Non-Pharmacological Management of Dry Eye Disease Flashcards
1
Q
What are the environmental/dietary modifications px with DED should make?
A
o Chronic nature of condition
o Omega 3
o Omega 6
o Environmental modifications
2
Q
What are the 4 levels of the treatment ladder in DED treatment?
A
Depends on px which level you start at
LEVEL 1:
- Education & environmental/dietary modifications
- Tear supplements
- Eye lid therapy
- Medication Changes
LEVEL 2:
- Preservative free
- Pharmaceuticals (topical anti-inflammatories, tetracyclines, secretagogues)
- Punctal plugs
- Moisture Chamber Spectacles
- Lipiflow
- Demodex
LEVEL 3:
- Autologous serum
- Oral secretagogues
- Contact lenses
LEVEL 4:
- Amniotic membrane
- Permanent punctal occlusion
- Surgery
3
Q
How would you explain evaporative and age-related DED?
A
- Explaining evaporative DED:
o Have different layers of tears, their oily layer isn’t so good & so doesn’t protect watery layer which vanishes v quickly which sends message to brain saying no water left – brain doesn’t really regulate this and sends too much - Explaining age related DED:
o If female px then can talk about how common it is - & often related to hormones
o V common
o V frequent problem that happens over time
4
Q
Describe omega 3 and omega 6 in DED?
A
- Omega 3 – veg, nuts, cereal, poultry
- Omega 6 – fish e.g. salmon, mackerel, tuna
- Diet vs supplements
o When take omega 3 & 6 from supplement, is in much higher concentration than if from diet - Research on this slightly inconclusive – but anti-inflammatory factors of these two
- Can take too much – especially woman who is or could become pregnant (no more than 2 portions of oily fish a week & avoid marlin, shark & swordfish because of mercury content)
- Contra-indications, including liver disease, atrial fibrillation and bleeding disorders; in these cases, medical advice should be sought prior to commencing supplementation – speak to GP
5
Q
What are the environmental modifications in DED?
A
- Air conditioning/cigarette smoke
- Wrap around glasses/sunglasses
o E.g. if in car in summer and blasting aircon
o Good when outside or in adverse environments a lot – good to seal in the area around eye - Lowering VDU monitor height
o Lowers top lid down & minimises exposure to environment - Regular breaks from VDU – 20/20/20 rule
- Increase humidity in the home
o Place bowl of water under radiator
o Commercial humidifiers - Blinking (normally 15-20 per minute) – can get an app
6
Q
Describe level 1: tear supplements (DED)?
A
- Used to maintain ocular surface hydration and to replace components of the tears, which may be absent or reduced
- Generally have a short retention time on the ocular surface and require regular use
- None of these treatments have been shown to be curative, but are used with the aim of improving patient symptoms
7
Q
Describe 1st line dry eye drops?
A
- Carbomer 980
o Common 1st line option on NHS formularies
o Research has shown it can be useful for increasing tear film thickness, protecting against desiccation and promoting tear retention at the ocular surface
o There does not appear to be any substantial difference in effectiveness among the different formulations and products (commonly 0.2%)
o E.g. Viscotears or Clinitas Gel
o Gel – good retention time – trickier to get in – blurry when in – make sure px can use it before they leave your practice - Hypromellose aka hydroxypropyl methylcellulose (HPMC)
o Still on many formularies
o Research shows it is safe and effective lubricant for mild to moderate DED
o Used in combination with lots of other ingredients
o Concentration can range from 0.2-0.8% (most common one is 0.3%)
o Doesn’t have as good a retention time as more watery
o Xaillin Hydrate is a preservative free option - Polyvinyl Alcohol
o Not on every formulary
o Viscosity enhancing agent (as are majority of dry eye preparations)
o Preservative and preservative free options
Working within formulary & NHS budget so if sxs not too severe then try 1st line tx but if it doesn’t work then move onto 2nd line and try that. Or even try multiple in 1st line before moving to 2nd line. 2nd line more expensive than 1st line
8
Q
Describe 2nd line dry eye drops?
