6/2/2019 - coavision.org Symposium... · 6/2/2019 3 Not Your Typical Dry Eye Clinical Considerations for Complex Cases John, etal Ophth 2017 Single application of Prokera in severe

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Not Your Typical Dry EyeContemporary Management Strategies for Challenging Cases

Michael DePaolis, OD, FAAO

Flaum Eye Institute / UR Medicine

[email protected]

[email protected]


FINANCIAL DISCLOSURE STATEMENT

▪ Associate Professor of Clinical OphthalmologyFlaum Eye Institute @ UR Medicine

▪ Clinical Investigator, Advisor, Consultant, Lecturer▪ Alcon▪ Allergan▪ AMO▪ Bausch & Lomb▪ Cooper Vision▪ Paragon Vision Sciences▪ Shire▪ SynergEyes▪ J&J Vision Care

▪ Optometric Editor, PRIMARY CARE OPTOMETRY NEWS

What do a …..

▪ 63 yof with non-small cell lung cancer

▪ 68 yof with filamentary keratitis & ABMD

▪ 44 yof with monthly subconjunctival hemorrhages

▪ 36 yom post PRK

▪ 56 yof with bilateral 7th nerve crush injury

…. have in common?

Not Your Typical Dry Eye

Clinical Considerations for Complex Cases

TFOS DEWS II Report

▪ 150 clinical & basic researchers from 23 countries

▪ 10 subcommittees and over 2 years in duration

▪ 400 page report published in Ocular Surface (July 2017)

Goals …

▪ Update definition & classification of DED

▪ Evaluate epidemiology, pathophysiology, mechanism &

impact

▪ Recommendations for diagnosis & management

▪ Recommendations for future study designs



TFOS DEWS II Report

Definition & Classification

“Dry eye is a multifactorial disease of the ocular surface

characterized by a loss of homeostasis of the tear film, and

accompanied by ocular symptoms, in which tear film instability

and hyperosmolarity, ocular surface inflammation and damage,

and neurosensory abnormalities play etiological roles.”

▪ Aqueous deficient dry eye (ADDE)

▪ Evaporative dry eye (EDE)

▪ Most often DED is a continuum


Clinical Considerations for Complex CasesTFOS DEWS II Report

Epidemiology

▪ Study prevalence ranges from 5 – 50%

▪ Most studies from North America, Europe, and Africa

Risk factors

▪ Age, sex (estrogen), and race (Asian)

▪ MGD

▪ CT disorders, Sjogren’s, androgen deficit, & stem cell transplantation

▪ Contact lens wear, computer use, low humidity, and medications

Possible risk factors

▪ Diabetes, rosacea, thyroid disease, viral disease, and psychiatric disease

▪ Allergic conjunctivitis and pterygium

▪ Refractive surgery

▪ Low fatty acid intake and certain other medications



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TFOS DEWS II Report

Pathophysiology

▪ Core mechanism is evaporation induced hyperosmolarity

▪ In ADDE hyperosmolarity results from reduced secretion

▪ In EDE hyerosmolarity results from evaporation

▪ Hyperosmolarity leads to goblet cell, epithelium, and glycocalyx damage

▪ In ADDE there is sensory blockage to lacrimal gland and blink mechanism

▪ Gland infiltration, nerve damage, drugs, refractive surgery, etc

▪ In EDE there is increased evaporation due to MG dysfunction

▪ Poor blinking, rosacea, MG dropout

▪ Ultimately, tissue damage results in local neuronal dysfunction



Tear Film

▪ 2 phase model of tear film

▪ Lipid layer – wax and cholesterol

▪ Muco-aqueous layer – 4 major mucins and 1500+ proteins & peptides

▪ No hallmark changes in lipid layer in DED

Pain & Sensation

▪ Nociceptive pain – results from actual tissue stimuli

▪ Neuropathic pain – due to lesion w/in somatosensory system

▪ Nociceptive pain receptors respond to pain, mechanical, and thermal

▪ Lacrimal secretions regulated by autonomic nervous system

▪ Ocular surface nerves also regulate blinking

▪ DED inflammation & tissue damage impacts innervation!



