”

109

Notes: The international workshop on meibomian gland dysfunction: report of the subcommittee on management and treatment of meibomian gland dysfunction. Geerling G, Tauber J,

Baudouin C, et al. Invest Ophthalmol Vis Sc i. 2011 Mar 30;52(4):2050-64

Function Structure

Normal Function Normal Structure

Meibomian Gland Function

110

Notes: Evaluation of lipid layer thickness measurement of the tear film as a diagnostic tool for Meibomian gland dysfunction. Finis D, Pischel N, Schrader S, Geerling G. Cornea. 2013

Dec;32(12):1549-53.

Meibomian gland diagnostic expressibility: correlation with dry eye symptoms and gland location. Korb DR, Blackie CA. Cornea. 2008 Dec;27(10):1142-7.

DRY NOT DRY

0 - 4 5 6 7 8 9 10+

FUNCTIONAL MGs in the Lower Lid

≤ 4, treatment necessary, (if glands present)

5-6, intervention highly advised

7-9, preventive treatment (PRN)

• A functional Meibomian Gland is a gland that releases its liquid

contents during a deliberate blink.

• The number of functional MGs along the lower eyelid can be used to

diagnose MGD and to direct therapeutic intervention

When the total number of functional glands is 10 or higher, but there is evidence of

compromise to gland function and/or structure, therapy should still be considered.

Meibomian Gland Structure

Visualization Prioritizes Therapy

Now MGD is detected and managed with ability to also visualize structure

Any compromise to gland structure is an indication to consider therapeutic intervention

111

MGD is Progressive

Examples of Compromised Function and Structure

Function

Structure

Normal Function Nonobvious MGD Obvious MGD Obvious MGD

Normal Structure Gland Duct

Dilation

& Drop Out

Gland Truncation

& Drop Out

Gland Duct Dilation,

Truncation & Drop Out

112

Notes: Siak JJ, et al. Prev alence and risk factors of meibomian gland dy sfunction: the Singapore Malay Ey e Study . Cornea. 2012;31(11):1223-1228.

Viso E, et al. Prev alence of asy mptomatic and sy mptomatic meibomian gland dy sfunction in the general population of Spain. Inv est Ophthalmol Vis Sci. 2012;53(6):2601-2606.

Hom MM, et al. Prev alence of meibomian gland dy sfunction. Optom Vis Sci. 1990;67(9):710-712.

The Cycle of Inflammation

Sy

mp

to

ms In

crease

Potential Long-term Damage Inflammation

Stasis, inspissation and obstruction of the Meibomian Glands

Meibomian Gland Dysfunction (MGD)

Tissue Changes

Decrease in Meibomian secretions

Decrease in tear film stability, increased aqueous tearing1

Increase in evaporative stress

Ocular surface exposure (between blinks) & Micro-trauma (during blinking)

113

1. Arita R, et al. Increased Tear Fluid Production as a Compensatory Response to Meibomian Gland Loss: A

Multicenter Cross-sectional Study. Ophthalmology. 2015 Jan 24. pii: S0161-6420(14)01195-6. doi:

10.1016/j.ophtha.2014.12.018. [Epub ahead of print]

• Wait for the onset of sequelae: The patient

tells you there is a problem

• Measure and manage dry eye sequelae

• Lead with palliative artificial tears

• Gradually advance treatment as sequelae

increase in severity1,2

A Change in Philosophy – MGD First

Dry Eye Approach MGD First/Root Cause Approach

• Evaluate everyone for MGD: Identify MGD at its

earliest stages

• Educate patients about the front line of defense

of the tear film – the lipid layer

• Offer the most efficacious MGD treatment as

early as possible

• Rehabilitate the ocular surface and manage

sequelae with adjunctive therapy

Goal: Restore and optimize gland

function/intervene in progression

• Root cause is not identified: Promotes

confusion, and patient despair

• Promotes patient and physician confidence

in MGD management.

