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Het (droge) oog: OTC druppel of verwijzing naar de (oog)arts?
Just sit down and relax…
Het oog
• The story of the patient (or family…)
• The spot diagnosis bythe pharmacist(check other drugs; know your client)
Different symptoms and degree of ilness…
titel 4 14-6-2017
Oogleden
Stand/sluiting
Ectropion Entropion
Stand/sluiting
lagoftalmie Ptosis
Chalazion Zona Ophtalmica
Xanthelasmata (goedaardig)
Tumoren
• Basocellulair epithelioma = kwaadaardig
Conjunctiva
• Degeneratieve afwijkingen
– Pingueculum
– Pterygium
Het rode oog: subconjunctivale bloeding
conjunctivitis
bacterieel viraal
(Epi)scleritis
banaal ernstig!hardnekkig opname!
Cornea
Ontstekingen cornea
Keratitis Ulcus
Trauma: cornea erosie
• Oorzaken:– Vingernagel– Tak– Plant– Papier
• Klacht:– Pijn ++– Epifora– lichtschuw
Oogverband
Trauma: corpus alienum
iritis/cyclitis
• Klacht: – « diepe » pijn– Tranenvloed– Lichtschuw– Wazig zicht
• Inspectie:– Pericorneale roodheid– Nauwe pupil– Descemet stippen– hypopyon
Anisocorie• Groter in het licht?
=probleem sphincter
• Groter in het donker?=probleem dilatator
Oorzaken anisocorie
• Druppels (verlammen sphincter en/of stimuleren dilatator)
• Ontsteking iris of cornea (miosis)• Traumatisch (sphincter)• Acuut glaucoma (mydriasis)• Neurologisch (corneareflex?)• Corectopie (trauma, HK, verkleving)• Planten! (trompetkelk; datura)
Corectopie
De oogdruk
Klassificatie glaucoom
• a. Chronisch open hoek glaucoma• b. Acuut gesloten hoek glaucoma• c. Infantiel glaucoom• d. Secundair glaucoom
Chronisch open hoek glaucoma
Chronisch open hoek glaucoma
• Klacht: geen « tot het te laat is »: scotomen
• Familiaal• Behandeling:
– 1. oogdruppels: productie, afvoer kamerwater
– 2. lasertherapie– 3. operatie
– …at vitam eternam….
Acuut gesloten hoek glaucoma
• Klacht:– Acuut– Hevige hoofdpijn– Braken– Rood oog– Grote onregelmatig pupil– Wazig zicht (oedeem cornea)
• Behandeling:– Druppels– Vochtafdrijvers:
diamox/mannitol– Laser iridotomie– Operatie (trabeculectomie)
Cataract
Cataract: behandeling
Cataract: Klachten
• Vooral last om VER te kijken• Minder last bij het lezen• “Veraf beter zonder bril”• Sneller verblind als de zon laag staat• Trage evolutie (maanden)
Glasvocht
Glasvochtloslating• Plotse floaters• Flitsen
• Complicatie:– Retinascheuren– Retinaloslating
II: Afwijkingen van de bloedvaten• a: Vaatsclerose• b: Diabetische
retinopathie• c: hypertensieve
retinopathie• d: occlusie a.centralis
retinae• e: occlusie v.centralis
retinae• f: « alle » andere
systeemziekten
diabetische retinopathie
hypertensieve retinopathie
• In fundo:– Vernauwing arteriolen– Overkruisingstekens– Vaatsclerose
– Bloedingen– Exsudaten– papiloedeem
Ziekten van de gele vlekRisicofactoren:
1. leeftijd2. familiaal / genetisch3. diabetes4. slechte voeding (cholesterol,…)5. UV 6. cardiovasculair + roken!
2 vormen:1. Droge vorm2. Natte vorm
Droge vorm van SMD
• Pathologie:– Afzetting van « drusen » (=
vetophoping) onder het pigmentepitheel
• Klacht:– Metamorfopsie (Amsler)– Last voor dichtbij
• Behandeling:– Voedingssupplement– Preventie!
Natte vorm van SMD• Pathologie:
– Loslating pigmentepitheel– Nieuwvatvorming– Exsudatie + Bloeding– Verlittekening macula
• Klacht:– metamorfopsie– Centrale vlek
• Behandeling:– Lasertherapie– Fotodynamische therapie– Intravitreale inspuitingen– chirurgie
Nervus opticus
papiloedeem• Zwelling van de
oogzenuwkop• Oorzaken:
– ICH– Papillitis– Compressie oogzenuw– Hypertensie– AION
Automatische perimetrie (statisch)
Het droge oog
Niet elk droog oog is hetzelfde
International dry eye workshop (DEWS) definition of DED
International Dry Eye Workshop. Ocul Surf 2007;5:75–92.
Dry eye is a multifactorial disease ofthe tears and ocular surface thatresults in symptoms of discomfort,visual disturbance and tear filminstability with potential damage tothe ocular surface. It is accompaniedby increased osmolarity of the tear filmand inflammation of the ocular surface
Prevalence
• About 15% of peopleover 50 years
• 370 million of patients worldwide suffering from DED
From irritation to blindness
DEWS describes two major types of DED
Adapted from International Dry Eye Workshop. Ocul Surf 2007;5:75–92.