TFOS DEWS II Report

Iatrogenic Dry Eye

▪ Results from drugs, contact lenses, surgery, etc

▪ Alters neural input -> decreased lacrimal and MG function

Diagnostic methodology

▪ Dry eye questionnaire (DEQ-5) or OSDI

▪ Presence of any 1 of following:

▪ Reduced NITBUT

▪ Elevated hyperosmolarity (>308) or inter-eye delta (>8)

▪ Ocular surface staining – cornea or conjunctival

▪ Secondary evaluation

▪ Tear meniscus height

▪ MG assessment



Management & Therapy

▪ Restore homeostasis of tear film and ocular surface

▪ Step 1

▪ Patient education – environment, medications, diet

▪ Lid hygiene & hot compresses

▪ AT’s

▪ Step 2

▪ PF AT’s

▪ Punctal occlusion or moisture goggles

▪ In office MG therapy (expression, LipiFlow, IPL Therapy

▪ Topical AB-Steroid, topical immunomodulators, oral AB’s

▪ Step 3

▪ Oral secretogagues, autologous serum gtt, bandage lenses

▪ Step

▪ Amniotic membrane, tarsorrhaphy



▪ Establish a treatment hierarchy

All patients

Disease & Medication Modification

Environmental Considerations Uchino, etal JAMA Ophth132(8):2014

Diet & Lifestyle modifications (omega 3’s)

Why omega 3’s and what’s appropriate ?

▪ Gilbard (Opt 2004) – thin meibum & block cytokines (IL 1a&b, Cox-2)

▪ Roncone (Cont Lens Ant Eye 2010 ) - Reduce TNFa in lacrimal gland ->

increased tear production

▪ Wojtowicz (Cornea 2011) – 450mg EPA + 300 mg DHA x 3mth -> 70% of

pts improved Schirmers & fluorophotometry vs 7% controls

▪ Kangari (Ophth 2013) - 360mg EPA & 240 mg DHA x 1 mth ->

Statistically significant improvements in TBUT, OSDI, Schirmers vs

controls



▪ Establish a treatment hierarchy – International Task Force

Grade 1 – Symptoms + TBUT + conjunctival stain

Hot compresses, lid hygiene, & artificial tears and gels

▪ Lacroix (2015) – wet washcloth vs commercial masks – 40*c > 5 minutes

Grade 2 – Above + mild corneal staining

Add short term corticosteroids / Restasis / Lifitigrast

Grade 3 – Above + moderate / severe corneal involvement

Punctal plugs / Topical azithromycin / oral doxycycline

Grade 4- Above and persistent

Moisture goggles qhs

Autologous serum gtt or Platelet Rich Plasma gtt

Amniotic membrane, Bandage lenses or Scleral lenses qd



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John, etal Ophth 2017

▪ Single application of Prokera in severe DED cohort

▪ Improved DED signs, symptoms, and corneal nerve density & function

McDonald ASCRS Meeting May 2017

▪ Dry Eye Amniotic Membrane Study (DREAMS)

▪ Improved DEWS severity level in 88% of patients in 1 week

Morkin & Hamrah Oc Surf 17:2017

▪ Single application of Prokera in 10 eyes with neuropathic corneal pain

▪ 75% improvement in pain scale within 1 week (persisted after removal)

▪ IVCM demonstrated 37% improvement in corneal nerve density



Clinical Case - 63 yof

Ocular History: Long standing successful monovision scl wearer. C/O dryness, blurred vision, and contact lens intolerance. “I think my dryness is due to my medications”

Contact Lens History: Cooper Frequency 55 Torics. ReNu qhs. Replaces q 2 mths.

Systemic History: HTN, hypothyroid, non-smoker’s lung CA.

Medications: Amlodipine, levothroxyine, & Tarceva. NKDA.

Exam: VA OD cc 20/60 & OS cc 20/50

Pupils, motilities, & CVF’s normal OU / IOP’s 14 OU


Clinical Considerations for Complex CasesClinical Case - 63 yof

Refraction: OD - 125-075x180 / +225 = 20/25OS - 200-050x170 / +225 = 20/40

Biomicroscopy: Grade 1 mgd, grade 1 injection, grade 2+ SPK, ACd&q, iris normal, grade 1 NS

Tear Osmolarity 308 mOsm/L OD & 319 mOsm/LTBUT 5s

DFE: Disc, macula, vessels, vitreous, and peripheral retina normal.

Impression: Combined etiology dry eye

Plan: ▪ Environment, hydration, & omega 3s▪ Hot compress qd x 5 minutes▪ Systane Balance PF qid,▪ Lotemax gel bid,▪ Clariti 1-Day toric OD / no lens OS


Clinical Considerations for Complex CasesClinical Case - 63 yof

2 week follow-up:

Ocular History: Compliant with all treatments. Right eye feels much better and is much clearer. Left eye still symptomatic.

