CROQ Vol 2 Number 4

CROQ ONLINE EDITION

Clinical Refractive & Optometry Quebec EDITION

VOLUME 2, NUMÉRO 4, 2017

CLIQUEZ ICI POUR TÉLÉCHARGER ET IMPRIMER CE NUMÉRO

Tous les articles sont accrédités par l’OOQ pour des crédits UFC de catégorie A

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery Principles of Dry Eye Disease: Diagnosis, Treatment and Management Tear Dysfunction and Osmolarity: Tales from the Trenches Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy Case Consultations: Dry Eye Treatment Regimens

OUTIL DIAGNOSTIC D’OSMOLARITÉ LACRYMALE

DIAGNOSTIC DE LA SÉCHERESSE OCULAIRE CETTE NOUVELLE APPROCHE POUR MESURER L’OSMOLARITÉ DU FILM LACRYMAL EST MAINTENANT DISPONIBLE RAPIDE • FIABLE • ÉCONOMIQUE ®

i-Pen est un dispositif diagnostique portable à utiliser en clinique conçu pour détecter et mesurer des niveaux élevés de l’osmolarité lacrymale associés à la sécheresse oculaire légère, modérée et sévère.

• Aucun calcul requis • Aucune procédure de configuration requise • Lecture en seulement 5 secondes • Résultats en moins de 15 secondes

®

Pour plus d’information sur i-Pen ou pour obtenir une démonstration dans vos bureaux, veuillez communiquer avec votre représentant I-MED Pharma.

Visitez-nous à www.osdcare.com ou appelez au 1-800-463-1008

MAINTENANT DISPONIBLE

Peut devenir rentable dans la plupart des pratiques en seulement 5 jours de consultations

Clinical

&Refractive Optometry Quebec

Comité de rédaction • volume 2, numéro 4, 2017 Rédacteur en chef Dr Yvon Rhéaume Montréal, Québec

Rédacteur en chef adjoint Dr Richard Maharaj Toronto, Ontario

Rédacteur en chef adjoint Dr François Piuze Québec, Québec

Rédacteur en chef adjoint Dr Leonid Skorin, Jr. Albert Lea, Minnesota

Collaborateurs à la rédaction Dr Brad Almond Calgary, Alberta

Dre Danielle DeGuise Montréal, Québec

Dr Langis Michaud Montréal, Québec

Dr Jean Bélanger Montréal, Québec

Dr Pierre Forcier Montréal, Québec

Dr Rodger Pace Waterloo, Ontario

Dr Scott D. Brisbin Edmonton, Alberta

Dr John Jantzi Vancouver, Colombie-Britannique

Dr Maynard Pohl Bellevue, Washington

Dr Lorance Bumgarner Pinehurst, Caroline du Nord

Dr Gerald Komarnicky Vancouver, Colombie-Britannique

Dre Barbara Robinson Waterloo, Ontario

Dre Barbara Caffery Toronto, Ontario

Dr Bart McRoberts Vancouver, Colombie-Britannique

Dr Jacob Sivak Waterloo, Ontario

Dr Louis Catania Philadelphie, Pennsylvanie

Dr Ron Melton Charlotte, Caroline du Nord

Dr Randall Thomas Concord, Caroline du Nord

Équipe éditoriale Éditeur Lawrence Goldstein

Directrice gérante Mary Di Lemme

Éditrice médicale Evra Taylor

Mise en page Colin MacPherson

Graphisme et design Mediconcept Inc.

Notre énoncé de mission Clinical & Refractive Optometry Quebec est une revue d’optométrie évaluée par les pairs produite en éditions imprimée et en ligne. La revue a pour mandat de publier des articles cliniques et scientifiques approuvés par COPE qui ont été accrédités par l’Ordre des optométristes du Québec (OOQ) et sont offerts comme cours donnant droit à des crédits UFC de catégorie A. Le contenu de cette publication est composé d’articles qui présentent une utilité ou un intérêt particuliers pour les praticiens professionnels des soins de la vue au Québec. Les participants qui répondent aux tests-questionnaires UFC contenus dans la revue et qui obtiennent une note de 50 % ou plus recevront un certificat de crédit UFC personnalisé par courriel.

Pourquoi la revue est-elle publiée en anglais ?

Les règles concernant les crédits d’éducation permanente au Québec ont été amendées. Dorénavant, les articles de revue donnant droit à des crédits UFC qui ont été approuvés par COPE, le conseil créé par The American Regulatory Board of Optometry (ARBO), peuvent être offerts en version imprimée et en ligne aux optométristes du Québec pour des crédits UFC de catégorie A. Il est important de rappeler cependant que tous ces articles ont été à l’origine rédigés, approuvés et accrédités en anglais et ne peuvent être traduits ou reproduits dans une autre langue. Pour cette raison, tous les cours donnant droit à des crédits UFC de catégorie A offerts dans cette publication sont présentés en anglais avec l’approbation de l’Ordre des optométristes du Québec (OOQ).

Clinical

&Refractive Optometry Quebec

Contenu • volume 2, numéro 4, 2017 ARTICLES DE CRÉDITS UFC

129

137

Les commandes d’annonces et les textes doivent être reçus avant le premier jour du mois qui précède la date de publication.

ABSTRACT: Silicone oil injection is associated with many postoperative complications in the eye. The emulsification and forward migration of silicone oil into the anterior chamber is regarded as an invariable phenomenon that will eventually occur following a given in situ period.

L’équipe éditoriale de Clinical & Refractive Optometry Quebec prend un grand soin pour assurer l’exactitude du contenu, mais nous recommandons toujours aux lecteurs de consulter les directives du fabricant avant d’utiliser les produits mentionnés dans nos pages. Les vues exprimées dans la revue sont celles des auteurs respectifs et non de l’éditeur.

Principles of Dry Eye Disease: Diagnosis, Treatment and Management Pavan Avinashi, OD

Tear Dysfunction and Osmolarity: Tales from the Trenches Richard Maharaj, OD INTRODUCTION: Dr. Maharaj began his presentation by stating that he would be discussing new treatment options for dry eye, also referred to as tear dysfunction, comprising three areas: 1) Clinical approaches to diagnostics in terms of the ocular surface in tear dysfunction; 2) Several case studies revolving around treatment options; and 3) How to apply tear osmolarity testing in the primary eye care arena

155

La revue est accessible à tous les optométristes praticiens du Québec à www.crojournal.com.

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery Tam Nguyen, OD; Nancy N. Wong, OD; Terry Luk, OD; David M. Galeoto, OD; Karen Wadhams, OD

INTRODUCTION: Dr. Avinashi began his presentation by highlighting that dry eye disease certainly represents a major opportunity in optometric practice. Since 2007, when the Delphi panel issued a more precise definition of dry eye disease, it’s been a constant and continual evolving paradigm shift in the approach to treating dry eye.

145

Clinical & Refractive Optometry Quebec est publié six fois par année par Mediconcept.

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy Paul M. Karpecki, OD INTRODUCTION: Dr. Karpecki began his presentation by noting that he established his first dry eye clinic in 1997 and in the first ten years of ocular surface disease, there wasn’t a lot to teach about dry eye disease as we were learning as we went along. In addition, there wasn't much practitioners could do for success. In fact, he noted, his success rate was probably less than fifty percent. In a survey conducted before he joined Kentucky Eye Institute, approximately 96% to 98% of patients said they were satisfied or very satisfied with their treatment results. Dr. Karpecki mentioned that in the last six or seven years, great strides have been made in the management of the ocular effects of dry eye disease and allergies.

Veuillez faire parvenir toute correspondance à : Mediconcept Rédaction et service des ventes 3484, boul. des Sources, bureau 518 Dollard-des-Ormeaux, Québec Canada H9B 1Z9 Tél. bureau : (514) 245-9717 Courriel : mdilemme@mediconcept.ca Imprimé au Canada. Tous droits réservés. Copyright © 2017 Mediconcept.

Le contenu de cette publication ne peut être reproduit par voie mécanique ou électronique en tout ou en partie sans l’autorisation écrite de l’éditeur.

Toutes les publicités de médicaments ont été approuvées par le Conseil consultatif de publicité pharmaceutique.

CONSULTATIONS DE CAS 166 Treatment Regimens for a Challenging Dry Eye Case Presented by: Henry Reis, MD Responses from: Ben Barrus, OD; Edward Chow, OD; Krista Flynn, OD; Francis Gaudreault, OD; Jules Plante, OD; Susana Sebestyen, OD

ISSN: 2369-498X; Date de ce numéro : Octobre 2017

Image de Couverture : Inverted or reverse hypopyon as a result of emulsification into the anterior chamber.

Gracieuseté de : Dre Tam Nguyen

CLIQUEZ ICI POUR IMPRIMER CET ARTICLE ET LE TEST DE CRÉDIT UFC

Clinical & Refractive Optometry Quebec is pleased to present this continuing education (CE) article by Dr. Tam Nguyen et al, VA Connecticut Healthcare System, West Haven, CT. This article has been approved for 1 Category A, UFC credit in Ocular Health by the Ordre des Optométristes du Québec. In order to obtain your credit, please refer to page 135 for complete instructions.

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery Tam Nguyen, OD, MS, FAAO; Nancy N. Wong, OD, PhD, FAAO; Terry Luk, OD, FAAO; David M. Galeoto, OD, FAAO; Karen Wadhams, OD, FAAO

ABSTRACT Silicone oil injection is associated with many postoperative complications in the eye. The emulsification and forward migration of silicone oil into the anterior chamber is regarded as an invariable phenomenon that will eventually occur following a given in situ period.

Emulsification of silicone oil can manifest as an “inverted hypopyon” or “hyperoleon,” filling up space in the superior portion of the anterior chamber. This can cause damage to a variety of structures, posing potential sight-threatening implications for patients. It is imperative for the clinician to be familiar with these potential complications so that timely identification and proper management can be initiated.

Treatment modalities for secondary glaucoma include conventional topical glaucoma therapies, silicone oil removal (SOR), inferior peripheral iridectomy, and glaucoma surgeries for the control of IOP. In general, treatment and management is case-specific and risk factors need to be modified according to individual clinical presentation.

INTRODUCTION The advent of vitreoretinal surgical techniques in the past 30 years has dramatically altered the management of retinal conditions such as macular and retinal holes or tears, epiretinal membranes and retinal detachments.

T. Nguyen — VA Connecticut Healthcare System, West Haven Campus, West Haven, CT; N.N. Wong — VA Hudson Valley Healthcare System, Wappingers Falls, NY; T. Luk — James J. Peters VA Medical Center, Bronx, NY; D.M. Galeoto — James J. Peters VA Medical Center, Bronx, NY; K. Wadhams — VA Portland Healthcare System, Portland, OR Correspondence to: Dr. Tam Nguyen, VA Connecticut Healthcare System, West Haven Campus 950 Campbell Ave. Building 2, Floor 4, West Haven, CT 06516; E-mail: drtamitsu@gmail.com and Tam.Nguyen5@va.gov This article has been peer reviewed.

Many advances have further expanded the repertoire of treatment modalities such as the introduction of vitreous substitutes as long-acting gases1 and the use of silicone oil in vitreous surgery.2 In particular, silicone oil has been used with increasing frequency.2,3 However, the administration of silicone oil is not devoid of side effects or the potential for complications. Moreover, complications have been well-documented in the literature and include elevated intraocular pressure, refractive change, cataract formation,4 emulsification of oil, silicone oil keratopathy, peri-oil fibrosis,4 re-detachment of the retina4 as well as the development of secondary glaucoma.5-7 Silicone (polymethysiloxane) oil is often used as an intraocular retinal tamponade following reparative retinal detachment surgery. For intraocular applications, silicone oil demonstrates a low density when compared with aqueous. The density disparity easily displaces aqueous downward. Silicone oil has the advantage of being optically transparent, allowing for visualization of the posterior segment surgical fields. Often, silicone is selected over gas for complicated cases because silicone provides permanent or extended retinal tamponade and is not absorbed by ocular tissues like the long-acting gases.

Currently, indications for the use of silicone oil in the eye include: internal tamponade in giant retinal tears, tamponade in traumatic or complex retinal detachments, dissection of epiretinal membranes with flattening of the retina, macular holes, and closure of breaks which are complicated by proliferative diabetic retinopathy4 and proliferative vitreoretinopathy.4 The intraocular use of silicone oil may result in adverse complications to multiple structures in the eye. At the posterior surface, silicone oil migration into subretinal spaces has been shown to occur in the presence of breaks in the retina.8 In addition, peri-oil fibrosis can occur at the pre-retinal surface resulting in adherent membranes4 that pose potential threats for retinal detachment. Pupillary block or iris bombé can occur if the silicone oil advances forward towards the anterior segment. Contact between the oil and the lenticular structures may result in refractive error shifts8 and induce cataract formation. Further migration anteriorly may cause interference with the outflow processes of the eye causing elevation in intraocular

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery — Nguyen et al

129

tensions.9,10 If silicone oil remains in direct contact with the trabecular meshwork, ultra-structural damage may occur9,10 which may further reduce outflow. Silicone oil contact with the corneal endothelium causes a characteristic keratopathy9,11-13 resembling band keratopathy. The use of silicone oil in the eye may result in multiple iatrogenic complications which may be sight-threatening. With the increased application of silicone oil in retinal repair surgeries, recognition of the postoperative complications represents significant clinical importance in the management of retinal diseases. These complications are unique to its use and often present a straightforward clinical profile. In patients with a history of vitreoretinal surgery with silicone oil administration, proper assessment of postoperative complications with sight-threatening effects is important for disease co-management.

CASE REPORT A 51-year-old African-American male presented to the Eye Clinic with complaints of a mild, dull, periorbital ache and pain in the left eye. The pain was graded as a 4 on a scale of 10. The intermittent pain had been ongoing for the past several weeks. The patient also had complaints of subsequent decreased vision in the left eye. He reported that he felt the reduced vision correlated temporally to when his antihypertension medications were taken. The patient denied symptoms of photophobia, photopsia, headache, and discharge. His last eye exam was approximately 3 months prior. Moreover, the patient had been receiving ongoing care over the course of three years and was co-managed by a local, private retina specialist for an inferior retinal detachment secondary to lattice degeneration. The patient’s ocular history was significant for retinal reparative surgery including pneumatic retinopexy, scleral buckling, pars plana vitrectomy with silicone substitution, phaco-extracapsular cataract extraction, and YAG capsulotomy in the left eye. Following reparative retinal surgery, the left eye had developed cystoid macular edema resulting in subsequent poor vision. Despite prompt treatment, visual acuity was never fully restored to better than counting fingers. The patient’s medical history was significant for type 2 diabetes mellitus, hypertension and benign prostrate hypertrophy, all of which were controlled with oral medical therapy. The patient’s blood pressure measured 115/83 mmHg. Review of laboratory findings indicated a glycosylated hemoglobin level of 7.8%, and a fasting blood glucose level of 117 mg/dL. The patient denied any history of allergies and was alert and oriented to time, person and place.

On clinical examination, the patient’s visual acuity was 6/6- (20/20-) and counting fingers at 5 feet with best spectacle correction of -4.50 -1.50 x 077 and -3.00 -1.50 x 071 for the right and left eyes, respectively.

The patient’s visual acuity was unchanged with pinhole. A

130

Clinical & Refractive Optometry Quebec 2:4, 2017

grade 2 relative afferent pupillary defect OS was again noted on examination. Extraocular muscles were unrestricted in all fields of gaze and cover testing demonstrated orthophoria at distance and a slight exotropia at near. On external examination, there was an OS upper lid ptosis which impinged on the visual axis. Palpebral apertures were 11 mm on the right and 5 mm on the left. Anterior segment evaluation by slit lamp biomicroscopy was remarkable for mild endothelial guttatta, stromal scarring OD>OS and inferior punctuate epithelial erosions OD>OS. Temporal endothelial incision scars were visualized in the peripheral cornea of the left eye. The bulbar and palpebral conjunctiva were quiet OD and trace perilimbal injection was observed in the OS. Further examination of the iris OS demonstrated tiny crystalline-like structures localized to the crypts of the iris furrows.

An opaque crystalline-substance occupied the top half of the anterior chamber. A demarcation line was evident 3.5 mm from the superior-most cornea in the left eye. The demarcation line in the anterior chamber separated the white crystalline opacity superiorly from the clear aqueous fluid inferiorly. Applanation tonometry was OD: 20 and OS: 38 mmHg. The anterior chamber appeared clear without cells or flare. In both eyes, angle estimation demonstrated grade 4 open angles by Van Herick technique. Gonioscopy of the left eye demonstrated open angles to ciliary body band in all quadrants except the superior portion where a thick, white, crystalline substance filled the angle. Intraocular pressure (IOP) OS was reduced to 27 mmHg following in-office topical instillation of brimonidine 0.2% and timolol maleate 0.5%.

The dilated fundus examination revealed trace nuclear sclerotic and cortical cataracts in the right eye.

The posterior chamber intraocular lens implant in the left eye was centered and clear of opacities. The vitreous in the right eye was unremarkable. Silicone oil was evident in the hyaloid space of the left eye. Fundus assessment revealed healthy optic nerves with a cup-to-disc ratio of 0.5 in both eyes. The neuroretinal rim was healthy and intact in the right eye. Pallor and peripapillary atrophy was noticed in the left eye. The macula was clear and flat in both eyes. The left eye demonstrated a foveal reflex. All vasculature was normal for course and caliber OU. The left eye demonstrated an inferior scleral buckle with an old hilar-shaped demarcation line that terminated 4 disc diameters from the macula. Extensive overlying retinal pigment epithelial hyperplasia and disruption were noticed along the demarcation line. The peripheral retina was flat and intact in both eyes.

The patient was diagnosed with hyperoleon or emulsified silicone migration into the anterior chamber resulting in subsequent elevation of intraocular pressure in the left eye. The patient was referred back for retinology evaluation. Retinology evaluation was elicited to consider

and left eyes, respectively. No silicone oil was evident in the anterior and posterior chamber of the left eye.

The patient was instructed to taper the topical steroid drops, and complete the antibiotic and non-steroidal anti-inflammatory drops for a 13-day course. He was maintained on the topical beta-blocker to control IOP.

Fig. 1 Inverted or reverse hypopyon as a result of emulsification into the anterior chamber. Migration of silicone oil into the anterior chamber displaces aqueous inferiorly and results in a density gradient demarcation line. (This image was originally published in the ASRS Retina Image Bank.

Michael Lambert, MD. Inverted Hypopyon – Silicone Oil Complication.

Retina Image Bank, 2016, Image Number 24099. © The American Society of Retina Specialists.)

Follow-up #2 A follow-up examination was performed one month following surgical silicone oil removal. The patient reported resolution of the aching sensation in the left eye and maintenance of stable vision. The patient confirmed compliance with timolol maleate 0.5% ophthalmic solution. Visual acuities remained stable at 6/6- (20/20-) and counting fingers at 5 feet, in the right and left eyes, respectively. The intraocular pressures were 19 mmHg OD and 28 mmHg OS. No silicone oil was evident in the anterior or posterior chamber of the left eye.

The patient was maintained on timolol maleate 0.5% b.i.d. OS for the control of pressure. Follow-up management included continued observation of glaucoma status.

DISCUSSION the risks, benefits and alternatives of either partial silicone oil removal from the anterior chamber or complete intraocular silicone oil extraction. The patient was maintained on timolol maleate 0.5% in the left eye to control intraocular pressure.

At the retinal evaluation, the patient was counselled on risks and benefits of further surgical procedures for silicone oil removal. The patient elected to undergo complete silicone oil removal. Silicone oil removal from the posterior cavity was completed via vacuum pump. The remaining silicone oil in the anterior chamber was removed by paracentesis and sodium hyaluronate. A washout procedure for the anterior chamber was also performed. The patient underwent the operative procedure without complications.

