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

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

Learning Objectives

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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.”

Craig JP, et al. Ocular Surf. 2017;15:276-283.

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• Conservatively affects between

5.3% and 6.8% of adults in the US ‒ As many as 16.4 million people

• Women 2 to 3 times more likely to

be affected than men

• Prevalence increases linearly with

age

Dry Eye Disease is Common

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 10 15 20 25 18-24 25-34 35-44 45-49 50-54 55-59 60-64 65-69 70-74 75+

Prevalence (%) Age (years)

Diagnosed Dry Eye Disease in the US

Male Female

18-49 years: 3.4% 50+ years: 11.3%

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Normal Eye Physiology

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

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Aqueous Deficient

• Lacrimal gland

deficiency/obstruction

• Systemic drugs
• Autoimmune disorders

Pathophysiology and Classification of Dry Eye Disease

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. 2017;299:7905.

• Patients may have both

aqueous-deficient and evaporative types

• Evaporative is the most

common ⎻ Meibomian gland dysfunction (MGD) is leading cause of dry eye disease

• ~2/3 of all cases

Deficient tear production and increased tear evaporation lead to hyperosmolarity and inflammation

Evaporative

• MGD
• Allergic

conjunctivitis

• Contact lens

wear

• Low blink rate

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Case Study: Kate

• 49-year-old white female
• Accountant
• Married with 1 child
• Avid runner
• Ocular history:

⎻ Daily contact lens wearer for 20 years

• Medical history:

⎻ Nonsmoker, nondrinker ⎻ Migraines, managed with sumatriptan nasal spray ⎻ Elevated LDL-C, managed with rosuvastatin

• She is at your office today for her annual wellness exam

LDL-C = low-density lipoprotein cholesterol.

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Case Study (cont’d): Kate’s Chief Complaints and Exam

• Feeling well overall, but her eyes have

been bothering her lately ‒ When she runs outside, especially

• n a cold windy day, she starts

tearing profusely ‒ Sometimes she wakes up in the middle of the night with eyes “burning and stinging,” like sand was thrown in them

• It’s hard even to open them just to

add tetrahydrozoline drops

Physical Exam Vital signs normal Ocular Exam Slight redness No mucus Cornea clear, no opacities No sign of crusting on the eyelids Visual acuity 20/20 with contacts

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Symptoms of Dry Eye Disease Are Nonspecific and May Be Inconsistent With Clinical Signs in Mild Disease

• Symptoms usually:

⎻ Worsen over the course of the day ⎻ Have been

• ccurring

chronically ⎻ Affect both eyes

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.

Common Symptoms of Dry Eye Disease Irritation or grittiness Itching Redness Soreness Fatigue or heaviness Burning sensation, stinging Photophobia Intermittent blurred vision Ocular discomfort Excessive tearing

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The First Step in Achieving a Diagnosis of Dry Eye Disease Is a Detailed Patient History

Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47.

• 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

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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, 2020; Pflipsen M, et al. Am Fam Phys. 2016;93:991-998.

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Dry Eye Disease vs Other Common Ocular Disorders That Cause Red Eye

Bilateral presentation with:

• Diffuse hyperemia
• Mild or no pain
• Mild blurring or normal vision

Discharge is… Continuous Intermittent Dry eye Watery

• r

serous Mucopurulent to purulent Viral conjunctivitis Allergic conjunctivitis Acute bacterial conjunctivitis Chlamydial conjunctivitis Itching Mild to none Moderate to severe

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 Kellogg Eye Center. No alterations were made to the image by PCE. Image license: creativecommons.org/licenses/by/3.0/legalcode.

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Class Individual Factors Environmental Conditions Dry climate ▪ long-term contact lens use ▪ prolonged periods of not blinking (as when staring at a computer screen) ▪ smoke ▪ wind Ocular Conditions Contact lens use ▪ ocular disease ▪ ocular surgery (especially LASIK) ▪ eyelid abnormalities Medications Antidepressants ▪ anticholinergics ▪ antihistamines ▪ antihypertensives ▪ decongestants ▪ eye drops with preservatives ▪ hormone replacement therapy Systemic Conditions Androgen deficiency ▪ connective tissue disorders ▪ diabetes ▪ menopause ▪ rheumatoid arthritis ▪ Sjögren’s syndrome ▪ systemic lupus erythematosus ▪ thyroid conditions Other Botulinum toxin application ▪ cosmetics ▪ eyelash growth enhancements ▪ LASIK ▪ use of a continuous positive airway pressure (CPAP) mask

Conditions/Factors That May Cause or Contribute to Dry Eye Disease

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.

