Systemisk sygdom og kontaktlinsebrug Særlige forholdsregler
Anne$e Slyngborg, MSc (optom) Dansk optometri og kontaktlinse konference 2012
Hvad inspirerede 9l de:e emne? BCLA 2011 Dr. Lisa Keay: Health and safe contact lens wear ”Upper respiratory tract infec@on and chronic diseases including thyroid disease and immune compromise can impact successful contact lens wear.”
Prof. Nathan Efron and Dr. Clare O’Donnell: Contact lenses and the diabe9c pa9ent ”An important decision for the prac@@oner is wether or not pa@ents with diabetes should be fi$ed with contact lenses”
Dr. Lisa Keay: Health and safe contact lens wear Egne notater fra foredrag: • 39/114 with poor health at the 9me for MK – Respiratory, generally run down and 9red, thyroid disease, diabetes and ¼ with other systemic diseases.
• Diabetes and thyroid disease: Greater risk for MK (2x) • CLARE associated with influenza Do not wear contact lenses when you are sick. Do not sleep in CL when you are not well.
Prof. Nathan Efron and Dr. Clare O’Donnell: Contact lenses and the diabe9c pa9ent The literature suggests that diabe9c pa9ents may have: • Altered tear chemistry and tear secre9on • Structural and func9onal changes to the corneal epithelium, endothelium and nerves. • Reported increased incidence of corneal infec9on • Reported CL induced complica9ons is mostly concerning pa9ents with advanced diabe9c eye disease using lenses on an extended wear basis. Diabe9c pa9ents may be par9cularly suscep9ble to developing ocular complica9ons during contact lens wear.
A prospec)ve study of contact lens wear in diabetes mellitus.
O'Donnell C, Efron N, Boulton AJ. Source European Centre for Contact Lens Research, Department of Optometry and Neuroscience, University of Manchester Ins9tute of Science and Technology, P.O. Box 88, Manchester M60 1QD, UK. clare.odonnell@umist.ac.uk
Abstract
A prospec9ve, controlled, observer-‐masked study was conducted to inves9gate the suitability of contact lenses for pa9ents with diabetes mellitus. 40 diabe9c pa9ents and 40 non-‐diabe9c control subjects were fi:ed with soh hydrogel contact lenses to be worn on a daily wear basis for 12 months. The ocular response was assessed using slit lamp biomicroscopy, ultrasonic pachometry, corneal aesthesiometry and visual acuity measures. Compared to non-‐diabe9c subjects, diabe9c pa9ents displayed significantly reduced corneal transparency, variable vision and reduced comfort with the contact lenses (p < 0.05). There were no significant differences between the two groups with respect to ocular hyperaemia, corneal staining, corneal thickness, corneal sensi9vity or high contrast visual acuity. Contrary to previous reports, the response of the diabe9c eye to contact lenses-‐-‐as observed clinically-‐-‐does not differ appreciably from that of the non-‐diabe9c eye. These results suggest that current genera9on daily wear soh contact lenses can be a viable mode of vision correc9on for diabe9c pa9ents. PMID: 11261347 [PubMed -‐ indexed for MEDLINE]
A prospec)ve study of contact lens wear in diabetes mellitus.
Diabe@c pa@ents displayed: • significantly reduced corneal transparency • variable vision • reduced comfort No significant differences between the two group: • ocular hyperaemia • corneal staining • corneal thickness • corneal sensi9vity • high contrast visual acuity These results suggest that current genera9on daily wear soh contact lenses can be a viable mode of vision correc9on for diabe9c pa9ents.
Diabetes and contact lenses in the future Furthermore, new research suggests that the measurement of tear glucose concentra9on could, in future, be used to monitor metabolic control non-‐invasively in diabe9c pa9ents. This could be carried out using contact lenses manufactured from hydrogel polymers embedded with glucose-‐sensing agents or nanoscale digital electronic technology.