Follow-up #1 A follow-up examination was performed one day following surgical silicone oil removal surgery. The patient reported post-surgical soreness but denied pain or photophobia.

Postoperative medications included: moxifloxacin 0.5% (Viagamox®, Alcon Canada, Mississauga, ON), prednisolone 1% (Pred Forte®, Allergan Canada, Unionville, ON), and ketorolac tromethamine 0.5% (Acular®, Allergan Canada, Unionville, ON). In addition, the patient was maintained on timolol maleate 0.5% (Timoptic®, Merck Canada, Kirkland, QC) in the left eye to control intraocular pressure. Visual acuities remained stable at 6/6(20/20-) and counting fingers at 5 feet, in the right and left eyes, respectively. Slit lamp biomicroscopy was significant for trace diffuse injection in the left eye. The ocular tensions were 19 mmHg and 30 mmHg in the right

The term “emulsification” refers to the breaking up of silicone into small intraocular fragments. The incidence of emulsification into the anterior chamber has been reported from as low as 0.7%9 to as high as 56%.4 Emulsification and migration of silicone oil into the anterior chamber displaces aqueous inferiorly and results in a density gradient demarcation line. The characteristic appearance has also been termed “inverted” or “reverse hypopyon” or “hyperoleon” (Fig. 1). Discrepancies exist in the literature as to whether or not the presence of silicone in the anterior chamber is directly responsible for elevated ocular tension. The emulsification of silicone with subsequent migration into the anterior chamber is a rare complication in phakic or pseudophakic eyes.2,14-16 The natural or pseudophakic lens acts as a barrier to prevent migration16,17 of the silicone oil into the anterior chamber. The incidence of migration is much higher in aphakes.15 The current case represents an uncommon complication of emulsification with migration of silicone into the anterior chamber despite the presence of a pseudophakic implant. Alternative theories suggest partial zonulysis following extracapsular cataract extraction enabling the oil to migrate around the implanted lens.15,16 In the current case, the surgical history is positive for extracapsular cataract extraction. The resultant disturbance of the lens zonules may have contributed to migration of the emulsified silicone oil into the anterior chamber.

The incidence of emulsification was thought to decrease with the development of higher viscosity oils.

Lower-viscosity oil had a tendency to emulsify more than higher viscosity laboratory grade silicone.9 Despite new innovations in vitreous substitutes, the problem of emulsification has not been eliminated. In particular, for cases in

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery — Nguyen et al

131

Fig. 2 Peripheral iridectomy in the inferior position of the iris in order to prevent pupillary block.

which prolonged internal tamponade is desired, 5000 centistokes (cs) of highly purified silicone oil is recommended.9 The current patient received 5000 cs silicone oil, which is characterized as one of the highest viscosity oils currently available for medical use. Despite such precautions, emulsification of silicone still resulted and IOP rise was observed.

In the current case, inverse hypopyon was readily visualized when the left eyelid was manipulated superiorly.

However, the emulsification of silicone and the deposition in the anterior chamber can also be subclinical.4 The droplet dimensions are smaller than a wavelength of light, therefore, slit lamp biomicroscopy and gonioscopy techniques may not facilitate visualization of the subclinical emulsified particles.4 Ultrasound biomicroscopy, however, has been shown to be more sensitive than the aforementioned techniques.18 Emulsification of oil droplets has been readily identified on ultrasound biomicroscopy as highly reflective images with a typical morphologic appearance.15,18,19 Moreover, ultrasound biomicroscopy should be performed in all cases where emulsification and migration is suspected and a hyperoleon cannot be visualized.

The incidence of IOP elevation secondary to silicone oil has been reported to range from 5.9% to 56% of treated eyes.20 The cause of elevated intraocular pressure may be either direct blockage of the trabecular meshwork or inflammation and damage to the trabecular meshwork cells.21 Elevation in IOP is a common finding following vitreoretinal surgery with silicone oil injection.15 However, elevated IOP should prompt consideration of possible surgical complications. In aphakes receiving silicone oil substitutes, elevated ocular tensions can occur immediately following the postoperative period as a result of pupillary block. Pupillary block glaucoma occurs if the silicone oil creates a barrier at the pupillary space and

132

Clinical & Refractive Optometry Quebec 2:4, 2017

prevents flow of aqueous into the anterior chamber.

Resultant anterior chamber narrowing and elevated intraocular pressure is evident from the misdirection of the aqueous. Pupillary block complications are circumvented by creation of a peripheral iridectomy (PI) in the inferior position of the iris, which allows for communication between the anterior and posterior chambers (Fig. 2). The incidence of elevated tensions in the aphakic individual immediately following surgery has decreased in patients that have received prophylactic treatment with a PI. Similarly, blockage of the iridectomy by blood, fibrin or oil in the postoperative course may be another mechanism for raised intraocular tensions. In phakic or pseudophakic individuals, the mechanism for acutely elevated IOP is likely to be true overfill with silicone oil.4 Elevated IOP in such cases typically demonstrates acute onset following surgery.13 If the intraocular pressure is as a result from true silicone overfill, surgical intervention to remove excess silicone generally has favorable results.13 Additionally, raised IOP may be a late-onset complication. Late-onset elevated pressure is caused by emulsification of silicone, pre-existing glaucoma, steroid induced glaucoma and uveitis.4 Not all patients with a hyperoleon have raised IOP. Many risk factors have been identified that may predispose the patient to an elevation of IOP following pars plana vitrectomy with silicone oil injection.5,7,22 Posner-Schlossman Syndrome generally presents with marked unilateral elevation (40 to 60 mmHg), with minimal conjunctival injection. This syndrome typically presents in young-to-middle-aged patients and is often accompanied with a history of recurrent episodes. In addition, this condition is responsive to steroid treatment.

A retrobulbar hemorrhage generally appears in patients with an extensive history of recent blunt ocular trauma or head injury. Accompanying signs on external examination would include subconjunctival hemorrhage, occasionally chemosis and proptosis of the globe. In patients with pigmentary glaucoma, a Krukenberg’s spindle may be visualized on the cornea, and patients are typically young males with intact accommodative systems. With inflammatory open-angle glaucoma, a moderate to severe anterior chamber reaction would be evident on slit lamp biomicroscopy. Medications can be responsible for inducing unilateral elevated intraocular pressures (e.g., steroid, topiramate). If the etiology lies in the structure of the lens, this can easily be visualized on slit lamp biomicroscopy.

Pupillary block would be evident as a result of a phakomorphic lens. Choroidal detachments and posterior segment tumors will be evident on B-scan ultrasonography of the anterior and posterior segment, respectively (Table I).

The presence of an inverted hypopyon or silicone droplets are pathognomonic for emulsification and migration of silicone oil into the anterior chamber. A history of retinal detachment repair with silicone injection

Table I The differential diagnosis in unilateral elevated intraocular tensions • Glaucomatocyclitic crisis (Posner-Schlossman Syndrome) • Retrobulbar hemorrhage • Pigmentary glaucoma • Inflammatory open-angle glaucoma • Medication-induced • Lens-induced • Choroidal detachment • Posterior segment tumor

is further supportive of the etiology of increased IOP. Isolation of the particular mechanism responsible for the postoperative rise in ocular tensions facilitates timely treatment and management. The causes of hyperoleon and unilateral elevated intraocular pressure in the immediate postoperative period include pupillary block and silicone overfill. Pupillary block generally appears in the aphakic individual and may be accompanied by a mid-dilated pupil. An overlying exudative membrane in pupillary block may be evident in patients with existing PI’s. A lack of an oil/aqueous interface in the pupillary plane is evident, as well as an absence of flare in the anterior chamber.

Silicone overfill generally appears in the pseudophake or phakic patient. The condition may be accompanied by signs of shallowing in the anterior chamber, as well as the presence of herniation of oil between the pupil and lens.

The causes of hypopyon and unilateral elevated intraocular pressure during the late postoperative period include steroid-induced glaucoma, pre-existing glaucoma, uveitis and emulsification of silicone. Topical steroids are frequently given following surgical intervention. In the present case, the patient was placed on a topical steroid but the steroid response elevation in IOP will often resolve following discontinuation of therapy. This mechanism is a diagnosis of exclusion. Pre-existing glaucoma may aggravate in IOP following re-attachment of the retina because repair reduces the uveal-scleral outflow afforded by the retinal detachment. Elevated intraocular pressure has also been shown to occur secondary to complex vitreal detachments. The condition is evidenced by the presence of cells and flare in the anterior chamber but such constituents should not be mistaken for fine silicone droplets which may mimic the clinical entity. Finally, the presence of silicone in the anterior chamber leads to the diagnosis of emulsification, as described in the current case.

Elevated Intraocular Tension and Considerations for Glaucoma Silicone oil use has been associated with emulsification of oil into the anterior chamber, subsequent elevated intraocular pressure, and secondary glaucoma.23-25 Silicone oil emulsification and glaucoma often are coexisting entities; however patients with emulsified silicone may never develop glaucoma, even after long term testing.8,14 The

pathogenesis remains obscure but generally, the hyperoleon is thought to be a contributor to ocular hypertension or glaucoma in some patients.13-15,26 In patients with emulsification and raised intraocular pressure, removal of the oil is recommended. Some investigators have showed minimal effect on IOP following silicone oil removal.27 Other investigators have demonstrated that removal affords for better control of ocular tensions.6 In general, secondary glaucoma is one of the most serious complications for patients with emulsification of silicone and increased IOP. Individuals with such indications should be followed closely for the development of secondary glaucomas.

CONCLUSION The use of silicone oil in the eye is becoming more prevalent with more advances in vitreoretinal surgery.

Silicone oil in the eye can lead to serious complications that have a specific clinical profile. Recognition of specific vitreous substitutes in retinal surgery allow for prompt diagnosis. Isolation of the mechanism for IOP-rise facilitate targeted treatment and management. In general, treatment and management is case-specific so risk factors need to be balanced and subsequently modified according to individual clinical presentation. ❏

REFERENCES 1.

Stern WH, Blumenkranz MS. Fluid-gas exchange after vitrectomy. Am J Ophthalmol 1983; 96: 400-401.

2. Lucke KH, Foster MH, Laqua H. Long-term results of vitrectomy and silicone in 500 cases of complicated retinal detachments. Am J Ophthalmol 1987; 104: 624-633.

3. Scott JD. A rationale for the use of liquid silicone. Trans Ophthalmol Soc UK 1977; 97: 235-237.

4. Chignell AH, Wong D. Management of vitreo-retinal disease: a surgical approach. London: Singer Press, 1999.

5. Honavar SG, Goyal M, Majji AB, Sen PK, Naduvilath T, Dandona L. Glaucoma after pars plana vitrectomy and silicone oil injection for complicated retinal detachments.

Ophthalmology 1999; 106: 169-176; discussion 177.

6. Nguyen QH. Lloyd MA, Heuer DK, et al. Incidence and management of glaucoma after intravitreal silicone oil injection for complicated retinal detachment. Ophthalmology 1992; 99: 1520-1526.

7. Henderer JD, Budenz DL, Flynn HW, et al. Elevated intraocular pressure and hypotony following silicone oil retinal tamponade for complex retinal detachment: incidence and risk factors. Arch Ophthalmol 1999; 117: 189-195.

8. Leaver PK, Grey RH, Garner A. Silicone oil injection in the treatment of massive preretinal retraction: late complications in 93 eyes. Br J Ophthalmol 1979; 63: 361-367.

9. Scott JD. Surgery for Retinal and Vitreous Disease. Oxford: Butterworth Heinemann. 1998.

10. McCuen BW, de Juan E Jr, Landers MB 3rd, Machemer R. Silicone oil in vitreoretinal surgery. Part 2: Results and complications. Retina 1985; 5: 195-205.

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery — Nguyen et al

133

11. Cockerham WD. Schepens CL, Freeman HM. Silicone injection in retinal detachment. Arch Ophthalmol 1970; 83: 704-712.

12. Grey RH, Leaver PK. Results of silicone oil injection in the treatment of massive preretinal retraction. Trans Ophthalmol Soc U K 1977; 97: 238-241.

13. Kim RW, Baumal C. Anterior segment complications related to vitreous substitutes. Ophthalmol Clin North Am 2004; 17: 569-576.

14. Federman JL, Schubert HD. Complications associated with the use of silicone oil in 150 eyes after retina-vitreous surgery. Ophthalmology 1988; 85: 870-876.

15. Avitabile T, Bonfiglio V, Circero A, et al. Correlation between quantity of silicone oil emulsified in the anterior chamber and high pressure in vitrectomized eyes. Retina 2002; 22: 443-448.

16. Riedel KG, Gabel VP, Neubauer L, et al. Intravitreal silicone oil injection: complications and treatment in 415 consecutive patients. Graefes Arch Clin Exp Ophthalmol 1990; 228: 19-23.

17. Ardjomand N, El-Shabrawi Y. Pupillary block after silicone implantation in a phakic eye. Eye 2001; 15: 331.

18. Genovesi-Ebert F, Rizzo S, Chiellini S, et al. Ultrasound biomicroscopy in the assessment of secondary glaucoma after vitreoretinal surgery and silicone oil injection.

Ophthalmologica 1998; 212: 4-5.

134

Clinical & Refractive Optometry Quebec 2:4, 2017

19. Azzolini C. Pierro L. Codenotti M, et al. Ultrasound biomicroscopy following the intraocular use of silicone oil.

Int Ophthalmol 1995; 19: 191-195.

20. Gedde SJ. Management of glaucoma after retinal detachment surgery. Curr Opin Opthalmol 2002; 13: 103-109.

21. Champion R, Faulborn J, Bowald S, Erb P. Peritoneal reaction to liquid silicone: an experimental study. Graefes Arch Clin Exp Ophthalmol 1987; 225: 141-145.

22. Budenz DL, Taba KE, Feuer WJ, et al. Surgical management of secondary glaucoma after pars plan vitrectomy and silicone oil injection for complex retinal detachment. Ophthalmology 2001; 108: 1628-1632.

23. Chan C, Okun E. The question of ocular tolerance to intravitreal liquid silicone: a long term analysis. Ophthalmology 1986; 93: 651-660.

24. Nakamura K, Refojo MF, Crabtree DV. Factors contributing to the emulsification of intraocular silicone and fluorosilicone oils. Invest Ophthalmol Vis Sci 1990; 31: 647-656.

25. Valone J Jr, McCarthy M. Emulsified anterior chamber silicone oil and glaucoma. Ophthalmology 1994; 101: 1908-1912.

26. Gao RL, Neubauer L, Tang S, Kampik A. Silicone oil in the anterior chamber. Graefes Arch Clin Exp Ophthalmol 1989; 227: 106-109.

27. Moisseiev J, Barak A, Manaim T, Treister G. Removal of silicone in the management of glaucoma in eyes with emulsified silicone. Retina 1993; 13: 290-295.

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A

2:4, 17

DIRECTIVES POUR UN CRÉDIT UFC DE CATÉGORIE A Ce cours a été approuvé pour 1 crédit UFC de catégorie A en santé oculaire par l’Ordre des optométristes du Québec.

Veuillez répondre à ce questionnaire et le soumettre pour notation avant le 31 mars 2018.

Si vous obtenez une note de 50 % ou plus, un certificat de crédit UFC vous sera envoyé pour vos dossiers.

POUR PRENDRE ET SOUMETTRE CE TEST EN LIGNE Commencez par cliquer <ICI> et suivez les instructions à l’écran.

Si vous êtes un abonné de test prépayé, vous serez automatiquement dirigé vers le questionnaire de test.

Une fois terminé avec succès, vous recevrez automatiquement un certificat de crédit UFC personnalisé par courrier électronique.

Si vous n’êtes pas un abonné de test prépayé, vous serez automatiquement dirigé vers PayPal pour acheter ce test. Après le paiement, vous serez automatiquement dirigé vers le questionnaire de test.

POUR PRENDRE ET SOUMETTRE CE TEST PAR LA POSTE Si vous êtes un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous.

Si vous n’êtes pas un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous ainsi qu’un chèque de 25 $ payable à Mediconcept Communications.

Envoyer à: CRO 3484 Sources Blvd., Suite 518, Dollard-des-Ormeaux, QC H9B 1Z9, Canada

IDENTIFICATION Prénom :____________________________ Nom :______________________________________ Adresse :_______________________________________________________________________ Numéro

Rue

Bureau

_______________________________________________________________________________ Ville

Tél. bureau : (

Province

Code postal

) _________________ Courriel : _____________________________________

No de permis professionnel :________________________________________________________

QUESTIONNAIRE Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery Tam Nguyen, OD, MS, FAAO; Nancy N. Wong, OD, PhD, FAAO; Terry Luk, OD, FAAO; David M. Galeoto, OD, FAAO; Karen Wadhams, OD, FAAO 1. ❑ ❑ ❑ ❑

In the Case Report presented, what degree of pain did the patient report at initial presentation?

Grade 1 Grade 2 Grade 3 Grade 4

2. ❑ ❑ ❑ ❑

All of the following statements are true, EXCEPT: In the Case Report presented, the patient’s ocular history was significant for scleral buckling In the Case Report presented, the patient’s visual acuity was fully restored to better than counting fingers For intraocular applications, silicone oil has a low density when compared with aqueous The use of silicone oil in the eye may result in complications which may be sight-threatening

Hyperoleon: Complications of Silicone Oil in Reparative Retinal Surgery — Nguyen et al

135

2:4, 17

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A 136

3. ❑ ❑ ❑ ❑

In the Case Report presented, what was the patient’s initial visual acuity?

6/6- (20/20-) 6/7.5- (20/25-) 6/9- (20/30-) 6/12- (20/40-)

4. ❑ ❑ ❑ ❑

All of the following statements describe the patient at follow-up #1, EXCEPT: He denied photophobia Visual acuities remained stable at 6/6- (20/20-) He reported Grade 2 pain Ocular tensions were 19 mmHg and 30 mmHg in the right and left eyes, respectively

5. ❑ ❑ ❑ ❑

What is the reported incidence of IOP elevation secondary to silicone oil?

2.4% to 56% of treated eyes 3.9% to 56% of treated eyes 4.8% to 56% of treated eyes 5.9% to 56% of treated eyes

6. ❑ ❑ ❑ ❑

All of the following statements accurately describe Posner-Schlossman Syndrome, EXCEPT: It typically presents in elderly women It is often accompanied with a history of recurrent episodes It responds to steroid treatment A retrobulbar hemorrhage generally appears in patients with an extensive history of recent ocular trauma or head injury

7. ❑ ❑ ❑ ❑

In the Case Report presented, all of the following clinical signs describe the patient at initial presentation, EXCEPT: The patient’s visual acuity was unchanged with pinhole Extraocular muscles were restricted in some fields of gaze On external examination, there was an OS upper lid ptosis which impinged on the visual axis The bulbar and palpebral conjunctiva were quiet OD

8. ❑ ❑ ❑ ❑

All of the following statements about use of silicone oil are true, EXCEPT: Its use has been associated with secondary glaucoma Silicone oil emulsification and glaucoma often are coexisting entities The majority of patients with emulsified silicone develop glaucoma Hyperoleon is thought to be a contributor to ocular hypertension in some patients

9.

In the Case Report presented, following in-office topical instillation of brimonidine 0.2% and timolol maleate 0.5%, the patient’s IOP OS was reduced to which of the following?

