dry eye education
TRANSCRIPT
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earing
Dry vs. Wet vs. Both
Kimberly Cockerham, MD, FACSPlastics-Orbit-Neuro-Ophthalmology
www.CalEyes.com
http://www.caleyes.com/http://www.caleyes.com/
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Systematic Approach to
Tearing Dry
Wet
Other Ocular Surace
Eyeli!
Orbit
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Dry Eye is a Disease of the
Lacrimal Functional Unit
1
2
3
4
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Dry Eye "s Pre#alent $.% million people in the &nite! States'
A top reason or #isits to Eye(Ds an! O!s
Patients oten !issatis)e! with treatments *re+uent !rops incon#enient
,imite! symptomatic relie
*rustrate! Want new options
' (ulti-Sponsor Sur#eys "nc. The 2005 Gallup Study of Dry Eye Suerers. $%.
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Dry Eye Patient *actors Ol!er age
*emale gen!er
Post-menopausal
Tobacco smo/ing
Contact lens wear Prolonge! staring 0e.g. computer
wor/1
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En#ironmental *actors Air Pollution
Arti)cial orce! air
Allergens
,ow humi!ity
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(e!ications Antihistamines
Anti!epressants
Antispasmo!ics
Diruetics
Oral contracepti#es 2ormonal therapy
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Disease 3elate! *actors Systemic4
Autoimmune !isease 0TED1
Neurologic !isease that re!uces blin/ 5itamin A !e)ciency
,ocal4 ,acrimal glan! in)ltration Eyeli! malposition la6ity
lagophthalmos Ocular surace !isease
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Lacrimal Glands:Lacrimal Glands:• Chronic irritationChronic irritation
• T-cell activationT-cell activation
• Cytokine secretion intoCytokine secretion intotearstears
Interrupted SecretomotorInterrupted Secretomotor
Nerve ImpulsesNerve Impulses
Tears Damage OcularTears Damage Ocular
SurfaceSurfaceCytokinesCytokinesDisrupt Neural ArcDisrupt Neural Arc
Disruption o normalDisruption o normalneuronal control oneuronal control otearin!tearin!
Pathophysiology oChronic Dry Eye Disease
,acrimalDamage
Stern et al. Cornea. '778.Nelson et al. Adv Ther. $.
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2ealthy Tears
Comple6 (i6ture Antimicrobial proteins
9rowth actors
Cyto/ines suppress in:ammation
(ucin secrete! by goblet cells 5iscosity
Electrolytes Osmolarity
"mage a!apte! rom4 Dry Eye and Ocular Surface Disorders. $;.Stern et al. "n4 Dry Eye and Ocular SurfaceDisorders. $;.
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*unctions o a
2ealthy Tear *ilm Optical clarity reracti#e power
Ocular surace comort lubrication
Protection rom en#ironmental an! inectiousinsults
Antibacterial proteins antibo!ies complement
3e:e6 tears :ush away particles
Trophic en#ironment or corneal epithelium
Necessary electrolytes maintain p2
Protein actors or growth an! woun! healing
Antio6i!ants
3olan!o et al. Dry Eye and Ocular Surface Disorders. $;.Stern et al. "n4 Dry Eye and Ocular Surface Disorders. $;.
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Tears in Chronic Dry EyeDecrease! proteins
an! growth actors
Altere! cyto/inebalance promotesin:ammation
Proteases acti#ate! "ncrease! electrolytes
Altere! #iscositySolomon et al. nvest Ophthal!ol "is Sci. $'.
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E>ects o Altere! Tear
Composition in Chronic DryEye Ocular surace tissue en#ironment altere!
,ubrication compromise! !ue to poor
#iscosity "ncrease! osmolarity
"mbalance! growth actors an! cyto/inesail to promote normal epithelial growth
Ocular surace !amage
,oss o corneal epithelial integrity
S+uamous metaplasia o con?uncti#al
epithelium
P:ugel!er. A! $ Ophthal!ol. $;.