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• 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

Menopause

Peck T, et al. J Midlife Health. 2017;8:51-54; Schaumberg DA, et al. Am J Ophthalmol. 2003;136:318-326.

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• Clues: unilateral presentation, sudden onset

Red Flags in a Patient Presenting With Red Eye That Should Prompt Referral to an Ophthalmologist

Cronau H, et al. Am Fam Phys. 2010;81:137-144; Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.

Mild or no pain, with mild blurring or normal vision Moderate to severe pain Vision loss, distorted pupil, corneal involvement

Vesicular rash (herpetic keratitis), severe mucopurulent discharge (hyperacute bacterial conjunctivitis), keratitis, corneal ulcer, acute angle glaucoma, iritis, traumatic eye injury, chemical burn, scleritis

Emergency

• phthalmology

referral Hyperemia Diffuse Focal Episcleritis No discharge Subconjunctival hemorrhage

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The Workup Is Informed by Classification of Dry Eye Disease Types

Craig JP, et al. Ocular Surf. 2017;15:276-283.

Dry Eye Aqueous-deficient Sjögren’s syndrome dry eye Evaporative Extrinsic Intrinsic Non-Sjögren’s dry eye

Secondary Primary Lacrimal gland duct obstruction Lacrimal deficiency Systemic drugs Reflex block Disorders of lid aperture MGD Drug action (eg, from isotretinoin) Low blink rate Topical drugs/ preservatives Vitamin A deficiency Ocular surface disease (eg, allergy) Contact lens wear

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Classification Criteria for Sjögren’s Syndrome

1. Have you had daily, persistent, troublesome dry eyes for more than 3 months? 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? 4. Have you had a daily feeling of dry mouth for more than 3 months? 5. Do you frequently drink liquids to aid in swallowing dry food? Must answer yes to ≥1 of these questions: Must score ≥4

Shiboski CH, et al. Arthritis Rheumatol. 2017;69:35-45.

Item Weight/Score Labial salivary gland with focal lymphocytic sialadenitis and focus score ≥1 3 Anti-SSA (Ro) + 3 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

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Case Study (cont’d): You Probe Further Into Kate’s Symptomatology

Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.

Kate’s responses

Mildly irritating

How severe is the eye discomfort

No

Do you have any mouth dryness or enlarged glands?

A couple months/gets worse at night

How long have you had symptoms? Were there any triggering events?

Yes

Is your vision affected? Does it clear on blinking?

No

Are the symptoms/redness much worse in one eye?

No

Do your eyes itch, are they swollen, crusty, or give off discharge?

Yes

Do you wear contact lenses?

Medications, yes

Any diagnosed conditions? Are you taking any medications?

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Further Clues From Kate’s Symptomatology

Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.

Kate’s responses

Mildly irritating

How severe is the eye discomfort

• If severe, could be trauma, infection, ulceration

No

Do you have any mouth dryness or enlarged glands?

• Trigger for Sjögren’s syndrome workup

A couple months/gets worse at night

How long have you had symptoms? Were there any triggering events?

• Dry eye is chronic, typically worsening at the end of

the day

Yes

Is your vision affected? Does it clear on blinking?

• Should clear on blinking

No

Are the symptoms/redness much worse in one eye?

• Dry eye is generally bilateral

No

Do your eyes itch, are they swollen, crusty, or give off discharge?

• Itching associated with allergies
• Mucopurulent discharge associated with infection

Yes

Do you wear contact lenses? Contacts can cause dry eye

Medications, yes

Any diagnosed conditions? Are you taking any medications?

• Certain systemic conditions and medications may

cause dry eye

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• Treatment goals

‒ Restore homeostasis of the ocular surface ‒ Provide long-term options to prevent a resurgence of disease and symptoms

• Management may require treatment individualized to the specific cause(s)
• f dry eye disease
• Ongoing management is often required rather than short-term treatments

Management of Dry Eye Disease

Jones L, et al. Ocular Surf. 2017;15:575-628.