114

Notes: 1. Management and Therapy of Dry Ey e Disease: Report of the Management and Therapy Subcommittee of the International Dry Ey e WorkShop. Geerling G et al. Ocular Surface. 2007 Apr;5(2) 163-

178,

2. The international workshop on meibomian gland dy sfunction: report of the subcommittee on management and treatment of meibomian gland dy sfunction. Geerling G, Tauber J, Baudouin C, et al. Inv est

Ophthalmol Vis Sci. 2011 Mar 30;52(4):2050-64

Goal: Treat Sequelae (primarily

symptoms)

MGD First: If the etiology is not treated, the Dry

Eye will not resolve

MGD First does not mean that the sequelae of dry eye should be ignored.

115

SYMPTOMS

VISION

TEAR INSTABILITY

OCULAR SURFACE DAMAGE

HYPEROSMOLARITY

INFLAMMATION

Compromised

Lacrimal Function

MGD

LipiFlow/ Manual Expression,

Warm Compress, lid hygiene, Blinking,

Lipid Drops Topical & Systemic

Medications

MEASURE AND MANAGE DRY EYE

SEQUELAE IDENTIFY AND TREAT THE CAUSE

MOST COMMON

Allergy,

Autoimmune Treat Accordingly

TREATMENT

Treat Accordingly

+

Non-Obvious MGD (NOMGD)

• MGD may be nonobvious without

inflammation and without other

obvious signs (NOMGD)

• NOMGD may be precursor to obvious

MGD

• Highly prevalent and under-diagnosed

– may be most common cause of

evaporative eye disease

• In a recent dry eye study of the 52

subjects that had MGD, 48% of them

had NOMGD.

116

Obstruction Inflammatory

Anti-inflammatories: Steroid

Loteprednol AzaSite

Doxycycline Omegas Restasis

Mechanical therapy:

Lid therapy Masks

In office manual expression Lid margin scraping MiBoFlo, LipiFlow

Mechanical therapy:

Lid therapy Masks



Loteprednol AzaSite


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Obstruction Inflammatory Obstruction and inflammatory

Steroid (anti-inflammatories) + mechanical therapy

Mechanical therapy:

Lid therapy Masks



Loteprednol AzaSite


ω6 ω3

Eicosanoids Omega-6

Increase blood pressure

Inflammatory

Platelet aggregation

Thrombosis

Vasospasm

Allergic reactions

Cell proliferation

Eicosanoids Omega-3

Increase blood pressure-opposite

Inflammatory-opposite

Platelet aggregation-opposite

Thrombosis-opposite

Vasospasm-opposite

Allergic reactions-opposite

Cell proliferation-opposite

The ideal ω6:ω3 ratio in the diet is

approximately 4:1

Current Western diets that ratio is

closer to 15:1

Simopoulos AP. (2002) "The importance of the ratio of omega-

6/omega-3 essential fatty acids." Biomed Pharmacother,

56(8):365-379.

Greater bleeding with ω3

Not recommended for surgery

“This case reveals a significant rise in INR

after the dose of concomitant fish oil was

doubled”

Buckley, Mitchell S., Angela D. Goff, and Walter E. Knapp. "Fish oil interaction

with warfarin." Annals of Pharmacotherapy 38.1 (2004): 50-53.

http://www.pharmacologyweekly.com/articles/fish-oil-omega-3-fatty-acids-EPA-

DHA-Lovaza-platelet-inhibition-bleeding-risk-mechanism

MGD patients

30 patients

-1.2g: EPA 720mg DHA 480 mg

30 patients

-400mg Vitamin E

http://www.medscape.com/viewarticle/843441

Jain A. World Cornea Congress (WCC) VII. Presented April 17,

2015.


Jain A. World Cornea Congress (WCC) VII. Presented April 17,

2015.

MGD

2x1000mg 3xDay Omega-3 vs

placebo

1 year

OSDI, TBUT, meibum score

improved Macsai, Marian S. "The role of omega-3 dietary supplementation in

blepharitis and meibomian gland dysfunction (an AOS thesis)." Trans Am

Ophthalmol Soc 106 (2008): 336-356.