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The ,oo/ o Dry
NormalAbnormal
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Tear @rea/up Time 0T@&T1
Tear )lm instability is a hallmar/ o !ry eye Correlates with a+ueous an! e#aporati#e tear !e)ciency 0P:ugel!er
et al '7781
T@&T measures tear )lm +uality *luorescein intro!uce! rom strip yellow )lter increases
sensiti#ity
T@&T time rom complete! blin/ to 'st !ry spot 0B repetitions1
T@&T ' secon!s abnormal0,emp '77%1
Anesthesia decreases T%&T 'de (aiva et al) 200*+
A,nor!al corneal surface - ,rea/-up spots
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,issamine 9reen Staining
in Dry Eye
,issamine green !etects !ea! or!egenerate! con?uncti#al cells
E6posure one
staining withlimbal sparing
E6posure one
staining withlimbal staining
"ntense !i>use
staining oe6posureone limbalstaining
s rom Dry Eye and Ocular Surface Disorders. $;.
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5ital Stains
*luorescein 3ose @engal ,issamine9reen
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Schirmers Strips
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FDry EyesG are 5ery
Common $%H o oIce #isits in a general
practice
; in ' Americans su>er rom !ryeye symptoms 09allup Poll $;1
A>ects $ million Americans 0(ar/et
Scope $;1 Pre#alence4 ';H o a!ults ;8 J 7'
years ol!
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Dry Eye Patient *actors Ol!er age
*emale gen!er
Post-menopausal
Tobacco smo/ing
Contact lens wear Prolonge! staring 0e.g. computer
wor/1
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En#ironmental *actors Air Pollution
Arti)cial orce! air
Allergens
,ow humi!ity
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(e!ications Antihistamines
Anti!epressants
Antispasmo!ics
Diruetics
Oral contracepti#es 2ormonal therapy
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Disease 3elate! *actors Systemic4
Autoimmune !isease Neurologic !isease that re!uces blin/ 5itamin A !e)ciency
,ocal4
,acrimal glan! in)ltration Eyeli! malposition or la6ity Ocular surace !isease
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(il! to (o!erate
Symptoms (inimal signs Consi!er en#ironmentKinta/e
A!! tear replacement
Osmolarity
5iscosity
Combination
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(o!erate to Se#ere
Symptoms Abnormal tear )lm corneal an!
con?uncti#al staining #isual signs Essential atty aci!s 0E*A1
*la6see! oil 2y!roeyeL Topical anti-in:ammatory agents
Cyclosporine
Oral cholinergics Pilocarpine 0SalagenL1 Ce#imeline
C T t t
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"#@ehrens et al. Cornea. $=.
Consensus TreatmentAlgorithm 9ui!elines
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Dry Eye (anagement
ild to oderateSy!pto!s (inimal or no signs
A!! Essential atty aci!s 0E*A1 *la6see! oil 2y!roeyeL
A!! tear replacement
Osmolarity
5iscosity
Combination
3estasis
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Dry Eye (anagementoderate to SevereSy!pto!s Signs present4 Abnormal tear )lm corneal
an! con?uncti#al staining
Essential atty aci!s 0E*A1 *la6see! oil 2y!roeyeL Topical anti-in:ammatory agents
Cyclosporine
" !ry mouth also present4 consi!er oralcholinergics Pilocarpine 0SalagenL1 Ce#imeline
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"$
3estasis
Dosing an! A!ministration Not Fas nee!e!G li/e tra!itional eye !rops
One !rop-each eye in morning M e#ening
5ials shoul! be !iscar!e! ater each use Two #ials per !ay are re+uire! an! thats
why its important or patients to recei#e$ trays or B !ays
Arti)cial tears may be use! orconcomitant relie 0no preservatives!uch ,etter 1+
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%&
3ESTAS"SL increases tear pro!uction
in some patients
"n pi#otal trials the use o 3ESTAS"SL
twice a !ay or = months 0$1 "ncrease! goblet cell !ensity
"ncrease! tear pro!uction
Decrease! corneal staining 3e!uce! reliance on arti)cial tears
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Dry Eye
Surgical (anagement Punctal occlusion
Plugs Cautery
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Thank You!Thank You!
Kimberly Cockerham, MD, FACSKimberly Cockerham, MD, FACS
www.CalEyes.com www.CalEyes.com
Los Altos –Come Visit !!!Los Altos –Come Visit !!!
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