Clin Exp Optom. 2012 May;95(3):328-‐37. doi: 10.1111/j.1444-‐0938.2012.00738.x. Epub 2012 Apr 27. PMID: 22537249 [PubMed -‐ indexed for MEDLINE]
Diabetes and dry eye • En af de mest almindelige okulære manisfesta9oner er tørt øje • Pa9enter med type 2 diabetes har tendens 9l dysfunk9on af tårefilmen • Et andet studie viste at type 2 diabe9kere har mindre tåresekre9on og BUT • Tendens 9l at udvikle SPK og corneal ulcera9on
Ernest L. Bowling OD, MS, FAAO, dipl. Optometric Management okt. 2011
Daglig praksis -‐ Diabetes • • • • • • • • • •
Bløde linser med høj Dk/t DD gerne fugsorbedret materiale Aldrig EW/CW Minimer infek9onsrisiko Vær opmærksom på nedsat følsomhed Grundig instruk9on i hygiejne og sikker håndtering Regelmæssige kontroller Særlig fokus på risiko for overflade skader / + FLUORESCEIN !! Svingende refrak9on – blodsukker Kontraindika9on ved 9dligere 9lfælde af cornea erosion eller andre 9lstande i forreste segment.
Risiko for mikrobiel kera9t
Risiko faktorer for MK Modificerbare • • • • • • • • •
Døgnbrug 16,9 KL brugt på ferie 15,1 Svømning uden goggles 5,5 -‐ håndvask inden udtagning 4,5 Lejlighedsvis døgnbrug 4,0 Dårlig hygiejne 3,9 Køb via internet 2,6 Dårligt helbred 2,3 Rygning 1,8
Ikke modificerbare • • • • •
EW i mindre end 6 mdr. Mand Vinter Høj socio-‐øko. status Ung alder
2,6 2,6 2,4 1,7 1,6
STAPLETON, FIONA MCOptom, PhD, FAAO; KEAY, LISA BOptom, PhD, FAAO; JALBERT, ISABELLE OD, PhD, FAAO; COLE, NERIDA PhD Optometry & Vision Science: April 2007 -‐ Volume 84 -‐ Issue 4 -‐ pp 257-‐272
The Epidemiology of Contact Lens Related Infiltrates
Recent studies have not confirmed a sta9s9cally significant reduc9on in either the absolute incidence or rela9ve risk of microbial kera99s with daily disposable lenses. Interim analysis of the unpublished la:er study has suggested that daily disposable lenses may reduce the risk of more severe disease. Conceivably, elimina9ng the contact lens storage case may reduce the likelihood of lens contamina9on by Gram-‐nega9ve bacteria, which have been shown to be associated with more severe disease. STAPLETON, FIONA MCOptom, PhD, FAAO; KEAY, LISA BOptom, PhD, FAAO; JALBERT, ISABELLE OD, PhD, FAAO; COLE, NERIDA PhD Optometry & Vision Science: April 2007 -‐ Volume 84 -‐ Issue 4 -‐ pp 257-‐272
Compliance – Risiko for MK
The most important risk factor for microbial kera99s is overnight contact lens wear (prescribed or not). Epidemiological studies have shown the rate of microbial kera99s with overnight wear of soh contact lenses has remained steady at 4 to 10 9mes the rate of microbial kera99s with daily wear (Schein et al, 2005; Stapleton et al, 2009; Schein et al, 1989). Overnight wear is also associated with higher rates of corneal infiltrates (Stapleton et al, 2007; Szczotka-‐Flynn and Diaz, 2007).
Survey results shed new light on the top noncompliance behaviors, and prac))oners offer )ps on how to improve adherence to lens wear and care regimens. By Sheila B. Hickson-‐Curran, BSc (Hons), MCOptom, FAAO Contact Lens Spectrum, Volume: 27 , Issue: January 2012, page(s): 38 -‐ 43
Compliance -‐ generelt Pa9ents who do not adhere to their prescribed regimens exist in all areas of health care. Studies have shown that about 35 percent of pa9ents with glaucoma do not use their IOP-‐lowering drops as directed (Dietlein et al, 2005), 38 percent of pa9ents with Type II diabetes fail to adhere to their insulin regimens (Cramer, 2004), and more than 40 percent of pa9ents do not take their osteoporosis medicine (Boccuzzi et al, 2005). Failing to take medica9on for these diseases can have a significant impact on morbidity and mortality.