VA: OD scl 20/25 (D) & OS sc 20/40 (N)

Biomicroscopy: Grade 1 MGD OU,

trace injection OS > OD,

trace SPK OD & grade 1+ SPK OS,

ac d&q, iris normal, grade 1 NS

Plan:

▪ Hydration and omega 3s

▪ Hot compress qd x 5 minutes

▪ Systane Balance PF qid

▪ Clariti 1-Day toric OD & Clariti 1-Day +025 OS




Questions for consideration …

Just what is Tarceva?

▪ Erlotonib is a kinase inhibitor approved for pancreatic cancer and metastatic non-small cell lung cancer

▪ Inhibits epidermal growth factor receptor activity in cancer cells

▪ Stevens Johnson Syndrome among side effects

▪ Ocular side effects: Reduced tear secretion, ocular surface disease, and corneal edema

What are reasonable adjunct treatments?

▪ Amniotic membrane

▪ Punctal plugs

▪ Cyclosporin or lifitigrast



Case – 68 yof

cc: Red, irritated eyes x 6 months. +fb sensation. +grittiness.

+photophobia. + variable vision. Moderate intensity. No significant

discharge. Oc hx: Pseudophakia OU Amblyopia OS.

Systemic hx: +asthma. +arthritis. +hypothyroid. +Sjogren’s. +depression.

+ seasonal allergies. No recent uri.

Medications: Advair, glucosamine/chondroitin, levothyroxine, & sertraline

qd. Claritin-D prn. NKDA.

Family hx: Father – AMD.

Social hx: No smoking. Minimal alcohol. Medical receptionist.

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Case 68 yof

VA OD +0.75-1.00x 100 / +2.50 = 20/60

OS +0.50-1.25x80 / +2.50 = 20/80-

Externals: Pupils, EOM’s, and CVF’s normal. No adenopathy.

IOPs: 14 OD & 14 OS

DFE: Healthy disc, macula, vasculature, posterior pole. Vitreous floaters.

Biomicroscopy:

▪ Gr 1+ MGD

▪ Gr 2 conj LG stain

▪ Tear meniscus < 0.25mm

▪ TBUT < 5 seconds.

▪ Coalesced SPK, filaments & ABMD

▪ PCIOL



Case 68 yof

Impression:

▪ Aqueous deficient & evaporative dry eye

▪ MGD ou

▪ ABMD ou

▪ Filamentary keratitis ou

Plan:

▪ In office removal of filaments ou

▪ Tobradex ung ou qid

▪ Systane Balance PF ou q2h

▪ Hot compress, hydration, & omega 3s

▪ Follow-up 1 week


Clinical Considerations for Complex CasesCase 68 yof - 1 week f/u

Cc: ‘eyes feel about 50% better.’ Complying with all tx. c/o ung blurring va.

No change in systemic health or meds.

VA: Rx OD 20/30 & OS 20/40-

Biomicroscopy:

Gr 1+ mgd, Gr 1 conjunctival LG staining ou

Tear prism < 0.25mm & TBUT < 5 secs

No filaments, gr 1 exposure keratitis, gr 1 abmd ou

Plan:

▪ Tobradex ung ou qhs x 2 wks then d/c

▪ Hot compress qd, good hydration, & omega 3s

▪ Systane Balance PF qid

▪ Xiidra bid

Not Your Typical Dry Eye Clinical Considerations for Complex Cases

Case 68 yof - 4 week f/u

Cc: ‘eyes feel no better.’ Complying with all tx. c/o blurring va. No change

in systemic health or meds.

Va: Rx – OD 20/30- & OS 20/50-

Biomicroscopy:Gr 1+ mgdGr 1+ conjunctival LG staining Tear prism < 0.25 mm & TBUT < 5 secGr1 abmd ou … with recurrence of corneal filaments osGr 1 exposure keratitis ou


Case 68 yof – 4 week f/u

Impression:

▪ MGD ou

▪ Aqueous deficient and evaporative dry eye ou

▪ abmd ou

▪ Filamentary keratitis ou

Plan:

▪ Continue hydration, omega 3s, and hot compresses qd

▪ Parasol punctal plug LL ou

▪ Systane Balance PF q2h

▪ Xiidra bid

▪ BioTrue daily disposable OS prn


Case 68 yof – Questions for consideration

Would have upper lid punctal occlusion been a better option?▪ Doane Ophth 98(8):1981 - Upper lid occusion slows “Krehbiel flow”

Would you consider ultimately tapering Xiidra?

