Conjunctival Staining

Transcription

1 Tear Break Up Time Conjunctival Staining Express Meibomian Glands Cotton Tip Swab Roll Upward Observe & Grade Discuss While Performing Procedure Mild lissamine green staining Quantify Volume Traditional Treatment Artificial Tears Cyclosporine Steroids Lid Hygiene/Warm Compress

2 Goals of Therapeutic Intervention Turn Off The Inflammatory Cascade Restore Normal Neural Feedback to Lacrimal Gland Decrease Lacrimal Gland Inflammation - Improve Gland Function Normalize Tear Film Ø Restasis Cyclosporine Ophthalmic Emulsion.05% Ø Lotemax Gel Loteprednol.5% Decrease Ocular Surface Inflammation - Stimulate Epithelial Healing Cyclosporine and MMP-9 MMP-9 expression was evaluated by immunohistochemistry. The mean percentage of MMP-9 expression of the conjunctival epithelial cells was significantly decreased. MMP-9 expression was evaluated semi-quantitatively by measuring cytoplasmic staining for MMP-9. N=24 eyes of patients with thyroid orbitopathy-related dry eye Punctal Occlusion Collagen/silicone/surgical Topical Anti-Allergy Omega III s Next Level [1] Gürdal C, Saraç O, Genç, et al. Ocular surface and dry eye in Graves' disease. Curr Eye Res 2011; 36: Calvin Roberts, M.D. Study Dual Approach Cyclosporine and Punctal Occlusion Combination More Effective Than Monotherapy

3 2009 Study - McCabe Next Level 108 Patients (216 eyes) 1 Year 43% of Patients Measured a Visual Acuity Improvement After Punctal Occlusion 92% Retention Rate 1 Year Moisture Chamber Night/Day Slow Release Inserts Autologous Serum Androgen Treatment Parasite Treatment Eyessentials Protective Sunwear Environmental Treatments Panoptx Dry Eye Wear Panoptx Dry Eye Wear Patented Orbital Seal Maintains moisture Blocks wind Developed by maxillofacial surgeon Different styles fit different faces Patented Orbital Seal creates moisture chamber New study findings demonstrate effectiveness

4 Need for Treatment Flow Sheet Treatment Flow Sheet Summary Sheet for Treatment Show Current and Previous Treatment Role of Lid Disease in Chronic Dry Eye Disease Posterior Blepharitis Co-Morbidity??? Anterior Blepharitis Posterior Blepharitis (Meibomian Gland Dysfunction) Chicken or Egg???

5 08.10 Meibomian Gland Expression New! Ophthalmic Surgical Instruments Collins Expressor Forceps (Item 98610) For aggressive expression of the Meibomian gland. Livengood Expressor Paddles Angled (Item 98620) & Flat (Item 98630) For mild or gentle expression of the Meibomian gland. BRUDER EYE COMPRESSES Microwave Activated Bruder Eye Hydrating Compress and Stye Compress conveniently provide an effective yet natural and drug-free way to help provide and maintain proper eye moisture. BENEFITS Replenishes Moisture Naturally Relieves Dryness Refreshes Tired Eyes Provides Drug Free Relief BRUDER STYE COMPRESS Item #34170 FEATURES Ready in Minutes from the Microwave Naturally Hydrating Washable & Reusable Clean Moist Heat Soft Conforming Design Non-Allergenic Dust-Free BRUDER EYE HYDRATING COMPRESS Item #34160 Meibomian Gland Expression Schaeffer Eye Protocol 1) OSD Evaluation 1) Includes test expression 2) All staining 2) RTC expression 1) At home massage with eye medibeads 2) minutes in waiting room with heat back ( or rear wait) 3) Expression 1 of 3 4) RTC 2 weeks $ 575 Rhein Medical Maskin Expressor MGD EXPRESSION Fees: $189 Out of pocket covers 3 visits 68 Per visit after those three / dry eye progress check before expression 2 visits at 3 level then One at 2

6 Anterior Infectious Bacterial Viral Parasitic Posterior Meibomian gland dysfunction Blepharitis Lid Disease Therapies Ø Lid Hygiene Samples or Written Instructions Ø Warm Compress/Tranquileyes Ø AzaSite, Zylet, Macrolide ung Ø Doxycycline mg bid Months Ø Alodox 20 mg w/scrubs Ø Omega III MGD???????? Lid Disease Ø Lid Hygiene Samples or Written Instructions Ø Warm Compress/Tranquileyes Ø Erythromycin Ointment H.S./Zylet,AzaSite Ø Doxycycline mg bid Months Ø Alodox 20 mg w/scrubs Ø Nutritional Supplements Lid Treatments TearScience Solution Warm Compress/Lid Hygiene Antibiotic and/or Combination AzaSite Zylet Tobradex Anti-inflammatory Ester vs Keytone Tetracycline/Doxycycline (Low Dose) Omega III LipiView OSI Meibomian Gland Evaluator LipiFlow Auto Disposable Caution: Investigational device. The LipiFlow Auto Console pictured is not approved for use in 84 the U.S. Limited by United States law to investigational use.

