Dry Eyes 2013

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In today's digital environment Dry Eyes and associated symptoms have become an epidemic. This presentation was recently delivered at a Pharmacy convention in Sydney Australia. It is applicable for anyone with dry eye problems.

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Dry Eyes 2013

  1. 1. Dry Eyes “There Won’t Be a Dry Eye in the House” Dr Jim Kokkinakis BOptom FAAO FISCLS GCOT
  2. 2. Before We Start Let’s Get It On The Table!
  3. 3. Outline  What is it?  How Common is it?  Causes  Current Treatments  MUST DO’s&  MUST NOT DO’s  When to Refer
  4. 4. What are Dry Eyes?  This might sound stupid  But…  The definition keeps evolving
  5. 5. DRY EYE DEFINED – DEWS REPORTS 1995 Dry eye is a disorder of the tear film due to: tear deficiency or excessive evaporation, which causes damage to the ocular surface and is associated with symptoms of ocular discomfort.”
  6. 6. 2007 “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&inflammation of the ocular surface.”
  7. 7. “MeibomianGland Dysfunction may be the leading cause of dry eye syndrome.” September 2008 statement by prestigious Tear Film & Ocular Surface Society (TFOS) following 2007 DEWS Report A NEW PARADIGM FOR DRY EYE
  8. 8. Let’s Rewind – Back to Basics
  9. 9. The Tear Film is NOT Simple! EVEN THIS IS SIMPLIFIED THERE ARE NEARLY 1000 DIFFERENT COMPONENTS TO THE TEAR FILM
  10. 10. What is a Tear Film?  Basically  3 layers  Lipid  Aqueous  Mucin
  11. 11. How is it Formed?  Aqueous ◦ Lacrimal Gland  Mucin ◦ Goblet cells  Lipid ◦ Meibomian Glands
  12. 12. Tears are Hormonally Driven
  13. 13. The Lacrimal Gland - Aqueous
  14. 14. Goblet Cells – Mucin
  15. 15. Meibomian Glands - Lipid
  16. 16. Lid Eversion
  17. 17. Tear Film Irregularity
  18. 18. Lipids Stop Evaporation  A reasonable quantity of lipid inhibits:  Aqueous evaporation And  Reduces Dry Eyes
  19. 19. Lipid Deficiency Of all dry eyes presenting to an eye clinic: 86% had either lipid deficiency on its own or in combination with aqueous deficiency Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Lemp MA, et al. Cornea. 2012
  20. 20. Add The Oil! MOST EYE DROPS ONLY DEAL WITH AQUEOUS DEFICIENCY!
  21. 21. What Are the Symptoms?  There are a multitude: ◦ grittiness, ◦ glare sensitivity ◦ burning, ◦ itchiness and ironically ◦ can then cause excessive tearing??
  22. 22. Causes of Dry Eyes  Age  Autoimmune disease  Computer use  Incomplete blink  Environment  Contact Lenses  Preserved Eye drops  Oral Medications  Laser Eye Surgery  Eyelid anomalies
  23. 23. Oral Medications & Dry Eyes  Anti-Hypertensives ◦ Diuretics  Antihistamines  Decongestants  Hormones ◦ Estrogens (increase) ◦ Androgens (decrease)  Antidepressants ◦ Anticholinergic effects
  24. 24. Oral Medications & Dry Eyes  Pain Relievers  Dermatologic ◦ Roaccutane  Gastrointestinal ◦ Proton Inhibitors ◦ H2 inhibitors  Chemotherapy  Antipsychotics
  25. 25. Causes & Associations 52% 10% 8% 18% 12% Primary associations with dry eyes Meds Gender Acute Inflammation Age Other
  26. 26. The Dry Eye Culprits OPTOMETRISTS! Pharmacists! But How Can That Be? GP’s
  27. 27. The Dry Eye Culprits Optometrists Prescribe Preserved Solutions… to clean Contacts Pharmacists Prescribe Preserved Decongestants (Benzalkonium chloride) Do not realise that all contact solutions are NOT same
  28. 28. The Dry Eye Culprits General Practitioners Poly-Pharmacy!
  29. 29. Treatments of Dry Eyes
  30. 30. Treatment Algorithm 1  Level 1 ◦ Education  Blinking ◦ Modify Environment ◦ Control Systemic medications ◦ Control Allergy ◦ Preserved Tears ◦ Mist Sprays
  31. 31. Treatment Algorithm 2  Level 2 ◦ Unpreserved Tears ◦ Lid heat & Massage ◦ Gels & Night-time Ointments ◦ Nutritional Support ◦ Topical Steroids ◦ Topical Cyclosporine
  32. 32. Treatment Algorithm 3  Level 3 ◦ Oral Tetracyclines ◦ Punctal Plugs  once inflammation is controlled
  33. 33. Treatment Algorithm 4  Level 4 ◦ Systemic immunosuppressants ◦ Moisture Goggles ◦ PunctalCautery ◦ Neuralgia Pain?  Lyrica??
  34. 34. New Treatments  LipiFlow ◦ MGD is part of most dry eyes ◦ Concurrent massage and heat ◦ Expensive ◦ Needs repeating every 12 months
  35. 35. Before LipiFlow Treatment
  36. 36. After LipiFlow Treatment
  37. 37. Where Do I Start?  Mainstay are tear replacements ◦ Non-Viscous ◦ Viscous ◦ Mist Sprays ◦ Preserved ◦ Unpreserved
  38. 38. Non-Viscous Tear Replacements  By far the most commonly used  Reasonable for very mild occasional symptoms  Disadvantages ◦ Lose effect very quickly  What about preservatives?
  39. 39. Viscous Tear Replacements  Better for moderate symptoms  Advantages: ◦ Last Longer  Disadvantages ◦ Temporary Vision blur  Preservatives?
  40. 40. Mist Sprays  Perfect for mild to moderate dry eyes  Unique delivery system  Can be used with: ◦ Makeup ◦ Contact Lenses
  41. 41. Mist Sprays  Remains sterile for 6 months  NO Vision disturbance  Effective up to 4 hours  Restores Lipid layer
  42. 42. Mist sprays  Spray directly onto a closed eye ◦ This makes instillation simple  Elderly have difficulty with drops ◦ This is also ideal for them
  43. 43. Mist Spray Actimist is slowly released This means it is long lasting
  44. 44. When to refer  Sometimes… ◦ LESS is MORE  Try to NEVER use DECONGESTANTS ◦ These are addictive and a toxic cause of dry eye  Never use Chlorsig if dry eye is present  If minimal relief occurs  If drops are required > QIDIF YOU SUFFER FROM DRY EYE MAKE AN APPOINTMENT TO SEE DR JIM KOKKINAKIS
  45. 45. Questions?

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