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FC_DG0511.indd 3   5/11/11 4:41 PM
Current Therapy            in Ocular Disease             by Drs. Ron Melton and Randall Thomas             Past recipients...
A Brief Overview of the Past Twelve Months                                              Supported by an unrestricted      ...
Glaucoma           New drugs may come and old drugs may go, but the essential question remains:           At what point do...
Glaucoma             blocker or brimonidine. Prosta-           Latanoprost Goes Generic             glandins are relativel...
Glaucoma           prudent, and medically substanti-                We charge a professional fee when                 Q: A...
Glaucoma               Select Appropriate Therapy               Let’s assume we have decided                            fo...
Glaucoma           concerns, which is the essence of     that can indeed safely use a topical    Glaucoma is very similar....
Glaucoma             has a thick cornea (greater than                     tients,” we assume you mean those               ...
Glaucoma                                                                                                       diagnosis. ...
Glaucoma               (continued from page 7A)                                                      • If you have not yet...
Glaucoma             Medical Management of Acute             Angle-closure Glaucoma             Almost all cases of angle-...
Glaucoma               Glaucoma Pearls                                                                                    ...
Beneath the Surface of            Dry Eye Disease            We now understand that most ocular surface dryness is related...
Dry Eye             which drop works best with contact             lenses?                A: We would generally select    ...
Dry E ye           whether it improves tear function         subject patients to more office visits      of action than om...
Dry Eye              A Scientific View on              Blepharitis and MGD             Recent literature has used the term...
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  1. 1. FC_DG0511.indd 3 5/11/11 4:41 PM
  2. 2. Current Therapy in Ocular Disease by Drs. Ron Melton and Randall Thomas Past recipients of the “Glaucoma Educator of the Year” Award by the American Academy of Optometry Authors of Review of Optometry’s annual Clinical Guide to Ophthalmic Drugs CONTINUING EDUCATION Our Courses on Your Computer! A team of California optometrists/educators has developed a website, OptSpace.com, to provide optometrists and their staff educational enrichment in the area of medical diagnosis and treatment, and other areas of interest to optometry. OptSpace has partnered with us for several video presentations that can be viewed from any computer or electronic media of your choice. This is a new way of accessing Melton and Thomasʼ lectures. Currently our emphasis is on glaucoma care, with additional topics available in the near future. Our series of lectures will be presented exclusively through the genius of OptSpace. We invite you to visit www.OptSpace.com for more details. Come to China with Us! June 12 - 23, 2012 Bridgitte Shen Lee, O.D., a bilingual and bicultural Chinese-American optometrist, created iTravelCE LLC and put together a truly first-class (and beyond!) enlightening journey into China for COPE-approved optometric CE. She will serve as both course director and tour guide. For the educational component of this exotic voyage, we will provide our comprehensive, 20-hour “Current Therapy in Ocular Disease” course. The itinerary includes: • Beijing, the imperial and modern capital city, rebuilt by Kublai Khan in 1215 and host of the 2008 Olympics • Xiʼan, the cradle of Chinese civilization, the seat of the Emperor for more than 10 dynasties and the start of the Silk Road • Yangtze River, cruise along the longest, most majestic waterway in Asia. We invite you to join us for a trip of a lifetime! For more details, visit www.iTravelCE.com, e-mail info@iTravelCE.com, or call 832-390-1393. Visit our website: www.eyeupdate.com000_dg0511_R&Rcourse.indd 49 5/11/11 4:36 PM
  3. 3. A Brief Overview of the Past Twelve Months Supported by an unrestricted grant from Welcome to the 2011 Clinical Guide to Ophthalmic Drugs! This year, we are attempting to answer many of the questions we have received during our lectures over this past year. We have col- lected well over 100 questions, and we are sharing our responses to as many of them as space allows. We encourage you to read this CONTENTS question-and-answer dialogue, as it contains many clinically practical pearls that we trust you will value There have been two significant additions to the therapeutic land- Glaucoma ............................. 2A scape during the past year: Zirgan and generic latanoprost. But there are also numerous “new and improved” remakes and enhanced formulations of medicines already in the marketplace: Beneath the Surface of • an increased concentration of gatifloxacin (Zymaxid, which is a Dry Eye Disease ................. 12A 0.5% formulation) • a decreased concentration of bimatoprost (Lumigan 0.01%) • a decreased concentration of dexamethasone combined with to- Corticosteroids .................. 18A bramycin (TobraDex ST) • another topical antihistamine for once-daily use (Lastacaft) • a reformulation of moxifloxacin (Moxeza) Topical Antibiotics ............. 22A • a newer, lipid-based artificial tear (Systane Balance) • the first once-daily topical NSAID, bromfenac (Bromday) Antiviral Strategies ............ 26A • loteprednol ophthalmic ointment (Lotemax ointment) So, you can see the waters have been stirred! We will try to put these changes, and other relevant topics, into a clinically practical per- Combination Drugs ............ 29A spective for you. It must be absolutely stressed that everything written in this guide is explicitly aimed at enhancing the lives of the patients we all serve. We can never lose sight of why we exist and what our Clinical Update on the mission is. NSAIDs ............................... 32A With all best wishes to our esteemed colleagues, Keeping Allergy Management Simple .......... 34A Overview of Oral Medicines .......................... 36A Ron Melton, O.D. Randall Thomas, O.D., M.P.H. Questions & Answers From the Trenches ............. 40A Note: The clinical views and advice expressed in this publication are those of the authors, and do not necessarily reflect those of the sponsor, Bausch + Lomb, or the publisher, Review of Optometry.001_dg0511_intro.indd 3 5/11/11 3:52 PM
  4. 4. Glaucoma New drugs may come and old drugs may go, but the essential question remains: At what point does the patient “convert” to glaucoma? fter 15 years of basking in A the warm sun, the curtain has fallen on the most successful glaucoma drug in the history of the world. Generic latanoprost should radically re-script glaucoma care from a financial perspective. This same fate will soon occur for Lipi- tor. We think, and hope, this will bring financial relief to the masses. Like all of you, we are watching from the bleachers to see how this radical transformation will play out. (See “Latanoprost Goes Generic,” page 3A.) There are other glaucoma medi- cines in research and development, and we anticipate newer and better therapies in the coming years. At what point, clinically, do you begin to inform patients that you are following them But don’t forget that a once-daily as a “glaucoma suspect”? This is an optic nerve that has converted to glaucoma. beta-blocker is an excellent second- Note the inferior erosion of the neuroretinal rim. line drug for monotherapy, or as additive therapy to a prostaglan- discontinuing it? Q: Would you use a prostaglan- din. All others must be used twice A: Studies have shown that the din to manage increased intraocular daily and preferably three times effects of prostaglandins last longer pressure in a steroid responder? a day—but it is rare that patients than the other classes. In our prac- A: Probably not. Most iatro- can perform these complex instilla- tices, we wait a month to recheck genic intraocular pressure increases tions with any significant degree of the intraocular pressure after stop- quickly vanish upon the discontinu- consistency. ping a prostaglandin. We generally ation of the offending corticoste- assess the effect of such “reverse roid, so additional medical therapy Q: When new patients present therapeutic trials” in two to three is usually unwarranted. to our office on multiple glaucoma weeks for the shorter duration-of- If the IOP was high enough to meds, we want to experiment with action drugs such as the alpha ad- warrant therapeutic intervention which meds are optimally effec- renergic agonists, the beta blockers, (perhaps over 35mm Hg to 40mm tive. How long does it usually take and the topical carbonic anhydrase Hg), then we would select a more for a medicine’s effect to stop after inhibitors. rapid onset medicine such as a beta 2A REVIEW OF OPTOMETRY MAY 15, 2011002_dg0511_glaucoma.indd 2 5/11/11 3:12 PM