22 mmHg 25 mmHg 26 mmHg 27 mmHg

❑ ❑ ❑ ❑

10. All of the following statements about the incidence of IOP elevation following vitreoretinal surgery with silicone oil injection are false, EXCEPT: ❑ It’s rare ❑ It rises with increased age ❑ It’s common ❑ Steroid response elevation in IOP typically continues despite discontinuation of therapy

Clinical & Refractive Optometry Quebec 2:4, 2017

CLIQUEZ ICI POUR IMPRIMER CET ARTICLE ET LE TEST DE CRÉDIT UFC

Clinical & Refractive Optometry Quebec is pleased to present this continuing education (CE) article by Dr. Pavan Avinashi, Hollyburn Eye Clinic, Vancouver, BC. This article has been approved for 1 Category A, UFC credit in Ocular Health by the Ordre des Optométristes du Québec. In order to obtain your credit, please refer to page 143 for complete instructions.

Principles of Dry Eye Disease: Diagnosis, Treatment and Management Pavan Avinashi, OD

INTRODUCTION Dr. Avinashi began his presentation by highlighting that dry eye disease certainly represents a major opportunity in optometric practice. Since 2007, when the Delphi panel issued a more precise definition of dry eye disease, it’s been a constant and continual evolving paradigm shift in the approach to treating dry eye. It’s no longer simply about giving a sample of an artificial tear and instructing the patient to use a hot compress at home with a towel and some warm water, which was and still is, common practice.

First, he noted, that’s very mild superficial palliative care; and second, it’s not really treating or managing the problem.

When patients are shown that something can be done above and beyond that, with a willingness to investigate things further, and that there are a lot of options in managing dry eye disease, they’re a lot more committed to the practitioner, with a greater degree of trust which will increase their retention and referral rates, as well.

PATIENT COMMUNICATION ABOUT DRY EYE DISEASE

inflammation. It’s not somebody stating that in the past few days they’ve had slight dryness in their eyes. Rather, these are patients who have tried various drops and have been suffering for years, with fluctuating vision as a result.

When Dr. Avinashi diagnoses someone with episodic, chronic or recalcitrant dry eye disease, he feels it’s essential to tell them three things. Number one, that dry eye is a disease. If it’s not labelled as such, it’s not given the importance that it deserves. Number two, it’s crucial to mention that dry eye disease is chronic and progressive; it’s not something that will go away forever. It may go away for a while, it may be suppressed or managed, but it’s going to be there persistently. If these factors aren’t stressed, patients may not be on board for compliance for what is being managed or recommended. Number three, he always emphasizes to them that the underlying problem with dry eye disease is inflammation. He does this because the treatment modality of introducing oral omega-3 topical steroids, cyclosporine or anything else of that nature is justified by trying to manage the inflammation as well. In addition, sometimes patients associate the inflammation more with chronic conditions so this way at least there’s a correlation.

TEAR FILM MATRIX COMPOSITION

According to the literature, ocular surface disease occurs in as low as 10% of the general patient population to as much as 70% according to one Japanese publication.

A common rule of thumb, said Dr. Avinashi, is that it occurs in almost one third of people who consult with an optometrist. The salient question, though relates to how many are being recognized and managed.

Dry eye is a multi-factorial disease affecting people’s comfort, lifestyle and visual stability. Dr. Avinashi explains to his patients that the condition is associated with increased osmolarity, which is the tear composition, and that the underlying problem with dry eye disease is P. Avinashi — Hollyburn Eye Clinic, Vancouver, BC Correspondence to: Dr. Pavan Avinashi, Hollyburn Eye Clinic, 1516 Marine Drive, West Vancouver, BC V7V 1H8 E-mail visualperformance@hotmail.com Dr. Avinashi has no direct financial or proprietary interest in any companies, products or services mentioned in this article.

This article has been peer reviewed.

In terms of the tear film, Dr. Avinashi stated, it’s essential to remember that the mucous layer has glycocalyx which act as a type of “cotton candy” to the corneal film. This is extremely important because with dry eye disease, when that gets compromised it also leads to apoptosis of the epithelial tissue and constant chronic conditions. Additionally, it’s where osmolarity can have a huge effect on stabilizing tear film at that level of the cornea and tear film.

Dr. Avinashi explains to his patients that the tear film has many purposes but it’s a complex composition of many different elements that have to be addressed. Hence, when we’re mentioning things such as osmolarity nowadays, it’s an index of the electrolyte concentration of the tear film in the eyes.

Regarding symptoms, one aspect that is always undermined is visual stability. One study showed that tear instability can constitute up to 20% of visual variability.

When a patient complains of visual instability, dry eye disease can’t be ruled out. Risk factors include age,

Principles of Dry Eye Disease: Diagnosis, Treatment and Management — Avinashi

137

Table I Systemic diseases associated with dry eye Inflammatory – Fibromyalgia, RA, SLE, Scleroderma, Osteoarthritis – Sarcoidosis, Raynaud’s, OCP – Thyroid Disease, Sjögren’s Neural – Bell’s Palsy, Compressive Lesions – IIIrd or Vth Nerve Damage/Disorders Hormonal – Post Menopause, Pregnancy – Rosacea

Infectious – Chlamydia, HZ, Viral URI Metabolic – Diabetes Mellitus, Amyloidosis – Vitamin A Deficiency Developmental – Ectodermal Dysplasia – Ichthyosis, Alacrima Medical/Therapeutic – Antihistamines, Decongestants – Sedatives, Anti-depressants – Beta Blockers, Diuretics – OCB, HRT Fig. 1 Tear film instability: a key underlying cause of dry eye disease.

environment, female gender, contact lenses, medications, and auto-immune disease.

Regarding medications, Dr. Avinashi noted that many medications have dry eye symptoms as a side effect, for instance, antihistamines.

SYSTEMIC DISEASES AND DRY EYE DISEASE While there are many systemic diseases associated with dry eye disease (Table I), Dr. Avinashi highlighted one that is often overlooked: diabetes. Depending on the studies being considered, 54% to 60% of all diabetics have some level of ocular surface disease. With these patients, typically, cataracts and retinopathy are the main concern, rather than the ocular surface.

TEAR FILM AND OSMOLARITY There are two different categories of dry eye disease: aqueous deficient dry eye and evaporative dry eye. The proportion of patients with a level of evaporative dry eye as a component is close to 100%. While Dr. Avinashi has seen the reported figure as low as 60%, it’s generally considered to be 80%; however, he has read and believes that it’s close to 100%. It may not be in the earlier stages but at some point it’s going to develop into that. So the question that remains is whether or not optometrists are managing their patients correctly in light of this. By sending them home with the aqueous supplement tear and nothing else, are these patients being managed properly?

The tear film is a causative mechanism of ocular surface disease. When the tear film becomes unstable, the epithelial tissue is breached and the layers are adversely affected which in turn causes a chronic cycle of inflammation (Fig. 1). This leads to local drying or hyperosmolarity of the exposed surface. This leads to a discussion of the second kind of causative mechanism. Osmolarity testing has been in existence for some time; however,

138

Clinical & Refractive Optometry Quebec 2:4, 2017

there is controversy about how valid the index is. Just in the last five years, more and more studies have been conclusive in the fact that this is actually a big parameter that has to be addressed, or at least looked at from the diagnostic perspective or a patient education perspective.

The bottom line, noted Dr. Avinashi, is that a hyperosmolar tear film is an indication of an inflammatory environment.

With an aqueous deficient tear flow and an unstable tear film, this leads to a hyperosmolar environment, which leads to cellular death, which leads to inflammation and it becomes a vicious cycle.

Tear osmolarity on the ocular surface causes a decrease in aqueous production, so a hyperosmolar condition or environment innately decreases the aqueous and lipid production, evaporation is increased, and this causes an upregulation of inflammatory mediators. This accelerates the entire cycle of disease and it becomes an overall toxic environment for the epithelial cell layer.

DIAGNOSTIC AND SCREENING TOOLS Dr. Avinashi stated that it’s critical to have a classification system for dry eye disease because that’s going to be the basis on which a treatment plan is developed. Furthermore, a comparison is needed when treating these patients six months or 12 months down the line.

Screening for dry eye disease should comprise symptoms as well as signs. One of the best tools is a formalized questionnaire for dry eye disease, examples of which are the Ocular Surface Disease Index (OSDI) and the Dry Eye Questionnaire (DEQ). Another widely used questionnaire is the Canadian Dry Eye Assessment Guide (CDEA).

Dr. Avinashi strongly suggests these as an introduction to dry eye management. While it may seem rudimentary and tedious, if the staff become involved and are educated

on administering these questionnaires, they can provide a plethora of information. For example, the CDEA, a numeric value that helps guide the level of dryness, the severity of what the patient is experiencing from a personal perspective.

This type of index with objective numbers is extremely valuable; whether it’s 3 months, 6 months or 12 months down the line, the questionnaire can be revisited and the number has a comparative quantifiable value.

Patients would return six months later asking what their number was and wanted to repeat the questionnaire to see if their situation had improved over the last visit.

As a result, Dr. Avinashi came to the realization that its value was more for the patients as much as anything else.

Furthermore, he emphasized that practitioners should look at more than tear breakup time. Everting the eyelids and expressing the meibomian glands should be standard tests done when managing dry eye disease patients. There are a lot of diagnostic tools and methods that can be used simply and inexpensively.

Tear breakup time is the most commonly used test, measured with the use of fluorescein. Fluorescein also helps give an indication of any type of epitheliopathy or punctate erosion of the cornea. However, with more practice, Dr. Avinashi also recommends using lissamine green. It greatly helps with further understanding the level of devitalized and desquamatized tissue of both the cornea and conjunctiva.

He posed the question, “Knowing that essentially 80% if not 100% of ocular surface disease is evaporative, are optometrists currently doing a good job in evaluating meibomian glands?” The diagnostic approach has vastly changed in the last few years with the introduction of the Oculus Keratograph® (Arlington, WA). Regarding meibography, Dr. Avinashi mentioned that Innova (Laval, QC) has an excellent machine; and Topcon (Boisbriand, QC) has a great attachment. These imaging tests indicate the level of congestion through a black and white composite; they non-invasively measure tear breakup time and blink rate. The degree of meibomian gland atrophy can now be measured in terms of stages 1, 2 and 3.

InflammaDry®, manufactured by Rapid Pathogen Screening Inc. (Sarasota, FL), is distributed by two companies in Canada. It’s an MMP-9 inflammatory marker test and it recently received FDA approval. It is another easy-toadminister, in-office diagnostic tool to help with the management of dry eye disease patients. One of its drawbacks, though, is that it produces a lot of false negatives.

TEAR OSMOLARITY As a key diagnostic tool, osmolarity testing provides a single biophysical measurement that denotes the balance of inputs and outputs. It’s now becoming increasingly accepted by many key opinion-makers and researchers across North America as being critical in the diagnosis of ocular surface disease management. Osmolarity has a

greater sensitivity and specificity than other diagnostic tests and its objective number is critical in deciding on the treatment approach.

A systematic review of 164 peer-reviewed articles related to the diagnostic value of tear osmolarity found that 72% were favourable and supported tear osmolarity as a diagnostic tool for DED. Numerous additional publications have underscored it as an excellent tool to use.

Now, after many years, said Dr. Avinashi, there is another viable resource to use, a testing device produced by I-MED, a Canadian company. This testing device is so economical that if a practitioner is thinking even remotely to try getting into dry eye disease management, it’s almost a necessity to have in one’s practice.

Even in the National Dry Eye Disease Guidelines for Canadian Optometrists (published in the Canadian Journal of Optometry, Vol. 76, Suppl 1, 2014), it actually says on the subject, “Tear film osmolarity is the most accurate single test for dry eye disease, but should not be used in isolation,” of course. It’s similar to the importance of tracking and setting goals in IOPs in glaucoma.

Anytime Dr. Avinashi has a new patient for cataract surgery or a LASIK consultation, he measures osmolarity preoperatively and postoperatively. With any patient going into contact lenses, he uses this measure as part of his workup and assessment as it may guide in how he recommends contact lenses, as well.

Osmolarity is measured in milliosmoles per litre and the statistical mean high normal value is 300 mOsm/L. Another element to consider is if there’s a variance in the osmolarity reading. Sometimes a reading in one eye is 290 and the other one is 302, which is still within normal and healthy range, but with that degree of variance between the two eyes, inflammation is producing the result.

There are two major osmolarity testing devices on the market: The TearLab Osmolarity System® (TearLab Corporation, San Diego, CA) and i-Pen® (I-MED Pharma, Montreal, QC) a small hand-held device which Dr. Avinashi has used in his practice and has found to be very convenient and easy to use. He reported that he has found it a lot easier to use than TearLab and it has recently been made available to Canadian optometrists. With its favorable cost, he considers it a valuable asset.

The difference between the two tests is that TearLab utilizes temperature sensitive impedance measurements to provide indirect assessment of osmolarity, whereas i-Pen uses impedance measurements, but these are based on the extracellular tissues in contact with the tear film.

Dr. Avinashi stated that his staff uses this measurement process as part of the pre-test and the readings are very quick, especially with the i-Pen.

MANAGEMENT OF DRY EYE DISEASE As per the Canadian Optometry Guidelines, the goals are to reduce symptomology, return the tear film to a healthier state, and decrease the frequency of symptoms. While

Principles of Dry Eye Disease: Diagnosis, Treatment and Management — Avinashi

139

Table II Comparative chart of artificial tears Preserved Tears

Gels/Ointments

Non-Preserved

Various Preservatives

Refresh Optive Advanced Refresh Optive Fusion Refresh Tears Refresh Ultra Tears Naturale Systane Ultra Systane Balance GenTeal HypoTears Liposic TheraTears Isopto Tears

Refresh Liquigel Tear-Gel GenTeal Gel Systane Gel Lacri-Lube Liposic Gel Tears Naturale PM HypoTears Ointment DuoLube Ointment

Refresh Plus Refresh Celluvisc Refresh Endura Refresh Unit Dose Bion Tears TheraTears Tears Naturale Free Systane Ultra Preservative Free i-drop HYLO Drops / Gel i-drop Pur i-drop Pur Gel

Purite BAK Polyquad Cetrimide Sodium Perborate

Certain artificial tears specifically address lipid tear film deficiencies – emulsion formula.

Some have wound healing properties.

Gentle, more acceptable preservatives with least disruption to the corneal surface are available.

practitioners may not be able to wholly fix patient’s symptoms, but they can reduce the symptomology and definitely reduce the progression. With episodic cases, said Dr. Avinashi, this is where palliative care is standard.

Using artificial tears and hot compresses is very important.

Non-ocular considerations are sometimes overlooked for the sake of brevity, to get the patient out of the chair, or to encourage them to buy glasses, versus actually managing their disease. Patients’ medications, diet, level of alcohol consumption, whether or not they smoke, and environmental factors play an enormous role as well. In Vancouver, particularly, there are frequent climate changes, and Dr. Avinashi finds that with the higher pollen count he has a lot more patients with dry eye symptoms visiting his clinic.

ARTIFICIAL TEARS Dr. Avinashi is an avid advocate for tear supplementation.

One of his maxims with any product in the realm of dry eye disease treatment is that practitioners should recommend what they sell and sell what they recommend. If optometrists are recommending a product but aren’t selling it, they’re encouraging the concept of patients going elsewhere for what they need and what has been recommended to them. It’s essential to get the staff on board, and to find products that are unique and above the average grade. He recommends first, selling items that patients can’t find in other retail locations; and second, creating more loyalty to one’s practice so that patients aren’t simply seeking out the lowest-cost products at big box stores. The practitioner’s responsibility is not to be cost sensitive to patients, but to provide them the best recommendations, whether it’s an artificial tear, a heat compress mask, a progressive lens, or a contact lens. In his view, optometry is far too conservative in terms of what the patient can and can’t spend. They need to be provided options, but should always be given the best one first.

140

Clinical & Refractive Optometry Quebec 2:4, 2017

There is a plethora of artificial tears (Table II), Dr. Avinashi noted that his view of artificial tears has greatly changed over the last few years. Most patients, roughly 80%, have evaporative dry eye disease, therefore, optometrists should be recommending lipid-based artificial tears. These patients are often consulting with their GPs and pharmacists for recommendations, and they’re using such products as Tears Naturale® 2 (Alcon, Mississauga, ON) and GenTeal® (Novartis, Dorval, QC).

Dr. Avinashi regards these as antiquated given that there has been such an evolution in artificial tears and newer, more advanced products are available. When a patient consults with an optometrist, they may not even mention that they have dry eyes, yet they use a small amount of artificial tears. He advises that practitioners take the time to find out what patients are using because sometimes they become complacent about their drops. They aren’t even aware of which product it is and if it’s appropriate for their situation. Inform them that a customized treatment regimen is what they need, more than anything else.

Sodium Hyaluronate Dr. Avinashi is a proponent of preservative-free artificial tears. For aqueous deficient dry eyes for which he doesn’t wish to use a lipid-based agent, he opined that if a practitioner isn’t prescribing a product containing sodium hyaluronate, they’re underserving their patient population.

In the European market, said Dr. Avinashi, if someone took a poll of every artificial tear that was being offered, 70% of these would contain sodium hyaluronate.

A few years ago in Canada, there were only one or two products; now there are perhaps eight, and in the next year or two there are going to be a lot more in the pipeline.

Sodium hyaluronate is a polymer that is found in the body’s synovial joints, aqueous humor, many collagen cells, and in the corneal tissue, as well. It’s a natural lubricant and the reason it’s so effective is that it has

viscoelastic properties with hypo-osmolar stability.

Sodium hyaluronate increases corneal surface binding which is extremely beneficial to a dry eye patient. It enhances tear film stability, corneal wettability and corneal epithelial healing. Various studies have shown that it actually promotes corneal epithelialization, and in turn decreases the overall toxic environment of the ocular surface. It’s also has a positive effect on lid wiper epitheliopathy, a condition which a lot of optometrists don’t diagnose or manage.

There are numerous preservative-free hyaluronate sodium products on the market, including i-drop® Pur and i-drop® Pur Gel from I-MED Pharma (Montreal, QC), as well as HYLO™ (CandorVision, Montreal, QC) and others coming down the product pipeline. In addition, there are an increasing number of dermatology products incorporating it for its ability to create a more youthful appearance to the skin as the result of epithelial tissue healing.

Hot Compresses Dr. Avinashi stated that hot compresses are another type of treatment that is not being properly managed by the profession. Whether acute or mildly chronic MGD, optometrists are telling patients about hot compress treatment, but aren’t going to the extent of educating patients regarding their proper application. Several studies have alluded to hot compresses as having some clinical effect on the meibomian glands. However, first, the compresses have to reach a certain temperature − between 41° and 43° Celsius; and second, they must be applied at that temperature for a minimum of 5-10 minutes.

The Bruder® moist heat mask (Bruder Healthcare Company, Alpharetta, GA) and the dry heat TheraPearl® mask, distributed by Bausch + Lomb in Canada, are two masks Dr. Avinashi uses. He favors the Bruder version because it contains a moisture bead component, and provides enhanced comfort and durability. An additional consideration is that a moisture release hot mask will provide the meibomian glands increased heat.

Lid Hygiene To ensure good lid hygiene, stated Dr. Avinashi, there are a variety of products available, such as i-Lid ’n Lash®, i-Lid ’n Lash® Plus, and i-Lid ’n Lash® Pro (I-MED Pharma, Montreal, QC) which has sodium hyaluronate embedded in it. Patients with chronic eczema and irritation find this product very soothing to their skin.

CHRONIC DRY EYE DISEASE Dr. Avinashi is of the opinion that for chronic dry eye disease, optometrists shouldn’t be reticent to prescribe steroids, cyclosporine and anti-inflammatory prescription drops in order to properly manage and treat ocular surface disease. He feels that current treatment exists on a very

superficial palliative level of care, rather than concentrating on long-term treatment that addresses the progression of the condition.

