Test 1: Ocular Surface Disease Flashcards
anterior blepharitis types
staphylococcal blepharitis - staph epidermis, staph aureus
seborrheic blepharitis - dermatologic condition
demodex - mite
staphylococcal blepharitis signs and symptoms
the classic appearance of staph bleph is yellowish debris or collates with complaints of matter or discharge and erythema and hyperemia of the eyelid margins
staphylococcal blepharitis treatment
warm compresses, eyelid hygiene (consider commercial lid cleansers)
add topical antibiotics for short term (7-10 days) to decrease the bacterial load
staphylococcal blepharitis pt edu
chronic nature of disease and that there is no known cure
long term maintenance is needed
seborrheic blepharitis signs and symptoms
oily or greasy matter in ashes, can have mild conjunctival injection and inferior punctate epithelial erosions
patient with complaint center on the eyelids themselves, including irritation, redness and itching
seborrheic blepharitis patient edu
chronic nature of the disease and that it will likely return
daily commercial lid scrubs may help to keep condition under control
demodex signs and symptoms
critical sign is cylindrical dandruff, with disorders of eyelashes, lid margin inflammation, meibomian gland dysfunction, blepharoconjunctivitis and blepharokeratitis
pt complaints including itching, burning, FBS, crusting and redness of the lid margin
demodex treatment
tea tree oil (cliradex wipes 4-Terpineol) a minimum 60 days of treatment is recommended to ensure eradication of the mite in all life cycles (approx. 30 day incubation)
meticulous hygiene of body and home is needed to fully eradicate the mites
allergic conjunctivitis
SAC
PAC
VKC
AKC
allergic conjunctivitis signs and symptoms
bilateral itching, hyperemia, lid edema
can be seasonal and occur with other allergic symptoms
allergic conjunctivitis treatment
drug of choice topical dual mechanism anti-allergy medications (combined H-1 receptor antagonist and mast cell stabilizers such as olopatadine) along with art tears to dilute allergens, cool compresses, and avoiding known allergens
severe allergies can be treated with topical steroids or oral antihistamines to control symptoms completely
other causes of non-lid related disease
chronic keratoconjunctivitis
chronic conjunctivitis
refractive surgery
aqueous deficient dry eye syndrome
sjogren syndrome dry eye
non-sjogren dry eye
primary sjogren’s syndrome dry eye
SS but no other autoimmune disease
secondary sjogren’s syndrome dry eye
SS and another autoimmune disease usually rheumatoid arthritis
non-sjogren dry eye
lacrimal deficiency, age related dry eye
reflex hypo secretion
a reduction in sensory feedback from the ocular surface causes dry eye in two ways: by decreasing reflex-induced lacrimal secretion and by reducing blink rate which increases evaporation
potential causes of reflex hypo secretion
herpes simplex keratitis, herpes zoster ophthalmicus, corneal surgery, limbal incision (extra-capsular cataract extraction), keratoplasty, refractive surgery, topical anesthesia, chronic contact lens wear, diabetes mellitus
lacrimal gland duct obstruction
normal aging changes, specific (rare)
intrinsic causes of evaporative dry eye
meibomian gland deficiency
disorders of the lid aperture, low blink rate, drug action (accutane)
meibomian gland deficiency
defined as chronic diffuse abnormality of meibomian glands
characterized by terminal duct obstruction and/or qualitative/quantitative changes in glandular secretion
these changes result in alteration of tear film, symptoms of eye irritation, clinically apparent inflammation and ocular surface disease
meibomian gland deficiency prevalence
the most common cause of evaporative DED 85% of evaporative DED
meibomian gland deficiency diagnosis
may be diagnosed by meibomian gland expression ONLY
any altered quality of expressed secretion, and/or by a loss of gland functionality (decreased or absent expressibility) is evidence of disease
as MGD progresses, patient symptoms develop and lid margin signs may become visible with biomicroscopy
meibomian gland deficiency treatment
warm compresses with lid massage, nutritional supplements (fish oil or omega-3)
in office MG expression has been shown beneficial
some success with off-label topical azithromycin on lashes
more significant disease might need oral doxycycline
extrinsic causes of evaporative DED
vitamin A deficiency topical drugs (preservatives) contact lens wear other types of ocular surface disease (allergic conjunctivitis)
vitamin A deficiency
vitamin A deficiency is a common cause of blindness in third world countries
the increasing popularity of gastric bypass surgery has caused an increase in cases of vitamin A deficiency resulting in severe dry eye including corneal scarring, corneal ulcers/perforation, and conjunctival dryness
screening for dry eye disease
patient symptoms and clinical signs don’t usually match
every patient should be screened for dry eye symptoms
screening exam
ask specific questions
evaluate DED risk factors - health history, meds, etc.