  5. 5. Glaucoma blocker or brimonidine. Prosta- Latanoprost Goes Generic glandins are relatively slow in their The biggest news in glaucoma in 2011 is that Xalatan lost its onset of action, and so are rarely patent protection March 28. This means we now have generic a class of choice when rapid IOP latanoprost. While this is bad news for the drug manufacturers, reduction is desired. it is good news for glaucoma patients. A basic understanding of market dynamics explains why Travatan Z and Lumigan Q: Do you recommend occluding have also reduced their costs (either directly or through rebate the nasolacrimal ducts to prevent programs, etc.) to be competitive with generic latanoprost. systemic effects from glaucoma Generally speaking, and when prudent to do so, we prefer to medicines? prescribe quality brand-name products as opposed to gener- A: As a general rule, glaucoma ics of unknown quality. For this reason, we plan to prescribe medicines are very well tolerated, Travatan Z or Lumigan 0.01% as long as the price points are and therefore there is not a need to similar to the generic latanoprost. undertake unnecessary medication- We encourage you to call around to your local pharmacies modifying procedures. to ascertain the cost of these medications. You will be amazed However, if the medicine was at the differences. At press time, our survey of local pharmacies revealed great disparity truly needed for glaucoma care, and among prostaglandin prices (anywhere from $25 to $85). Overall, it seems that $38 is the patient had a rare side effect generally the going price. This brings great relief to the cost-burden of glaucoma therapy. (such as taste perversion, a cough, Also note that the prostaglandins exert a therapeutic effect well beyond 24 hours. For slight shortness of breath, brady- a few of our indigent patients with non-severe glaucoma, we have reduced dosing to cardia, etc.), then punctal occlusion Monday, Wednesday and Friday. may be wise. Now let’s think about this rationally and apply some common sense: The goal in glau- However, we would try switch- coma management is to achieve and maintain an intraocular pressure within the target ing to another class of drug first, if range deemed to be “safe” for each patient individually. With that in mind, medication possible. In caring for many hun- management becomes very elementary: We simply check the IOP at one month and at dreds of patients with glaucoma, two months after dosage-reduction to see if the IOP remains the same as it did with we have never found the need to once-daily dosing. If that is the case, then we have achieved our IOP goal, and helped the punctally occlude. patient from not only a health standpoint, but a financial one as well. We simply need to be thinking, compassionate and attentive doctors. Q: If a visual field is abnormal, and repeat testing is normal, do you would repeat the field every six to we provide a standard dilated eye retest? Or is one normal visual field 12 months to continue to monitor examination. all you need? for stability or progression. If there is a history of glaucoma A: Clinically significant visual If the next field shows “progres- suspicion in the family, then we field defects are largely predictable, sion,” such “progression” MUST would likely obtain pachymetry and not like a box of chocolates. be confirmed by repeat testing in addition to our always thor- Generally speaking, if the visual (again, in weeks to months based ough study of the optic nerves via field is normal, consider it to be on the overall status of the patient’s biomicroscopic-enabled (90D, etc.) so. If the visual field is defective condition). It is well established ophthalmoscopy. and the catch trials (fixation losses, that the vast majority of “progres- If the optic nerve(s) appear etc.) are reasonably normal, and sion” is artifactitious, and disap- compromised in their structure, we if the optic nerve neuroretinal rim pears upon repeat testing! would then consider accomplishing tissues are intact, then we would nerve fiber layer assessment, and if not believe this defective field to be Q: When you see a family mem- this were to be suspicious, then we a reflection of reality, and therefore ber of a glaucoma suspect patient, would likely obtain a visual field would repeat the field in a few do you perform a full dilated assessment. weeks (or even a few months). comprehensive eye exam? Do you Notice that all subsequent testing However, if there are defects charge them, or is just a quick look is driven by the sequential findings that correspond to alterations in with the indirect ophthalmoscope during the course of the eye exami- the optic nerve head anatomy (such sufficient? nation. We do not do tests that are as polar erosion), then we would A: If it has been over a year since unwarranted, and we always obtain believe that the defect is true, and the patient has seen an eye doctor, exam elements that are rational, REVIEW OF OPTOMETRY MAY 15, 2011 3A002_dg0511_glaucoma.indd 3 5/11/11 3:12 PM
  6. 6. Glaucoma prudent, and medically substanti- We charge a professional fee when Q: At a recent glaucoma lecture, ated. Appropriate charges are whatever service or procedure per- the specialist stated that nerve fiber assessed for indicated professional formed is medically prudent. One analysis was pushing back glau- services and diagnostic testing. could code “glaucoma suspect” if, coma diagnosis by 10 years; that Some of these may be accomplished in one’s sound clinical judgment, is, initiating treatment for patients at the initial visit; others may be there is rational justification to in their 50s rather than their 60s. done days or weeks later, depend- conduct such an examination along Bottom line: With no visual field ing on assessed risk, the disease with any rational ancillary testing defect, would you treat based on stage, the patient’s desires, insur- needed to facilitate accurate deci- nerve fiber layer analysis, given the ance coverage, etc. sion making. potential for long-term consequenc- es of using glaucoma medicines? Q: How do you code a claim Q: At what intraocular pressure A: First, glaucoma medicines are for a family member’s glaucoma would you treat the patient on the generally very well tolerated, even examination when the results are same day as the exam? in patients who have ocular surface normal? A: Probably 40mm Hg or disease, so that concern is a mini- A: How does an orthopedic greater, and even at lower IOP if mal player in decision making. The surgeon code for a radiographic there were substantial optic nerve larger question is actually much study if it is normal? The answer: compromise. bigger than structural vs. functional Topical Glaucoma Drugs BRAND NAME GENERIC NAME MANUFACTURER CONCENTRATION BOTTLE SIZE Beta Blockers Betagan, and generic levobunolol hydrochloride Allergan, and generic 0.25% 5ml, 10ml 0.5% 5ml, 10ml, 15ml Betimol timolol hemihydrate Vistakon Pharm. 