Sheila B. Hickson-‐Curran, BSc (Hons), MCOptom, FAAO Contact Lens Spectrum, Volume: 27 , Issue: January 2012, page(s): 38 -‐ 43
Compliance i daglig praksis Anbefaling for at minimere risiko for MK: • Undgå døgnbrug • Vær påpasselig med hygiejnen • Især på ferie og i vandmiljøer • Svøm ikke med KL på, uden goggles • Få individuel 9lpasning og plejesystem ( undgå internetkøb) • Brug ikke KL når du er syg • Rygning øger risiko for MK
Vær proak)v – forebyg drop-‐out Kontaktlinse problemer: Acne rosacea Autoimmune sygdomme • Allergi • Sjögren’s syndrome • Rheumatoid arthri9s Tørre øjne: Menopause Sarcoidosis Thyroid problemer
Medicin som kan give tørre øjne: • Vanddrivende • An9-‐depressiva • P-‐piller • Hormon erstatning • Beta-‐blockere • Afslappende • An9cholinerge, an9histaminer • Bedøvende • Accutane
Proac)vely Prevent Contact Lens Dropout, by Susan Kovacich, OD, FAAO Contact Lens Spectrum, Issue: April 2007
Conclusion: DD contact lenses offer a barrier to airborne an9gen which is enhanced by modern lenses with enhanced lubrica9ng agents.
Generel  allergi Â
Daglig praksis -‐ allergi • • • • • • • • •
1 Day linser, bedst med indhold af fugtestoffer Alterna9vt: Hydrogen peroxide plejesystemer bedst Linser renses grundigt inden desinfek9on GP linser med minimalt EC I perioder, evt. linsepause
Vær pro-‐ak9v Indlevelse => tryghed Kend pollenkalenderen Tal med kunden om forebyggelse / behandling
Daglig praksis -‐ allergi • Kolde ”kuns9ge tårer” • Forebyggende: Mastcelle stabiliserende øjendråber • Behandlende: An9histamin øjendråber • Oral an9histamin, binyrbarkhormon næsespray • evt. receptplig9g binyrebarkhormon
Mastcelle -‐ histamin
Associa)ons of Systemic Diseases, Smoking and Contact Lens Wear with Severity of Dry Eye Systemic diseases, smoking, ocular surgeries and contact lens wear have been linked with dry eye but it is not known if these factors are also associated with severity of dry eye. A cross-‐sec9onal inves9ga9on was conducted on the effect of various systemic and ocular condi9ons with respect to the severity of dry eye in Asian pa9ents. Out of 510 pa9ents (25% men), mean +/-‐ S.D. age 53.0 +/-‐ 14.1 years, 25 had previous diagnosis of rheumatoid arthri9s, 30 had diabe9c mellitus, 41 had thyroid disease, and 33 were current smokers; 23 and 41 pa9ents had previous LASIK and cataract surgery respec9vely and 90 were current contact lenses wearers. A previous diagnosis of rheumatoid arthri9s was associated with more severe superior corneal fluorescein staining (OR = 11.2, 95% CI 4.6-‐27.4). The researchers concluded that generally, with the excep9on of rheumatoid arthri9s, there were no associa9ons between dry eye severity and systemic diseases, smoking, previous ocular surgeries and contact lens wear. Dry eye pa9ents with rheumatoid arthri9s tend to have more severe ocular surface damage in the superior cornea.
Lee SY, Petznick A, Tong L. Associa9ons of systemic diseases, smoking and contact lens wear with severity of dry eye. Ophthalmic Physiol Opt. 2012 Sep 7. doi: 10.1111/j.1475-‐1313.2012.00931.x. [Epub ahead of print]
Resultat af undersøgelsen Sammenhæng ml. graden af tørre øjne og forskellige 9lstande: • Diabetes mellitus -‐ • Thyroid disease -‐ • Rheumatoid arthri9s + • Rygere -‐ • Kontaktlinsebrugere -‐ • Tidligere øjenopera9on -‐
Lee SY, Petznick A, Tong L. Associa9ons of systemic diseases, smoking and contact lens wear with severity of dry eye. Ophthalmic Physiol Opt. 2012 Sep 7. doi: 10.1111/j.1475-‐1313.2012.00931.x.
