16. DED Management & Therapy II Flashcards
What are step two treatments for dry eye treatment?
Addition to ...
General
* ...
* ...
* ...
Aqueous deficient
* ...
* ...
* ...
Evaporative
* ...
* ...
* ...
* ...
* ...
What are step two treatments for dry eye treatment?
Addition to step one
General
* moisture chamber spectacles/goggles
* ointments
* topical anti-inflammatories
Aqueous deficient
* aqueous-based lubricant drops, non-preserved
* punctal occlusion
* prescription medications
Evaporative
* lipid-based lubricant drops, non-preserved
* Demodex treatment
* in-office, physical heating and expression of meibomian glands
* in-office intense pulsed light therapy
* prescription medications
Ointments
Contain ..., ..., and .... Can help with ....
Instructions for patients (for ... use):
1. ...
2. ...
3. ..., making sure to ...
4. ...
5. ...
6. ...
Ointments
Contain white or yellow soft paraffin, liquid paraffin, and wool fats. Can help with mucin release.
Instructions for patients (for bedtime use):
1. Wash hands before use
2. Pull lower lid down to form a pocket
3. Squeeze a thin line of ointment along lower lid, making sure to avoid contact with the tube and eye
4. hold eye closed for 30secs
5. blink slowly to spread ointment around
6. repeat on other eye if necessary
Topical anti-inflammatories
Help as cornea .... These drugs are ... and are meant for ... use.
Topical anti-inflammatories
Help as cornea starts to get inflammed. These drugs are corticosteroids and are meant for short-term use.
Cyclosporin (topical anti-biotic) (1)
Found in Restasis (not available in Aus) and Cequa.
Restasis
* Cyclosporin A 0.05% emulsion
* Acts on ... in the ..., ..., and ...
Cequa
* Indicated for ...
* Dose: ...
Cyclosporin (topical anti-biotic) (1)
Found in Restasis (not available in Aus) and Cequa.
Restasis
* Cyclosporin A 0.05% emulsion
* Acts on T-cells in the tears, conjunctiva, and cornea
Cequa
* Indicated for moderate-to-severe DED
* Dose: one drop, twice daily
Cyclosporin (topical anti-biotic) (2)
Precautions:
Shouldn’t be used in patients with: ..., ..., or ...
Use with care in patients with ..., ..., or .... Need to wait before ... to avoid ....
Adverse effects:
* ... and ... is common
* ..., ..., ..., ... are less common
Cyclosporin (topical anti-biotic) (2)
Precautions:
Shouldn’t be used in patients with: active or suspected ocular/periocular infection, ocular/periocular pre/malignant conditions, or children <18years
Use with care in patients with potential for eye injury, infections, or contact lens wear. Need to wait before inserting contacts to avoid absorption and toxicity.
Adverse effects:
* pain on installation and conjunctival hyperaemia is common
* blepharitis, eye irritation, headache, UTI are less common
Lifitegrast (topical anti-inflammatory) (1)
Found in Xiidra (Lifitegrast 0.5% solution)
It is an ... receptor antagonist which inhibits ... by blocking .... Overall, decreases .... Dose: ...
Lifitegrast (topical anti-inflammatory) (1)
Found in Xiidra (Lifitegrast 0.5% solution)
It is an integrin receptor antagonist which inhibits T cell-mediated inflammation by blocking binding of two cells surface proteins. Overall, decreases inflammatory response on ocular surface. Dose: 1 drop, twice daily
Lifitegrast (topical anti-inflammatory) (2)
Precautions:
* Safety and efficacy have not been established in ...
* No information in ...
* ..., need to wait before ... to avoid ....
Adverse reactions:
* ..., ..., ..., ... are common
* ..., ..., ..., ..., ..., ..., and ... are less common
Lifitegrast (topical anti-inflammatory) (2)
Precautions:
* Safety and efficacy have not been established in individuals <17years
* No information in pregnant women
* contact lens wear, need to wait before inserting contacts to avoid absorption and toxicity.
Adverse reactions:
* eye irritation, discomfort, blurred vision on installation, unusual taste sensation are common
* blurred vision, conjunctival hyperaemia, headache, increase lacrimination, discharge, puritis, and sinusitis are less common
Punctal occlusion
They ... tear drainage and can be located at ... or ....
They are used in the management of ....
There are two types of plugs:
* .../... - ...
* ...
Punctal occlusion
They physically block tear drainage and can be located at level of punctal opening or deeper in canaliculus.
They are used in the management of aqueous dry eye disease.