Dry eye disease
Excess evaporation in the presence of
normal lacrimalsecretory function
Reduced lacrimal tear secretion
and tear volume
Aqueous deficiency Evaporative
The ocular surface
Kanski & Bowling. Clinical Ophthalmology, 7th edn. Elsevier, 2011.Figure adapted from Gipson. IOVS 2007;48:4391–8Image is for illustrative purposes only.
Epithelium
Tear film
Meibomian gland
Main lacrimal gland
Accessory lacrimal gland
Glycocalyx
Goblet cells
Pre-ocular tear film
Lacrimal glands
Meibomian glands
EpitheliumAqueous layer
7-8 μm Lipid layer
0.1 μm Mucine layer
0.8 μm
Meibomian gland dysfunction
• Associated with dermatoses such as acne rosacea, seborrhoeic dermatitis and atopic dermatitis1
• Diagnosis based on morphological features2
– Acini and duct orifices, – Presence of orifice plugging,– Thickening or absence of expressed meibum_ Irregular lid margin
Clinical features of MGD
1. Tomlinson et al. MGD Workshop. IOVS 2011;52:2006–49.2. International Dry Eye Workshop. Ocul Surf 2007;5:75–92.
Photographs courtesy of Professor P Aragona
The healthy tear film
Water evaporation from tears is normally ~33% of the total tear flow1
1. Rolando et al. Br J Ophthalmol 2009;94(Suppl. 1):i1–9.Image is for illustrative purposes only.
Lipid layer
Aqueous/ mucin layer
Epithelial cells
In DED, the tear film and ocular surface are damaged
Water evaporation is now ~75% of the total tear flow1
Compromised tear film• Lipid layer
defective• Cells dehydrated• Osmotic balance
disrupted
Lipid layer
Aqueous/ mucin layer
Epithelial cells
1. Rolando et al. Br J Ophthalmol 2009;94(Suppl. 1):i1–9.Image is for illustrative purposes only.
Evaporation of the aqueous layer may lead to hyperosmolarity
Aqueous layer
Lipid layer
Mucin layer
Conjunctival cells
Compatible solutes
Evaporation Evaporation
Water
Apoptosis
WaterHyperosmolarity
Image is for illustrative purposes only.
Cellular response to hyperosmolarity
Exposure to hypertonic environment
Water loss
Regulatory volume increase
Uptake of inorganic solutes
Decreased cell function, stress
activation
Normal cell
Adapted from Strange et al. Adv Physiol Educ 2004;28:155–9.
Dehydratedcell
Restoredcell volume
Hyperosmolarity
Cell damageand death
In DED, quantity of water in tear film is decreased, due to either increased evaporation or insufficient water production
Image is for illustrative purposes only.
Fuorescein staining
Severity Level 1 2 3 4
Treatment
• Patient education• Environmental and
dietary modifications
• Eliminate offending systemic medications
• Artificial tear substitutes, gels/ointments
• Eyelid therapy
• Anti-inflammatories• Oral tetracyclines• Punctal plugs• Secretagogues• Moisture chamber
spectacles
• Serum• Contact lenses• Permanent punctal
occlusion
• Systemic anti-inflammatory therapy
• Surgery (lid surgery, tarsorrhaphy; mucus membrane, salivary gland, amniotic membrane transplantation)
If no improvement, add level-2 treatments
If no improvement, add level-1 and -3 treatments
If no improvement, add level 4 treatments
1. Management and Therapy Subcommittee. Ocul Surf. 2007.
Dry Eye WorkShop (DEWS) Treatment Guidelines1
Artificial Tears are a widely recognized First-Line Treatment
The ideal drop….• Protects cells of
cornea and conjunctiva
• Improves mucin layer• Adds volume• Limits evaporation• Feels good• Limited instillations• Easy instillation• Non toxic
The ideal artificial tear• Protects cells of
cornea andconjunctiva
• Improves mucin layer• Adds volume• Limits evaporation• Feels good• Limited instillations• Easy instillation• Non toxic
• Osmoprotectants
• mucine (like) substance
• lipids• Not too viscous, shear
thinning
• preservatives!
• Many products contain a single osmoprotectant but…
Osmoprotectants are thought to be most effective when several are combined into one formulation
No Treatment PURITE® Benzalkonium chloride
PolyquadSodium perborate
Preservatives…or not?6
Transplantation of labial salivary glands
• Subtarsal incision of conjunctiva
• Dissection+Recession of conjunctiva
• Suturing the graft with two submucosal running Prolene sutures entering the skin nasally and leaving it temporally
1 day and 2 weeks postop
How do they help?
- via direct secretion of “tears” or essential tear components (mucins,…)??
- via secretion of molecules that stimulate the lacrimal gland, the goblet cells of cornea and conjunctiva (TFF, Lacritin,…)??
Mass Spec
• Quadrupole Orbitrap(ThermoFischerQ Exactive PlusTM)
• Thousands (!) of proteinspecies detected
• Much more sensitiveanalysis of small and lessabundant proteins
The smile of a tear by Joan Miró
Dank!