▪ Donnenfeld & Perry Rev Oph 8:2003

How much omega 3’s are necessary?

▪ 500mg EPA+DHA up to 4,000mg EPA+DHA (Lovaza qid)

Would FreshKote be a reasonable option ?

▪ High osmotic pressure

▪ Amisol, lacrophillic aqueous, mucomimetic components

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Ocular History:

Previously wore soft contact lenses, but d/c due to dryness

Referred by corneal specialist

Has tried Optive, Systane, & TheraTears

Has tried Pred Forte & Alrex

Current eye gtt: Patanol ou bid, Restasis ou bid.

Cc: ‘I get eye hemorrhages monthly.’ I’d like to get back into wearing contact lenses if possible’.

Systemic History: +Anxiety. (-) Thyroid. (-) Arthritis.

(-) Blood dyscrasias / hematology work-up.

Medications: Fluoxetine qd, Fish oil qd.




VA: OD Rx 20/20- & OS Rx 20/20.

Externals: (+) malar flush

Biomicroscopy:Grade 3 mgd ouGrade 2 conjunctival chalasis ouGrade 1 conjunctival LG stain ouCornea clear with TBUT < 10 sec ouTear prism <0.5mm ou

Impression:▪ MGD ou▪ Keratoconjunctivitis sicca ou▪ Rosacea (ocular)▪ Subconjunctival hemorrhage ou

(Menstrual related ?)




Plan:

▪ Spoke with ob-gyn – r/o causes for menorrhagia

▪ Spoke with pcp – doxycycline 50 mg qd

▪ Hot compresses with digital massage ou bid

▪ Nordic Naturals ProOmega – 2 softgels po qd

▪ Lotemax ou bid

▪ Patanol ou qam

▪ Restasis ou bid

▪ F/u 1 month

1 month f/u

Doing much better.

Plan: 1) D/C Lotemax 2) Continue all other tx 3) f/u 2 months


Clinical Case - 44 yof 3 month

CC: ‘doing great, no hemorrhages in 2 months.’ VA: OD Rx 20/20 & OS Rx 20/20.

Biomicroscopy: Gr 1 mgdGr 1 conjunctival chalasis w/o LG stain ouCornea clear with TBUT ~ 10 sec ou

Plan:▪ Continue hot compress ou qd▪ Continue Restasis ou bid & Patanol ou prn▪ Continue ProOmega qd▪ Doxycycline 50 mg qod x 1 mth, then d/c▪ BioTrue Daily Disposable




Questions for consideration ….

Is conjunctivoplasty indicated in symptomatic LIPCOF ?Acera, etal Invest Ophth Vis Sci 54(13):2013N = 12 eyes conjunctival resection for conjunctivochalasisImproved pro-MMP-9 levels led to less epithelial defects, epiphora, and symptoms

Yamamoto, etal Eye Cont Lens Aug 12, 2015 (epub)N = 362 pts: CCh + visually demanding tasks = 3+ SCHN = 38 pts conjunctivochalasis (CCh) surgery for SCH80+% no SCH recurrence after surgery

If the ‘menstrual cycle’ subconjunctival hemorrhages return, is a low dose oral contraceptive indicated ?

Dua, etal Ophth Plast Reconstr Surg 30(2):2014Case of ‘vicarious orbital menstruation’ responds favorablyto oral contraceptives


Clinical Case - 36 yom

▪ Ocular History: Myopia & Astigmatism OU.

Contact lens intolerance secondary to DED.

▪ Systemic History: (+) Depression (+) Anxiety (+) Allergies.

▪ Current Medications: Xanax qd. Claritin prn. NKDA.

▪ Family History: AMD – aunt. POAG – grandmother.

▪ Surgical History: Bilateral advanced surface ablation (PRK).

▪ Chief complaint: Dryness & asthenopia.

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Clinical case – 36 yom

▪ Unaided VA: OD 20/40 OS 20/70

▪ Externals: Pupils, EOM’s, and CVF’s normal OU

▪ IOP: 15 OU

▪ DFE: Normal posterior pole OU

Biomicroscopy:

▪ Grade 1+ Blepharitis & MGD

▪ Weak tear prism OU

▪ TBUT 5-7 s

▪ Arcuate haze OD

▪ Central haze OS


Clinical Case – 36 yom

Pre-operative Rx

OD -7.50 -0.50 x 165 = 20/15

OS -7.00 -0.75 x 180 = 20/15

Postoperative Rx

OD +1.50 -1.25 x 21 = 20/20=

OS -1.25 -1.00 x 142 = 20/20-

Keratometry

OD 37.78 x 39.32 D

OS 39.87 x 40.95 D


Clinical Case – 36 yom

Treatment:

▪ Hydration, reduced caffeine, and omega 3’s

▪ Hot compress and eyelid hygiene qd

▪ Blink gtt tid & gel qhs

▪ Bilateral lower lid punctal plugs

Contact Lenses:

▪ OD B&L PureVision 2 8.9 +1.50 -1.25 x 20 = 20/25+

▪ OS B&L PureVision 2 8.9 -1.25 -0.75 x 140 = 20/25+

▪ Clear Care qhs

▪ Wears contact lenses ~ 5 days per week.

