2020 Symposia Series 1 New Options for a Common Condition: - PowerPoint PPT Presentation

2020 Symposia Series 1

New Options for a Common Condition: Management of Dry Eye Disease

Learning Objectives • Evaluate patients for risk factors, symptoms, and signs of dry eye disease • Identify pharmacologic and nonpharmacologic approaches to the treatment of dry eye disease • Apply strategies to educate patients on management of dry eye disease 3

Dry Eye Disease: Definition • From the Tear Film and Ocular Surface Society Dry Eye Workshop II: “Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.” 4 Craig JP, et al. Ocular Surf . 2017;15:276-283.

Dry Eye Disease is Common • Conservatively affects between Diagnosed Dry Eye Disease in the US 5.3% and 6.8% of adults in the 25 50+ years: 11.3% US Male Female ‒ As many as 16.4 million people Prevalence (%) 20 • Women 2 to 3 times more likely to 15 be affected than men 18-49 years: 3.4% • Prevalence increases linearly with 10 age 5 0 18-24 25-34 35-44 45-49 50-54 55-59 60-64 65-69 70-74 75+ Age (years) Dana R, et al. Am J Ophthalmol. 2019;202:47-54; Farrand KF, et al. Am J Ophthalmol. 2017;182:90-98; Stapleton F, et al. Ocular Surf . 2017;15:334-365. 5

Normal Eye Physiology 6 Clayton JA, et al. N Engl J Med. 2018;378:2212-222.

Pathophysiology and Classification of Dry Eye Disease Aqueous Deficient • Lacrimal gland • Patients may have both deficiency/obstruction aqueous-deficient and • Systemic drugs • Autoimmune disorders evaporative types • Evaporative is the most Deficient tear production common and increased tear evaporation lead to ⎻ Meibomian gland hyperosmolarity and inflammation dysfunction (MGD) is leading cause of dry Evaporative eye disease • MGD • Allergic • ~2/3 of all cases conjunctivitis • Contact lens wear • Low blink rate Craig J, et al. Ocular Surf . 2017;15:276-283; Rabensteiner DF, et al. Acta Ophthalmol . 2018;96:e707-e711; Wolffsohn J, et al. Pharmaceutical J. 7 2017;299:7905.

Case Study: Kate • 49-year-old white female • Medical history: ⎻ Nonsmoker, nondrinker • Accountant ⎻ Migraines, managed with • Married with 1 child sumatriptan nasal spray • Avid runner ⎻ Elevated LDL-C, managed • Ocular history: with rosuvastatin ⎻ Daily contact lens wearer for 20 years • She is at your office today for her annual wellness exam 8 LDL-C = low-density lipoprotein cholesterol.

Case Study (cont’d): Kate’s Chief Complaints and Exam • Feeling well overall, but her eyes have Physical Exam been bothering her lately Vital signs normal ‒ When she runs outside, especially Ocular Exam on a cold windy day, she starts Slight redness tearing profusely No mucus ‒ Sometimes she wakes up in the Cornea clear, no opacities middle of the night with eyes “burning and stinging,” like sand was No sign of crusting on the eyelids thrown in them Visual acuity 20/20 with contacts • It’s hard even to open them just to add tetrahydrozoline drops 9

Symptoms of Dry Eye Disease Are Nonspecific and May Be Inconsistent With Clinical Signs in Mild Disease Common Symptoms of • Dry Eye Disease Symptoms usually: ⎻ Irritation or grittiness Worsen over the course of the day Itching ⎻ Have been Redness occurring Soreness chronically Fatigue or heaviness ⎻ Affect both eyes Burning sensation, stinging Photophobia Intermittent blurred vision Ocular discomfort Excessive tearing American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020; Cronau H, et al. Am Fam Phys . 2010;81:137-144; Shih KC, et al. HK Pract . 2016;38:113-119. Wolffsohn JS, et al. Ocular Surf . 2017;15:539-574. 10

The First Step in Achieving a Diagnosis of Dry Eye Disease Is a Detailed Patient History • Chief complaints and current symptoms • Medical history • Ocular history, including surgical history and contact lens use • Systemic medications • Allergies • Prior and current therapy for dry eye disease 11 Milner MS, et al. Curr Opin Ophthalmol . 2017;28(Suppl1):3-47.

The Next Step in Achieving a Diagnosis Is a Physical Exam Appropriate to Primary Care • Inspect eyelid and sclera for inflammation, abrasions, hemorrhage, erythema or lesions • Evert the upper eyelid if corneal abrasion or foreign body is suspected • Inspect the eyelid and periorbital region for rashes or vesicles • Examine the cornea for opacities • Examine conjunctiva for injection, erythema • Note evidence of discharge; assess eyelids for crusting • Assess visual acuity Kaur S, et al. www.acofp.org/ACOFPIMIS/Acofporg/PDFs/OFP/Articles/2019_MarApr/2019_MarApr_PrimaryApptoEyeCond.pdf. Accessed April 25, 12 2020; Pflipsen M, et al. Am Fam Phys . 2016;93:991-998.