There are two types of plugs:
* absorbable/temporary - used to determine efficacy of occlusion prior to permanent occlusion
* non-absorbable
Punctal occlusion: types of plugs
Collagen (diagnostic)
* Last ...-... days
* Can be used in ...
* Come in different ... (...mm and ...mm)
* Come in different ... (...-...mm)
* Have to ... to ...
* ... and ... not essential
* Patient should report ... then ...
Silicone plugs (therapeutic)
* ...
* Can be used in ...
* Come in different ... (...mm, ...mm, and ...mm)
* Come in different ... (...-...mm)
* ... and ... are useful
Punctal occlusion: types of plugs
Collagen (diagnostic)
* Last 7-10 days
* Can be used in either puncta
* Come in different lengths (2mm and 1.6mm)
* Come in different widths (0.2-0.6mm)
* Have to lavage to determine patency initially
* measurement and punctal dilation not essential
* Patient should report initial improvement then worsening of symptoms
Silicone plugs (therapeutic)
* more permanent
* Can be used in either puncta
* Come in different lengths (1.3mm, 1.6mm, and 1.8mm)
* Come in different widths (0.5-0.8mm)
* measurement and punctal dilation are useful
What are the potential complications for punctal plugs?
...-
...due to over-dilation -
...in the canthus - Abrasion of
...or... -
...: due to...due to...or... -
...during insertion or removal -
...of plug that... -
...or...
What are the potential complications for punctal plugs?
spontaneous plug extrusion, up to 60%-
rupture of punctumdue to over-dilation -
discomfortin the canthus - Abrasion of
conjunctivaorcornea -
epiphora: due tohypersecretiondue toforeign body sensationorinsufficient drainage -
breakage of plugduring insertion or removal -
distal migrationof plug thatrequires surgical removal -
canaliculitisordacryocystitis
What are step three treatments for dry eye treatment?
Addition to steps 1+2
General
* ...
Aqueous-deficient
* ...
* ...
What are step three treatments for dry eye treatment?
Addition to steps 1+2
General
* therapeutic contact lenses
Aqueous-deficient
* oral secretagogues
* autologous/allogenic serum eyedrops
Oral secretagogues
Used to treat ...-associated dry eye disease
Two types of ...: ... and ....
General effects:
* Efficacy appears great in the treatment of ... compared to ...
* Potential ocular benefits: ..., ..., and ...
Side effects..., ..., ..., ...; worse with ....
Oral secretagogues
Used to treat severe Sjogren-associated dry eye disease
Two types of cholinergic agonists: pilocarpine and cevimeline.
General effects:
* Efficacy appears great in the treatment of oral dryness compared to ocular dryness
* Potential ocular benefits: reduced dry eye, decreased ocular surface staining, and increased tear production?
Side effectsExcessive sweating, headaches, nausea, abdominal report; worse with pilocarpine.
Serum eye drops: autologous (px’s own blood)
- Serum has these factors that are very similar to tears:
...,...,...,... - Inhibits the
... - Supports
...and...of epithelial cells - Evidence says
...in management of severe dry eye (...) - Shelf-life of
...week and up to...months if frozen -
...free
Serum eye drops: autologous (px’s own blood)
- Serum has these factors that are very similar to tears:
pH,nutrient content,growth factors,fibronectin - Inhibits the
release of inflammatory cytokines - Supports
proliferationandmigrationof epithelial cells - Evidence says
may assistin management of severe dry eye (ocular surface disease secondary to dry eye) - Shelf-life of
1week and up to6months if frozen -
Preservativefree
Serum eye drops: allogenic (blood donor’s blood)
- Designed in response to
... - Concerns still exist in allogenic sources due to
... - Donations are tested for
...such as...and... - Similar risks and outcomes to autologous serum
Serum eye drops: allogenic (blood donor’s blood)
- Designed in response to
concerns about using patient's own blood if they have active systemic inflammation - Concerns still exist in allogenic sources due to
theoretical risk of an immune response to foreign antigens - Donations are tested for
major blood borne virusessuch asHIVandHepatitis B+C - Similar risks and outcomes to autologous serum
Therapeutic contact lenses
Used on ....
The risks of ... need to be carefully balanced against potential benefits.
Therapeutic contact lenses
Used on extended wear basis.
The risks of microbial keratitis need to be carefully balanced against potential benefits.
Soft contact lenses (bandage contact lenses)
* Main purpose is to ... and to reduce the effects of ... on the ocular surface
* They are ... lenses
* They may ... and assist with ...
* They may aid in management of .. by ...