▪ Uses Pataday prn for overlying ocular allergy symptoms.


Clinical Case: 36 yom

Questions for consideration ….

Is there a relationship between depression and dry eye ?▪ vanderVart, etal AJO 159(3):2015▪ 7,200 DED, 20,000 anxiety, and 30,100 depression▪ Adjusted odds ratio of 2.8 DED/anxiety and 2.9 DED/depression

Does vitamin C play a role in mitigating post PRK haze?▪ Stojanovic, etal J Ref Surg 19(3):2003▪ 500 mg bid x 1 mth -> significantly lessens haze (n=500 eyes)

Would ‘mini-PRK’ have been a better surgical option ?▪ Mini- PRK (Scott MacRae, MD URMC Flaum Eye Institute)

▪ 7 mm vs 8.5 mm = 34% reduction in epithelial defect size

▪ Bandage lens Rx -1.00 D Rx for 1-2 weeks

What is our game plan going forward?▪ Leccisotti J Cat Ref Surg 35(4):2008.▪ Mitomycin C improved H-PRK haze, predictability, and efficacy


Case - 56 yof

Cc: c/o extreme dry eye and diplopia ou. Hx of MVA with bilateral 7th CN

‘crush’ injury. Bell’s palsy -> corneal ulceration -> tarsorraphy -> punctal

cauterization Meds: saline gtt ou q15 minutes, bland ung ou qhs, Pred

Forte ou bid.

Systemic hx: Osteopenia. Boniva q1mth. NKDA.

Family Hx: non-contributory.

Social Hx: No nicotine. No alcohol. Office administration.


Case – 56 yof

VA: OD +3.25 - 2.00 x 4 = 20/100

OS +1.50 – 3.50 x 120 = 20/400.

Externals: Perrla (no apd), EOM – constant OS 20pd et, cvf – full ou.

IOP’s: 15 OD & 14 OS goldmann @ 10 am.

DFE: Healthy posterior pole OU.

Biomicroscopy:

Grade 1 MGD and lower lid punctal cautery OU

Stromal scarring with neovascularization OU

Incipient cataract OS > OD

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Case – 56 yof

Impression:

▪ Mild MGD OU

▪ Neurotrophic dry eye OU

▪ Corneal neovascularization & scar OU

▪ Esotropia OS

▪ Incipient cataract OS > OD

Plan:

▪ Continue with sterile saline OU prn

▪ Hot compress OU qd

▪ Pataday ou qam & Alrex OU qhs


Case - 56 yof – 2 week f/u

OD SynergEyes Duette 7.80 14.5 -1.50 MED

Central, acceptable movement,

VA cc Rx = 20/20-

OS Clariti 1-Day 8.6 +4.00

Central, optimal movement,

VA = < 20/400

Plan:

▪ Initiate contact lens wear

▪ ClearCare qhs & SE saline qam

▪ Pataday OU qam & Alrex OU qhs

▪ Sterile saline gtt OU prn


Case – 56 yof – Questions for consideration

Is cyclosporine or Lifitigrast indicated here?

▪ Neurotrophic vs inflammatory

Are there other options for neuroparalytic keratitis ?

▪ Turkoglu, etal Semin Ophthal 29(3):2014

▪ Both autologous serum and amniotic membrane effective for acute care

▪ Amniotic membrane slightly better in deep stromal ulcers

Would a scleral lens be a better option (given extensive neo)?

▪ Compan, etal IOVS 55(10):2014

▪ DK > 120 + Thk <200u + Vault < 150u = No edema!


Flaum Eye Institute / URMedicine

Rochester, NY

[email protected]

[email protected]

Thank you for attending!

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6/2/2019 - coavision.org Symposium... · 6/2/2019 3 Not Your Typical Dry Eye Clinical Considerations for Complex Cases John, etal Ophth 2017 Single application of Prokera in severe