Current short-term management of moderate to severe dry eye disease involves a steroid, whether it’s ketone- or ester-based. He prefers Lotemax® (loteprednol etabonate ophthalmic suspension, Bausch + Lomb, Vaughan, ON) not only because it has a high safety profile, but also because it has recently been launched in gel form in Canada, in a formula that contains 70% less BAK. This translates to substantially less stinging, extensive corneal interface time and improved results.

In fact, the gel form of Lotemax has become the gold standard in the U.S. All of Dr. Avinashi’s patients are currently using the gel form; he uses the ointment only in certain cases. The duration of steroid use depends on the patient’s history, however, generally prescribes it q.i.d. for two weeks. Naturally, follow-ups are necessary to monitor IOP changes. He recommends Restasis® (cyclosporine ophthalmic emulsion 0.05%, Allergan, Unionville, ON) for long-term treatment.

Studies have proven that practitioners don’t have to wait until a patient’s dry eye disease is at Stage 3 or a severe state to use Restasis, he said. Several studies have demonstrated that the patients who benefit most from a long-term anti-inflammatory such as cyclosporine are actually chronic mild and moderate cases.

Essential Fatty Acids Dr. Avinashi explained that when he recommends omega-3 fatty acids, it’s critical to educate patients as to why he’s doing so, also noting the difference between properly formuated omega-3s and the generic forms. The 2014 Canadian Guidelines, as well as the U.S. Guidelines, are now recommending an omega-3 even in mild patients; they should be one of optometrists’ first lines of treatment.

Especially in Vancouver, where there is strong interest in managing conditions more naturally, this is an important management modality to consider before prescribing any therapeutics. He always recommends omega-3s with a triglyceride base versus an ethyl ester base.

Many omega-3 products have various ratios of EPA to DHA, but a high ratio of EPA to DHA 3:1 or 4:1 is needed to better target the ocular surface. GLA is a derivative of the fatty chain of omega-6, which may be counterproductive; however, in the proper ration with EPA/DHA it has been shown to have significant antiinflammatory properties effective in the inflammatory cycle of dry eye disease. This is also outlined in the Canadian Dry Eye Guidelines. The effective dose is typically 2,000 mg per day, and they should be taken with a meal for higher absorption. Several studies have outlined that it can take upwards of two months for any omega-3 to have a proper clinical effect.

Principles of Dry Eye Disease: Diagnosis, Treatment and Management — Avinashi

141

MGD patients. He finds that it has some limited effectiveness for his MGD patients, but not nearly enough to rationalize spending $200 per treatment.

Other new therapies on the market and in the product pipeline include those by Oculeve (San Francisco, CA), as well as Intense Pulse Light (IPL) treatment which works on the exterior of the dermis. It uses heat and intense light to act on meibomian gland atrophy. The initial results Dr. Avinashi has heard are that it’s extremely effective.

CONCLUSION Dr. Avinashi concluded his talk by presenting several key points for building a dry eye practice:

Fig. 2 Scleral contact lenses have been proven effective in severe dry eye disease.

Punctal Occlusion Dr. Avinashi feels that this technique has a role to play in dry eye disease management, but that it’s not as widely used in optometric circles. Ten or fifteen years ago, punctal plugs were routinely used whereas now practitioners use it at the end of the treatment process. When a plug is inserted it maintains the inflammatory mediators on the tear film which simply propagates the disease cycle.

Scleral Lenses Dr. Avinashi began using scleral lenses two years ago because there were some patients in whom no matter what the treatment, the ocular surface symptomatology was still quite severe (Fig. 2). In patients with severe dry eye disease mini scleral lens have been proven successful.

LipiFlow The debate concerning LipiFlow® (TearScience, Morrisville, NC), thermal pulsating treatment for the meibomian glands, isn’t about whether or not it works clinically, but rather, the duration of its efficacy and whether or not it is an end solution. In Dr. Avinashi’s view, the fee is high, at $1,500 per eye or per treatment, and is a prohibitive factor to many patients.

Blephex The Blephex® concept is based on microblepharoexfoliation. It removes the biofilm plaque that builds up on lid orifices. While Dr. Avinashi thinks that it has a large part to play in optometric practice, he reserves it for his chronic anterior blepharitis patients, not necessarily his

142

Clinical & Refractive Optometry Quebec 2:4, 2017

Number one: Make a commitment to do so. For example, when using the slit lamp, make an active effort to look at things beyond simply the cornea and eyelids.

Number two: Create protocols for treatment. Describe it in writing which always makes it official and, more importantly, involve and educate the staff. Treatment of dry eye is a constantly evolving technology. Whether it’s progressive lenses, contact lenses or therapeutics, if the staff isn’t being educated and updated, they’re not on board with the practitioner’s efforts and it’s difficult to build a practice without employee involvement.

Number three: Refer to the National Dry Eye Disease Guidelines for Canadian Optometrists (CJO, Vol. 76, Suppl. 1, 2014), an excellent piece of literature that comprises everything concerning dry eye disease and provides a template for developing a dry eye disease practice.

Number four: With the latest advancements in diagnostic testing such as the i-Pen from I-MED Pharma, focus on delivering customized therapeutics, and have in hand their osmolarity readings and tear breakup times. So when they return in six-months, or for their postoperative follow-up, or after treatment with cyclosporine, a comparison can be made. While these tests provide good information, practitioners should still customize a patient’s treatment and explain to them why this particular drop, lid wipe or hot mask is being recommended. Provide them information founded on science-based evidence that supports the treatment plan.

Number five: Dr. Avinashi is a strong advocate of properly informing and educating patients. In his practice, if he admits someone to his dry eye clinic, he spends the time required to dialogue with them. If this isn’t being done, they’re not going to be compliant with the treatment plan being proposed.

Number six: Don’t be afraid to aggressively treat inflammation in particular and Dry Eye Disease in general.

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A

2:4, 17

DIRECTIVES POUR UN CRÉDIT UFC DE CATÉGORIE A Ce cours a été approuvé pour 1 crédit UFC de catégorie A en santé oculaire par l’Ordre des optométristes du Québec.

Veuillez répondre à ce questionnaire et le soumettre pour notation avant le 31 mars 2018.

Si vous obtenez une note de 50 % ou plus, un certificat de crédit UFC vous sera envoyé pour vos dossiers.

POUR PRENDRE ET SOUMETTRE CE TEST EN LIGNE Commencez par cliquer <ICI> et suivez les instructions à l’écran.

Si vous êtes un abonné de test prépayé, vous serez automatiquement dirigé vers le questionnaire de test.

Une fois terminé avec succès, vous recevrez automatiquement un certificat de crédit UFC personnalisé par courrier électronique.

Si vous n’êtes pas un abonné de test prépayé, vous serez automatiquement dirigé vers PayPal pour acheter ce test. Après le paiement, vous serez automatiquement dirigé vers le questionnaire de test.

POUR PRENDRE ET SOUMETTRE CE TEST PAR LA POSTE Si vous êtes un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous.

Si vous n’êtes pas un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous ainsi qu’un chèque de 25 $ payable à Mediconcept Communications.

Envoyer à: CRO 3484 Sources Blvd., Suite 518, Dollard-des-Ormeaux, QC H9B 1Z9, Canada

IDENTIFICATION Prénom :____________________________ Nom :______________________________________ Adresse :_______________________________________________________________________ Numéro

Rue

Bureau

_______________________________________________________________________________ Ville

Tél. bureau : (

Province

Code postal

) _________________ Courriel : _____________________________________

No de permis professionnel :________________________________________________________

QUESTIONNAIRE Principles of Dry Eye Disease: Diagnosis, Treatment and Management Pavan Avinashi, OD 1. ❑ ❑ ❑ ❑

According to the literature, what is the incidence of ocular surface disease in the general population?

10% to 70% 15% to 60% 25% to 50% 30% to 80%

2. ❑ ❑ ❑ ❑

One study showed that tear instability can constitute up to ______ percent of visual variability?

5 10 20 25

Principles of Dry Eye Disease: Diagnosis, Treatment and Management — Avinashi

143

2:4, 17

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A 144

3. ❑ ❑ ❑ ❑

All of the following statements about Dry Eye Disease (DED) are true, EXCEPT: Osmolarity has a greater sensitivity and specificity than other diagnostic tests It’s progressive in some cases Lotemax® (loteprednol etabonate) has a high safety profile Level of alcohol consumption plays a role

4. ❑ ❑ ❑ ❑

What percentage of diabetics have some level of ocular surface disease as reported in the literature?

23% to 43% 38% to 50% 49% to 52% 54% to 60%

5. ❑ ❑ ❑ ❑

What is the high normal level of tear film osmolarity?

300 mOsm/L 302 mOsm/L 303 mOsm/L 305 mOsm/L

6. ❑ ❑ ❑ ❑

All of the following can have an impact on DED, EXCEPT: Environment Smoking Diet Genetics

7. ❑ ❑ ❑ ❑

What percentage of artificial tears contain sodium hyaluronate?

50% 60% 70% 80%

8. ❑ ❑ ❑ ❑

What is the appropriate ratio of EPS/DHA to GLA in omega-3 supplements?

1:1 or 2:1 2:1 or 3:1 3:1 or 4:1 4:1 or 5:1

9. ❑ ❑ ❑ ❑

All of the following are recommended treatments for DED, EXCEPT: Long-term steroids Hot compresses Cyclosporine Preservative-free artificial tears

10. ❑ ❑ ❑ ❑

Approximately what percentage of patients have evaporative DED? 65% 70% 75% 80%

Clinical & Refractive Optometry Quebec 2:4, 2017

CLIQUEZ ICI POUR IMPRIMER CET ARTICLE ET LE TEST DE CRÉDIT UFC

Clinical & Refractive Optometry Quebec is pleased to present this continuing education (CE) article by Dr. Richard Maharaj, Clinical Director, eyeLABS, Brampton, ON. This article has been approved for 1 Category A, UFC credit in Ocular Health by the Ordre des Optométristes du Québec. In order to obtain your credit, please refer to page 153 for complete instructions.

Tear Dysfunction and Osmolarity: Tales from the Trenches Richard Maharaj, OD, FAAO

INTRODUCTION Dr. Maharaj began his presentation by stating that he would be discussing new treatment options for dry eye, also referred to as tear dysfunction, comprising three areas: 1) Clinical approaches to diagnostics in terms of the ocular surface in tear dysfunction; 2) Several case studies revolving around treatment options; and 3) How to apply tear osmolarity testing in the primary eye care arena.

He noted that he feels the concept of osmolarity is going to be gaining momentum with new diagnostics coming onto the market and may even differentiate how we traditionally have looked at tear film osmolarity.

On the anatomical side, he reviewed that tears are made up of three layers, the aqueous, mucin and lipid, all coming from the lacrimal glands goblet cells and meibomian glands, respectively. There is also a sensory motor component where the eyelids start to play a role.

In the way patients blink and the way their eyelids close, the aperture seal is extremely important. The combination of neurosensory and anatomical components is really the crux of a healthy ocular surface and a stable tear film.

TEAR OSMOLARITY AND THE INFLAMMATION CASCADE Dr. Maharaj stated that the basic concept is whether a patient has an isotonic, hypertonic or hyperosmolar tear film; in other words, a salty or non-salty tear (Fig. 1).

Most practitioners have experience with Muro 128® (sodium chloride hypertonicity ophthalmic ointment, 5%, Bausch + Lomb, Vaughan, ON) which is a hypertonic solution that draws water out in order to dehydrate the tissue

R. Maharaj — Clinic Director, eyeLABS, Brampton, ON; Staff Optometrist, Humber River Regional Hospital - York/Finch Eye Associates, Toronto, ON; Clinical Adjunct Associate, University of Waterloo, School of Optometry, Waterloo, ON Correspondence to: Dr. Richard Maharaj, 7900 Hurontario, Suite 406, Brampton, ON L6Y 0P6; E-mail: rmaharaj@eyelabs.ca This article has been peer-reviewed.

it’s in contact with, for example, to treat corneal edema.

If the patient’s eyes are being bathed in a hypertonic solution, the water will be drawn out of the tissue leaving it in a dehydrated state. What ends up happening as a result of the dehydration is a type of insult that starts the inflammatory process, with epithelial breakdown and an inflammatory cascade. It is therefore crucial to properly identify hyperosmolar patients early on because many times, hyperosmolarity precedes dry eye symptoms.

Dr. Maharaj stated that there are various components to dry eye, namely anatomical impact, environmental impact and age-related changes. Any dysfunction in these areas will result in insult to the ocular surface. On the physiological side, there is activation of inflammation, as well as an immune response involving the T-cells. Restasis® (cyclosporine ophthalmic emulsion 0.05%, Allergan, Unionville, ON) which, Dr. Maharaj noted, targets the T-cell pathway, working on immunomodulation. The question is, at what point do optometrists address the inflammatory cascade equation as the primary eye care doctors? How can they enter this equation a bit earlier? With any disease, whether it is glaucoma, meibomian dysfunction or diabetic eye disease, for example, early intervention or risk reduction has always led to better prognosis.

All of the factors mentioned above contribute to friction, which is actually what brings a patient to optometry offices. No patient comes for a consultation and says, “I feel wonderful, my eyes feel like butter and I think I have dry eye.” Until they feel it, until there is insult that they can actually describe, they’re not going to say anything. This leads to the issue of diagnostic criteria: How can practitioners identify risk factors for this friction?

When considering the chronology of tear dysfunction, osmolarity tends to be an early indicator. Patients don’t start to feel anything until well after osmolarity has begun to peak and then their symptoms start to worsen. Longterm unmanaged hyperosmolarity can contribute to neuroinflammation which will inevitably lead to corneal hypoesthesia. Subsequently, the patient feels better as if to say, “It’s magic, I’m cured.” The question is not what the practitioner has done but what has the patient done? The natural history of untreated hyperosmolarity has led them to neuropathy and hypoesthesia, and in some cases dysesthesia, referred to as pain without stain by Dr. Perry Rosenthal of the Boston Eye Pain Foundation. The objective is to avoid them arriving at this point through

Tear Dysfunction and Osmolarity: Tales from the Trenches — Maharaj

145

Concept of Hyperosmolarity Isotonic

Hypertonic

(no net exchange of water)

(net loss of water from ocular cells)

Tear Film

Tear Film

H2O

H2O

Surface of the eye

Surface of the eye

H2O

H2O Epithelial cells

Fig. 2 Reducing surface friction: Identifying the cause of friction is essential. electrolytes

Epithelial cells

electrolytes

Fig. 1 Tear hyperosmolarity triggers an inflammatory cascade.

Table I Role of the tear film 7 major functions of the tear film 1. Maintains hydration of the eye 2. Lubricates the ocular surface 3. Nourishes the cornea 4. Cleanses the ocular surface 5. Defends against bacterial invasion 6. Buffers the pH of the ocular surface 7. Refracts light for visual clarity

early intervention; and on this point, measuring osmolarity is the key.

Figure 2 depicts a patient with damaged corneas or bilateral epitheliopathy, before and after treatment, who is planning on having cataract surgery. Identifying the source of friction requires an understanding of the tear film function, including seven major points listed in Table I, some of which the patient highlighted. The main objective is to maintain hydration. Second is to lubricate the ocular surface as lubrication leads to decreased friction which translates to less inflammation. The tear film is antibacterial as well. Finally, and again this is where patients may become symptomatic, the tear film actually helps the visual pathways so it transmits and refracts light. If a patient has a transient visual complaint, it’s important not to dismiss the tear film as a culprit in the differential diagnosis.

A healthy tear film contains a complicated cascade of chemicals, including cytokines, proteins, mucin-related factors, and potassium, to name a few. Dr. Maharaj stated that it’s possible in the future there may be panel testing for these constituents because the tear film is actually very similar to blood in terms of the constituents. This panel testing is only as useful as existing targeted therapies to treat the specific components of a dysfunctional tear film.

In comparison to blood, the water content of the human tear is similar and, in fact, the osmolarity overall is quite similar. If there is a wealth of information in the vascular

146

Clinical & Refractive Optometry Quebec 2:4, 2017

system, that same wealth of information resides in the tear film as well. For example, Google has already designed a contact lens that will measure a patient’s fasting glucose levels. Industry is looking at different ways to do this through the tear film because it’s more accessible than blood. Dr. Maharaj highlighted that it’s critical to understand that there are similarities and therefore, very likely, there are some answers that lie in the tears that may not have already been thought of.

Regarding the proportion of dry eye patients in the average practice, some studies show that it has the highest prevalence of the major eye disease categories in general practices; because of this high prevalence, it makes sense to identify these patients and help them in a more meaningful way than we are currently. Dr. Maharaj remarked that early in his training and career, the treatment of mild corneal fluorescein staining would be one of a bag of various artificial tears, and the practitioner would advise the patient to use them as needed. That was, and perhaps still is in some cases, acceptable patient management.

The report from the International Dry Eye Workshop (DEWS) in 2007 did an excellent job at raising awareness in both the academic circuit and in general in the eye care world, on the etiology and classification of dry eye. There are evaporative patients who are affected primarily by environmental factors, lid inflammation and surface anomalies; and there are aqueous deficient patients. Years ago it was thought that the majority of dry eye disease (DED) patients were aqueous deficient and treatment involved artificial tearing every single patient. The followup to the Dry Eye Workshop was the International Workshop on Meibomian Gland Dysfunction (MGD) in 2011 sponsored by the Tear Film & Ocular Surface Society (TFOS). The summary of that entire meeting pointed to MGD being perhaps one of the leading causes of dry eye around the world; we know now that evaporative and aqueous causes may not exist in mutually exclusive pools.

In fact, noted Dr. Maharaj, they likely exist together on a spectrum, however, with aqueous patients specifically, it’s important to think about these various categories. The

Fig. 3 A 52-year-old Asian female with moderate dry eye.

Sjögren’s cases, which probably represent an underdiagnosed population just because historical testing has demonstrated poor specificity and sensitivity for diagnosis. There is now a blood smear test available in the United States called Sjö which may help to increase identification of these patients. Additionally, there are medically induced cases resulting from certain medications such as antidepressants and antihistamines, among others. All of these categories affect aqueous production.

MEASURING OSMOLARITY For the purpose of tear film metric, osmolality and osmolarity are synonymous. Osmolality refers to measures in a solid state, while osmolarity is in a liquid state. It’s the concentration of osmoles or moles of a solute per liter of a solution.

There are three main measuring methods, one of which is familiar to most practitioners. Freezing point depression uses the temperature at which a solution freezes below its normal temperature that can be calculated to an osmolarity value. It does require a rather large sample (0.2 µL) and it is not something that is amenable to a clinical setting. It is, however, a very accurate way of measuring osmolarity and is commonly used in academic settings. The converse to that is vapor pressure, the temperature above which a solution will vaporize. The difference between the temperature at which it vaporizes is calculated into an osmolarity value. The sample size required, 5 µL, sounds small, however, it is actually an extremely large sample for the average tear film of 7 µL. Collecting that amount is actually nearly impossible.

The electrical impedance model is employed in glucose measuring systems, with which all optometrists are familiar.

It measures the electrical impedance of a solution which is proportionate to solute concentration. TearLabTM

(San Diego, CA) and i-Pen® (Montreal, QC), for instance, use this process. Tears have an ionic content and will alter its conductivity which is then calculated to yield an osmolarity value.