A
- Carmellose sodium ask caboxymethylcellulose (CMC)
o Commonly used viscosity enhancing agent
o “Can bind to corneal epi cells and promote epithelial cell healing”
o Research shows success in managing mild to moderate DED
o Usually in preservative free doses
o Thick & difficult to get out of each vial – make sure px can use before they leave - Sodium Hyaluronate aka hyaluronic acid (HA)
o Functions as a tissue lubricant, it is a component of cartilage and found in synovial fluid, the vitreous and the aqueous humour
o Increases viscosity and provides lubrication
o “studies have demonstrated its ability to bind to ocular surface cells and its potential wound healing properties”
o Concentrations from 0.03-0.4%
o All in image are preservative free – as in bottle design
o Hylo-tear when asking GP to give to px
Hyco-san when asking px to buy from shop - HP-Guar
o Thickener
o Is dispensed as a drop but on contact w/ tears, reaction changes it into a low viscosity gel
o Reduction in pH, dilution of sorbitol leads to an increased density of HP-Guar
o Has preservative in it so pxs may react to it & not like it
Know what is available in your shop but also what is on market to ask pxs to get that product if you think they would benefit
9
Q
Describe ointments for dry eye?
A
- Don’t use during day as blur vision
- Good for night time use to protect the cornea during sleep (avoid recurrent erosions)
- VERY thick
- Common main ingredient is paraffin
- Can also include vitamin A (Hydramed night sensitive), lanolin (lacrilube), vitamin A and lanolin (Hycosan Night/Hylo Night), mineral oil and lanolin(Xailin night)
o Lanolin may cause reaction in some pxs
o If px reports they don’t like the drop – find out what it is about it e.g. they don’t like the viscosity or they are having a reaction to it - Carbomer 980 is also a gel and can be used at night time
10
Q
Describe lipid based dry eye drops?
A
- For primary evaporative dry eye – to enhance lipid layer
- Replace/enhances lipid layer to prevent evaporation of the aqueous layer. Therefore interrupting feedback loop that leads to excessive aqueous production
- E.g.s: castor oil, mineral oil, soybean oil
- New product:
o EvoTears
o Contains 1 ingredient only (perfluorohexyloctane) which is designed to replace lipid layer
o Preservative free
Keep eye on market – new drops coming all time - & many may get discontinued
11
Q
Describe combination drops for dry eye?
A
- Drops that contain multiple ingredients to try and improve the tear film.
- Examples include:
o Optive Fusion – mixture of CMC, sodium hyaluronate and glycerine
o Thealoz Duo – mixture of sodium hyaluronate and trehalose (an osmoprotectant & prevents desiccation of ocular surface)
o Hylo-Care – mixture of sodium hyaluronate and dexpanthenol (aids corneal healing)
o Systane Balance – mixture of HP-Guar and mineral oil
o Visu-XL – crosslinked sodium hyaluronate and co-enzymes
12
Q
Describe mucus drops for dry eye?
A
- On slit lamp you may see mucus filaments or a mucus plaque
- Patient may report sticky/stringy discharge
- Ilube: eye drops, 5% acetylcysteine, 0.35% Hypromellose
- Instil one or two drops into the affected eye three or four times daily (CMG on Dry Eye)
- Stings on installation
- Contains BAK – can be toxic to cornea
- Not available to entry level, must be IP
- Acetylchysteine
o Mucolytic
o Shown to dramatically reduce viscotiy
o Combined with hypromellose
13
Q
When should you issue ocular lubricants?
A
- There is no set criteria
- The decision can often be symptom, not sign, driven as we know there can be poor correlation between signs and symptoms
- On the other hand if there is a compromised ocular surface without symptoms then we need to try to prevent further problems i.e. in a diabetic patient with reduced corneal sensation
o Or someone who has had DE for so long that they have corneal desensitization
o These pxs can be tricky in convincing them that there is a problem & we need to treat it - There is a trial-and-error element to managing DED
o Lots of drops work for different people
o No rhyme or reason to which work – often personal preference - Important to remember nighttime use as well
14
Q
What is the dosage of ocular lubricants?
A
- Standard dosage is 3-4 x a day
- But with preservative free formulations this can be increased to as often as the patient feels necessary
- If there is significant corneal staining I will ask for 1-2 hourly application until the staining is controlled then it can be reduced to a maintenance dose
o When corneal staining, drops used to manage dry eye but with staining they are also acting to keep ocular surface clean and minimise risk of infection - Overuse of preserved drops can lead to a toxic reaction
- If requesting more 4-6 times a day then should switch to preservative free formulation
15
Q
Describe bottle design in ocular lubricants?
A
- Px needs to be able to instil the drops
- Make sure to have px demonstrate them putting the drops in before leave appt
- Different drops require different dexterity & strength
o Research done into “squeezability” of different drops - Remember it may not just be px you are dealing with – may need to teach carers etc
- Can buy gadgets/aids to help put drops in – can buy from Boots