Soft contact lenses (bandage contact lenses)
* Main purpose is to improve eye comfort and to reduce the effects of external environment on the ocular surface
* They are high oxygen permeability lenses
* They may stabilise tear film and assist with restoration of epithelial turnover
* They may aid in management of corneal pain by `insulating sensitised corneal nerves
Rigid contact lenses (scleral contact lenses)
* Large lenses that ... with a ... and ...
* Use has been investigated in ... and ...
Rigid contact lenses (scleral contact lenses)
* Large lenses that vault the cornea with a liquid reservoir and land on the conjunctiva/sclera
* Use has been investigated in Graft-Versus-Host-Disease and Stevens-Johnson Syndrome
What are the step 4 treatments for dry eye disease?
Addition to ...
General......
Aqueous-deficient...
What are the step 4 treatments for dry eye disease?
Addition to steps 1-3
GeneralTopical corticosteroids for longer durationsOther surgical approaches
Aqueous-deficientSurgical punctal occlusion
Amniotic membrane grafts
Dry eye often develops secondary to other ocular surface conditions and can lead to ..., ..., and ....
Made from amniotic membrane/amnion which is the .... Has ... and ... properties and contains a wide variety of ... and ....
Amniotic membrane grafts
Dry eye often develops secondary to other ocular surface conditions and can lead to epithelial defects, corneal ulceration, and scarring.
Made from amniotic membrane/amnion which is the innermost layer of the placenta. Has anti-inflammatory and anti-fibrotic properties and contains a wide variety of neuropeptides and neurotransmitters.
Amniotic membrane grafts, proposed mechanism of action
Basement membrane is similar in ... to the .... Supports ... cells, ... cells, and ... cells. Promotes ... and ... cell differentiation excluding inflammatory cells and their protease activities. Stromal face of amniotic membrane suppresses ... of ... to reduce ....
Amniotic membrane grafts, proposed mechanism of action
Basement membrane is similar in composition to the conjunctiva. Supports epithelial cells, limbal stem cells, and corneal transient amplifying cells. Promotes goblet and non-goblet cell differentiation excluding inflammatory cells and their protease activities. Stromal face of amniotic membrane suppresses myofibroblast differentiation of normal fibroblasts to reduce scar and vascular formation.
Amniotic membrane grafts, types
Hydration state: ... or ...
Application method:
* Sutured with ... or ...
Amniotic membrane grafts, types
Hydration state: cryo-preserved or dehydration
Application method:
* Sutured with dissolving or non-dissolving sutures
Amniotic membrane grafts
Uses:
* ... in the case of ...
* Assists with ... the ...
* As a ... for ...
Considerations:
Ocular:
* ... can be poor and possibly have .... No ....
* Systemic: ... so ...
Potential complications:
* ... induced by ...
* ... from underneath bandage CL
Amniotic membrane grafts
Uses:
* promote healing in the case of persistent epithelial defects
* Assists with reconstructing the ocular surface
* As a graft for ocular surface melts
Considerations:
Ocular:
* Comfort can be poor and possibly have blurred vision. No eye rubbing.
* Systemic: allogenic tissue so implicit risk of infectious disease transmission
Potential complications:
* Corneal abrasion induced by placement
* Ejection of membrane from underneath bandage CL
Surgical punctal occlusion
This is the ... of puctum in patients who are unable to ... or ... punctal plugs
Wide variety of methods exist:
* ...
* ...
* ...
* ...
* ...
Complications are fewer with ..., but main complication is ....
Surgical punctal occlusion
This is the permanent closure of puctum in patients who are unable to retain or tolerate punctal plugs
Wide variety of methods exist:
* total or partial thermal cauterisation
* occlusion with conjunctival flap or graft
* punctal plug suturing
* total destruction of canaliculus
* canalicular ligation
Complications are fewer with cauterisation, but main complication is epiphora.
Other surgical approaches
Tarsorrhaphy
* Temporary or permanent procedure where eyelids are ...
* Mainly performed in cases of ... in ...
* Aim is to reduce ...
Salivary gland transplantation
* Aims to provide some ... to a ...
* Transplanted into ...
* Intends to provide a level of ... and ... that would typically exist in tears
Other surgical approaches
Tarsorrhaphy
* Temporary or permanent procedure where eyelids are partially or totally closed using sutures
* Mainly performed in cases of persistent epithelial defects in highly severe dry eye
* Aim is to reduce ocular surface dessication
Salivary gland transplantation
* Aims to provide some functioning exocrine tissue to a highly severe dry eye
* Transplanted into sub-conjunctival space
* Intends to provide a level of lubrication and epitheliotrophic factors that would typically exist in tears