Dry Eye Disease vs Other Common Ocular Disorders That Cause Red Eye Mild to Viral none conjunctivitis Watery Bilateral presentation with: • Diffuse hyperemia or Itching • serous Mild or no pain • Mild blurring or normal vision Allergic Moderate conjunctivitis to severe Continuous Discharge is… Acute bacterial conjunctivitis Intermittent Mucopurulent to purulent Chlamydial Dry eye conjunctivitis Cronau H, et al. Am Fam Phys . 2010;81:137-144. Bacterial conjunctivitis image attributed to Tanalai at English Wikipedia. No alterations were made to the image by PCE. Image license: creativecommons.org/licenses/by/3.0/legalcode; Chlamydial conjunctivitis image attributed to Jonathan Trobe, MD, University of Michigan 13 Kellogg Eye Center. No alterations were made to the image by PCE. Image license: creativecommons.org/licenses/by/3.0/legalcode.

Conditions/Factors That May Cause or Contribute to Dry Eye Disease Class Individual Factors Dry climate ▪ long-term contact lens use ▪ prolonged periods of not blinking Environmental (as when staring at a computer screen) ▪ smoke ▪ wind Conditions Contact lens use ▪ ocular disease ▪ ocular surgery (especially LASIK) ▪ Ocular Conditions eyelid abnormalities Antidepressants ▪ anticholinergics ▪ antihistamines ▪ antihypertensives ▪ Medications decongestants ▪ eye drops with preservatives ▪ hormone replacement therapy Androgen deficiency ▪ connective tissue disorders ▪ diabetes ▪ menopause Systemic Conditions ▪ rheumatoid arthritis ▪ Sjögren’s syndrome ▪ systemic lupus erythematosus ▪ thyroid conditions Botulinum toxin application ▪ cosmetics ▪ eyelash growth enhancements ▪ Other LASIK ▪ use of a continuous positive airway pressure (CPAP) mask American Optometric Association. www.aoa.org/patients-and-public/eye-and-vision-problems/glossary-of-eye-and-vision-conditions/dry-eye. Accessed April 25, 2020; Lee BS, et al. Clin Ophthalmol . 2020;14:119-126; Shih KC, et al. HK Pract . 2016;38:113-119; Zhang R, et al. Ocular Surf . 2020;18:158-169. 14

Menopause • Hormonal influences of menopause can affect the tear film and cause dry eye • Women over 50 years of age have twice the risk of dry eye disease as men of the same age 15 Peck T, et al. J Midlife Health . 2017;8:51-54; Schaumberg DA, et al. Am J Ophthalmol . 2003;136:318-326.

Red Flags in a Patient Presenting With Red Eye That Should Prompt Referral to an Ophthalmologist • Clues: unilateral presentation, sudden onset Subconjunctival Diffuse No discharge hemorrhage Mild or no pain, with mild blurring or Hyperemia normal vision Episcleritis Focal Vesicular rash (herpetic keratitis), severe mucopurulent discharge Vision loss, Emergency (hyperacute bacterial distorted pupil, Moderate to conjunctivitis), keratitis, corneal ophthalmology corneal severe pain ulcer, acute angle glaucoma, iritis, referral involvement traumatic eye injury, chemical burn, scleritis 16 Cronau H, et al. Am Fam Phys . 2010;81:137-144; Wolffsohn JS, et al. Ocular Surf . 2017;15:539-574.

The Workup Is Informed by Classification of Dry Eye Disease Types Dry Eye Aqueous-deficient Evaporative Sjögren’s Non- Sjögren’s Extrinsic Intrinsic syndrome dry eye dry eye Vitamin A Lacrimal MGD Primary deficiency deficiency Topical drugs/ Disorders of lid Lacrimal gland Secondary preservatives aperture duct obstruction Contact lens Low blink rate Reflex block wear Ocular surface disease Drug action (eg, Systemic drugs (eg, allergy) from isotretinoin) 17 Craig JP, et al. Ocular Surf . 2017;15:276-283.

Classification Criteria for Sjögren’s Syndrome 1. Have you had daily, persistent, troublesome dry eyes for more than 3 months? Must answer yes to ≥1 of 2. Do you have a recurrent sensation of sand or gravel in the eyes? 3. Do you use tear substitutes more than 3 times a day? these 4. Have you had a daily feeling of dry mouth for more than 3 months? questions: 5. Do you frequently drink liquids to aid in swallowing dry food? Item Weight/Score Labial salivary gland with focal lymphocytic sialadenitis and focus score ≥1 3 Anti-SSA (Ro) + 3 Must score ≥4 Ocular staining score ≥5 (or van Bijsterfeld score ≥4 on ≥1 eye) 1 Schirmer score ≤5 mm/5 min on ≥1 eye 1 Unstimulated whole saliva flow rate ≤0.1 mL/min 1 18 Shiboski CH, et al. Arthritis Rheumatol . 2017;69:35-45.