0.25% 5ml 0.5% 5ml, 10ml, 15ml Betoptic-S betaxolol hydrochloride Alcon 0.25% 5ml, 10ml, 15ml Istalol timolol maleate Ista 0.5% 5ml Timoptic, and generic timolol maleate Aton Pharma, and generic 0.25% 5ml, 10ml, 15ml 0.5% 5ml, 10ml, 15ml Timoptic (preservative-free) timolol maleate Aton Pharma 0.25% unit-dose 0.5% unit-dose Timoptic-XE, and generic timolol maleate Aton Pharma, and generic 0.25% 2.5ml, 5ml 0.5% 2.5ml, 5ml Prostaglandin Analogs Lumigan bimatoprost Allergan 0.01%, 0.03% 2.5ml, 5ml, 7.5ml Travatan Z travoprost Alcon 0.004% 2.5ml, 5ml Xalatan, and generic latanoprost Pfizer, and generic 0.005% 2.5ml Alpha Agonists Alphagan P, brimonidine Allergan, 0.1%, 5ml, 10ml, 15ml and generic brimonidine generic 0.15%, 0.2% 5ml, 10ml, 15ml Carbonic Anhydrase Inhibitors Azopt brinzolamide Alcon 1% 5ml, 10ml, 15ml Trusopt, and generic dorzolamide Merck 2% 5ml, 10ml Combination Glaucoma Medications Combigan brimonidine/timolol Allergan 0.2%/0.5% 5ml, 10ml Cosopt dorzolamide/timolol Merck 2%/0.5% 5ml, 10ml 4A REVIEW OF OPTOMETRY MAY 15, 2011002_dg0511_glaucoma.indd 4 5/11/11 3:12 PM
  7. 7. Glaucoma Select Appropriate Therapy Let’s assume we have decided for our black patients, and 0.25% ing frequency a patient merits IOP reduction, for white patients. Furthermore, and compliance. so what drug do we select? numerous studies clearly support In recognition of • Prostaglandins. Most the use of these two non-selective this reality, these of the time, the answer is a beta blockers once daily. It is drugs are general- prostaglandin, preferably one best to have patients instill beta ly prescribed b.i.d. of the lower-concentration blockers shortly upon awakening (approximately formulations (having less for maximum therapeutic effect. every 12 hours). side effect potential) such Understand that these drugs sup- The CAIs are as latanoprost 0.005% or press beta adrenergic tone. Our known by their travoprost 0.004%—and now adrenergic system is active while brand names: bimatoprost 0.01%. All of the we are awake, and physiologi- Trusopt (dorzol- prostaglandins lower IOP near- cally asleep while we are asleep. amide, Merck; and generic) and Azopt ly identically, so prescribing There is little benefit in attempting (brinzolamide, Alcon). Since brimonidine decisions are based on side to pharmacologically suppress a seems to be slightly more effective than effect profile and affordability system that is already physiologi- a topical CAI, we generally try it as our for most patients.1 cally suppressed. This is why it is “Plan B” of choice. The time of instillation important to dose beta blockers • Combinations. What about the should center around when shortly upon awakening. “combination” drugs, such as 0.5% the patient finds it to be the The vast majority of our glauco- timolol with 0.2% dorzolamide (Cosopt most convenient. Remember, ma patients are successfully man- [Merck], which has been generic since compliance is the weak link aged with either a prostaglandin, October 2008) or 0.5% timolol with 0.2% in the treatment chain, so or a beta blocker, or a combination brimonidine (Combigan [Allergan], an we need to do whatever we of the two. This is relatively inex- expensive combination of two relatively can to make adherence most pensive, and requires a drop either inexpensive generic products)? We know achievable for once daily, or if using both, b.i.d. that timolol is only each patient. • Carbonic anhydrase inhibitors and needed once daily, • Beta block- alpha adrenergic agonists. If there is and we know that ers. Alternatively, a need to move beyond a prostaglandin brimonidine and if cost is an over- and/or a non-selective beta blocker, then the CAIs are most riding factor (and do a therapeutic trial of either brimoni- effective at their cost can compro- dine or a topical CAI—brinzolamide or FDA-approved mise compliance), dorzolamide. Both of these drugs are labeling of t.i.d. initiate therapy FDA-approved for t.i.d. therapy, and We suggest try- with a non-selec- when used as monotherapy, will best ing timolol alone, tive beta blocker serve the patient as one drop every and to only “add” such as timolol or eight hours. The problem is that there dorzolamide or levobunolol. They is an inverse relationship between dos- brimonidine if truly are available in needed to achieve 0.25% and 0.5% target IOP. These concentrations, are rare occa- and are readily sions. available for about 1. Parrish RK, Palmberg $4 per 5ml at P, Sheu WP; XLT Study Group. A comparison of many pharmacies. latanoprost, bimatoprost, Since melanin and travoprost in patients with elevated intraocular pigments can bind pressure: a 12-week, some medicines, randomized, masked- evaluator multicenter we use the 0.5% study. concentrations REVIEW OF OPTOMETRY MAY 15, 2011 5A002_dg0511_glaucoma.indd 5 5/11/11 3:13 PM
  8. 8. Glaucoma concerns, which is the essence of that can indeed safely use a topical Glaucoma is very similar. With the this question. The decision is just nonselective beta blocker. We have, limits of our current technology, it not so dichotomous! in fact, had the occasion to do such, could well be reasonable to pro- For background, we are currently but only after consultation with the claim a repeatable visual field defect treating hundreds of patients with patient’s primary care or pulmo- as the “Holy Grail” of glaucoma glaucoma medicines who do not nary physician. It has recently been confirmation. However, we have have glaucoma! We obsessively- demonstrated that systemic beta patients with 0.8 cups with no visu- compulsively assess each of our pa- blockers are in fact therapeutic in al field defects, and we confidently tients; for those whom we feel are the setting of COPD for many such tell them that they have glaucoma at considerable risk to develop glau- patients. So, if you have a need to (based on progressive cupping, thin coma, we intervene therapeutically use a beta blocker in a patient with corneas, and/or high IOPs). So, in what we believe will prevent the what you might think are systemic in one sense, the question may be development of glaucoma. Ex- contraindications, consult the pa- more academic and philosophical amples of such patients are younger tient’s physician—it may well be than clinical and firm. people with very high intraocular that your therapeutic need can be pressures; very thin corneas (physi- successfully met. Q: A very similar question: At ologically, not via keratorefractive what point, clinically, do you begin surgery); compromised optic to inform patients that you are nerve head tissues (based on following them as a “glaucoma either stereoscopic ophthalmos- suspect”? copy or a nerve fiber layer scan- A: It depends. If there is a ning device or both, without vi- family history of glaucoma, a sual field defects); a very strong borderline IOP (around 18mm family history; or a combination Hg to 26mm Hg), a 0.4 to 0.6 of the above. These decisions cup, a corneal thickness below are complex and require the as- 510µm, then such patients might similation of a constellation of be considered “suspicious.” parameters. But, these various parameters Lastly, note that doctors of cannot be viewed in a vacuum! equal competence legitimately The entire clinical picture must differ on the decisions of treat- be considered collectively. Only ing vs. attentive monitoring. then can “risk” be rationally The soundness of whichever de- When does the diagnosis change from ocular assessed. cision is made usually becomes hypertension to glaucoma? clear over the ensuing five to 10 Q: When would you discon- years. A patient is rarely a “glau- Q: When does the diagnosis tinue glaucoma therapy started by coma suspect” beyond five to eight change from ocular hypertension another clinician? years, because during this time span to glaucoma? Does the diagnostic A: If, in your