7 LipiFlow Thermal Pulsation System Heat applied to the palpebral surfaces of the upper and lower eyelids directly over the meibomian glands Overall Therapeutic Goal of the LipiFlow Alleviate meibomian gland obstruction in both upper and lower eyelids simultaneously, using a short in-office procedure (12mins per eye) Lid Warmer Applies directional heat to inner eyelid Insulated lid warmer shields eye from heat and vaults above the cornea to prevent corneal contact Eye Cup Applies intermittent pressure to the outer eyelid Graded pulsatile pressure delivered to the outer eyelid Heat facilitates release of secretion from obstructed meibomian glands Inflatable air bladder Liquefy the meibomain gland contents Facilitates release of secretion from the meibomian gland Therapeutic Goal of Heat Therapy Increase likelihood that the glands can resume normal function Lid Warmer Applies directional heat to inner eyelid Insulated lid warmer shields eye from heat and vaults above the cornea to prevent corneal contact Heat facilitates release of secretion from obstructed meibomian glands Inflatable air bladder Eye Cup Applies intermittent pressure to the outer eyelid LipiFlow Contraindications Do not use the LipiFlow System in patients with the following conditions: Ocular surgery, ocular injury, ocular herpes of eye or eyelid within prior 3 months Active ocular infection or inflammation, or history of chronic, recurrent ocular inflammation within prior 3 months Eyelid abnormalities that affect lid function Eyelid abnormalities or ocular surface abnormalities that may affect/compromise corneal integrity or lid function Macrolides Reduce gene expression of proinflammatory cytokines and adhesion molecules at the transcriptional factor level Inhibit cytokine production Reduce production of proinflammatory mediators Antiinflammatory effect AzaSite Suppresses MMP9 in HCEC Results Cultured HCEC secrete abundant pro-mmp-2 and pro-mmp-9 HCEC exposed to AzaSite demonstrated MMP-9 expression reduced by 33% 1 Suppressive effect greater than vehicle treatment Cultured HBEC secrete abundant pro-mmp-2 BCEC exposed to AzaSite did not demonstrate reduced MMP-2 expression Conclusion AzaSite inhibits MMP-9 expression in HCEC, providing preliminary data for exploring the use of AzaSite in corneal disorders associated with pathologic MMP-9 expression Jacot J, et al. Evaluation of MMP2/9 Modulation by Azithromycin and DuraSite on Human Corneal Epithelial Cells and Bovine Corneal Endothelial Cells in vitro Annual Meeting Abstract and Program Planner [on CD-ROM]. Association for Research in Vision and Ophthalmology. Abstract 1985.

8 Nutritional Therapy Building a Solid Foundation for Ongoing Relief of Symptoms-Eye Health and General Health Essential Fatty Acids Over the past 6-8 years EFAs have been in the spotlight as having positive effects related to reduced inflammatory response in the eye and other body areas EFAs are: Omega 3-EPA, DHA & ALA -found in cold water fish, walnuts and cod liver oil Omega 6-LA & GLA-found in milk, ice cream, butter, beef and other natural sources Nutritional Supplements Omega III Dosing In inflammatory conditions 3-4 grams of EPA/DHA Thera Tears Nutrition mg Flaxseed ALA, Fish 150mg EPA, 100 DHA, Vitamin E Bio Tears - Omega 3 & 6 stable Cod Liver and Black Currant Seed oils, 100 mg EPA per capsule, 70 mg DHA per capsule, 235 mg GLA per capsule (Omega 6), Vitamins A, C, B6 and Mg LifeGuard - TG Form of Omega 3 (90% absorbability), Omega 3-Fish Oil (triglyceride base), EPA-420 mg per capsule, DHA-140 mg per capsule, Other Omega 3s-110 mg per capsule Nordic Naturals Adults should consume at least 2 grams of EPA/DHA per day Adults with specific chronic conditions should consume at least grams of EPA/DHA per day Experience with Omega Formulations Average time to symptomatic relief reported by patients is 4-8 weeks Patients begin taking full dosage for 2-3 months and many reduce to lower levels and maintain relief Patients that discontinue the formulations experience recurrence of symptoms in 2-3 days In moderate to severe dry eye, Omega 3 plus Restasis is a good long-term combination with early use of Loteprednol Merchandising and Compliance