Week 4 - Eyelid therapy and pharmacological treatments

Question 1

Level 1 management of dry eye:

Answer 1

LEVEL 1
- education and environmental/ dietary modifications
- tear supplemets
- eye lid therapy
- medication changes

Question 2

Level 2 management of dry eye:

Answer 2

LEVEL 2
- preservative free
- pharmaceuticals (topical anti-inflammatories, tetracyclines,
secretagogues)
- punctal plugs
- moisture chamber spectacles
- Lipiflow
- demodex

Question 3

Level 3 management of dry eye:

Answer 3

LEVEL 3
- autologous serum
- oral secretagogues
- contact lenses

Question 4

Level 4 management of dry eye:

Answer 4

LEVEL 4
- amniotic membrane
- permanent punctal occlusion
- surgery

Question 5

Dry eye disease is present in:

Answer 5

• 50% of people with staphylococcal blepharitis
• 25-40% of people with seborrhoeic blepharitis

Question 6

How do you explain Blepharitis to a patient?

Answer 6

CMG: “Blepharitis is a condition in which chronic (i.e. long-term) inflammation of the eyelid margins causes symptoms of eye irritation”

Question 7

How do you explain MGD?

Answer 7

“Meibomian Gland Dysfunction (MGD), results when the condition affects the inside rims of the eyelids (just behind the eyelashes) which contain the meibomian glands. (The meibomian glands produce a thin layer of oil which normally prevents the tears from evaporating too quickly; if they are inflamed, this mechanism does not work properly)”

Question 8

Hot compresses - why?

Answer 8

• Attempt to melt/soften the meibum then manually express glands
• Temperature recommended is 40°C (that is the temp of the palpebral conj/glands)
• The more severe the blockage, the higher the temperature required (45°C considered the maximum to avoid thermal damage)
• Research is divided on whether a wet or dry compress will heat more effectively (wet can help soften crusts in anterior bleph)

Question 9

Hot compresses - on the market

Answer 9

• Multiple options with slight variations
. Can contain different ingredients such as flax seed, silica beads, synthetic gel beads
• Certain practices will stock their preferred option
• Can require a microwave for heating
• The MGD Rx EyeBag was highlighted in the DEWS II report

Question 10

Hot compresses - plug in

Answer 10

Blephasteam
• Plug in device that creates a warm, humid environment around the
eye
• Theory is that it will “maintain a stable heat for the duration of treatment”
• You wait 15 minutes for it to warm up and then it will remain warm for 10 minutes
• £200 RRP

Question 11

Eyelid Massage

Answer 11

• Not enough just to melt the meibum
• You need to encourage the blockage out before it solidifies again
• Firm massage below the lower glands and above the upper glands on completion of the hot compress
• Demo this with every patient.

Question 12

Lid Cleansing - options

Answer 12

• Commercial eyelid cleansing solution
• Commercial wipes
•Baby shampoo
• Cooled boiled water
• Bicarbonate of soda

Question 13

Technique for lid hygiene:

Answer 13

• How would you describe the technique?
• My preference is to liken it to removing make up. Men and women understand this well.
• How long for?
• Demo in practice

Question 14

Compliance:

Answer 14

• Compliance is usually notoriously poor - might be because no “instant results”
• How can we ensure compliance?
- Explain the chronic nature. Communication is most importance.

Question 15

BlephEx

Answer 15

• In office lid hygiene
• Involves moving a rotating micro-sponge along the lash margin
• This should remove debris and exfoliate the lid margin
• Manufacturers advise repeating every 4-6 months
• Still carry out daily lid hygiene at home
• I use an analogy of a scale and polish at the dentist

Question 16

Level 2 - Demodex

Answer 16

• Demodex Folliculorum live in and around hair follicles i.e. eyelashes, around 0.3-0.4mm in length
• Demodex Brevis live deeper in sebaceous glands i.e. rosacea and MGD, around 0.2-0.3mm in length
• Research is still debating how these mites correlate with anterior segment disease. General consensus that they can be harmless but an over-population or an immune compromised patient can lead to symptoms
• Symptoms tend to be worse at night and on waking
• Itching can be a common symptom - any ideas why?

Question 17

Demodex appearance/finding

Answer 17

• It is the tail of D Folliculorum that we are looking for at the base of the eyelashes
• 40x mag on slit lamp required
• Look for cylindrical dandruff/” volcanoes” waxy debris at the base of the lashes that hasn’t responded to standard lid hygiene (ensure patient has been compliant)
• The material will not grow along the eyelash
• Using tweezers twist the eyelash clockwise and anti-clockwise or laterally right and left and in and out and the tail can often emerge more clearly

Question 18

Demodex management:

Answer 18

• Demodex do not respond to standard lid hygiene, a mitacidal is
• Tea tree oil has been shown to be mitacidal. BUT is also toxic to the ocular surface..