clinical opinion, it should become clear whether definition of glaucoma require a and after a thorough examination, they have progressive disease or just visual field defect? you feel the patient may not merit benign risk factors. A: This question is ubiquitous therapy, then a thoughtful “reverse and haunts most glaucoma clini- therapeutic trial” is very reason- Q: Are topical nonselective beta cians. Glaucoma is not like a light able. We would have a long conver- blockers an absolute or a relative switch; either present or absent, but sation with the patient explaining contraindication in patients hav- rather like a light controlled by a how good doctors commonly have ing reactive airway disease and/ rheostat. As you begin to reduce the different approaches to the same or chronic obstructive pulmonary energy flow to the light, the light condition, and that at the least you disease (COPD)? begins to become less bright—but would like to know the patient’s A: Only recently has it become when would the average person say true baseline intraocular pressure. clear to us that the correct answer the luminance goes from “bright” This is something we do commonly, is “relative.” There are patients to “dim”? There is a zone or range especially if the patient has no who have lesser expressed asthma in which this declaration is made. positive family history of glaucoma, 6A REVIEW OF OPTOMETRY MAY 15, 2011002_dg0511_glaucoma.indd 6 5/11/11 3:13 PM
  9. 9. Glaucoma has a thick cornea (greater than tients,” we assume you mean those shortly upon awakening, regardless 580µm—our subjective cutoff), who have a 0.4 to 0.5 or greater of the actual time of the day. Pros- and/or has healthy-appearing optic cup. If the cup is small and the pres- taglandin efficacy is, by and large, nerve heads. We also get a Consent sure is normal, this is almost always time of instillation-independent. for Release of Records from the pa- a plain ol’ normal patient. But, if While slightly more effective when tient so that we can have the benefit the optic nerve head is suspicious in taken toward the end of a waking of the prior doctor’s observations appearance, there is a 100% chance period, actual time of instillation is and thoughts. we will assess the corneal thickness! not a major issue with the prosta- glandins. So, regardless of the time Q: Do you obtain pachymetry Q: For patients who work second of the patient’s sleep cycle, it is on all of your low-normal tension or third shift, how do you recom- always best to instill beta blockers patients, just to see if the cornea is mend dosing schedules for prosta- shortly upon awakening. While it is thin? glandins and beta blockers? best to instill the prostaglandins just A: By “low-normal tension pa- A: Beta blockers are best instilled prior to retiring, time of dosing is Key Points to Ponder in Glaucoma Management It is well established that there is some diminution in quality of • Visual field test results are extremely variable, and it life when a person is diagnosed with glaucoma, as at that point may take three to five tests over a two to four-year period of their lifestyle is encumbered with medication habituation behav- time to truly know the extent (if any) and/or rate of progres- ior, as well as cost concerns, and perhaps the ultimate concern sion of a visual field defect. The exception to this is if there is a of going blind. Note that we, like you, are attentive physicians, strong clinical correlation. For example, if there is observable infe- and we carefully monitor our patients. If there are any consistent rior erosion of the optic nerve rim, and there is a dense superior signs of accelerated progression, we would institute therapy. Yet field defect, then such a defect can be viewed with certainty, and we have learned over the past 30 years to not be trigger-happy, probably annual retesting is all that is indicated. but rather to be very thoughtful in our management decisions. The much more common finding, however, is a generalized Standard white-on-white perimetry can facilitate diagnosis, as scattering of scotomas, or a nonspecific clustering that does not well as provide guidance regarding progression. correlate with the optic nerve anatomy or a nerve fiber analyzer scan. It is these vague, non-clinically-correlatable visual field • Always initiate therapy with a lesser concentration of defects that must be verified by repeat testing, perhaps three to medication if available. Remember, in therapeutic intervention, five times, in order to know with certainty whether the defect(s) we have a target IOP range in our heads, and our goal should be is a true reflection of optic nerve damage or simply artifacti- to achieve an IOP within this range with the least medical inter- tious noise. A classic mistake is to observe what appears to be a vention possible. change in the visual field and make management decisions based Unfortunately, we have few lower-concentration options in upon “apparent” demise of the visual field. This is almost always glaucoma therapy: 0.25% timolol (or levobunolol), bimatoprost an error in clinical judgment and management. 0.01% and pilocarpine 1%. Being faithful to this concept, our rou- In summary, if the field is normal, believe it to be normal; if it is tine dilating drop only contains 0.25% tropicamide (Paremyd also borderline or questionable, then repeat the testing. contains 1% hydroxyamphetamine hydrobromide). Thankfully, we now have the lesser concentration of bimatoprost (0.01%) and the • It is by and large a myth that short wavelength (blue-on- concentration of BAK has been increased from 0.005% to 0.02% yellow) or frequency doubling perimetry detects glaucoma (the same as is in latanoprost). earlier than standard (white-on-white) automated perimetry. A couple of unsubstantiated thoughts come to mind: Because Furthermore, it truly may not be in the patient’s best interest to BAK enhances drug penetration, it may be that this higher con- be diagnosed “too early” in the setting of early glaucoma. Recent centration of preservative is what enables the 0.01% bimatoprost results from the Ocular Hypertension Treatment Study follow-up to provide the same reduction in IOP as the 0.03%, and that it is showed that delaying IOP reduction for a few years did not result not the BAK potentially causing side effects, but rather the active in any loss of ultimate control. On average, glaucoma progresses drug itself. The manufacturer claims a significant reduction in at about 3% per year. With the excellent medicines available to side effects with the 0.01% rendition of the bimatoprost. So keep us, we can intervene therapeutically in a thoughtful, timely man- in mind that “less is better,” as long as the target IOP goal is ner to gain good control of the intraocular pressure once the need achieved and maintained. for control is clearly indicated. (continued on page 9A) REVIEW OF OPTOMETRY MAY 15, 2011 7A002_dg0511_glaucoma.indd 7 5/11/11 3:15 PM