Tear osmolarity actually came into the dry eye conversation in the 1970s. The late Jeff Gilbard, MD, an ophthalmologist, discussed and wrote extensively on osmolarity at that time. In the late 1980s, he wrote a paper on how it related to MGD, which was well ahead of his time. The paper discussed the relationship between osmolarity and meibomian gland obstruction, and it wasn’t until the 2011 MGD Workshop (TFOS) that there was actually a consensus about that relationship.

In 2007 at the DEWS workshop, tear osmolarity was finally incorporated into the clinical definition of DED. It is a very strong indicator so it has the higher positive predictive value when compared to other metrics such as tear breakup, Schirmer, staining and tear meniscus height according to Lemp et al, 2009. Dr. Maharaj highlighted that one of his educational objectives for practitioners is to have a common language with which to speak intraprofessionally. Osmolarity is a concept that is agreed upon in both ophthalmology and optometry, so it’s an effective bridge when discussing patients.

CASE STUDIES Case #1 Dr. Maharaj presented several cases from his clinical practice, some of which are still in progress. The first is a 52-year-old Asian female who had had LASIK surgery two years prior (Fig. 3). She reported to the clinic with moderate symptoms. Dr. Maharaj quantifies his patients’ symptoms using the SPEEDTM (Standard Patient Evaluation of Eye Dryness score, TearScience, Morrisville, NC). It’s a very quick questionnaire that takes his technician five

Tear Dysfunction and Osmolarity: Tales from the Trenches — Maharaj

147

Fig. 4 A case of progressive dry eye with meibomian gland atrophy.

minutes to complete and it provides a validated number from a measure of 28. This patient had a score of 16.

Symptom scores are very helpful in the identification and management of patients’ symptoms because they provide the patient and practitioner a measurement to quantify their condition.

This patient’s symptoms were consistent with moderate dry eye. Shortly after her LASIK she was put on Restasis OU b.i.d., so she had been on it for roughly one-and-a-half years. Dr. Maharaj noted that it typically takes a minimum of three months to appreciate clinical improvement. She was previously a monthly contact lens wearer who disliked wearing her lenses, which was part of her motivation for LASIK. Dr. Maharaj uses an Oculus Keratograph® 5M (Arlington, WA) for meibography, an infrared lighting system that examines the meibomian glands. In this case, it showed gland truncation, which signals gland atrophy measured on a Heiko Pult scale. It also showed the meibomian gland ductules were dilated, which is a sign of obstruction that can lead to meibomian gland atrophy. This is very telling of progressive evaporative dry eye. The patient presented with significant gland atrophy in both eyes, more so in the right than the left.

Her osmolarity was 315 mOsm/L in the right eye and 327 mOsm/L in her left (Fig. 4).

Additionally, Dr. Maharaj uses an MMP-9 indicator which measures the concentration of an inflammatory marker in the tear film and provides a positive or a negative result, similar to a home pregnancy test. Testing positive for MMP-9 generally signifies surface inflammation. MMP — matrix metalloproteinase — are proteolytic enzymes in the tear film that are produced by surface epithelium when under duress. This patient was MMP-9 negative (InflammaDry®, RPS Inc., Sarasota, FL) which would lead to the conclusion that she doesn’t have inflammation on her

148

Clinical & Refractive Optometry Quebec 2:4, 2017

ocular surface, despite her having a hyperosmolar tear film.

Dr. Maharaj subsequently consulted with the patient’s optometrist who had done a tear analysis prior to her having LASIK. Her pre-LASIK osmolarity was 299 and 301; for reference, generally a number of 300 mOSm/L or below is considered “normal.” Even before the patient had LASIK, she was on the borderline between normal and mild dry eye. Now that she wasn’t wearing contacts anymore and her eyes were essentially naked to the air, she was becoming symptomatic. Then two years later, her osmolarity had increased. But why was her MMP-9 negative?

Dr. Maharaj diagnosed the patient with untreated CLIDE, contact lens induced dry eye, even though she was a post-LASIK patient. Her tear breakup time at this particular visit was markedly reduced in both right and left. MGYLS is a meibomian gland yielding liquid secretion score, a standardized way to measure gland function by diagnostic expression to uncover glands secreting fluid. Dr. Maharaj measured 15 in a row, 5 nasal, 5 central and 5 temporal. This patient had MGYLS of 3 in her right eye and 1 in her left, and they were severely inspissated. She had evaporative dry eye which was exacerbated by her incomplete blinking which is very common in this population. At home she was diligent about using warm compresses with a microwavable heat mask.

Dr. Maharaj explained that he tends to be conservative in his treatment, but in this case it was obvious that the patient needed more help than simply a hot compress at home. He used LipiFlow® (TearScience, Morrisville, NC) thermal pulsation which consists of in-clinic vectored heat therapy applied to the posterior gland surface combined with pulsatile pressure. It does a very good job of clearing out all the meibom and aims to leave behind a patent meibomian gland with which the patient can function.

Dr. Maharaj then stopped administration of preservative tears and replaced them with i-drop® Pur Gel (I-MED

Normal mOsm/L + irritation complaint Epithelial basement membrane dystrophy (EBMD) Conjunctival chalasis Demodex blepharitis Non-obvious meibomian gland dysfunction (MGD) Contact lens/solution toxicity Lagophthalmos

Tear Prism Solute Gradient

Hyperosmolar Meibomian gland dysfunction (MGD) Contact lens induced dry eye (CLIDE) Androgen deficiency Peri-surgical Sjögren’s syndrome

Low volume high solute

High volume low solute

+ + +++ +++ ++

Solute gradient towards low solute

++ + + ++ + + + + ++ + + ++ + +

Osmotic pressure

Table II Analysis of dry eye patient symptoms in consideration of osmolarity.

This is why normal mOsm/L with symptoms should not be assumed to resolve with cyclosporine A alone.

Fig. 5 Proposed pathway for measuring tear prism solute gradient.

Pharma, Montreal, QC), a non-preserved hyaluronic acid derivative which works very well in such cases.

After one month, the patient’s SPEED score was reduced from 16 to 4. At this point she reported feeling “normal.” The take-home from this is that there was some information gathered preoperatively that was missed.

When looking at her history and taking the reference mark of her osmolarity into account, suddenly the picture became a lot clearer. She could have been identified earlier and actually been pre-treated for her ocular surface disease, in which case, Dr. Maharaj opined, she would have done better.

Dr. Maharaj questioned whether optometrists are doing enough for their contact lens patients and “insulating their contact lens practice.” He stated that the contact lens industry in general and the impact of competing forces are concerning to some practitioners in terms of possibly losing market share to retail environments with greater buying power. Dr. Maharaj has a differing point of view, namely that practitioners actually have an opportunity to really improve their contact lens healthcare.

By identifying patients who are at risk for developing CLIDE, practitioners can build a care model around that to ensure that their contact lens patients are diagnostically screened, using a healthy product contact lens modality.

Perhaps a reusable contact lens wasn’t the best idea for this patient; maybe she should have been on a one-day lens.

He posed the question, “Can tear osmolarity help increase compliance; to get the patient who is paying two hundred dollars for a year’s supply of a monthly lens and stretching it to a two month lens, to understand why a one-day lens may be more suitable?” He feels that it’s very possible and suggested that a contact lens practice is a dry eye practice that can be enhanced for prevention of ocular surface related conditions.

In 2011, Dr. Michael Lemp published a paper in Cornea that established the hallmark of what is now known as the defining number, with 308 mOsm/L as the cutoff point between normal and clinical dry eye disease.

In his study of 146 patients, he showed that specificity of

tear osmolarity testing climbs when the osmolarity increases higher than 308. He also demonstrated that tear osmolarity (tOsm) as a measure had a very high positive predictive value, for people who have the disease. If a patient’s osmolarity is 327, there is a 95% chance the patient has dry eye disease. Dr. Lemp compared osmolarity to Schirmer, tear breakup time and Ocular Surface Disease Index. Osmolarity was the strongest predictor of DED among all measures.

Marguerite McDonald, an ophthalmologist in the U.S., presented her work at 2013 ASCRS, examining the prevalence of dry eye in a large sequential cohort. They put patients through a very simple assessment including, demographic, history, and a yes or no series of questions, and then cross-referenced that against osmolarity. The study population was n=9,067.

What they found was that of the patients were actually reporting dry eye symptoms, half did not meet the clinical criteria of 308 mOsm/L for dry eye, which is a very interesting finding.

What is equally intriguing, said Dr. Maharaj, in fact more troubling, is that almost 50% of patients who were considered asymptomatic by the definition of the study, were hyperosmolar. These were patients who had a hyperosmolar tear film but were not reporting any significant symptoms. These are silent sufferers who are eventually going to develop this condition and are slipping through the cracks of treatment. These are LASIK and premium cataract patients who are possibly remaining underdiagnosed and this is where Dr. Maharaj feels practitioners can improve in identifying that patient base.

The question is why do these patients have three or more symptoms if their osmolarity is “normal”? Table II explains this. A patient can have discomfort on the ocular surface without having a hyperosmolar tear film, depending on the stage of the condition. There is an entire host of conditions with which patients may in fact exhibit normal

Tear Dysfunction and Osmolarity: Tales from the Trenches — Maharaj

149

Table III Tear osmolarity and MMP-9 categorization of OSD (Maharaj Ocular Surface Classification Model).

Category 1

Category 2

Category 3

Category 4

Tear Osmolarity

Normal

High

High

Normal

MMP-9

Negative

Negative

Positive

Positive

Diagnostic Status

Non-DED

Early DED or on current MMP-9 targeted therapy Treat other aspects of tear dysfunction (MGD)

Moderate to severe DED

Postoperative CCh, EBMD, other etiology (diagnostically may not be tear dysfunction)

Fig. 6 A 69-year-old female patient, one-month post-surgery.

osmolarity. These include epithelial basement membrane disorders, conjunctival chalasis and non-obvious MGD. What is important to understand is that osmolarity isn’t there to classify the patient having one condition or the other, it’s actually meant to signal a practitioner to look more closely into the true etiology of the patient’s discontent.

MEIBOMIAN GLAND DYSFUNCTION One of the questions frequently asked of Dr. Maharaj is, “How does this tie in to meibomian gland dysfunction (MGD)? What do osmolarity and tear film have to do with the glands?” Dr. Anthony Bron in the UK published a paper that described the solute gradient (Fig. 5). Within the tear prism, there is a high concentration at the apex of the tear film and a very dilute concentration at the base; therefore, there is osmotic pressure being applied to the surface of the lid. The osmotic gradient actually forces solutes to the epithelial surface, contributing to the inflammatory process and eventual apoptosis. The epithelial cells, the meibomian gland surface, the orifice and then therefore the glands posterior to them, are being subjected to

150

Clinical & Refractive Optometry Quebec 2:4, 2017

insult, namely, inflammation and injury. This gradient is another reason to measure and ensure that osmolarity is being identified.

The use of MMP-9 measures complements the use of osmolarity measurement similar to using both OCT and the visual field in a glaucoma patient. He stated that there are four possible scenarios, as shown in Table III. Category 1: The patient shows normal osmolarity and negative MMP-9, in which case they are considered normal. They don’t have or at least don’t meet existing clinical diagnostic criteria at this point to be considered having DED. Category 2: The patient may be hyperosmolar, but have a negative MMP-9. Recalling the case study previously outlined, the patient was on Restasis and it has been demonstrated in several papers that the drug inhibits the presence of MMP-9 on the surface. Therefore, generally speaking, this combination of findings is going to indicate either a patient who has early dry eye disease or a condition that is being pharmacologically managed.

Category 3: The patient has a hyperosmolar tear film and has a positive MMP-9 measure. This patient most likely has moderate to severe dry eye and may require more

pharmacological attention to control the inflammation.

Category 4: Osmolarity is normal, however, the patient has a positive MMP-9. Dr. Maharaj pointed out that these four categories can help guide practitioners in their diagnosis and treatment of dry eye.

The demographic of a dry eye patient is more consistent with being female than male and over the age of 50, who also tend to be decision-makers in their families.

This profile represents the target for an optometrist’s primary care practice, and is certainly in a demographic that should be identified well in advance. In addition, in terms of pre- and post-surgical care, it’s vital to see these patients before they have surgery. It’s crucial to manage their osmolarity and tear dysfunction, or at least identify it and mitigate their risk of postoperative dryness, as demonstrated in the case below.

Case #2 A 69-year-old female, one-month post cataract surgery OD, was referred to Dr. Maharaj by her eye surgeon. Her left eye was yet to be done and the difference in ocular surface staining is clear (Fig. 6). In fact, Dr. Maharaj saw this patient preoperatively after being referred initially for preoperative ocular surface optimization. He was asked to pre-treat her dry OS cornea preoperatively. The patient opted to have only one eye pre-treated. At this time OS was scheduled for surgery prior to OD, which eventually was changed.

At this second presentation, OD showed that tear and ocular surface metrics were extremely poor. In addition, the patient had blink dysfunction — she wasn’t having full aperture closure due to floppy eyelid syndrome (FES) — and her tear breakup time was low. In terms of osmolarity and MMP-9, though, she was negative on MMP-9 and she did present with a hyperosmolar tear film 331 mOsm/L and 301 mOsm/L OD and OS, respectively.

As a result, she fell into Category 2 (Table III). Did the patient have early dry eye disease or was she an MMP-9 targeted therapy? The fact that she was on postoperative Lotemax® (loteprednol etabonate 0.5% ophthalmic suspension, Bausch + Lomb, Vaughan, ON) which downregulates and decreases MMP-9 at the surface, it explains her negative MMP-9 result.

Naturally, the patient was very uncomfortable with a severely compromised cornea and multiple sources of friction. Dr. Maharaj used a bandage contact lens (senofilcon A, Johnson & Johnson Vision Care, Markham, ON) which, he said, works very well for these cases. He also prescribed non-preserved hyaluronate and had the patient return for a follow-up. The purpose of the bandage contact lens was to decrease friction because the patient’s lid wiper was rubbing against her cornea and abrading it repeatedly, every time she blinked. He also continued her on loteprednol b.i.d. for another two weeks. In addition, he used his “triad treatment” which is a non-surgical meibomian gland treatment, which consists of eye lid scaling, meibomian gland expression and tear film neutralization with a basic mineral oil solution.

The patient responded well to the combination of anti-inflammation with meibomian gland optimization via the triad treatment in follow-up care. Physiologically, the improvement in both signs and symptoms happens by managing the obstructive component to her MGD. The obstruction leads to a build-up of biofilm at the lid margin, which contributes to the inflammatory state at the surface.

Gland clearance and removal of devitalized epithelium reduce the chemical burden of the surface and allow for more efficient epithelial repair. MMP-9 metrics were misleading in this case because her post-surgical topical regimen included loteprednol 0.5%.

This case led into a review of William Trattler’s PHACO study (Prospective Health Assessment of Cataract Patients Ocular Surface Study) which was a prospective multi-centre observational pilot study of 143 patients scheduled to undergo cataract surgery. Key findings of the study suggested that the prevalence of DED signs is more common than frequently reported, with as much as 76.8% of patients testing positive for fluorescein corneal staining of which 50% had significant central staining.

Dr. Maharaj opined that with the changing landscape of “premium” cataract and refractive surgery, it’s becoming more and more necessary to optimize the ocular surface.

Failing to do so may impact the quality of surgical outcomes and therefore confidence in predicting refractive outcomes. He briefly discussed the study by Alice Epitropoulos, MD et al, in which pre-surgical patients with hyperosmolarity had a statistically significant greater variability in average K readings which impacted IOL power difference by more than 0.5 D. Of note, this difference was not observed when the same patients were grouped by self-reported dry eye, which highlights the value of tOsm as a significant preoperative measure. In a broader sense it further stands to reason that the ocular surface or the peri-surgical patient truly requires primary eye care by optometrists because the complications related to postoperative dry eye will inevitably fall into the hands of optometry long term.

Case #3 Dr. Maharaj discussed a 27-year-old female patient, 2 months post-LASIK, who had chronic eye pain and peri-ocular discomfort as her chief complaint. She was a previous compliant contact lens wearer who did not report discomfort prior to surgery. She was prescribed Restasis b.i.d. OU by her surgeon, in addition to non-preserved hyaluronate q3-4h and larci-lube q.h.s. She was also using lid wipes for ocular hygiene. Despite having maximal symptom scores (SPEED=28), her pain was disproportionate to her clinical findings as noted on the incoming referral, as well as during presentation to the dry eye clinic. Oxford staining was <1 OD and OS, TBUT 6s OD, 7s OS, and tOsm 289 and 285 mOsm/L OD and OS, respectively. MMP-9 was negative and tear volume was normal. When referencing Dr. Maharaj’s categorization of

Tear Dysfunction and Osmolarity: Tales from the Trenches — Maharaj

151

ocular surface disease by MMP-9 and tOsm, this patient falls into Category 1 – Non-DED. An increasing diagnostic entity that both parallels and intersects with DED is neuropathic pain. These cases can be particularly frustrating and often get lumped together by clinicians as the “crazy patient” who cannot seem to be pleased. However, Dr. Maharaj noted, it’s in fact a real entity, but due to diagnostic limitations can only be confirmed by exclusion and careful examination of clinical history and presentation. Managing neuropathic pain can be treated by managing the cyclo-oxygenase (COX) pathways (1 and 2) via COX inhibition, by use of human autologous serum (ranging in 20% to 40% concentrations), and some evidence has pointed to amniotic tissue transfer having some impact on nerve repair. Amniotic tissue in both cryopreserved and dehydrated options has demonstrated efficacy anecdotally with rapid reduction in pain with healing corneas, with cryopreserved possibly having superior impact on nerve repair. Although this list isn’t exhaustive, it represents a cursory review of current literature on pharmacological options for this group of patients.

On discussion with the patient and her surgeon, she was initially managed with topical NSAID Prolensa® (bromfenac 0.07%, Bausch + Lomb, Vaughan, ON) q.d. for 1 month with the option of human autologous serum vs. amnion membrane transfer to be considered after 1 month. At the time of this lecture, the patient had sought out ocular surface reconstruction by a U.S. surgeon in addition to meibomian gland intraductal probing and was currently receiving that care.

This prompted a short discussion on another commonly dry eye masquerader known as conjunctival chalasis, which is noted by conjunctival redundancy due to loss of Tenon’s fascia causing displaced tear fluid from the ocular surface and mechanical rubbing. Again, in review of Dr. Maharaj’s categorization, these patients may likely fall into Category 4.

Case #4 A 63-year-old female presented to the dry eye clinic with a large OS central corneal abrasion. What made the treatment of this case more complicated was that the patient had previously arranged same day travel to Calgary.

Although it was her first visit to the clinic, the patient noted a long history of recurrent corneal erosions (RCE) occurring almost monthly. Dr. Maharaj noted that the diagnostic difficulty of this case was low, however he highlighted that the long-term treatment would become more relevant as an educational tool. She was fitted with a bandage contact lens (senofilcon A, Johnson & Johnson Vision Care, Markham, ON) and started on topical Vigamox® (moxifloxacin hydrochloride 0.5%, Alcon, Mississauga, ON) t.i.d., and Muro 128. Arrangements were made for her to follow up with a colleague in Calgary the next day so as not to disrupt her travel. She responded well to therapy and the bandage lens was removed in Calgary 3 days later, with complete visual recovery.

