Dry Eye and Blepharitis Flashcards
What Dietary Changes to make in Dry Eye Disease?
- Omega 3 and 6 shown to have anti-inflammatory effects
- Omega 3 obtained through vegetables, nuts, cereals, poultry
- Omega 6 obtained through fish
When to Have Caution Before Commencing Supplementation?
- Liver disease
- Atrial fibrillation
- Bleeding disorders
Environmental Modifications to make in Dry Eye
- Reduce air con exposure
- Reduce cigarette smoke exposure
- Wrap around glasses
- Lower VDU height
- Reduce VDU time to increase blink rate
What is Carbomer 980?
- 1st line tear supplement
- Gel (so harder to instil)
- Commonly 0.2% concentration
- Can be generic carbomer, viscotears or clinics gel
What is Hypromellose?
- 1st line tear supplement
- Watery drop (so poorer retention time)
- Concentration 0.2-0.8% (commonly 0.3%)
- Xialin Hydrate
What is Polyvinyl Alcohol?
- 1st line tear supplement
- Not on many formularies (on Lothian)
- Concentration 1.4%
- Liquifilm tears
What is Carmellose Sodium?
- 2nd line tear supplement
- Can promote epithelial healing
- Celluvisc 1.0% or Xailin Fresh 0.5%
What is Sodium Hyaluronate?
- 2nd line tear supplement
- Is a tissue lubricant used naturally in the body
- Hylo-forte/Hycosan
What is HP Guar?
- 2nd line tear supplement
- Dispensed at drop but becomes more viscous upon contact with ocular surface
- Systane Balance
How to Use Ointments
- Protects cornea overnight to prevent recurrent erosions
- Used at night as it blurs vision
- Squeeze out 1cm, apply to lower lid, blink and then sleep
Drops for Mucus Dry Eye
- Aceytylcysteine 5% and hypromellose 35%
- Stings upon instillation
- 1 or 2 drops on affected eye 4x daily
When to Issue Tear Supplements
- Can be sign or symptom driven
- Be wary of corneal desensitisation
- Remember ointment for night time usage
Tear Supplement Dosage
- 3-4x daily is maintenance dose
- Can be increased to as required if unpreserved
- With severe staining use every 1-2 hrs until staining under control then reduce to maintenance dose
Punctal Plugs in Dry Eye Management
- Improves tear retention by preventing drainage
- Risks include infection, migration, loss and epiphora
- Contraindications are EDE, CL wear (infection) and blepharitis
Contact Lenses in Dry Eye Management
- RGP or low water content SCLs
- Only tried in sever dry eye when other options have failed
- Risk of infection and neovascularisation
When to Refer Dry Eye
- Normally no referral
- Refer routinely if adequate trial of treatment fails
- Refer if complications e.g neovascularisation, infection
- Refer suspect Sjogrens to GP
Hot Compresses and Lid Cleaning for Blepharitis
- 40-45 degrees
- Temperature maintained over 5-7 minutes
- Cleaning can be done with commercial wipes, baby shampoo, bicarbonate of soda, cooled boiled water or in shower.
- Focus on cleaning at base of lashes
What is BlephEx?
- In office cleaning procedure repeated 6 monthly
- Achieves good baselines hygiene level, patient still needs to continue with lid hygiene
- Involves rotating spong through lash margin
- Not painful
Demodex Treatment
- Doesn’t respond to lid hygiene
- Weekly in office 50% tea tree oil treatment where eyes must be kept closed throughout
- Specialist wipes at home made up of tea tree oil, patient must keep eyes closed for 30s afterwards to avoid toxicity, use morning and night for 6 weeks.
Steroid Use for Dry Eye Management
- Use non-penetrating steroid e.g. Loteprednol, fluromethalone or Predsol
- QID for 1 week and then taper over next 3 weeks
Steroid Tapering in Dry Eye Management
- 4x daily for 1 week
- 3x daily for 1 week
- 2x daily for 1 week
- 1x daily for 1 week
- Stop
Steroid Contraindications
- Infection
- Glaucoma
- No CL wear at instillation (can be worn 15-30 mins after)
- Caution in pregnancy and breastfeeding
Steroid Side Effects
- Raised IOP (Steroid glaucoma)
- PSCC
- Scleral/corneal thinning
- Headaches
- Secondary infection
How to monitor IOP in Steroid Use
- On day before commencing (baseline) then 2 days after then at 1 week
- Weekly monitoring likely wise in dry eye patients
Cyclosporin in Dry Eye Management
- Immunomodulatory drug with anti-inflammatory properties
- Initiated by ophthalmologists
- Ikervis 0.1% concentration
- 1x daily dosage
- Stings upon insitllation
Chloramphenicol in Blepharitis Management
- Entry Level
- Not default option, mostly indicated around surgery to clean up
- 1% ointment rubbed into lid margin bd for 1 week
- Patient must also continue with lid hygiene
Azithromycin in Blepharitis Management
- IP level and off label use
- Has mild anti-inflammatory properties
- Azithromycin 1.5%
- bd for 3 days (same as bacterial conjunctivitis)
When to Use Systemic Tetracyclines in Blepharitis Management
- 2nd line management
- Chronic cases that haven’t responded to treatment
- When there is associated rosacea (co-manage with GP)
Systemic Tetracycline Dosage
Doxycycline
-100mg bd for 2 weeks
-100mg 1x daily for 10 weeks
- OR modified release for at least 5 months
Minocycline
- 50mg 1x daily for 2 weeks
- 100mg 1x daily for 10 weeks
Systemic Tetracycline Contraindications
- Hypersensitivity to any drug in the family
- Less than 12 years of age
- Pregnancy and breastfeeding
- Kidney or liver impairment
- Systemic lupus
Systemic Tetracyclines Cautions
- Photosensitivity
- May affect oral contraception
- Antacids reduce absorption of tetracycline
- Px taking anticoagulants may require a dose reduction
Systemic Tetracyclines Side Effects
- GI disturbances
- HA
- Photosensitivity
- Some can indicate benign intracranial hypertension
- Blurred vision
- Field loss
- Diplopia
- Discoloration of conjunctiva and lacrimal secretions