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OTC Ophthalmic Products: A Quick Overview

May Contain Pros Cons Comment Artificial Tears (drops) Viscous agent, anti-evaporative, preservative Usually effective, inexpensive Difficulty with drops? Tolerance of preservative? Consider preservative free (but  expense) Artificial Tears (gels, ointments) Blurred vision Use overnight Antihistamines Pheniramine For allergy Can increase dryness Only if allergy Vasoconstrictors Naphazoline, tetrahydrozoline “Get the red out” Rebound effect Avoid

Cleveland Clinic. health.clevelandclinic.org/choosing-right-eye-drops-itchy-dry-watery-eyes/. Accessed May 11, 2020; Cronau H, et al. Am Fam

• Phys. 2010;81:137-144; Horton M, et al. www.reviewofoptometry.com/article/master-the-maze-of-artificial-tears. Accessed April 28, 2020.

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Case Study (cont’d): Management Plan

• You recommend that Kate try OTC artificial tears 4 times daily, with caveats

‒ Look for preservative-free products ‒ Avoid topical antihistamines, vasoconstrictors, or anything marketed to “get the red out”

• You advise her to

‒ Use warm compresses on her eyes in the morning and at bedtime ‒ Apply an OTC artificial tear ointment at bedtime

• You ask her to take more frequent breaks from her computer and phone screen,

to wear her glasses instead of her contacts more regularly, and to blink more

• You ask her to try this regimen for 4 weeks

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Case Study (cont’d): Kate Comes Back After 4 Weeks

• After 4 weeks, Kate reports that her symptoms are a little better but she’s still

tearing profusely when she runs

• When you ask if she is adhering to her treatment she says she is:

‒ Using her artificial tears 4 times a day ‒ Applying the ointment at night ‒ Using warm compresses in the morning and night ‒ Wearing glasses more regularly ‒ Not taking breaks from her computer screen—she is “working on this” ‒ Blinking more

• You decide to refer her to an ophthalmologist for a full workup

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• Chronic, untreated dry eyes may result in ocular surface damage such as

abrasions and corneal ulcers, leading to vision impairment

• Without adequate tears, there is an increased risk of infection

Chronic Dry Eye Can Become Serious if Not Treated

Mayo Clinic. www.mayoclinic.org/diseases-conditions/dry-eyes/symptoms-causes/syc-20371863. Accessed April 25, 2020.

Corneal ulcer

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The Ophthalmologist’s Basic Diagnostic Algorithm for Dry Eye Disease

Jones L, et al. Ocular Surf. 2017;15:575-628.

Symptoms + ≥1 of: Homeostasis Markers

• Tear breakup time <10

seconds

• Osmolarity
• Ocular surface

staining

• Diagnosis of dry eye disease confirmed if patient has dry eye symptoms

and ≥1 positive homeostasis test result

• Subtype then determined

Triaging Questions Risk Factor Analysis Evaporation Aqueous deficiency Subtype Classification Tests Step 1 Step 2 Step 3 Step 4

Aqueous/Evaporative Spectrum

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Classification of Dry Eye Disease Types

Craig JP, et al. Ocular Surf. 2017;15:276-283.

Dry Eye Aqueous-deficient Sjögren’s syndrome dry eye Intrinsic Non-Sjögren’s dry eye

Secondary Primary Lacrimal gland duct

• bstruction

Lacrimal deficiency Systemic drugs Reflex block Disorders of lid aperture MGD Drug action (eg, from isotretinoin) Low blink rate Topical drugs, preservatives Vitamin A deficiency Ocular surface disease eg, allergy Contact lens wear

Evaporative Extrinsic

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Case Study (cont’d): Examination by the Ophthalmologist

Examination:

• Visual acuity: 20/20 with glasses
• Tear breakup time: 10 seconds (cutoff is 10 seconds)
• Tear osmolarity: 330 mOsm/L (cutoff is 308 mOsm/L)
• Ocular surface staining:

‒ Punctate epithelial staining with fluorescein indicating mild keratopathy

• No evidence of meibomian gland involvement

Diagnosis:

• Aqueous-deficient dry eye disease

Wolffsohn JS, et al. Ocular Surf. 2017;15:539-574.