152

Clinical & Refractive Optometry Quebec 2:4, 2017

At her two-week follow up back at the dry eye clinic, she received a full ocular surface work-up due to her frequency of RCEs. InflammaDry testing showed positive for MMP-9 which, along with clinical history, resulted in this patient being put on a two-month course of oral doxycycline 50 mg, in addition to loteprednol 0.5% b.i.d. in the affected OS. She was also started on non-preserved 0.3% hyaluronate (i-drop® Pur Gel, I-MED Pharma, Montreal, QC) for the duration. The choice of this combination was based on multiple studies relating MMP-9 inhibition to reduced RCE episodes. Dr. Maharaj reviewed the literature demonstrating oral doxycycline’s efficacy at reducing MMP-9 activity in corneal epithelial cultures, in addition to the benefits of low dose (20 mg) doxycycline when compared to anti-infective doses (200 mg b.i.d.). Whenever prescribing this combination however, patients should always be warned of the potential gastrointestinal discomfort and UV skin sensitivity when taking oral doxycycline, and this medicine should be avoided in patients who are pregnant, nursing or under the age of 13.

Finally, Dr. Maharaj concluded the presentation by reviewing the osmolarity systems, with TearLab being one of the devices currently available for clinical use.

He also introduced the i-Pen® osmolarity meter (I-MED Pharma, Montreal, QC) which was launched in June 2016. Dr. Maharaj remarked that he has been betatesting the system since July of 2015 and has been involved in some clinical studies using the i-Pen in a DED prevalence study that is yet to be completed. He reminded the audience of his disclosures, particularly his consultancy with the manufacturer, but he is not financially benefiting from this product.

SUMMARY Tear osmolarity represents the single-most defining metric of DED and based on current literature can uncover up to 50% of silent dry eye sufferers in primary eye care practices. Optometry’s role in contact lens care and peri-surgical care is growing rapidly, therefore Dr. Maharaj reminded the audience to identify these patients early and pre-treat surgical cases so as to optimize outcomes. Lastly, tear chemistry represents one of the most interesting areas of DED from both a diagnostic and therapeutic perspective.

Using the Maharaj Ocular Surface Classification Model (Table III) as outlined in the cases discussed, the combination of tear osmolarity and MMP-9 may provide clinicians with a tear panel to better classify patients and therefore improve targeted treatment outcomes. He finished by articulating his passion for this area of care and emphasized that optometry’s growing role in managing anterior segment diseases will only grow, so keeping abreast of current literature and treatment options is vital to the growth of the profession. ❏

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A

2:4, 17

DIRECTIVES POUR UN CRÉDIT UFC DE CATÉGORIE A Ce cours a été approuvé pour 1 crédit UFC de catégorie A en santé oculaire par l’Ordre des optométristes du Québec.

Veuillez répondre à ce questionnaire et le soumettre pour notation avant le 31 mars 2018.

Si vous obtenez une note de 50 % ou plus, un certificat de crédit UFC vous sera envoyé pour vos dossiers.

POUR PRENDRE ET SOUMETTRE CE TEST EN LIGNE Commencez par cliquer <ICI> et suivez les instructions à l’écran.

Si vous êtes un abonné de test prépayé, vous serez automatiquement dirigé vers le questionnaire de test.

Une fois terminé avec succès, vous recevrez automatiquement un certificat de crédit UFC personnalisé par courrier électronique.

Si vous n’êtes pas un abonné de test prépayé, vous serez automatiquement dirigé vers PayPal pour acheter ce test. Après le paiement, vous serez automatiquement dirigé vers le questionnaire de test.

POUR PRENDRE ET SOUMETTRE CE TEST PAR LA POSTE Si vous êtes un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous.

Si vous n’êtes pas un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous ainsi qu’un chèque de 25 $ payable à Mediconcept Communications.

Envoyer à: CRO 3484 Sources Blvd., Suite 518, Dollard-des-Ormeaux, QC H9B 1Z9, Canada

IDENTIFICATION Prénom :____________________________ Nom :______________________________________ Adresse :_______________________________________________________________________ Numéro

Rue

Bureau

_______________________________________________________________________________ Ville

Tél. bureau : (

Province

Code postal

) _________________ Courriel : _____________________________________

No de permis professionnel :________________________________________________________

QUESTIONNAIRE Tear Dysfunction and Osmolarity: Tales from the Trenches Richard Maharaj, OD, FAAO 1. ❑ ❑ ❑ ❑

Which of the following conditions has the highest prevalence of the major eye disease categories in general practices?

Diplopia Blepharitis Open-angle glaucoma Dry eye

2. ❑ ❑ ❑ ❑

At what level of tear osmolarity will a patient be suspected of having dry eye disease?

290 mOsm/L or more 300 mOsm/L or more 305 mOsm/L or more 310 mOsm/L or more

Tear Dysfunction and Osmolarity: Tales from the Trenches — Maharaj

153

2:4. 17

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A 154

3. ❑ ❑ ❑ ❑

All of the following statements accurately describe the patient in Case #1, EXCEPT: She had a SPEED score of 14 Her symptoms were consistent with moderate dry eye She was previously a monthly contact lens wearer She had previously had LASIK surgery

4. ❑ ❑ ❑ ❑

According to the literature, approximately ______ percent of patients who were considered asymptomatic were hyperosmolar?

30 40 50 60

5. ❑ ❑ ❑ ❑

All of the following statements accurately describe the patient in Case #2, EXCEPT: She had blink dysfunction Her tear breakup time was normal She was negative on MMP-9 She had hyperosmolar tear film

6. ❑ ❑ ❑ ❑

According to William Trattler’s PHACO study, approximately what percentage of patients tested positive for fluorescein corneal staining?

50% 58% 67% 77%

7. ❑ ❑ ❑ ❑

The following statement regarding the patient in Case #3 is TRUE: Her chief complaint was peri-ocular discomfort Her SPEED score was 26 Her MMP-9 was positive Her tear volume was low

8. ❑ ❑ ❑ ❑

All of the following statements accurately describe the patient in Case #4, EXCEPT: At her initial presentation to the clinic, she showed no history of corneal erosions At her initial presentation to the clinic, she was fitted with a senofilcon A bandage contact lens At her two-week follow-up at the dry eye clinic, she showed positive for MMP-9 At her two-week follow-up at the dry eye clinic, she was prescribed oral doxycycline 50 mg

9. ❑ ❑ ❑ ❑

All of the following are components of dry eye, EXCEPT: Anatomical impact Genetic impact Environmental impact Age-related changes

10. ❑ ❑ ❑ ❑

All of the following statements about MMP-9 are true, EXCEPT: A patient can show normal osmolarity and negative MMP-9, in which case they are considered normal A patient may be hyperosmolar, but have a negative MMP-9 Hyperosmolar patients treated with cyclosporine will have a positive MMP-9 Lotemax® (loteprednol etabonate) down-regulates and decreases MMP-9 at the surface

Clinical & Refractive Optometry Quebec 2:4, 2017

CLIQUEZ ICI POUR IMPRIMER CET ARTICLE ET LE TEST DE CRÉDIT UFC

Clinical & Refractive Optometry Quebec is pleased to present this continuing education (CE) article by Dr. Paul M. Karpecki, Kentucky Eye Institute, Lexington, KY. This article has been approved for 1 Category A, UFC credit in Ocular Health by the Ordre des Optométristes du Québec. In order to obtain your credit, please refer to page 164 for complete instructions.

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy Paul M. Karpecki, OD, FAAO

INTRODUCTION Dr. Karpecki began his presentation by noting that he established his first dry eye clinic in 1997 and in the first ten years of ocular surface disease, there wasn’t a lot to teach about dry eye disease as we were learning as we went along. In addition, there wasn't much practitioners could do for success. In fact, he noted, his success rate was probably less than fifty percent. In a survey conducted before he joined Kentucky Eye Institute, approximately 96% to 98% of patients said they were satisfied or very satisfied with their treatment results. Dr. Karpecki mentioned that in the last six or seven years, great strides have been made in the management of the ocular effects of dry eye disease and allergies.

THE CURRENT OCULAR ALLERGY LANDSCAPE When an allergy is seasonal, it's an acute condition; however, in patients with perennial allergies, dry eye and blepharitis, it’s typically chronic. As a result, said Dr. Karpecki, practitioners have to be able to teach them that this is progressive and will typically last for the rest of their life.

In addition to chronic, acute, perennial and GPC forms of allergy, the sight-threatening forms, vernal and atopic keratoconjunctivitis, which are not very common, occur at a rate of about 3-5 cases per year in his clinic. Seasonal allergies are by far responsible for the largest proportion of allergies. Fluctuations in weather are particularly hard on allergy sufferers. In fact, what makes it tougher is that patients get a bolus of pollen in the spring depending on the allergen, then relatively little for a few months and then they often get another bolus of allergens in the fall.

This pattern makes it difficult on allergy suffers to perform P.M. Karpecki — Director of Corneal Services and the Advanced OSD Clinic, Kentucky Eye Institute, Lexington, KY Correspondence to: Dr. Paul M. Karpecki, Kentucky Eye Institute, 601 Perimeter Drive, Suite 100, Lexington, KY 40517; E-mail: paul@karpecki.com This article has been peer-reviewed

at their optimum at all times and can affect everything from sleeping to reading and concentration.

Environmental allergens, such as grass pollen in summer and ragweed in the fall, are common causes, as well as animal dander and dust mites which are more perennial. Cat dander holds on to the conjunctiva or skin; ragweed resembles burrs and can stick to clothing and even ocular structures; and grass pollen is so small that it can stay in the cul de sac before it’s washed away. This also raises a key clinical pearl when managing allergies: Don't forget to tell patients to wash the allergen away using preservative-free artificial tears. Practitioners often think of artificial tears for dry eye, but they play a key role in allergy because it’s important to dilute all of these elements that are adhering to the conjunctival surface.

Perennial Allergy Animal dander is one of the most common forms of perennial allergy, but the biggest cause is dust mites. They’re impossible to get rid of so, unfortunately, if a person is allergic to dust mites, they can’t truly clean a home any more than we do today because these mites are only 10 to 24 microns in size. Furthermore, said Dr. Karpecki, it's not the dust mites themselves that people react to; it's actually their droppings, their waste pellets: they eliminate approximately 10 to 20 a day. One gram of dust equates to about 240,000 dust mite droppings. It has been said that after five years, without a pillow cover, 50% of the weight of one’s pillow is actually dust mite droppings.

In terms of the clinical presentation, it’s typically a bilateral condition resulting in a glossy or thematic appearance with mild injection. A unilateral form of type 1 hypersensitivity is contact dermatitis, for instance, a reaction to nail polish. This involves the eyelids more than the eye, and typically it's unilateral as contact dermatitis can affect the conjunctiva, skin and neck. Contact dermatitis is best treated with topical corticosteroids.

Dr. Karpecki highlighted that in North America optometry treats allergic conjunctivitis more than any other medical specialty. Symptoms of burning, tearing, redness, itching, photophobia, and grittiness all imitate dry eye disease, making the differential between allergic conjunctivitis and dry eye disease difficult at times. One key differential is that allergic conjunctivitis is associated with rhinitis and dry eye disease is not.

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy — Karpecki

155

Looking forward, there are some interesting technologies emerging, including those by TearLab (San Diego, CA), which is working on their next innovation. They measure osmolarity right now, but they're working on IgE and inflammatory markers, among other things that may create a multi-chip format allowing us to differentiate the presence of various ocular diseases before we even see the patient.

Within a year one would actually sample the tears and know how much allergy is present, compared to dry eye inflammation and even specific inflammatory markers that may dictate the optimal treatment. This currently exists in cardiology with panels of tests, as they’re referred to. These tests aren’t currently available in eye care, therefore, practitioners have to be the ones who differentiate it. Itching, the hallmark symptom of allergies, could be caused by dry eye disease or blepharitis such as demodex blepharitis. When a patient presents at the office and says, “My eyes itch,” a good differentiating question is, “Do you feel better after you rub them?” If so, typically it’s more of a histamine involvement.

An additional question relates to the location of the allergy. Allergic conjunctivitis is located on the conjunctiva or in the canthal region. If it’s in the eyelids or eyelid margins, demodex or staphylococcal blepharitis plays a role. A patient recently stated to Dr. Karpecki that her eyes were itchy, but on further questioning was identified as particularly around her lashes. The diagnosis was demodex blepharitis, so he proceeded with Cliradex® (4-Terpineol, Bright Optical, Toronto, ON) treatment on her eyelids. The condition cleared up completely and her itching was resolved. In this case, it wasn't allergies, even though allergy is the first thought when one hears the term itching.

ALLERGY SYMPTOMS AND DIFFERENTIATORS Dr. Karpecki noted that an optometrist can quickly recognize a person with allergies due to a glossy-looking eye. It's not beet red as with most bacterial conjunctivitis and there's no discharge. In allergic conjunctivitis, a tearing or mucin discharge is present. One can sometimes see papillae, especially in the lower fornix area, and possible eyelid swelling; however, the key is the chemotic look of the conjunctiva. These types of differentiating signs and symptoms are crucial to treatment.

The other differential is viral forms which not only need to be differentiated from allergic conjunctivitis but also bacterial conjunctivitis. Dr. Karpecki pointed out that when looking for discharge, it’s vital to look at the tear lake or lower tear meniscus. Debris in the tear film is also discharge and can help differentiate a bacterial conjunctivitis. Patients will report that when they woke up their eyes were matted shut and a yellow substance on their lashes was visible; this is more typical in bacterial conjunctivitis.

156

Clinical & Refractive Optometry Quebec 2:4, 2017

In viral conditions a watery discharge is more common.

These patients tend to have an eye that may not be as red although in some forms such as epidemic keratoconjunctivitis (EKC) it can be. One differentiating factor is preauricular lymphadenopathy, which is why it's always important to check by actually rubbing the preauricular area to try and find a pea-sized nodule. What’s more, in viral forms, it starts in one eye and then spreads to the other, whereas with allergies it is a bilateral presentation immediately. Naturally, mentioned Dr. Karpecki, if patients have had it for more than a week and it’s something like EKC, there may be subepithelial infiltrates which are a help in finding the differential, but the goal is to try and pick up on that sooner than later. If the viral form is detected early, it can often be managed early.

DIAGNOSTIC TOOLS There are a number of diagnostic steps to take, and point of care diagnostics are now available. Rapid Pathogen Screening in Florida makes the AdenoPlus® test. A former colleague and coworker of Dr. Karpecki’s asked for a consult with a case he suspected might be preseptal cellulitis. This patient had one of the most severe cases of conjunctivitis Dr. Karpecki had seen. The patient was extremely chemotic and red, and he determined that it was a case of EKC. He had an AdenoPlus which indicated positive for adenovirus. Some of the worst-looking conjunctivitis cases are EKC, so that's a good way to differentiate it from allergy as well.

TREATMENT OPTIONS FOR EKC The other advantage with EKC in Canada is that there are good treatment options we don’t have in the United States. In the U.S., Zirgan® (ganciclovir ophthalmic gel, Bausch + Lomb, Rochester, NY) has been shown to decrease the course of EKC from about 18 days to roughly 5 days. Another option is Betadine® (povidone iodine, Purdue Pharma, Stamford, CT) and although it’s available in the States in bottle form, Canada has the preservative-free Minims® (povidone iodine 5%, Bausch + Lomb, Vaughan, ON). The dosage is three drops after having put Alcaine® (proparacaine hydrochloride ophthalmic solution 0.5%, Alcon, Mississauga, ON) or Minims Tetracaine (tetracaine hydrochloride 0.5%, Bausch + Lomb, Vaughan, ON) in the eyes, followed by an NSAID drop. Have the patient close their eyes, roll them around for about a full minute, and then use balanced saline to rinse it out completely. Dr. Karpecki stated that it will eradicate the virus immediately. Patients won't typically get subepithelial infiltrates; they'll achieve great results and they'll be grateful, although not immediately as the eye is very uncomfortable for about 24 hours. For this reason, steroid drops q.i.d. for 4 days should also be recommended.

Fig. 1 Various phases of the allergic conjunctivitis cascade.

Seasonal Allergies With seasonal allergies, it's important to truly understand the mechanisms. What occurs is a cascade of allergic conjunctivitis (Fig. 1). The early stage is characterized by antigens in the tears, a major histocompatibility complex that involves T-cells, plasma cells and an antigen presenting cell in the conjunctiva. The first time an allergen presents, IgE forms on the mast cell. On the second presentation a cross binding occurs between the two IgE on the cell.

When this happens, the entire mast cell becomes destabilized and all of the content including histamine is released.

In the early stages there is an immediate response which is primarily made up of histamine, heparin, chymase and tryptase (Fig. 2). The person presenting at this stage will complain of itching, sometimes severe. There are two treatment choices, a steroid or an antihistamine combination – and despite what most of my residents answer (steroids for severe itching), the correct answer is an antihistamine combination drop. In the early stages of the allergic conjunctivitis, the main element causing itching

is histamine and nothing stops itching as effectively as an antihistamine. Pataday® (olopatadine hydrochloride ophthalmic solution, Alcon, Mississauga, ON), Patanol® (olopatadine hydrochloride ophthalmic solution, Alcon, Mississauga, ON) or Bepreve® (bepotastine besilate ophthalmic solution, Bausch + Lomb, Vaughan, ON) in Canada are possible options, in addition to Zaditor® (ketotifen fumarate, Alcon, Mississauga, ON). In the early stages, they’re more effective than a steroid for itching symptoms, even if the condition is severe.

If the condition is allowed to progress, the allergic cycle gets to a level called synthesis, which typically doesn't take a long time. This may occur at 48, 72 or even 12 hours in some cases, depending on the severity. At that point, leukotrienes, prostaglandins, cytokines and platelet activating factor (PAF), which are inflammatory components, are present and the most effective treatment at this stage is a topical corticosteroid.

Patients will manifest more injection or redness, chemosis and overall inflammatory signs. Dr. Karpecki

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy — Karpecki

157

Fig. 2 The early phase response occurs in allergic conjunctivitis.

stated that differentiating treatment based on the pathophysiology makes sense given the two treatment options (steroids and antihistamines). The patientâ&#x20AC;&#x2122;s signs are a key element, most notably the redness and chemosis which may also be considered symptoms. Patients often mention this because they feel self-conscious about how they look.

A steroid would be a better choice when the signs are comparable to the symptoms. In fact, with Pataday, and Bepreve, neither of these have a US FDA indication for clinical signs of redness. However, AlrexÂŽ (loteprednol etabonate ophthalmic suspension 0.2%, Bausch + Lomb, Vaughan, ON) has an indication for signs and symptoms.

The general rule would be: when there are more symptoms of itching than signs, use an antihistamine; when the signs (redness, chemosis, etc.) have caught up, the appropriate choice is a steroid. Sometimes both are appropriate to achieve good control of both elements. In the late phase, the condition is virtually completely inflammatory, however, and therefore corticosteroids may well be the better treatment option (Fig. 3).

158

Clinical & Refractive Optometry Quebec 2:4, 2017

There are studies showing that antihistamines are faster-acting against itch than steroids but there are others indicating that steroids have greater efficacy against clinical signs than any antihistamine by far. Antihistamines won't control the chemosis or redness to the level that a steroid will. It is quite a significant disease though, said Dr. Karpecki, and optometrists have become somewhat complacent about it because in North America optometry prescribes more allergy medications than any other discipline. We have to be reminded of the significant morbidity associated with allergic disease. Of the patients who have seasonal allergies, 70% said their reading is greatly affected to the point that it affects work. Driving is affected, which obviously is quite significant. Concentration has been shown to be diminished. Even difficulty sleeping is among the many functions affected by this disease. Therefore, itâ&#x20AC;&#x2122;s essential to counsel patients, explaining the need for treatment and setting the right expectations about it being a chronic disease in the case of perennial allergies. If their problem is seasonal, it

Fig. 3 Late-phase reactions occur only in more severe allergic states and represent a cellular response to prolonged allergic challenge in conditions such as vernal keratoconjunctivitis.

will most likely return. In fact, Dr. Karpecki schedules his patients for their follow-up according to their seasonality.