evaluate dis lashes, blink, lid closure, conj
evaluate tear film TBUT
evaluate cornea for fluorescein staining - immediately after TBUT evaluate the cornea for staining including severity, location and pattern
elements of a comprehensive dry eye work-up
case history with dry eye questionnaire - symptoms surveys, ocular surface disease (normal 1-12, mild 13-22, moderate 23-32, severe 33-100), standard patient evaluation of eye dryness
assess tear osmolarity - tear lab
assess tear quantity and volume - schirmer 1 test, phenol red thread test
anterior seg evaluation with white light
tear stability - TBUT
evaluate ocular surface integrity with dyes
meibomian gland expression and assessment
tear osmolarity
measured within 10 sec in TearLab
readings higher than 308 mOsmol/l are considered diagnostic of DED
schirmer 1 test
sensitivity 85% and specificity 83% no anesthetic - place strip in lower fornix and patient closes eyes for 5 min normal - greater than 10 mm borderline - 5-10 mm abnormal - less than 5 mm
phenol red thread test
phenol red impregnated cotton thread inserted in lower fornix of lid for 15 sec
color change of wetted thread is easy to observe and measure directly with scale on package
a value >9 mm is normal
sensitivity 86% and specificity 83%
evaluating ocular surface integrity with dyes
fluorescein is best for assessing cornea
lissamine green is better for conj
documentation of staining should include pattern, position, depth, and grade
location of corneal staining
superior quadrant - superior limbic keratoconjunctivitis
diffuse punctate staining - toxicity
staining near lid margin - indicative of blepharitis
interpalpebral staining - incomplete blink or nocturnal lagophthalmos
sectoral staining - FB or localized irritant like GPC, concretions, loose lash or debris
location of conjunctival staining
staining occurs more frequently on the nasal conjunctiva in patients with DED, whereas temporal staining is more indicative of SS
meibomian gland expression and assessment
express Megs and evaluate composition of secretions
record findings - clear, cloudy, cloudy with debris, thick or paste like, or non-expressive
multiple ways to express - the mastrota paddle, the MG evaluator, or simply by a finger or cotton swab
treatment and management goals
primary goal is to reduce symptoms and return tear film and ocular surface to as close as possible to normal state of health
frequency and severity of symptoms and how do they affect patient’s ADLs
what portion of ocular dysfunction is attributable to evaporative causes (evaluate MG) or aqueous deficiency (evaluate quantity and volume)
is the integrity of ocular surface compromised
episodic
symptoms and signs are not consistently present but occur under certain environmental conditions or during specific visual tasks
chronic
assumed to be caused by inflammation
the treatment goal in chronic DED is to control inflammatory mediators, to reduce signs and symptoms, and to minimize disease progression
recalcitrant
progressive DED despite maximal conventional therapies
uncommon strategies may be required
episodic treatment protocol
art tears
warm compresses
lid hygiene
environmental modifications
chronic treatment protocol
short term steroids topical cyclosporine omega 3s doxycycline MG expression lid taping restasis
recalcitrant treatment protocol
scleral lenses
amniotic membranes
tarsorrhaphy
art tears
type of AT used does matter
remember to consider preservative, lipid content, osmolarity, viscosity
if prescribed more than 4 times/day, it should be PF
warm compress
should be used at least 2 times/day for 2 weeks
compress should be warm and held on lids for at least 4 min
lid hygiene
commercially available lid scrubs better for various forms of anterior blepharitis and MGD if the patient can tolerate
environmental modifications
avoid air from any source blowing directly into the eye, use a humidifier
medications
are there any medications that can be stopped or changed?
anti-inflammatories
topical steroids - use to calm allergies, or inflammation, particularly helpful before starting topical cyclosporine
cyclosporine
Restasis
Xiidra
MG expression
cotton swab, mastroda paddle, BlephEx, LipiFlow