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15

“grass-based diets can significantly

improve the fatty acid (FA) composition

and antioxidant content of beef”

Daley, C. A., Abbott, A., Doyle, P. S., Nader, G. A., & Larson, S. (2010). A review of fatty

acid profiles and antioxidant content in grass-fed and grain-fed beef. Nutrition journal, 9(1),

10.

“Several studies suggest that grass-

based diets elevate precursors for

Vitamin A and E, as well as cancer

fighting antioxidants”

Daley, C. A., Abbott, A., Doyle, P. S., Nader, G. A., & Larson, S. (2010). A review of fatty

acid profiles and antioxidant content in grass-fed and grain-fed beef. Nutrition journal, 9(1),

10.

“And where do the fish get these omega-

3s? They eat it…With grass-fed

cows...Omega-3s are in their meat—

because they're eating grasses and clover rich in these heart-healthy fatty

acids.”

http://www.npr.org/2010/04/08/125722082/the-truth-about-grass-fed-beef

Meat cuts 18 cattle

Grain vs grass fed

Trimmed of visible fat & connective tissue and

then minced

7 g were used for fatty acid (FA) analysis.

Ponnampalam, Eric, Neil Mann, and Andrew Sinclair. "Effect of feeding systems on omega-

3 fatty acids, conjugated linoleic acid and trans fatty acids in Australian beef cuts: potential

impact on humnan health." Asia Pacific Journal of Clinical Nutrition 15.1 (2006): 21-29.

“significantly higher level of total omega-

3 (ω-3)…in grass-fed beef (P< 0.0001)

than the grain-fed groups regardless of

cut types.”

Ponnampalam, Eric, Neil Mann, and Andrew Sinclair. "Effect of feeding systems on omega-

3 fatty acids, conjugated linoleic acid and trans fatty acids in Australian beef cuts: potential

impact on humnan health." Asia Pacific Journal of Clinical Nutrition 15.1 (2006): 21-29.

“Each day that an animal spends in the

feedlot, its supply of omega-3s is

diminished”

http://www.americangrassfedbeef.com/grass-fed-natural-beef.asp

Duckett, S. K., D. G. Wagner, et al. (1993). "Effects of time on feed on beef nutrient

composition." J Anim Sci 71(8): 2079-88.

Moderate/severe or

not improving

• Add PO tetracycline

• Recommendation:

• Doxycycline 50mg bid x 4-8 weeks then taper to qd

• Periostat (20 mg doxycycline) bid

• OcuSoft: ALODOX – generic 20 mg

Contraindications

• Pregnant or child bearing age

• Children

How to Minimize Stomach

Problems with Tetracycline

1. Do not take the second pill (bid) before

going to bed

2. Do not take pills with acidic beverages

3. Take pills with food (except a high

dairy meal)

4. Prescribe the lowest dose available













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MGD Medical-Instrument

Treatment

136

Treatment of MGD/NOMGD

In-Office Therapy

Manual Expression

Off-Label Pharmacotherapy

Oral tetracycline/doxycycline

Topical Antibiotics – erythromycin, tobramycin

Topical Steroids – dexamethasone

137

At Home Therapy

– Warm compresses

– Eyelid Scrubs

– Self expression Mechanical therapy: Lid therapy

Masks

Lid margin scraping

MiBoFlo, LipiFlow

In office manual expression

LEO method

MGD TREATMENT

Warm compresses

Meibomian gland scrubs

Home expression

Blinking

Office expression

Secretagogues – Androgens

Maskin Expressor

$ 575

Rhein Medical

WARNING

Hot compresses can change the corneal tissues and structure

Possible Link to Keratoconus

Evidence Based Medicine

Meibomina Gland Expression

Schaeffer Eye Protocol

1) OSD Evaluation

1) Includes test expression

2) All staining

2) RTC expression

1) At home heat with eye medibeads

2) 15-20 minutes in waiting room with Bruden’s heat pack ( or rear wait)

3) Expression 1 of 3

4) RTC 2 weeks

MGD

Maskin Expressor

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O’Dell L. Hom MM. Does in-office manual expression for

Meibomian Gland Dysfunction (MGD) work? Optom Vis Sci

2015;92:E-abstract

n=24

Single treatment

2 wks and 1 month: OSDI and

SPEED improved over control

No MG secretion improvement

O’Dell L. Hom MM. Does in-office manual expression for

Meibomian Gland Dysfunction (MGD) work? Optom Vis Sci

2015;92:E-abstract

n=24

Single treatment

2 wks and 1 month: OSDI and

SPEED improved over control

No MG secretion improvement

O’Dell L. In-office manual expression. In press.