If he knows they have spring allergies, he typically sees them in March or April in order to try to alleviate their symptoms.

These patients should be educated about how to minimize problems in their environment. The website www.pollen.com indicates the level of pollen in a given city. During “red” days, these patients should be more cautious. For example, if they are avid runners, they ought to run on the treadmill that day. They should keep their car windows up and avoid the outdoors for a short period of time. They should also be advised to wash their linens more frequently than they normally would and to keep the speed of the ceiling fan to a lower level or turn it off.

From a palliative perspective, at level 1, a cold compress can have a tremendous impact on chemosis, whether it's a cloth, an icepack or a commercial cool compress over the closed eyes.

Giant Papillary Conjunctivitis Dr. Karpecki discussed giant papillary conjunctivitis (GPC) which has seen a surge related to silicone hydrogel lenses. It’s much more difficult to treat than it was 20 years ago. It’s still GPC; it just appears to take longer to manifest and is a little more resilient to treatment.

GPC is one of the four allergic eye diseases and is defined as large papillae on the upper tarsal plate and is easy to identify not because of itching, but rather, decreased contact lens wearing time and the presence of mucin discharge. Switching patients from silicone hydrogel contact lenses to a non-silicone hydrogel lens is recommended. However, even after six months of treatment, the papillae may still be visible, but the patient may not be symptomatic. What the practitioner should actually be treating is the hyperemic papillae. If the papillae are red, there is too much inflammation. After treatment, if there is a normal pink tarsal plate, even if a few papillae remain, that's acceptable, as long as they're not hyperemic.

Dr. Karpecki explained that it’s a matter of active versus

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy — Karpecki

159

Fig. 4 Vernal shield ulcers are indicative of an eosinophilic reaction.

non-active states. If it's active, hyperemia, and usually a fairly large level of papillae, will be present.

It’s important to flip eyelids on patients fairly regularly in order to gauge its presence, especially in people who have worn silicone hydrogel lenses for more than three years.

Sometimes the symptoms are related to makeup, however, most of the time it's a contact lens issue. Refractive surgery may be a treatment option, stated Dr. Karpecki. While patients don't want to be out of their contact lenses, if the practitioner can get them to stop their wear for at least a week during treatment, that's more effective. During that week, they should be put on Lotemax® (loteprednol etabonate ophthalmic suspension, Bausch + Lomb, Vaughan, ON) q.i.d. then tapered to b.i.d. before and after contact lens insertion and removal.

Even though studies have shown that there has never been an infection complication related to loteprednol and contact lens wear during GPC treatment, there is one study by Dr. Jimmy Bartlett on GPC using Lotemax and it showed incredible effectiveness, more than any other previous steroid has shown, perhaps because it's much more lipophilic.

Dr. Bartlett’s study showed that the incidence of significant IOP rise, i.e., 10 mmHg or more increase from baseline, was 8%, rather than the traditional 1% or 2% reported in all the other studies. When it’s put on a lens it becomes a depot and the same complication rate of IOP results as with the older ketone steroids is evident. As a result, he prefers not to put any topical corticosteroid on a contact lens, if possible. Once the patient is back in a lens, reduce the treatment to twice a day, before and after lens wear, continuing for approximately four to six weeks if pressures are normal.

Regarding Lotemax gel form, it's still 0.5% concentration, with less preservative; it doesn’t have to be shaken, and there is the advantage of moisturizing agents.

160

Clinical & Refractive Optometry Quebec 2:4, 2017

It’s expected to show the same effect, but there has not yet been a study confirming this. An important component of treatment success is hygiene and patient compliance.

There is a need for patients to learn to replace their lenses on a regular basis. In most of the patients experiencing problems, they extended the use time, they topped up their solution, or there was some other form of non-compliance.

Vernal Keratoconjunctivitis Vernal keratoconjunctivitis (VKC) is a warm weather condition and Dr. Karpecki sees roughly eight to ten cases in the course of a summer. It typically occurs in male children between the ages of roughly 4 and 16 and manifests with very large cobblestone papillae on the upper tarsal plate. The key to diagnosis, because 17% of cases have this, is to note an area of elevation at the limbus. If a child presents with allergic conjunctivitis, the practitioner should look very carefully at the limbus 360 degrees. If there is any elevation, even if it's just one clock hour, that's a diagnosis of VKC. The elevation signifies Horner-Tranta’s dots which are eosinophilic accumulations at the limbus.

Dr. Karpecki highlighted that VKC is sight-threatening and can lead to what's called a shield ulcer (Fig. 4). The former thinking was that the papillae rubbing on the surface caused these ulcers. Actually, it's something called basic major protein that is released in the inflammatory cascade or immunology. The limbal accumulations are eosinophils so they release the major basic protein and will cause the epithelium to slough, leading to a shield ulcer; these can scar if they're not treated. Management of the condition includes an antibiotic, antihistamines and low grade anti-inflammatories which might get it controlled over time. One of the best treatments for vernal shield ulcers is a cyclosporine (Restasis®, Allergan, Unionville, ON) twice a day, or even four times a day. Following this, lubricate the eye and use an antihistamine combination, all of which work even better than steroids in cases of VKC.

Dr. Karpecki addressed the issue of why Restasis works immediately in VKC when in dry eye it takes so long to take effect. The precise answer isn’t known, but it relates to the physiology – the type of cells that are present, and a different mechanism of action. It’s thought that for some reason cyclosporine inhibits major basic protein more than other therapeutics or some key receptor in the inflammatory cascade. The reason why it doesn't work as quickly in dry eye patients is that it primarily affects migrating T-cells, which can take some time to be fully affected. In dry eye, one has to wait for those cells to die off; it takes roughly 90 days for a T-cell to run its normal apoptotic cycle. However, in the case of shield ulcers, major basic protein can be suppressed right away with cyclosporine and other non-approved options such as tacrolimus.

Dr. Karpecki emphasized that VKC requires very aggressive treatment. Steroids are essential until the point of a shield ulcer, dosed at every two hours for about the first week, plus the antihistamine, olopatadine, bepotastine, or ketotifen. Systemic antihistamines are an option, even though they dry the eyes. Children don't have as much dry eye, so oral antihistamines should not be a problem. Aspirin has been shown to help children, but the studies on this have been inconclusive. Children should be instructed to avoid eye rubbing as this exacerbates the problem.

Another sight-threatening allergic eye disease seen occasionally is atopic keratoconjunctivitis (AKC). It more commonly affects men ages 30 to 50, and the hallmark of atopic keratoconjunctivitis, which is the fourth form of the type I hypersensitivity conditions. Contact dermatitis is a type IV hypersensitivity, the delayed response type of allergies. The key signs of AKC are eczema and neovascularization or pannus on the cornea; classic presentations not seen in any other allergy form. Roughly nine out of ten of these patients have asthma, but 95% have eczema somewhere, often around the eyes, with conjunctivalization in the severe form. Often it's just slight neovascularizational encroachment, especially in a non-contact lens wearer.

Typically, these patients can't wear their lenses and they have typical symptoms of burning and itching, therefore, it sounds like allergies; it goes into remission, then there are exacerbation episodes.

To treat the eczema, Dr. Karpecki suggests a triamcinolone cream, 0.1% which is a kenalog steroid, or Lotemax ointment if there is concern of the patient getting the cream in their eyes.

As these patients have dry eyes, neovascularization is a concern. If that's present, prescribe heavy corticosteroids, every two hours until it can be reversed. Lotemax gel every two hours would be ideal because of its safety profile, however, if it's very severe, Pred Forte® (prednisolone acetate, Allergan, Unionville, ON) works well. A Japanese study showed that Lotemax gel was equivalent to branded Pred Forte. In severe cases such as uveitis and AKC, one can start with Pred Forte and then use Lotemax longer term, but they

are very comparable now that the gel formulation has come out. Therapy needs to be adjusted on a two-week basis; typically, dosing is every couple of hours for a week or two, then q.i.d. for a week or two. Dr. Karpecki prefers loteprednol because this regimen involves long-term use of steroids. He would rather use the safest agent, but if it's not producing a response, Pred Forte is required. Again, eye rubbing is a concern in this group; and this could be why there's a high incidence of keratoconus in these patients.

Regarding comorbidities, for example, in patients with dry eye and rhinitis, Dr. Karpecki recommends avoiding oral antihistamine treatments, which is contrary to current teaching: These patients’ primary complaint revolves around their eyes and their systemic condition can be treated at a later point.

PHARMACOLOGIC AND NON-PHARMACOLOGIC TREATMENT OPTIONS The Role of Oral Antihistamines Regarding oral antihistamines, Dr. Karpecki cited a study

by Dr. Osler that came out of Harvard University, showing the effect if a person used Claritin® (loratadine, Bayer, Mississauga, ON) which is actually not one of the most drying antihistamines, taken once a day for four days. It resulted in a drop in tear volume of 34% which is significant – and most of our patients don’t use oral antihistamines for just four days – most use it for a month or the entire allergy season. Imagine the effects on the tear film of Benadryl® (diphenhydramine hydrochloride, Johnson & Johnson, Markham, ON) which has potent antimuscarinic receptor activity. He tells his residents to take their patients off oral antihistamines if they're willing to do so because an antihistamine drop is not going to dry their eyes and is also going to get through their sinuses, throat and non-ocular tissues. This was shown in research involving a drug available in the U.S. called bepotastine which showed statistically significant improvement in the secondary markers, namely, nasal congestion, rhinitis, itchy palate, and itchy throat.

The only exception to prescribing an oral antihistamine at the onset of treatment would be allergic sinusitis where a patient presents with pain around their eyes involving the sinus cavities and no signs of infectious sinusitis. If allergic sinusitis is diagnosed, Claritin-D®, Allegra-D® (fexofenadine hydrochloride; pseudoephedrine hydrochloride, Sanofi Canada, Laval, QC) and Zyrtec-D® (cetirizine HCl 5 mg/ pseudoephedrine HCl 120 mg, Johnson & Johnson, Markham, ON) all make sense because a decongestant is needed. But if it's just for allergies and it's the non-decongestant form, Dr. Karpecki would try to avoid it at the early stages of allergic conjunctivitis. Patients think that it’s helping their eyes, however, it's actually drying them by at least 34% after just four days, at once-daily dosing.

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy — Karpecki

161

Decongestants For the treatment of allergies, decongestants such as Visine-A® (naphazoline, Johnson & Johnson, Markham, ON) or Naphcon-A® (naphazoline, Alcon, Mississauga, ON) are not recommended for three reasons. First, they contain significant amounts of BAK, usually about double what is found in good artificial tears. They represent a significant amount of toxicity potential based on just the preservative. Second, they cause constriction of blood vessels. The reason they're dilated to begin with is they're trying to heal something, so by constricting them, their disease isn’t being helped. A much better choice is a steroid where vascular permeability is maintained. Third, and this is commonly known, decongestants and vasoconstrictors cause rebound hyperemia. Once a patient is on it, they’re “addicted” because the moment they’re off the medication there is a rebound effect that may be even worse than when they started these medications. In fact, if someone comes into the office, a diagnosis of allergic conjunctivitis is made and they say, “I've been using Visine for the last six months,” I wouldn’t recommend immediate discontinuation because their eyes are going to become more injected and they will question the practitioner’s abilities. The best way to get them off of the decongestant/vasoconstrictor is to taper them. Start them on a steroid such as loteprednol q.i.d. for two weeks, then b.i.d. Allow them to use the Visine no more than the steroid such as four times a day for a week, then taper down each week because by then the steroids will have the ocular surface under control. Therefore, said Dr. Karpecki, it’s best just to avoid them in the first place but, unfortunately, if they've already chosen an overthe-counter (OTC) vasoconstrictor, it’s best to switch medication to a corticosteroid and taper them off the vasoconstrictor agent.

If a patient has to use an OTC medication, Dr. Karpecki prefers combination agents over vasoconstrictors as his key treatment, including ketotifen, Alaway® (Bausch + Lomb, Rochester, NY) and Zaditor® (Alcon, Fort Worth, TX). There is alcaftadine in the U.S., and in Canada and the U.S., olopatadine and bepotastine are available. Bepotastine is probably the best treatment for severe itch that he has ever seen, but it’s advisable to disguise its taste. Although bepotastine is a very good product, it’s perhaps better reserved for moderate to severe itching. However, it works about as well as olopatadine for mild and moderate allergic conjunctivitis.

Ester Steroids and Other Treatments Dr. Karpecki shared that he favors ester steroids, a safer version and yet still very potent for ocular surface conditions such as allergic conjunctivitis. Because there are enzymes known as esterase in the body, it can break down ester steroids. In the case of ketone steroids, there is no enzyme to break down the metabolites that can now attach to the IOP receptors or create a Schiff base on the

162

Clinical & Refractive Optometry Quebec 2:4, 2017

crystalline lens, which can lead to cataract development.

In fact, there has never been a reported cataract on loteprednol, even after over approximately 40 million scripts. There is still a risk of IOP rise: About 2% of patients on loteprednol have a 10 mm or more increase in pressure so it doesn't mean that it can be prescribed without monitoring IOP. As he noted, he still doesn’t write any refills the first time he writes a prescription for steroids.

Dr. Karpecki uses either the on-label option of 0.2% loteprednol (Alrex) in most cases of allergic conjunctivitis or in severe cases, 0.5% (Lotemax). The Lotemax gel has some unique properties; it's still 0.5% concentration but the gel provides more advantages such as significantly less BAK, along with better moisturizers and a longerlasting effect due to the vehicle. Additionally, it doesn’t need to be shaken, which is extremely important as most patients don't shake suspension steroids the required 30 times for true re-suspension. For this reason, drops that don’t need to be shaken are a huge advantage for patients.

It can be administered every couple of hours for the first few days in severe forms involving significant chemosis or injection. Patients can’t take it forever; their pressure will still need to be monitored, but it’s extremely effective against the signs that are present in allergic conjunctivitis.

Alrex is a 0.2% concentration indicated for temporary short-term relief of signs and symptoms. Dr. Karpecki typically tells patients that a couple of months is good as maximum therapy duration. If they have a lot of itching, he adds the antihistamine component.

Dr. Karpecki mentioned that he avoids oral antihistamines, even though the majority of patients think that all antihistamines help relieve their itchy eyes. The frequently used options are oral Claritin, Allegra and Zyrtec. If the eyes are dry and the patient has allergies, the allergen remains. He would therefore avoid these, except in cases of sinus congestion where the decongestant is the key.

Regarding pseudoephedrine, which is the common decongestant in most of these oral antihistamine/ decongestant medications, physicians must be cautious in patients with known hypertension as it has been shown to cause a hypotensive state. Dr. Karpecki also pointed out that the newer forms may not be as sedating as the older oral allergy medications, however, they're still very drying to the ocular surface. If a medication like Claritin-D is needed because a patient has sinusitis, simply increase the use of artificial tears.

There was an article or research paper published a while ago that discussed anticholinergics and over-thecounter drugs in relation to dementia, and Benadryl is one of those. A recent study reported that anticholinergics like Benadryl are contraindicated because they cause effects in patients with dementia.

In terms of mild conditions where patients self-treat, a study showed that over 80% of people will try something over-the-counter before they come into an optometrist's office. Practitioners then have to educate patients about

vasoconstrictors and how to get off of them, as well as the risks of using them long term because typically that’s a common OTC selection.

Dr. Karpecki noted that if there is significant systemic involvement, with rhinitis, itchy throat, cough, or sinus congestion, he would use a topical medication. The use of loteprednol is substantiated in clinical studies. However, if oral administration is the chosen route, Benadryl is an effective choice provided the patient has no risk of dementia, administered before the patient goes to bed.

Inhalers such as Dristan® (oxymetazoline, Pfizer, Montreal, QC) or Otrivin® (xylometazoline, Novartis, Dorval, QC) are available in Canada and provide the desired effect where it’s wanted, without going through the drying effects of taking a pill. Regarding long-term corticosteroids, one must bear in mind that cataracts can result, in addition to the low risk of IOP rise, not at the level of drops, but still a risk to consider.

Non-Pharmacologic Treatments Dr. Karpecki stated that he favors non-preserved artificial tears because patients with allergies are already atopic; therefore, the less preservatives, the less chance of a reaction. In the early phase or if itching is their chief or only complaint, he prescribes an antihistamine/mast cell stabilizer. If they're saying, “It’s just the itching, it's unbearable, it's incapacitating,” that requires an antihistamine combination agent if it is severe.

In terms of non-pharmacologic therapies, mucolytic agents are suitable for severe cases; likewise in severe allergic signs, select Lotemax instead of Alrex.

There are many options for preservative-free artificial tears that will work. Dr. Karpecki opined that Canada has some of the best products available, such as HYLO™ (CandorVision, Montreal, QC) and especially for allergic conjunctivitis, HYLO Dual, (CandorVision, Montreal, QC).

In advanced cases, his patients are very appreciative of its effects. Refresh Optic Fusion™ (Allergan, Unionville, ON) is another good product containing hyaluronic acid. On the lipid side, there are Liposic® (Bausch + Lomb, Vaughan, ON), Refresh Optive® Advanced (Allergan, Unionville, ON), Refresh® Ultra (Allergan, Unionville, ON), and Systane® Balance (Alcon, Mississauga, ON).

Mast cell stabilizers can be used alone, however, they won’t affect the histamine or relieve the itch, so one might as well use a combination. Equally, Dr. Karpecki doesn’t like to use NSAIDs alone. Looking at the arachidonic acid pathway of inflammation, there are two pathways, the cyclo-oxygenase pathway and the lipoxygenase pathway.

NSAIDs only block prostaglandin formation of the cyclooxygenase pathway, not the entire leukotriene pathway, whereas steroids block both pathways. The same occurs with a mast cell stabilizer alone, as it would be preferable to have antihistamine and mast cell stabilization.

CONCLUSION Dr. Karpecki concluded his presentation by reviewing several clinical pearls. The first of these is to educate patients about the importance of avoiding eye rubbing. If a patient rubs their eyes and feels better for a moment, that's usually a sign of allergies. He advises them to avoid this tendency because they’re going to mechanically degranulate the mast cells and make the condition worse over the long term.

Second, refrigerate eye drops. Sometimes, the first time a person will ever put drops in their eyes is when they have allergies and so they're missing their eye, and they can't tell if it went in or not. By refrigerating them, they can tell if it's in the eye, plus it provides a soothing, cool compress effect.

Next, tell patients to keep ceiling fan speeds lower; change their lenses more often, place protective covers on pillows, shower before sleeping; avoid being outdoors during the peak season; and keep house and car windows closed, if possible.

In terms of medications, be aware of the side effects of some of the oral antihistamines. Most of these patients are going to present on an oral antihistamine, but may not even list it on their medication intake form because it is OTC; educate them about the potential side effects of these agents.

Furthermore, when treating with topical corticosteroids, be sure to check their intraocular pressures in three to four weeks. Write zero refills the first time, just to be on the safe side. That way, they have to come back in three or four weeks to get another prescription. Dose these b.i.d. with a contact lens wearer, as previously discussed, with GPC. Get them out of their lens when they’re on Lotemax q.i.d., but then put them in a new lens and use the drops before and after lens wear.

With regard to prescribing Patanol versus Pataday, Dr. Karpecki typically starts with Pataday as he feels it offers better efficacy, with slightly higher concentration.

However, if the patient says, “I'm having to use this much more than once a day” when they return, and there are many who do, this often means that they either need a steroid or are better served with a b.i.d. antihistamine/mast cell stabilizer agent. If they're on a steroid and they're still saying that, he’ll prescribe Patanol where they can justifiably use it a couple of times a day and achieve slightly better results. A preferred solution is adding in a steroid if there is more clinical sign involvement. Dr. Karpecki’s rationale is that many times, patients will say, “The itching is fine, but I'm using it more often because I can't get this redness controlled.” That would be an indication for adding a topical corticosteroid.

