Dry Eyes Presentation
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This document discusses tear substitutes for managing dry eyes. It begins by outlining the goals of dry eye management. It then discusses various treatment options for dry eyes including tear replacement drops. The document focuses on tear substitute drops, explaining that different formulations can provide relief from dry eye symptoms and improve vision and eye health. It describes the ideal properties of tear substitutes and the components commonly found in artificial tears like cellulose derivatives, polyols, dextran, and hyaluronic acid. The document recommends choosing a tear substitute based on the cause and severity of dryness, as well as cost and formulation. It highlights the benefits of a blended cellulose derivative drop like Refresh Liquigel in providing extra protection, action,
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Dry Eyes Presentation
- 1. Demystifying Tear Substitutes --Dr. C.A.P Prabhu Sushrutha Eye Hospital Mysore
- 2. Goal: • Alleviate symptoms • Reduce ocular morbidity • Prevent complications • Improve the quality of life • Improve productivity • Maximize benefits at minimum cost
- 3. Management of “Dry” Eyes • Tear replacement • Warm compresses • Education & Lifestyle modification • Control of inflammation • Tear conservation
- 4. How to keep “Dry” eye ‘not’ “Dry” ? Can we use: • Water? • Saline? • Tear Substitute?
- 5. Tear Substitutes: Gives relief of symptoms Improve vision Helps in restoration of normal ep. of cornea and conj. Improves the quality of life
- 6. WhichTear Substitute ? • So many formulations… • So many companies… • Are they all same? • How to choose?
- 7. Which drops? Cause of dry eye Severity Formulations Cost and affordability
- 8. DemystifyTear Substitutes • Components • When to prefer?
- 9. IdealTear Substitute Works like normal tears Should not alter the clarity Lower surface tension of the tear film Forms a hydrophilic layer Enhances the tear volume Should not react with the tear proteins Should not alter the lipid layer
- 10. Ideal tear substitute pH: 6.5 to 7.5 Refractive Index: 1.336 Surface Tension: 40.1 +/- 1.5 dyne/cm Osmolarity: 302 +/- 6.3 mosm / L Viscosity: 6-12 cps
- 11. Anatomy of an artificial tear
- 12. Demulcent?
- 13. FDA - 6 groups of Ophthalmic Demulcents • Cellulose derivatives • Liquid polyols • Dextran 70 • Gelatin • Povidone • Hyaluronic acid
- 14. Cellulose Derivatives • CMC: 0.25 - 2% • HPMC: 0.2% -0.3% • Oil in water emulsion • Also helps Mucin and lipid deficiency • Can be blended with Glycerine, Carnitine, Erythritol • Refresh tears: 0.5% lower conc. -less blurring • Refresh liquigel: 1.00% • Momentary Blurring • HPMC is found in Alcon brand lubricants
- 15. Cellulose Derivatives • Celluvisc 1% High viscosity CMC • Refesh liquigel is a blend of 0.35% high visc. CMC +0.65%medium visc. • Contrast sensitivity 24 min for celluvisc vs 13 min for refresh liquigel
- 16. Cellulose derivatives Viscosity Retention time on eye surface Celluvisc 350 + + + + + + Liquigel 70 + + + Systane 10 + + + Refresh Tears 1 +
- 17. P o l y o l s Sugar hydrogenated carbohydrates-polyhydric alcohols Propylene glycol (PG)0.3% Polyethylene glycol 400 0.4%(PEG 400) Does not increases the viscosity Combined with HP guar Together forms a cross linked Mucomimetic layer Increase Retention time Protects corneal surface & promotes repair Better lubricity > HPMC > CMC
- 18. Dextran 70 High mole.wt.polysacharide Enhances the demulcent nature of HMC Tears Naturale: 0.3% HPMC +0.1% dextran 70 More viscous & Soothing drop Increases the retention time Evaporative dry eyes