  10. 10. Glaucoma diagnosis. It is well established that a subset of the population has quite marked nocturnal hypotensive epi- sodes. This could cause a pathologi- cally low perfusion pressure to the optic nerve (and brain) during the sleep cycle. For this reason, patients with true low tension glaucoma (and especially patients who have had nonarteritic anterior ischemic optic neuropathy in one eye) should perhaps only take their blood pres- sure medicine near breakfast time and never at bedtime, where this “piling on” effect could play a key role in optic nerve tissue demise. A conversation with the patient’s pre- Confrontational visual field testing as a screening tool is standard-of-care, but is this scribing physician certainly should test really adequate? be accomplished. not a major issue with the prosta- function was treated. I realize it’s a Q: Since breath-holding can glandins. multifactorial disease, but let’s rule increase episcleral venous pressure out the easy options. and therefore intraocular pressure, Q: What is your opinion on A: Thoughtful question. One should we routinely emphasize confrontational visual field testing would think that thyroid disorders “keep breathing normally” during as a screening tool in the context of could have an impact on aqueous tonometry? comprehensive eye examination? production and/or outflow. In all of A: We would suggest that the This is standard-of-care, but is this our exhaustive reading of the world clinician simply be attentive during test really adequate? literature, we have never read of the procedure, and perhaps just en- A: The world’s premier author- any such association with thyroid courage the patient to relax before- ity in neuro-ophthalmology is Neil dysfunction. We can’t explain your hand. It is usually obese, anxious, Miller, M.D., at the Wilmer Eye anecdotal observations, and, as you short-waisted, large upper body- Institute at Johns Hopkins. He rightfully point out, glaucoma is a size patients that often struggle to stated that 90% of all clinically multifactorial disease, so perhaps properly position themselves at the significant neurologically-related other factors are at play that are slit lamp. This is why we all need to visual field defects can be detected not yet fully elucidated. have alternative instruments at the by confrontation examination. He ready to enable more accurate IOP recommended that this assessment Q: Since it is known that some assessments in these patients, such be done as counting-fingers in each low tension glaucoma patients as a handheld (Kowa or Perkins) quadrant, not bringing in a target may be compromised by nocturnal applanation tonometer or an Icare from non-seeing areas into see- systemic hypotension, should these Rebound tonometer. Also, beyond ing areas. We have followed Dr. patients have a sleep study? breath-holding, the blepharospas- Miller’s guidance since the early A: Perhaps. This is an area of tic patients most always do better 1980s, and have found his observa- ongoing research, and in select with handheld devices than those tions to be spot-on. patients, knowing their diastolic mounted at the slit lamp. nocturnal blood pressure profile Q: Why isn’t thyroid function could potentially be very helpful. Q: Do prostaglandins cause or part of the glaucoma workup? Along this same line of thought is increase the risk of recurrent cor- I have seen three patients, and the consideration of the patient’s neal erosions? heard of more, with high IOP that medical treatment for systemic A: This question acknowledges normalized after their thyroid dys- hypertension, if they carry that two clinical realities: 8A REVIEW OF OPTOMETRY MAY 15, 2011002_dg0511_glaucoma.indd 8 5/11/11 3:15 PM
  11. 11. Glaucoma (continued from page 7A) • If you have not yet acquired a nerve fiber layer imaging instrument, we encourage you to do so as soon as you can • Do not “micromanage” any single component of the justify the cost of the purchase. Without debate, the technology glaucoma workup. For example, refrain from performing a quan- to acquire is an ocular coherence tomography (OCT) unit. We rec- titative analysis on central corneal thickness: the cornea is simply ommend spectral-domain OCT technology because it can give you thick, thin, or normal. Here are our entirely subjective breakpoints: quantitative information on the retina nerve fiber layer for glauco- thick is >580µm to 590µm, and thin is <500µm to 510µm. ma assistance, and also provide diagnostic help for hydroxychlo- What’s in the middle is essentially normal, and minimally impact- roquine and other screenings, as well as for macular conditions ful to our decision-making process. such as central serous retinopathy, macular edema, etc. By the way, the cornea reaches adult thickness by age 10. We While the Fourier (spectral)-domain platform is the most have already discussed how incredibly subjective visual field data sophisticated technology available, the truth is that a basic OCT are. Even so-called “objective” tests, such as nerve fiber layer is amply adequate to meet the vast majority of the clinical needs analyses, are not precisely objective; they are simply less variable. of practicing eye doctors. We’d much rather see an O.D. have We have seen nerve fiber layers “thicken” a bit year to year, and a time-domain OCT than not have an OCT in his/her diagnostic test to test, but short of retinal edema, nerve fiber layer thickness armamentarium at all. One can always upgrade later. We have stays the same or slowly thins. So we know an “improved” nerve never encountered an O.D. who acquired an OCT who was not fiber layer is just a change relative to a prior test. As with visual thrilled to have it. Do note, though, that the time-domain OCT fields, do not make a management change based on the result of technology is not adequate for hydroxychloroquine screening. This a single test, even those that are supposedly objective. is the most notable shortcoming of the time-domain technology. With IOP, we know it can fluctuate wildly. Thus, if the IOP is up on one visit and down the next, we do not make proclamations • We think there is now a such as “You’re doing great!” or “You’re getting worse;” rather, technology “ready for prime we proclaim that “overall, it appears that your pressure control is time” (it is awaiting FDA- pretty stable,” or some other appropriate statement. We most cer- approval) to allow patients tainly do not know what each individual’s IOP is during sleep. to do self-tonometry. It is It is well established that there is considerable inter- and intra- from Icare, the inventor of observer variability in the numeric assessment of the optic disc the Icare Rebound tonometer anatomy (i.e., the cup-to-disc ratio). It would perhaps be over- (www.Icaretonometer.com). confident to chart “cup has enlarged from 0.3 to 0.4, therefore It uses the same exact will initiate therapy,” etc. One would more likely have to see a 0.2 rebound technology as the change, or perhaps even a 0.3 change in order to state with any standard, handheld unit, but is authority that there has been progressive optic neuropathy. placed in a special handheld frame type device that should allow So, it can be seen that there are several opportunities to most adults to competently obtain a series of measurements become bogged down with minutiae in the global context of the on their own, and outside of typical office hours. This should comprehensive glaucoma evaluation. There are plenty of data be a huge help to learn our glaucoma suspects’ and glaucoma points, plenty of parts, so that a thoughtful doctor should be able patients’ IOP behaviors early in the mornings, late in the evenings, to assimilate these various pieces and arrive at a rational stratifi- and perhaps even mid-sleep, for those patients who habitually cation of risks for, or stage of, glaucoma. awake during the night to use the bathroom. (1) Prostaglandins potentiate the stage for epithelial erosions. glaucoma suspects. I have a large cytoarchitecture remodeling ability While this question is quite intel- geriatric population, but is that of extracellular matrix metallopro- lectual, and obviously has a sound percentage too much? teinases. This is indeed the mecha- scientific basis, we are not aware A: It seems reasonable that your nism of action by which prostaglan- of any studies that point toward percentage is in keeping with the dins enhance uveoscleral outflow. an increased tendency in patients prevalence of glaucoma suspects (2) There is an abundance of to experience recurrent corneal in an aged population. We do matrix metalloproteinases at sites erosions while using prostaglandin know that increased age is a key within the cornea where the epi- eyedrops. risk factor for the development thelium is loosely adherent. These of glaucoma. We commend your destructive enzymes weaken the Q: I’ve carefully studied my keen attention to your patients, and epithelial-basement membrane-an- patients’ optic nerves, and I esti- further commend your focus on the terior stromal complex, setting the mate that 5% to 10% of them are optic nerve, not the IOP. ■ REVIEW OF OPTOMETRY MAY 15, 2011 9A002_dg0511_glaucoma.indd 9 5/11/11 3:15 PM
