OCULAR SURFACE DISEASE AND DRY EYE SYNDROME This is why… Blepharitis Prevalence Study

This is why…
People are still self
treating.
OCULAR SURFACE DISEASE
AND DRY EYE SYNDROME
why are we still talking about this?
The 2008 Gallup Survey of Dry Eye Sufferers Reports That
Patients Are Frustrated With Their Dry Eye Condition
Blepharitis Prevalence Study
3

This survey of dry eye sufferers indicated that

72% of patients had physicians recommend artificial
tears for their dry eye problem (n=541)

82% of patients somewhat agree or strongly agree
that they wish there was something more effective to
treat their dry eye (n=751)

97% of patients report that their dry eye condition is
frustrating (n=751)
Methodology:
• Computer-assisted telephone interviewing using a
questionnaire designed to elicit information on symptoms
suggestive of blepharitis
• N = 5,019
• Questions were asked regarding past 12 months:
–
–
–
–
Itching/burning eyelids
Crusts or flakes on eyelids upon awakening
Eyelids heavy / puffy
Eyelids red upon awakening
Lemp MA, Nichols KK. Blepharitis in the United States 2009: A survey‐based perspective on prevalence and treatment. Ocular Surface 2009;7(2): S1‐14
The 2008 Gallup Study of Dry Eye Sufferers.
Patient Impact
2007 International Dry Eye Workshop
Prevalence and Frequency of Symptoms
%
Extrapolated Prevalence*
At least 1 symptom in past 12 months
79
182 million
More than 1 symptom in past 12 months
63
145 million
At least 1 symptom in past 12 months at
least half the time
32
74 million
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.
*Based on percentage of US population of ~229 million ≥18 years of age in 2008.
Lemp MA, Nichols KK. Blepharitis in the United States 2009: A survey‐based perspective on prevalence and treatment. Ocular Surface 2009;7(2): S1‐14.
DEWS Delphi Panel
Causes and Exacerbations of Ocular
Surface Disease
Environmental
It is
important to
make sure
we are
asking
about work,
home and
sleeping
environment.
Treat ocular inflammation



Restasis
Soft steroid gtts
NSAID orals and gtts
Inflammation: CD4+ T-Cells


Inflammatory mediated response cascade
Can live for 6 months on the ocular surface
Helps explain the chronic progressive nature of the
disease
 No quick fixes
 Combined treatment modalities

Allergies



Allergies
The ocular allergic reaction is an IgE antibodydependent hypersensitivity response.
Inflammatory response
Causes disruption of the mucin, aqueous, lipid layers
Lid disease
Mast cell degranulates
releasing histamine
Meibomian gland dysfunction (MGD) is now
considered the leading cause of dry eye
according to the published findings of the 2011
International Workshop on MGD.
DOI:10.1167/iovs.10-6997
Investigative Ophthalmology & Visual Science, Special Issue 2011, Vol. 52, No. 4
Copyright 2011 The Association for Research in Vision and Ophthalmology, Inc.
Lid disease
Patients with Lid Disease
Chief Complain or reason for exam.
Percentage of patients who of some sort of
lid disease present
Patients
Patients may
may not
not seek
seek treatment
treatment specifically
specifically for
for blepharitis
blepharitis
Lemp MA, Nichols KK. Blepharitis in the United States 2009: A survey‐based perspective on prevalence and treatment. Ocular Surface 2009;7(2): S1‐14. Graph reproduced with permission from Campbell Alliance group.
Lid Disease Cascade
“The lack of concordance
between signs and symptoms
presents a problem in the
diagnosis of the disease and
the assessment of severity”Dr. Michael Lemp
Diagnostic Testing





Diagnostic: TearLab
History/ OSDI index
Vital dyes- quality
Schirmers- tear production
Tear Lab- osmolarity
InflammaDry- MMP (not available in the US at this
time)
osmolarity values above 308 mOsms/L are generally indicative of
dry eye disease.
Will we ever diagnose and treat ocular surface
disease like we treat glaucoma?
Covered by VSP
Diagnostic: InflammaDry RPS
Treatment

Elevated MMP may be the best
indicator of dry eye
Decreased MMP (matrix metalloproteinase-9) activity
 Elevated MMP may be the best indicator of dry eye




Normal Level of MMP is 0-40ng/mL
Doxycycline or Azasite
Lid Wash/Wipes
Steroid or combo for acute phase
Omega 3: EPA anti-inflammatory effect
Autologous Serum

Blood Draw: Virology Testing
HIV
 Hep A IGM
 Hep B Core Antibody IGM
 Hep D Surface Antigen
 Hep C Virus Antibody
 O’brien Pharmacy
Custom Compounding


Fax: 913-322-0002
 Ph: 913-322-0001

Scleral Lenses

Moisture Chamber
Fill with preservative free Optive
 9% sodium chloride inhalation solution

5% Transdermal Cream in a Versa Base.


BID
DHEA (Dehydroepiandrosterone) 1%
TID
 anabolic properties that upregulate cell division and
repair


0.1% vitamin A ointment (retinoic acid)

cell membrane repair and speeds epithelial growth
Lacrisert sustained release
Plugs… Why don’t we do them more?
Plugs… Why don’t we do them more?


Can make the condition worse
Complications
Awareness
 Ejection
 pyogenic granuloma
 Dacryocystitis

Plugs
1.
2.
3.
4.
Temporary collagen
Standard long term plug of choice
Oasis Form Fit
Lacrimedics Medium term occlusion
Maskin Probe Procedure
Gush of
sequestered
meibum
Takes me about 30 minutes to do upper and lower lids of both eyes. I was able to
open about 12 glands upper and lower lids OD,OS with multiple resulting in a gush of
meibum being released.
MASKIN PROBE Theory
Intraductal
fibrotic and
neovascular
membranes.
Disposable and Inexpensive
These were
able to be
opened up by
probing
allowing
sequestered
plug of
meibum to
escape.
Anesthetize the lids

Topical: Leiter’s Compounding Pharmacy

8% lidocaine with 25% jojoba in a petrolatum ointment
base.
Place a drop of proparacaine 0.5% or tetracaine 0.5%
solution in the conjunctival sac.
 Place a generous amount of anesthetic ointment on the
lower lid margin using a sterile cotton tipped applicator.
 Repeat application every 5 minutes for 15-20 minutes

Procedure
TIP
Procedure
Procedure
Even with topical anesthetic the patient usually jumps a little when the probe
breaks through the membrane.
Supply List




Maskin Aluminum Handle, Male Fitting $99
Starter Kit with 3-1mm probes 2-2mm probes $79
10 of any size for $150
Anesthetic Gel $37
Supply Information
3360 Scherer Drive North, Suite B
St. Petersburg, FL 33716
Office: (727) 209-2244 / (800) 637-4346
Fax: (727) 341-8123
Leiter’s Compounding pharmacy.
1700 Park Avenue . Suite 30 San Jose . California 95126
Ph. 800-292-6773 . Ph. 408-292-6772 . Fx. 408-288-8252
Leiterrx.com