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Nonspecific Management of Dry Eye Disease

• Education

⎻ The condition, its management, treatment, and prognosis ⎻ Potential dietary modifications (including oral essential fatty acid supplementation)

• Modification of local environment and lifestyle

⎻ Humidification, breaks from screen time, avoiding smoke, avoiding direct fan exposure to eyes in car and at home

• Identification and potential modification/elimination of offending systemic and topical

medications

• Ocular lubricants of various types

⎻ If MGD is present, consider lipid-containing supplements

• Lid hygiene and warm compresses of various types

American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020.

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• Supplementation

‒ Randomized, placebo-controlled DREAM study (N = 535)

• No significant differences between omega-3 and placebo
• Both groups experienced similar, significant improvement in signs/symptoms

‒ In contrast, a meta-analysis of 17 randomized clinical trials (N = 3363)

• Supported efficacy of omega-3 supplementation in improving

signs/symptoms vs placebo

• Diet

‒ A diet high in omega-3 fatty acids may protect against development of dry eye disease

Essential Fatty Acids in Dry Eye Disease: Evidence Not Compelling, But Little Harm in Trying

DREAM = Dry Eye Assessment and Management Study. Asbell PA, et al. N Engl J Med. 2018;378:1681-1690; Giannaccare G, et al. Cornea. 2019;38:565-573; Miljanović B, et al. Am J Clin Nutr. 2005;82:887-893.

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Examples of Specific Therapies for Dry Eye Disease

Conventional Therapy for all Subtypes: Artificial tears, artificial tear

• intment, warm

compresses/ lid scrubs Doxycycline/ azithromycin +/– Topical steroids +/– Omega-3 BlephEx

• r

Maintenance antibiotics Thermal pulsation

• r

IPL with manual expression

• r

Probing Punctal plugs

• r

CsA 0.05%  Punctal plugs or lifitegrast or  Frequency of CsA 0.05% Autologous serum tears & Consider systemic workup

Aqueous-deficient dry eye disease Evaporative Dry Eye Disease

IPL = intense pulsed light. American Academy of Ophthalmology. www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp-2018. Accessed April 25, 2020; Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47.

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Therapeutic Expression of the Meibomian Glands

Arita R, et al. Clin Exp Optom. 2020. [epub ahead of print].

• Therapeutic expression of

thickened and toothpaste-like meibum in a patient with MGD with use of a meibomian gland compressor

Image courtesy of Arita R, et al.

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IPL

Procedures for Dry Eye Disease

Lee BS, et al. Clin Ophthalmol. 2020;14:119-126; Milner MS, et al. Curr Opin Ophthalmol. 2017;28(Suppl1):3-47.

• Beye. www.beye.com/product/eyexpress-eye-hydration-system. Accessed April 25, 2020.

TrueTear iLux Aqueous tear deficiency

• Punctal plugs
• Cautery occlusion
• Amniotic membrane

transplantation

• Intranasal tear

stimulation (TrueTear) Blepharitis/MGD (evaporative or nonevaporative)

• In-office thermal pulsation and/or

lid massage

• Debridement of the lid margin
• Intense pulsed light (IPL)
• Meibomian gland probing

⎻ Light-based heat and compression (iLux) ⎻ Open-eye wearable therapy (TearCare) ⎻ EyeXpress (goggle system) TearCare

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Case Conclusion

• Ophthalmologist recommends 8-week trial of the following:

‒ Continue warm compresses, morning and night ‒ Prescription CsA, 0.05%, 4 times daily (may take 6-8 weeks to see results) ‒ Prescription tear ointment at night

• After 8 weeks, Kate reports:

‒ Symptoms have subsided dramatically ‒ No longer tearing profusely when running ‒ Has not experienced burning or stinging at night

• She is advised to continue her regimen indefinitely

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PCE Action Plan

✓ Bilateral involvement and gradual onset should prompt suspicion of dry eye disease ✓ Examine the eyelids, conjunctiva, cornea, sclera, and periorbital region when assessing for dry eye disease ✓ Advise patients with dry eye disease to avoid topical antihistamines, vasoconstrictors, or anything promising to “get the red out” ✓ Be sure to educate patients that management of dry eye disease may be a long-term process

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PCE Promotes Practice Change

2020 Symposia Series 1