  12. 12. Glaucoma Medical Management of Acute Angle-closure Glaucoma Almost all cases of angle-closure glau- coma can be successfully—and calmly— managed in the office. First, one needs to have on hand all the meds that might be useful in such a rare presentation. These would include acetazolamide tab- lets, either 250mg or 500mg. Do not use the 500mg Diamox Sequels because an extended, time-release of the medicine is not as impactful as the quicker onset of action that one gets from the tablet forms. You also need to have 0.5% nonselec- tive beta blocker, brimonidine, and 2% pilocarpine at the ready. There is little to no value in the use of a prostaglandin in the setting of acute angle-closure glaucoma, as the aforementioned rapid- A gonioscopic image (above) of an counterproductive to opening the angle. onset medications perform very nicely. angle in closure. In a different eye in The 2% seems to be the optimum bal- The prostaglandins’ speed-of-onset is acute angle closure (below), note the ance between effectively stimulating the relatively slow, and is simply not needed fixed, mid-dilated pupil in a red eye. parasympathomimetically innervated (like too many cooks in the kitchen) in this musculature of the iris sphincter, and situation. not creating overall iris volume expan- In the event the patient is vomiting, sion. Keep in mind that the iris sphincter have Compazine (prochlorperazine) sup- becomes very lethargic when the IOP positories stored in the refrigerator. It is exceeds around 60mm Hg, so the pilocar- counterproductive, if not impossible, to pine will be most pharmacologically active get oral acetazolamide tablets into the once the intraocular pressure drops into patient’s system when the patient has the 50s or 40s. uncontrolled vomiting. A single antiemetic This is why the aqueous suppressants suppository quickly calms the storm are used first, and pilocarpine shortly in most cases, and thereby allows the after. Of course, once the IOP is con- appropriate administration of oral medi- trolled, the patient is kept on the 2% pilo- cation. (Note that most patients prefer drops, and then a second drop of brimo- carpine q.i.d. until a YAG photoiridotomy to insert the suppositories themselves; nidine in two to three minutes. Both beta can be performed—which may take a another good reason to keep gloves avail- blockers and alpha adrenergic agonists day or two to schedule, depending upon able in the office.) rapidly decrease aqueous production via the location and availability of this ser- Since all carbonic anhydrase inhibitors separate pharmacologic mechanisms. vice. Of note, there can be considerable contain a sulfa moiety, there is perhaps In 10 minutes or so, instill 2% pilocar- conjunctival injection present as well, and a slight chance of a sulfa allergy even in pine. It is the pilocarpine that will actually if so, then a potent corticosteroid, such these non-sulfonamide medicines. Just to physically open the angle—the other as Lotemax, Durezol or Pred Forte used be thorough, always inquire if there is a three meds simply reduce the IOP by radi- q.i.d., can help the eye look and feel bet- history of severe allergic reaction to sulfa. cally subduing aqueous production. ter, particularly if there is any associated If there is no history of such, then have Why not use 4% pilocarpine? anterior uveal inflammation present. the patient take 500mg of acetazolamide Pilocarpine is an acetylcholinergic agonist In summary, the diagnosis and treat- right away. If there is no asthma, then (parasympathomimetic) and can cause ment plan for the uncommon presentation instill a drop of beta blocker, followed by blood vessel dilation, thus enlarging the of acute angle-closure glaucoma is very a second drop in two to three minutes. mass volume of the iris, and in turn caus- straightforward. The key is to have all the Get in a drop of brimonidine in between ing some anterior-posterior dimensional medications necessary at the ready to the two administrations of beta blocker swelling of the peripheral iris, which is treat the patient quickly and efficiently. 10A REVIEW OF OPTOMETRY MAY 15, 2011002_dg0511_glaucoma.indd 10 5/11/11 3:15 PM
  13. 13. Glaucoma Glaucoma Pearls • Even glaucoma subspecialists cannot always judge optic • Childhood glaucoma is very rare. Note that virtually all nerve glaucomatous “progression” from sequential optic cases of childhood glaucoma have significantly increased intra- nerve head photographs. “Interobserver agreement among ocular pressure. glaucoma specialists in judging progressive optic disc change The key in such suspicious cases is to examine the optic from stereophotographs was slight to fair. After masked adju- nerves of parents and/or siblings, to photodocument the optic dication, in 40% of the cases in which the optic disc appeared nerves, and to attentively follow these children every six to 12 to have progressed in glaucoma severity, the photograph of the months until it becomes clear whether these suspicious optic ‘worse’ optic disc was in fact taken at the start of the study. nerves are either a physiological variant, or there is evidence of Caution must be exercised when using disc change on photo- progression. Bear in mind that asymmetry of approximately 0.2 graphs as the “gold standard” for diagnosing open-angle glau- cup-to-disc ratio is a common physiological finding.1 coma or determining its progression.”4 It may take longer than the five to 50 months (median 26 • Central corneal thickness reaches adult status by age months) of analysis performed in this study to accurately discern 10. changes in optic nerve anatomy. Because glaucoma progresses on average at a rate of 3% per year, it may take more like eight • Most patients with ophthalmoscopically visible optic to 10 years to competently and accurately judge progression nerve drusen manifest wide-ranging variations of visual field using optic disc photography. We think sequential nerve fiber defects. If these patients are observed to have high intraocular layer scanning technology may be a more refined manner to pressure, or if there is a documented steady increase in IOP over assess progression. time (years), then it may be prudent to institute IOP-lowering therapy. By and large, visual field and nerve fiber layer scanning • “Objective” technology is not absolutely objective, only data will be relatively useless, and so keeping IOP at physiologi- objective relative to other subjective tests. It is well under- cal levels is likely the wisest course. stood that visual field testing can be highly variable from test to test. We love our nerve fiber layer scanning instruments, and • The single most challenging decision in the care of depend upon them to aid us in the assessment of our glaucoma patients who are glaucoma suspects endures: When should patients, but even these wonderful “objective” tests can vary therapy be initiated? “In the end, the physician is struck with slightly from test to test. the persistent problem of whom to treat and whom to watch… Our advice: Never micromanage any single component of the The endless symposium and debate on how to best manage glaucoma evaluation, but rather look for repeatable trends over with ocular hypertension will probably continue unabated.”2 time (years). This seminal declaration precisely establishes the imprecision Regarding visual field testing, we recommend the Humphrey of decision-making and caring for patients with glaucoma. One 24-2 SITA-Standard or SITA-Fast, using standard white-on-white doctor may judge the best course of care to be watchful waiting, perimetry (standard achromatic perimetry, SAP). Newer research while another may pursue a course of active treatment. In these as shown that there is little or no advantage to using blue-on-yel- unclear cases, one doctor cannot declare the other errant in clini- low (short-wavelength automated perimetry, SWAP) or frequency cal judgment. The truth is, it may require many years of following doubling technologies.5-7 such a patient in order to know with certainty which course con- 1. Beck A. Evaluating and Managing Optic Disc Cupping in Children. Glaucoma Today. fers the greater benefit to the patient. Jan-Feb 2009. We urge the clinician to provide all glaucoma suspects a 2. Sommer A. Treatment of ocular hypertension: Hamlet’s Lament revisited. Arch Ophthal- mol. 2010 Mar;128(3):363-4. state-of-the-art assessment, develop a solid patient care plan, 3. Barkana Y, Dorairaj SK, Gerber Y, et al. Agreement between gonioscopy and ultra- and be confident in that care plan. Do not concern yourself with sound biomicroscopy in detecting iridotrabecular apposition. Arch Ophthalmol. 