Pre-treatment

LEO

L=Liquify

E=Express

O=Observe


Pre-treatment

LEO

L=Liquify

E=Express

O=Observe


Pre-treatment

Omega 3, home warm compresses,

steroids, AzaSite


Pre-treatment

Omega 3, home warm compresses,

steroids, AzaSite


LEO L=Liquify Tranquileyes, Bruder, Bundle 10 min Anesthesia Lid margin scrape


LEO L=Liquify Tranquileyes, Bruder, Bundle 10 min Anesthesia Lid margin scrape

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LEO E=Express Expression forceps Mastrota paddle and cotton bud Collin’s expressor


LEO E=Express Expression forceps Mastrota paddle and cotton bud Collin’s expressor


LEO O=Observe Follow-up MiboFlo, LipiFlow, ProKera, Scleral lens Options: Tobradex ointment can be used after initial expression


LEO O=Observe Follow-up MiboFlo, LipiFlow, ProKera, Scleral lens Options: Tobradex ointment can be used after initial expression

Pros Cons

Lower cost than LipiFlow Not covered by insurance

Corneal distortion with lid therapy Outer lid

Moderately invasive

O’Dell L. Hom MM. Thermoelectric heat therapy for dry eye: a

case series. Optom Vis Sci 2015;92:E-abstract

11 cases

Single treatment

1 month: MG secretion improved

over control (p=.003)

No symptomatic improvement

O’Dell L. Hom MM. Thermoelectric heat therapy for dry eye: a

case series. Optom Vis Sci 2015;92:E-abstract

11 cases

Single treatment

1 month: MG secretion improved

over control (p=.003)

No symptomatic improvement

3/17/2017

19

Maskin Probe

Leiter Pharmacy

8% lidocaine with 25% Jojoba in ung base

OBSTRUCTIVE MGD

Warm Compress Treatment

Increase in LLT Following Treatment with

Warm Compresses in Patients with MGD

Olson, Korb, Greiner, Eye & CL, 2003

Baseline LLT = 60 nm

5 minutes = 105 nm

15 minutes = 117 nm

30 minutes = 122 nm

Not published: 1 to 2 mins – minimal or no improvement

Warming devices : Goto et al., 2002; Mori et al., 2003; Nagymihalyi et al., 2004;

Mitra et al., 2005; Di Pascuale et al., 2005; Spiteri et al., 2007

Warm Compresses: Olson et al., 2003: Matsumoto et al., 2006

Sutureless Amniotic Membrane

ProKera – Amniotic Membrane for wound healing

Cryopreserved

Bio Optix

Dry Membrane

Biological Scaffolding

Helps initiate an active healing process by providing proteoglycans and growth factors

Collagens, fibronectin and lamillin

Cryopreserved membrane contains heavy-chain hyaluronic acid

Inhibits proinflammatory cells

Suppress T Cells

Persistent Corneal Defect

Recurrent Cornea Erosion

Corneal Ulcer

Pterygium Graft

Bullous Keratopathy

Band Keratopathy

Sutureless Amniotic Membrane

ProKera – Amniotic Membrane for wound healing Corneal Ulcer

Bullous Keratopathy

Folds in Descemet’s

Chemical Burns

Mechanical Complications 2ary to graft

Disruption of surgical wound

Non-healing surgical wound

Insertion of Pro-Kera

Remove from inner pouch

Rinse with saline (prevents stinging from preservation media

Apply topical anesthesia

Hold upper lid and have patient look down

Insert into superior fornix

Slide under lower eyelid

Check for centration

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Possible Tape Tarsorrhaphy

powerpoint presentation to avenova bid ou in 2 weeks 27 demodex ... ocular surface discomfort and...

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