Case: Kronisk tørre øjne og ptose • • • • •
Ung kvinde Myop: -‐1,00 D. Diag.: KCS Medicinsk behandling i 2 år Tidl. brugt bløde linser
• Cornea-‐sclerale GP linser • Fuld daglig bære9d • Symptomer og staining a€julpet
Incidence of dry eye in an older popula9on
10-‐årigt studie(n:2827). Incidence: 21.6%, øges med alderen. Riskofaktorer: Ikke associeret med: • Kvinder > mænd • Arthri9s • Thyroidea sygdomme, ikke reguleret med hormon • Allergi / an9histaminer • An9angst medicin • An9depressiva • Orale steroider • Vitaminer • Dårligt selvvurderet helbred
• • • • • • • • • •
Hypertension Cardiovascular sygdom Højt kolesterol Diabetes Gigt Osteoporosis Calcium channel blockers An9kolesterol medicin Rygning, kaffe eller alkohol Afslappet livss9l
Moss SE, Klein R, Klein BE. Long-‐term incidence of dry eye in an older popula@on. Optom Vis Sci 2008;85:668-‐74.
Anxiety and Depression in Pa)ents with Dry Eye Syndrome Case-‐control study: 89 DES subjects (heraf 13 Sjogren’s) SAS: Self Ra9ng Anxiety Scales SDS: Self Ra9ng Depression Scales OSDI: Ocular Surface Disease Index
Prævalens af: • SAS: DES gruppen > kontrol • SDS: DES gruppen > kontrol Sammenhæng mellem: • SAS og OSDI samt uddannelsesniveau • SDS og OSDI
Ingen sammenhæng ml.: SAS / SDS og • Alder • Køn • Husstands indkomst • Tåre break up 9me (BUT) • Schirmer Test • Corneal fluorescein staining • Visus
Li M, Gong L, Sun X, Chapin WJ. Anxiety and depression in pa@ents with dry eye syndrome. Curr Eye Res. 2011 Jan;36(1):1-‐7.
Børn og tørre øjne Juvenile rheumatoid arthri9s: 13 % Børn med Type 1 diabetes: 15 % Alder og køn reguleret kontrolgruppe: < 2 % (Akinci et al, 2007) Når børn klager over tørre øjne – mistænk systemisk sygdom !
Dry Eyes Are Less of a Problem in Young Contact Lens Wearers BY JEFFREY J. WALLINE, OD, PHD, & MARJORIE J. RAH, OD, PHD Contact Lens Spectrum, Issue: July 2009
Defini9on på ”tørre øjne” New Defini)on of Dry Eye
Dry eye is a mul9factorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear instability with poten9al damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflamma)on of the ocular surface.
Published in April 2007 as part of the Report of the Interna9onal Dry Eye Workshop (DEWS) in the journal The Ocular Surface.
Inflamma)on in Dry Eye Disease “Inflamma9on is at the root of dry eye disease and appears to develop quickly in the disease process. Targeted therapies such as cyclosporine A, cor9costeroids, oral doxycycline, and essen9al fa:y acid supplements have known effects on ocular surface inflamma9on.”