2007 Oct;125(10):1331-5. the potential for another clinician’s different approach. Above all, 4. Jampel HD, Friedman D, Quigley H, et al. Agreement among glaucoma specialists in carefully, attentively follow the patient.2 assessing progressive disc changes from photographs in open-angle glaucoma patients. Am J Ophthalmol. 2009 Jan;147(1):39-44.e1. 5. van der Schoot J, Reus NJ, Colen TP, Lemij HG. The ability of short-wavelength auto- • The website gonioscopy.org is a magnificent way to mated perimetry to predict conversion to glaucoma. Ophthalmology. 2010 Jan;117(1):30-4. 6. Bengtsson B, Heijl A. Diagnostic sensitivity of fast blue-yellow and standard automated improve your assessment of the iridocorneal angle anatomy. perimetry in early glaucoma: a comparison between different test programs. Ophthalmol- “In routine clinical practice, gonioscopy should be performed in ogy. 2006 Jul;113(7):1092-7. 7. SWAP or DOUBLE? International Glaucoma Review: The Journal for the World Glau- a dark room to avoid misdiagnosis of treatable iridotrabecular coma Association. 2008 Sep; 10-2. Available at: www.e-igr.com/SP/index.php?issue=102 apposition.”3 &supID=7&pageID=146. REVIEW OF OPTOMETRY MAY 15, 2011 11A002_dg0511_glaucoma.indd 11 5/11/11 3:15 PM
  14. 14. Beneath the Surface of Dry Eye Disease We now understand that most ocular surface dryness is related in one way or another to meibomian gland dysfunction, which affects the tear film lipid layer. rom a disease management F perspective, the single most common clinical challenge we face each day is helping patients who suffer from ocular surface disease, predominantly ocular surface dryness. It is now realized that most ocular surface dryness is related in one way or another to meibomian gland dysfunction.1 This leads to a poorly perform- ing tear film lipid layer. Logical thought would then move us to recommend a lipid-based artificial tear as initial therapy. Dry spots on the corneal surface are associated with reduced tear film break-up time. In addition, we start all of our dry eye patients on 2,000mg of hances meibomian gland function. the ultimate treatment/management fish oil. We urge them to take such This gives more rapid improvement of meibomian gland disease is heat with breakfast. We do not get of patient comfort and simultane- and massage, not medical. hung up on micromanaging this ously buys time for the fish oils With this comprehensive back- oral supplement with regard to the to kick in. (For those few patients ground, we now answer questions debate over triglyceride versus ethyl who cannot swallow these rather regarding dry eye. ester formulations—just fish oil. By large capsules, Nordic Naturals, the way, and just for perspective, Coromega and others make very Q: If a patient were to be allergic cardiologists commonly prescribe palatable liquid formulations.) to doxycycline, what would you Lovaza (GlaxoSmithKline), a puri- A more thorough discussion of recommend for treating meibomian fied omega-3 fish oil supplement of meibomian gland gland dysfunction? an ethyl ester variety. treatment is found A: We have never encountered While fish oil can help with mei- on page 12A, but this; the answer is probably oral bomian gland secretions, it often erythromycin or oral azithromycin. takes four to six months to begin We might even prescribe a 5mg to see an effect. For this reason, we steroid Dosepak, just to potentiate often prescribe 50mg of oral doxy- the mild anti-inflammatory proper- cycline once daily for two to three ties of these two antibiotics. months. From our observations, it more quickly and more potently en- Q: In the setting of dry eye, 12A REVIEW OF OPTOMETRY MAY 15, 2011012_dg0511_dryeye.indd 12 5/11/11 3:25 PM
  15. 15. Dry Eye which drop works best with contact lenses? A: We would generally select any artificial tear that is not BAK- preserved, and have the patient use it as often as is needed to achieve and maintain comfort. We like to use punctal plugs to diminish the frequency of, or need for, any artifi- cial tear. Don’t forget to use fish oil supplements as well. We commonly recommend 2,000mg taken every day with breakfast. Q: For dry eye, Leiterspharmacy. com will fill an Rx for 5% albumin Most ocular surface dryness is related in one way or another to meibomian gland drops—any comments? dysfunction. This leads to a poorly performing tear film lipid layer. Logical thought A: We have never used this ap- would then move us to recommend a lipid-based artificial tear as initial therapy. proach with any of our patients, but for those few dry eye patients for whom the “kitchen sink” approach New MGD Device on the Way has not achieved control and relief, While not yet FDA approved, there is an incredibly ingenious device known as the this would likely be worth a try. LipiFlow Thermal Pulsation System (TearScience Inc.), which both heats the eyelid Another approach that is talked (from the tarsal conjunctival side about in these more challenging where adequate heat levels can cases is the use of autologous serum, be achieved), while simultane- which we have each used on rare oc- ously massaging/expressing the casions with success, and think that glands. Both the heat application this more comprehensive source of and compression pressure are ocular nutrition would be superior precisely controlled for optimum to albumin. patient care. We foresee the day when a Q: How do you approach the patient who needs meibomian contact lens-wearing dry eye pa- gland therapy will schedule a tient? follow-up appointment to come A: There are a number of ap- into the office for a “meibomian proaches. Here’s what we usually expression treatment” session do: using the LipiFlow technol- • Quantify the degree of ocular ogy. Such a therapeutic session surface dryness. has the potential to reduce or • Replace “rewetting drops” with eliminate symptoms for six to 12 a top-quality artificial tear. We have months. had excellent success with lipid- Necessity is the mother of based tears. invention, and the LipiFlow tech- • We recommend 2,000mg of fish nology may just be what the doc- oil supplementation every day for tor will soon order. It should come nearly all of our dry eye patients. as no surprise that the inventor Note that it may be three to six of this technology is Donald Korb, months before an effect can be ap- O.D. He has done so much over preciated. Whatever the case, fish oil the years to enhance patient care is a very healthy substance, and is and make our profession proud. likely beneficial to total body health, REVIEW OF OPTOMETRY MAY 15, 2011 13A012_dg0511_dryeye.indd 13 5/11/11 3:25 PM