Concerning the issue of when to remove contact lenses in patients with seasonal allergies, the answer may be in the upper eyelids. Evert the upper eyelid and if it's hyperemic, the contact lens is contributing to their symptoms and it does need to be taken out for a while. If the eyelid looks normal, simply advise the patient to use drops before and after contact lens wear, along with preservative-free hydrogen peroxide solutions. In addition, instruct patients to hydrate their lenses regularly throughout their wear. ❏

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy — Karpecki

163

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A

2:4. 17

DIRECTIVES POUR UN CRÉDIT UFC DE CATÉGORIE A

164

Ce cours a été approuvé pour 1 crédit UFC de catégorie A en santé oculaire par l’Ordre des optométristes du Québec.

Veuillez répondre à ce questionnaire et le soumettre pour notation avant le 31 mars 2018.

Si vous obtenez une note de 50 % ou plus, un certificat de crédit UFC vous sera envoyé pour vos dossiers.

POUR PRENDRE ET SOUMETTRE CE TEST EN LIGNE Commencez par cliquer <ICI> et suivez les instructions à l’écran.

Si vous êtes un abonné de test prépayé, vous serez automatiquement dirigé vers le questionnaire de test.

Une fois terminé avec succès, vous recevrez automatiquement un certificat de crédit UFC personnalisé par courrier électronique.

Si vous n’êtes pas un abonné de test prépayé, vous serez automatiquement dirigé vers PayPal pour acheter ce test. Après le paiement, vous serez automatiquement dirigé vers le questionnaire de test.

POUR PRENDRE ET SOUMETTRE CE TEST PAR LA POSTE Si vous êtes un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous.

Si vous n’êtes pas un abonné de test prépayé, téléchargez une copie de ce formulaire, remplissez les informations demandées ci-dessous dans la section IDENTIFICATION, puis répondez à chacune des 10 questions à choix multiples dans la section QUESTIONNAIRE. Veuillez envoyer ce formulaire à l’adresse indiquée ci-dessous ainsi qu’un chèque de 25 $ payable à Mediconcept Communications.

Envoyer à: CRO 3484 Sources Blvd., Suite 518, Dollard-des-Ormeaux, QC H9B 1Z9, Canada

IDENTIFICATION Prénom :____________________________ Nom :______________________________________ Adresse :_______________________________________________________________________ Numéro

Rue

Bureau

_______________________________________________________________________________ Ville

Tél. bureau : (

Province

Code postal

) _________________ Courriel : _____________________________________

No de permis professionnel :________________________________________________________

QUESTIONNAIRE Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy Paul M. Karpecki, OD, FAAO 1. ❑ ❑ ❑ ❑

Which of the following types of allergy is most common?

Perennial Chronic Giant papillary conjunctivitis Seasonal

2. ❑ ❑ ❑ ❑

All of the following statements about perennial allergy are true, EXCEPT: Contact dermatitis involves the eyelids more than the eye Typically it’s unilateral In North America, optometry treats allergic conjunctivitis more than any other medical specialty Contact dermatitis is best treated with topical corticosteroids

Clinical & Refractive Optometry Quebec 2:4, 2017

FORMULAIRE DE DEMANDE DE CRÉDIT UFC DE CATÉGORIE A

2:4, 17

3. ❑ ❑ ❑ ❑

All of the following are possible signs of allergic conjunctivitis, EXCEPT: Glossy-looking eye Papillae Deep red coloration Eyelid swelling

4. ❑ ❑ ❑ ❑

Which of the following is NOT characteristic of viral forms of allergy?

Watery discharge Preauricular lymphadenopathy It begins unilaterally, then spreads to the other eye It begins bilaterally

5. ❑ ❑ ❑ ❑

All of the following statements about seasonal allergies are true, EXCEPT: Steroids have been shown to be faster-acting than antihistamines against itch When the signs are comparable to the symptoms, corticosteroids are the preferred treatment Overall inflammatory signs are typical Chemosis may be present

6. ❑ ❑ ❑ ❑

What percentage of patients with seasonal allergies reported that their reading was greatly affected?

50% 70% 80% 85%

7. ❑ ❑ ❑ ❑

In Dr. Osler’s Harvard University study concerning seasonal allergies, Claritin® resulted in what percentage of decrease in tear volume?

22% 34% 44% 56%

8. ❑ ❑ ❑ ❑

Giant papillary conjunctivitis (GPC) is characterized by all of the following, EXCEPT: Large papillae on the upper tarsal plate Mucin discharge Ocular swelling Decreased contact lens wearing time

9. ❑ ❑ ❑ ❑

In Dr. Bartlett’s study on GPC, Lotemax resulted in what percentage of IOP increase from baseline?

5% 6% 7% 8%

10. ❑ ❑ ❑ ❑

Which of the following describes the profile of a patient with vernal keratoconjunctivitis (VKC) Male children between the ages of roughly 4 and 16 Female children between the ages of roughly 4 and 16 Male children between the ages of roughly 5 and 17 Female children between the ages of roughly 5 and 10

Diagnosis and Treatment of Ocular Surface Conditions: Focus on Allergy — Karpecki

165

Consultations de Cas CROQ is pleased to present this second case in the Case Consultations Series by Dr. Henry Reis. The patient is a controlled diabetic with untreated Rosacea presenting with complaints of “gritty eyes” for which he has been self-medicating without success using Visine. Five randomly selected optometrists from across the country have been asked to review this case and recommend a specific treatment plan for this patient based entirely on their anecdotal experience. Their unedited recommendations have been reproduced below exactly as they were received. Please let us know how they compare to yours.

Refraction/BCVA • OD: -4.75/sph 20/20 J1; OS: -4.50/sph 20/20 J1 Slit Lamp Examination • Moderate MGD, Demodex [-], LWE [+] • Mild conjunctival injection; diffuse SPK 1+/4+ present • No other abnormalities seen

Henry Reis, MD Burnaby, BC CASE DESCRIPTION RMS, is a 33-year-old software programmer presenting with a chief complaint of gritty, red eyes, mostly at work for the last year. He has been using Visine Red Eyes p.r.n., without much relief.

Ocular History • Blepharitis – chronic; has used warm compresses intermittently over the last month • No history of contact lens wear • Happy with current glasses (-4.50/sph OU providing 20/20 J1)

Dilated Fundus Examination • ONH: 0.40x0.30 OD; 0.35x0.35 OS • Vitreous: OU floaters • Macula: OU clear • Posterior pole: OU clear • Peripheral retina: OU clear and flat, no holes/breaks Tear Osmolarity (i-Pen) • OD: 322 mOsm/L; OS: 318 mOsm/L SM Tube • OD: 2 mm; OS: 1 mm Oculus Keratograph • NIKBUT 3s OD; 4s OS • Abnormal lipid layer (irregular pattern) • Receded meibomian glands with drop-out OU 2+/4+

Medical History • DMI – controlled with Insulin • Rosacea – not being treated at the moment Allergies • NKDA; no environmental allergies

Questions for the Case Consultations Panel 1.

2.

3.

4.

5.

166

What type of treatment regimen would you recommend for this patient and would that treatment regimen include the regular use of an eye drop?

Do you usually recommend a specific type of eye drop, or do you usually leave the choice of a specific eye drop up to the patient?

If you do recommend a specific type of eye drop, what essential ingredients do you want that eye drop to contain and why?

From your experience, is compliance with an eye drop regimen an issue; and if yes, what do you feel are the main reasons for noncompliance?

Do you usually schedule a return-to-clinic visit in order to assess your patient’s progress; and if you do, in what time interval?

Clinical & Refractive Optometry Quebec 2:4, 2017

Ben Barrus, OD Calgary, AB The treatment regimen I would recommend for this patient is: 1) stop use of Visine; 2) i-drop hyaluronate artificial tear stabilizing drops to improve tear retention time, increase TBUT and reduce dry eye discomfort; 3) 4-5 g re-esterified Omega-3 targeting more than 1500 mg EPA daily; and 4) prescribe topical ivermectin 1% and/or metronidazole 1% daily for 3 months to manage Demodex induced meibomian gland dysfunction (MGD) and anterior blepharitis.

I prescribe an unpreserved artificial tear in all cases.

In instances of rapid tear breakup I prefer a hyaluronatebased drop. If TBUT is good, then using a saline drop to improve osmotic balance is helpful.

Hyaluronate is my preferred stabilizing agent.

There are several stabilizing additive drops on the

market but I find that they provide less consistent results than i-drop. My second choice is Hylo. I do not use Hylo-Dual.

From my experience, I do not feel compliance is an issue. Showing the patient the results and explanation using images or photos generally creates very good compliance.

I see patients back for dry eye follow-up on a 3-month re-visit schedule. When treating Demodex infection I often see them back in 6 weeks to ensure compliance and clinical signs are improving. Following Demodex eradication I assess MGD for improvement from baseline. If improvement is not sufficient, then referral for LipiFlow or IPL treatment is arranged. In the case presented above I would anticipate that the patient would have facial rosacea and as such I would anticipate and educate the patient with an eye towards referring him for IPL at our 3-month visit.

Susana Sebestyen, OD, FAAO Oakville, ON My short treatment regimen for this patient would be to replace Visine with an artificial tear such as i-drop Pur, Hylo, or Hyabak which not only builds up the lipid layer and tear volume but also has an anti-inflammatory property. I would also add Thealoz to help restore the epithelium and address the lid wiper epitheliopathy. I would address the blepharitis in the short term with i-lid ’n lash pads and Bruder Mask compresses followed in 3-4 weeks with BlephEx/debridement treatment.

For long-term treatment, I would prescribe Doxycycline Hyclate 100 mg per day for 1 month, and then drop this down to 50 mg for another month, and continue every other day for another 2 months as maintenance. I would also ask the patient to start taking Omega-3 triglyceride supplements at 2000-3000 mg per day. I always try to emphasize to my patients that symptomatic relief will not cure dry eye disease or meibomian gland dysfunction, but that effective treatment will protect their ocular surface and help maintain clear and comfortable vision.

I always prescribe a specific eye drop. I find that when I let the patients select their own drops they tend to be less compliant. They sometimes start mixing and matching different commercial eye drops, and in turn that can compromise the effectiveness of the prescribed treatment regimen. I prefer non-preserved drops, containing hyaluronate and lipid building ingredients such as i-drop Pur, i-drop Pur Gel and Hylo Gel for nighttime use.

I’ve found that compliance becomes a significant issue when patients become less symptomatic. When that happens, I point out that dry eye disease is a vision disease, and when I feel that it’s necessary to reinforce that point, I challenge my patients to keep their eyes open for a full minute to see if it affects their vision, and it always does.

As for follow-up visits, I tend to call patients back in as little as 1-2 weeks. If the treatment protocol is working well and I feel that the patient is compliant, I may schedule the next follow-up visit in 6 months. I hardly ever leave it longer than that, even if it’s just to re-educate the patient or to enhance their treatment regimen with other possibilities.

Case Consultations

167

Edward Chow, OD Markham, ON My treatment plan would be the following: 1) discontinue Visine immediately as it may exacerbate his dry eye; 2) perform an in-office hot compress and manual gland expression; 3) prescribe Lotemax Gel q.i.d. x 2 weeks and b.i.d x 2 weeks; 4) lipid based emulsions such as Systane Balance q.2h; 5) preservative-free artificial tears with hyaluronan such as i-drop Pur q.i.d.; 6) Bruder heating mask at home q.d. x 8 mins; 7) triglyceride-based omega-3 fatty acid q.d.

(1,800 mg EPA+DHA); 8) consider doxycycline 50 mg p.o. q.d. but in Ontario, we are limited to 14 days of oral antibiotic treatment. I would refer him to his family physician to treat for the rosacea as indicated.

I always recommend specific eye drops to my patients as patients are indecisive.

I recommend preservative-free eye drops as preservatives are known to promote inflammation and reduce cellular viability. I also recommend hyaluronate as it is the only natural substance found within the eye that has viscoadaptive and corneal regenerative properties. For the very severe dry eye, I use a bioprotectant such as trehalose or ectoine to prevent osmotic degradation.

Compliance is always an issue because we all know that life gets in the way and patients forget to use eye drops. The key to proper compliance is patient education.

I schedule a follow up after 2 weeks to ensure compliance and to check for progress and tailor the treatment accordingly.

Jules Plante, OD, MSc, FAAO Montreal, QC This patient is demonstrating a potentially severe mixed dry eye condition, as shown by the highly positive tear osmolarity measure, short tear break-up time and diffuse superficial punctate keratitis. Clinical signs are pointing toward both aqueousdeficient dry eye (SM Tube reduced and signs of lid wiper epitheliopathy) and evaporative dry eye (meibomian gland drop-out, abnormal lipid layer) possibly aggravated by chronic blepharitis and rosacea. Considering his rather young age, his environment (intensive computer usage) and the fact that he is affected by diabetes, I would go for an aggressive treatment plan to avoid long-term exacerbation of his ocular condition.

The meibomian gland dysfunction component has to be treated either with warm compresses or thermopulsation (LipiFlow) and daily Omega-3 (2000 mg to 3000 mg). Inflammation needs to be controlled with a soft

168

Clinical & Refractive Optometry Quebec 2:4, 2017

steroid (Lotemax Gel) t.i.d. for 2 weeks and b.i.d. for another 2 weeks. The aqueous deficiency has to be treated by lubricant unpreserved eye drops composed of sodium hyaluronate (i-drop Pur and/or i-drop Pur Gel) used 4 times daily and cyclosporine A 0.05% b.i.d.

(Restasis). The patient should also use lid scrubs and warm compresses on a daily basis.

I usually prescribe sodium hyaluronate nonpreserved drops for its viscoelastic properties and I encourage the patient to be compliant with the scheduled regimen. I also stress the importance of using nonpreserved eye drops and explain to the patient that all eye drops are not equal.

I believe that the main reasons for noncompliance are misunderstanding of the condition and poor relief of the ocular irritation. To avoid this, I usually prefer to prescribe a moderately viscous gel drop, for which the residency time is longer than traditional eye drops.

Finally, I schedule a follow-up within 3 months to confirm the treatment effectiveness.

Francis Gaudreault, OD Quebec City, QC

Krista Flynn, OD Kingston, NS

The primary defect in ocular rosacea is the meibomian gland inflammation leading to meibomian gland dysfunction (MGD) and gland atrophy. These result in eyelid margin erythema, telangiectasia, inspissated meibomian gland orifices and blepharitis.

Chronic inflammation will also cause a loss of lacrimal gland secretions.

Both quantitative and qualitative abnormalities of the tear film should cause hyperosmolarity. Every patient with ocular rosacea like this patient should have a long-term therapy because of the chronicity of the condition. Consider LipiFlow to clear the blocked glands and restore normal function of the residual meibomian glands. Treat the inflammation with a topical steroid such as Lotemax Gel q.i.d. x 14 days and b.i.d. x 1 month. Start topical cyclosporine (Restasis) twice daily for long term. The anti-inflammation effect of Restasis on the ocular surface associated with tear production augmentation will improve the signs and symptoms of this patient. Lid hygiene and Omega-3 supplements (Systane Vitamins) would also be recommended every day. Warm compresses like Bruder Moist Heat Eye Compress should be done two to three times a week to maintain the effect of the LipiFlow. The use of an eye drop should be as needed.

I always recommend a specific eye drop depending if it’s an aqueous tear deficiency or an evaporative dry eye.

Every drop has a different function and is more effective depending on the type of disorder. i-drop Pur Gel is preservative free, it hydrates and stabilizes the tear film very well in mostly all cases. Refresh Optive Fusion preserved with gentle Purite is good for aqueous deficiency and against hyperosmolarity. I also use Refresh Optive Advanced for patients who need a lipid-based tear.

Ideally, I use preservative-free eye drops. If not, I use drops with a gentle preservative such as Purite. Hyaluronic acid is an essential ingredient. Also, viscoelastic properties ensure a superior moistening and a long-lasting comfort.

Some patients will not be compliant if we don’t take enough time to explain the real benefits of theses eye drops and why it’s so important for their condition. They will return to a less expensive eye drop.

The patient should have a 3-month follow-up.

Consider oral doxycycline if needed. Apprilon 40 mg once daily for 2 months is my first choice.

The primary goal would be to start this patient on a regime that will focus on treating their chronic meibomian gland dysfunction (MGD). This would consist of warm compresses (Bruder) 10 min q.d., lid wipes (i-lid ’n lash Plus) daily and Omega-3 supplementation (Ascenta EPA+).

Because of the increased osmolarity and low tear volume, I would start them on an artificial tear containing sodium hyaluronate t.i.d. and reassess in 6 weeks. Adding Maxitrol ung to lid rims q.h.s OU x 1 month would be considered if significant blepharitis and inflammation remained at follow up.

My preference is to recommend a specific eye drop to patients based on the findings of their examination. For patients with a higher osmolarity (>320) or eyes that appear more inflamed with any level of MGD, I prescribe a tear containing sodium hyaluronate (Refresh Fusion, Hylo or i-drop Pur Gel). I prefer non-preserved artificial tears for patients that require a t.i.d.+ dosing. I will recommend a lipid-based tear (Refresh Optive Advanced or Systane Balance) to those patients who have a lower osmolarity with mild to moderate MGD. In my experience, compliance can become an issue for patients who: experience stinging on insertion, who feel the drops are not helpful, or once they become symptom free. To improve compliance, I usually schedule multiple follow-up visits from 6 weeks.

Summary of Treatment Recommendations For Meibomian Gland Dysfunction Bruder Mask Omega-3 LipiFlow Manual Gland Expression For Inflammation Lotemax Restasis For Hyperosmolarity i-drop Hylo Systane Refresh Essential Eye Drop Ingredient Hyaluronate Is Compliance an Issue?

Yes No Next Scheduled Follow-Up Visit In 2 Weeks In 6 Weeks In 12 Weeks

6 out of 6 6 out of 6 3 out of 6 1 out of 6 3 out of 6 2 out of 6 6 out of 6 3 out of 6 2 out of 6 2 out of 6 6 out of 6 5 out of 6 1 out of 6 2 out of 6 1 out of 6 3 out of 6

Case Consultations

169

®

GOUTTE OCULAIRE VISCOADAPTIVE

TRAITER LA SÉCHERESSE OCULAIRE POUR UN SOULAGEMENT LONGUE DURÉE DE LA SÉCHERESSE OCULAIRE LÉGÈRE, MODÉRÉE ET SÉVÈRE i-drop® est la première et la seule goutte oculaire viscoadaptive multidose et sans agent de conservation disponible dans deux concentrations pour le traitement de la sécheresse oculaire tant légère à modérée que modérée à sévère.

• meilleure protection de la cornée • durée de résistance prolongée • clignements plus aisés • confort supérieur • excellente hydratation de la cornée • évaporation réduite du film lacrymal

La seule goutte oculaire qui renforce chacune des trois couches du film lacrymal Pour plus d’information sur le produit i-drop® ou pour obtenir une démonstration dans vos bureaux veuillez communiquer avec votre représentant I-MED Pharma dès aujourd’hui.

Visitez-nous à www.osdcare.co ou appelez au 1-800-463-1008

i-drop® Pur 0,18 % d’acide hyaluronique viscoadaptif pour la sécheresse oculaire légère à modérée

i-drop® Pur GEL 0,30 % d’acide hyaluronique viscoadaptif pour la sécheresse oculaire modérée à sévère