By Paul Karpecki, OD, FAAO, Contact Lens Spectrum, Issue: July 2009. Refernces #164
Kosƒlskud 9l behandling af tørre øjne • • • • •
EFA kosƒlskud: betydelig rolle i behandling af tørre øjne Ideelt forhold. Omega 3 : Omega 6 = 1 : 3 Kvinder med højeste indtag af Omega 3 : laveste rate af DES PUFA indtag : posi9v rolle i sund MG funk9on Kosƒlskud med GLA: a€jælper Arthri9s gener
Essen)al FaWy Acids and Dry Eye: What Do We Know? BY LYNDON JONES, PHD, FCOPTOM, FAAO, Cl spectrum – references #164
Kostvejledning • Anbefale pa9enter at reducere deres indtag af Omega 6 (animalsk fedt) og øge indtaget af Omega 3 (fed fisk, nødder, hørfrø, bladsalat med olie m.m.) • Det vil reducere både symptomer og tegn på tørre øjne
Essen)al FaWy Acids and Dry Eye: What Do We Know? BY LYNDON JONES, PHD, FCOPTOM, FAAO Dietary Changes, Supplements May Improve Ocular Health, BY WILLIAM L. MILLER, OD, PHD, FAAO Cl spectrum – references #164 and SE2010
Anterior eye and nutri9on; implica9on for contact lens prac9ce Lav ascorbinsyre diæt: cornea skader Normal diæt: ingen skader af UV belysning Limbal hyperæmi reduceret med mega dosis ascorbinsyre Jo mere sukker vi indtager, jo mere vit.C behøver vi Vit.D forbedrer corneal epithel barriere Omega 3: MGDê, Tørt øjeê Test af Theratears Omega 3: 70% blev asymptoma9ske mod 37% i placebo gruppen • Resveratrol: Forbedrer cornea topografi • • • • • • •
Stuart Richer, OD, PhD, FAAO. Director, Ocular Preven9ve Medicine Laboratory, Captain James A Lovell Federal Health Care Center, USA. Presenta@on at the BCLA Conference 2012
Behandlingsplan ved DES • • • •
Tilpas systemisk væskebalance og ernærings9lstand Skih KL materiale og/eller plejesystem Kuns9g tårevæske godkendt 9l KL brug Informer/instruer kunden ved hvert kontrolbesøg om korrekt rensning og desinfek9on, samt hygiejne.
William L. Miller, OD, PhD, FAAO, Contact Lens Spectrum, Issue: September 2011
Konserveringsmiddel ohest ass. med diskomfort? PHMB (biguanides) None (All the same impact) Polyquaternium / PHMB Polyquaternium / Aldox
Hydrogen peroxide Polyquaternium / Alexedine
Survey from a sample of eyecare prac99oners from the Contact Lens Spectrum readership via an online market survey from March 15th through April 25th, 2012. 457 respondents
ARCH OPHTHALMOL/VOL 129 (NO. 6), JUNE 2011 WWW.ARCHOPHTHALMOL.COM 798
A vitamin mangel – cornea problemer og lysfølsomhed
Cornea degenera9on – generelt helbred Systemiske sygdommes som ohe er associeret med cornea degenera9on: • Rheumatoid arthri9s • Syphilis • Crohn's disease Ændringer i corneas væv: • Aflejringer • Udtynding • Karindvækst Vig9gt at lave en omfa:ende anamnese! Degenera)ons and dystrophies: Learn their telltale signs and symptoms and how to diagnose and treat them. BY LOUISE SCLAFANI, OD, FAAO, Contact lens Spectrum issue: August 2003
Scleral linser Fordele ved terapeu9sk 9lpasning af linser • KCS • Rheumatoid arthri9s • Sjögren's syndrome
Case: KCS før og eher 5 9mer med sclerale GP linser Fi`ng Scleral Lenses for Ocular Surface Disease, By LyneWe K. Johns, OD, FAAO Defining fi`ng goals and pa)ent expecta)ons is an important first step in managing OSD with sclerals.
Opsummering • Vær pro-‐ak9v • Især opmærksom på diabetes, arthri@s, Sjögreens, allergi, Crohn’s, thyroidea sygdomme, angst/depression, meno-‐pause samt vitamin mangel@lstande eller fejlernæring
• Medicin, især an@histamin, an@-‐depressiva og afslappende midler,
hormoner, steroider, vanddrivende, acnemidler og generelt an@cholinerge
• Reduk9on af gener ved kostvejledning • Individuelt kontaktlinse-‐ og væske valg • Omhyggelig vejledning og instruk9on • Reduk9on af infek9onsrisiko Ohest kun rela9v kontraindika9on Med engagement og indlevelse skabes tryghed og 9lfredse kunder
Tak for opmÌrksomheden Tak fordi I valgte at høre om systemisk sygdom og kontaktlinsebrug Tak fordi I valgte at deltage i konferencen