  16. 16. Dry E ye whether it improves tear function subject patients to more office visits of action than omega-3 supplemen- or not. than needed? We never use intra- tation, so for our more symptom- • Try loteprednol 0.5% b.i.d. (a canalicular plugs because of an atic and inflamed dry eye patients drop in the morning a few min- increased risk of canaliculitis, and we often prescribe 100mg (50mg utes prior to lens insertion, and a we like to be able to see the plug at b.i.d.) of generic oral doxycycline second drop after lens removal in the punctum. This way, we—and for a week or two, then decrease to the evening) in the setting of acute our patients—can tell if the plug is 50mg once daily for two to three inflammation. It is exceedingly rare present or not. more months. After having been that an individual has a legitimate on the doxycycline for two reason (laziness is not one of them) months, we often start fish oil to sleep in contact lenses. as well. So, as we finish the • If, after a month of the above course of doxycycline, the fish maneuvers, the patient remains oil should be able to pick right symptomatic, try a punctal plug in up where the doxycycline the lower eyelid of the more symp- leaves off. Both doxycycline tomatic eye, and then evaluate the and fish oil render a benefit results in another month. to meibomian gland func- • Try a different brand of contact tion. The topical steroid helps lenses. to quiet the ocular surface • Try Restasis (cyclosporine, Al- If the patient remains symptomatic after a inflammation, while the doxy- lergan). It may do the trick in some month of usual maneuvers, try a punctal plug in cycline and/or fish oil supple- patients. Like fish oil, it takes three the lower eyelid of the more symptomatic eye. mentation aids meibomian to six months to produce an effect. gland function, which yields • Try a different disinfecting While all punctal plugs work a two-pronged approach in helping system, such as a hydrogen perox- well, we have evolved into using the the dry eye patient. ide system. Odyssey brand because of ease of By attentively and systematically insertion and retention properties. Q: If you do get an increased considering the above interven- We do measure punctal diameter in intraocular pressure while using tions, most patients can be helped an attempt to obtain the most op- Lotemax, what do you suggest? considerably. timum fit. Note that punctal plugs A: It depends on how well the create some beneficial scarring once patient has responded to this ther- Q: Is it safe to use OTC Vase- the plug has resided in the punc- apy, and the degree of intraocular line petroleum jelly directly into tal tissues for several weeks. This pressure increase. If the patient was the lower cul-de-sac at bedtime for explains why many patients do not getting a good response to the cor- chronic nocturnal lagophthalmos? revert to symptomatic status once a ticosteroid, then we would consider The cost is very minimal compared plug has been lost or extruded. switching to the 0.2% loteprednol to a tiny tube of petrolatum jelly/ (Alrex) if the IOP increase was less mineral oil combination. Q: I recently read that flaxseed than 10mm Hg above baseline, and A: It must be safe, because we oil causes inflammation of the monitor the intraocular pressure. have had many, many patients over prostate. Has this influenced your If the IOP increase is greater the years use Vaseline-type products recommendation for the male dry than 10mm Hg, then we would try in their eyes without a problem. eye patient? a topical NSAID or cyclosporine A: Yes, it has. We instead recom- IF the patient had a positive initial Q: Which punctal plug do you mend fish oil (2,000mg per day) for response to anti-inflammatory use for maximum patient comfort all of our dry eye patients. therapy. If there was little initial and efficacy, and do you ever use response to the steroid, we see little dissolvable/temporary plugs? Q: If you are using Lotemax in potential to try other anti-inflam- A: From the outset, we have the setting of managing dry eyes, matory approaches. always used permanent plugs. It is when would you consider add- 1. Green-Church KB, Butovich I, Willcox M, et al. The inter- our clinical impression that well- ing oral doxycycline, and for how national workshop on meibomian gland dysfunction: report of the subcommittee on tear film lipids and lipid-protein trained clinicians can determine the long? interactions in health and disease. Invest Ophthalmol Vis Sci. need for occlusion or not, so why A: Doxycycline has a faster onset 2011 Mar 30;52(4):1979-93. 14A REVIEW OF OPTOMETRY MAY 15, 2011012_dg0511_dryeye.indd 14 5/11/11 3:26 PM
  17. 17. Dry Eye A Scientific View on Blepharitis and MGD Recent literature has used the terms posterior blepharitis and meibomian gland dysfunction as if they were synonymous, but these terms are not interchangeable. hanks to the recent report MGD Report Released T from the International Work- shop on Meibomian Gland Dysfunction, organized by the Tear Just as the Dry Eye WorkShop (DEWS) report brought greater understanding of dry eye in 2007, the International Workshop on Meibomian Gland Dysfunction report published in March Film & Ocular Surface Society, 2011 brings greater understanding of meibomian gland dys- we have new and more scientifi- function. All optometrists should read this report, if not in cally proper nomenclature for these its entirety, then at least the “executive summary.” These (mostly) distinct clinical entities. can be viewed via www.tearfilm.org/mgdworkshop. Here is the definition from the Although several critical questions remain unanswered, MGD workshop: this landmark report advances our understanding of “Posterior blepharitis is used to meibomian gland functions and their clinical significance. describe inflammatory conditions Because it is well known that most “dry eye” is underpinned by of the posterior lid margin, includ- meibomian gland dysfunction and disease, it is imperative that all O.D.s acquaint them- ing MGD. Indeed, recent litera- selves with this report. ture has used the terms posterior blepharitis and meibomian gland constitutes the vast majority of “professional” therapeutic modal- dysfunction or MGD as if they afflictions to the posterior tissues ity, and should completely replace were synonymous, but these terms of the eyelids. So, to keep things the older, out-of-date baby sham- are not interchangeable. Distinct simple, blepharitis is an anterior poo approach. from the portion of lid margin ante- infectious/inflammatory condition, There are those patients who do rior to the gray line, which includes while MGD represents the prepon- have clinically significant eyelid the skin and eyelashes, the posterior derance of posterior eyelid disease. erythema and other signs of inflam- lid margin contains the marginal They are managed very differently. mation, such as lash misdirection mucosa, the mucocutaneous junc- and madarosis. These inflammatory tion, the meibomian gland orifices Blepharitis signs are predominantly manifested and associated terminal ductules, Blepharitis (like rheumatoid as a response to staphylococcal and the neighboring keratinized arthritis and dandruff) is a chronic exotoxins. When there is clinically skin. Posterior blepharitis is a term disease, and the absolute mainstay significant eyelid inflammation, used to describe inflammatory con- for control (not cure) is initial and medical therapy is indicated to help ditions of the posterior lid margin, enduring eyelid hygiene. Forget achieve tissue restoration. This can of which MGD is only one cause. baby shampoo; this is obsolete be accomplished in several ways. Other causes include infectious or when compared to commercially One way is the use of combination allergic conjunctivitis and systemic available eyelid scrub products such antibiotic/steroid eye drops q.i.d. conditions such as acne rosacea.”1 as OCuSOFT Eyelid Cleanser or for two to four weeks. Options here It has been our observation that SteriLid (TheraTears). These have include Zylet, generic TobraDex, MGD, with or without rosacea, the appearance and function of a TobraDex ST, or generic Maxitrol. REVIEW OF OPTOMETRY MAY 15, 2011 15A012_dg0511_dryeye.indd 15 5/11/11 3:26 PM

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