- 19. Glycerine Polyols Glycerine 0.2% Absorbs water Polysorbate 80 used oil incorporated emulsions Refresh endura, Soothe etc. Inactive ingredient in restasis along with cyclosporine A
- 20. PolyVinylAlcohol One of early lubricants . Hydrophilic polymer All purpose lubricant Almost doubles TUBT 0.1% to 4% Tears plus Can be combined with PEG 400 or povidone (0.6%)
- 21. Povidone (PolyVinyl Pyrollodine) Iodine - antiseptic Demulcent property Increses solubility Pataday - Olopatadine 2% Increases the retention time
- 22. Hyaluronic Normally found in joints, vitreous gel & tears High water retaining property Increases bio adhesion Example: Blink tears, Hyla, Hyvisc, etc. More useful in Aqueous deficiency acid
- 23. Carbomer 980 Cross linked Poly Acrylate Polymer High clarity & viscosity Short flow properties High retention time on eye
- 24. • Reliable viscosity agent • Seldom used Gelatin
- 26. Bi-carbonate Normal component of natural tears It helps in maintaining Mucin layer everywhere It helps in repairing and maintaining epithelial layer
- 27. Potassium It helps in maintaining Corneal Thickness
- 28. Ointments Mineral oil White petrolatum HPMC Preservative Night application
- 29. Mild- 0.5 % CMC, 0.3% HPMC or Carbomer Moderate - polyols +/- gelling agents Severe - 1% CMC , hyaluronic acid, with osmo protectants Combination of 2 different tear substitutes Totally preservative free Ointments, gels WhichTear Substitute?
- 30. How Refresh Liquigel is beneficial Extra Protection A blend of high and medium – molecular weight CMC polymers for optimum viscosity 6 With added electrolytes 6 6. Simmons et.al, Refresh LiquigelA NewApproach to the treatment of persistent dry eye, Ophthalmic Pract, 2002;20(2):77-80
- 31. How Refresh Liquigel is beneficial Extra Action Superior mucoadhesivity due to its polyanionic charge 6 Mimics the natural mucins of ocular 6 6. Simmons et.al, Refresh LiquigelA NewApproach to the treatment of persistent dry eye, Ophthalmic Pract, 2002;20(2):77-80
- 32. How Refresh Liquigel is beneficial Extra Relief Brings about significant reduction in signs and symptoms of dry eye 7 Provides continued improvement over time 6 Brings about Goblet Cell Regeneration 6. Simmons et.al, Refresh LiquigelA NewApproach to the treatment of persistent dry eye, Ophthalmic Pract, 2002;20(2):77-80,7. Simmons et. al, Clinical performance of a mid-viscosity artificial tear for dry eye treatment, Cornea. 2007 Apr;26(3):294-302.
- 33. Thank you
Editor's Notes
- all of them contain polymers that work as demulcent and viscosity agent. they will also have some preservatives., electrolytes,gelling agents and buffers.
- demulcent is agent that supposedly forms a soothing film over inflamed mucous membrane relieving pain and inflammation. - also referred to as muco protective agents. we have heard emolient -used internally demulcent - used externally they generally have mucilaginous or oily . they provide lubricity. Also, the often mucilaginous makeup of demulcents provides them with a water-binding capacity that can help keep the ocular epithelium hydrated.
- fda has recognised 6 groups of demulcent. some tear sustitute may conatin up to 3 demulcents. cellulose derivatives and polyols are most commonly used.
- adsorb on cornea , stabelising fluid layer , increase tear film. it lowers surface tension at oil water interface. non irritating. . non toxic. provide palliative effect. they also increase viscocity and increase retention time cmc - carmellose hpmc - hypromellose comparable
- these are next most imp. class of demulcents hp guar isnonionic polymeric thickener and film former. it is ph dependent. higher ph more gelling occurs increasing retention and lubrication
- glycerine and glycerol are same. it is a colourless odourless viscous liquid.itisweet tasting ndnontoxic