Question 19

Tea tree oil treatment:

Answer 19

• In-office weekly treatment of 50% tea tree oil (often mixed with another oil such as macadamia nut).
• Eyes must be kept closed throughout. Use a cotton bud (after thorough lid hygiene) to apply to the base of the lashes.
• This should be done by an experienced practitioner, ask around at work. Then make sure you observel

Question 20

Demodex Wipes:

Answer 20

• Specialist lid wipes/cleaners
• Contain various strengths of TTO or the active ingredient Terpinen-4-ol
• They can sting, need to advise patient to keep their eyes closed for 15-30 seconds after
• Use at night. As this is when mites pop out
• Most manufacturers recommend morning and night
• Can also advise a facial tea tree wash

Question 21

Potential demodex management:

Answer 21

• Various other agents have been suggested but large scale research trials are required
- Manuka honey
- Castor oil
- Okra compounds
• Drugs currently used for dermatological conditions
- Ivermectin
- Metronadazole
• Product licensed by the FTA (Xdemvy)
- Lotilaner ophthalmic solution (BD for 6 weeks)

Question 22

Level 2 - Lipoflow

Answer 22

• Lipiflow is an in-office treatment offered by some clinics throughout the UK
• The aim is to manually express lipid from the Meibomian glands by simultaneously heating and massaging the eyelid, takes 12 minutes
• Offered by one of the multiples for £395 per eye with the recommendation of a repeat procedure every 12-18 months

Question 23

Level 2 - IPL

Answer 23

• Intense pulsed light
• Previously been used to deliver pulses of light to help with skin pigmentation and acne
• Now being used for MGD
• One theory is that the pulsed light liquefies the contents of the gland and the optom expresses the material to allow normal flow of meibum
• Available commercially in the UK, usually repeated several times
• One independent offering £120 per treatment plus £30 for expression, repeated 3 times

Question 24

IPL and demodex?

Answer 24

• Also been proposed as a potential management option for Demodex
• Recent studies shows a reduction in mite count
• Works via a heat transfer

Considerations with IPL:
• Fitzpatrick skin type V or VI
• Could also cause lightening or darkening of the skin
• Pregnancy/breastfeeding/skin cancer/connective tissue disorder/tanning beds/metal plates etc in the face/active herpes infection

Question 25

Level 2 - Topical Anti-inflammatories

Answer 25

• Steroids
• Cyclosporin
- Designed for short term use where there is a severe inflammatory reaction i.e. intense conjunctival hyperaemia

Question 26

Steroid types:

Answer 26

Which one?
• Loteprednol (Lotemax) (non penetrating)
• Fluoromethalone (FML) (non-penetration)

• Dexamethasone (Maxidex/Dropodex)
• Prednisolone (Predsol/Pred Forte)

NB - This is an IP

Question 27

Steroids - Dosage examples:

Answer 27

Dosage examples:
• Fluoromethalone - QID for 1 week ( can choose to taper over the next 3 weeks)
• Loteprednol - QID for 1 week (can choose to taper over the next 3 weeks)
The CMG simply says “may be considered for short-term use in some cases”

You will come across ophthalmologists who use the penetrating steroids such as Pred-forte or Dropodex.

Question 28

Steroids - contraindications / cautions

Answer 28

• Infection, be confident in your diagnosis
• Glaucoma
• Contact lenses
• Pregnancy and breast-feeding

Question 29

Steroids - side effects

Answer 29

This is NOT an extensive list of side effects but some to think about:
• Raised IOP
• PSCC formation
• Secondary infection
• Headache

IOP should be monitored, even on non-penetrating steroids. Make sure to check this at the dry eye follow up.

Question 30

Cyclosporin/ciclosporin (UK spelling)

Answer 30

• Immunomodulatory drug (not a steroid) with anti-inflammatory properties
• Strong level 1 evidence to support the use of cyclopsporin
• Initiated by ophthalmologists
• They may request an IP optometrist to issue an Rx

• Expensive! £72 for 30 single dose units (2017 price).
• UK name is Ikervis (aka Restasis in America), concentration is 0.1%
• For use once a day. Can sting on instillation.

Question 31

Ciclosporin Contraindications/Cautions

Answer 31

Contraindications:
• Hypersensivity to the agent
• Active or suspected ocular infection
• Ocular or peri-ocular malignancies

Cautions:
• Pregnancy/breast feeding
• No trials have been done in children
• Glaucoma
• Ocular herpes
• Contact lenses

Question 32

Level 2 - Topical Antibiotics

Answer 32

• Tends to be used short term to reduce the bacterial loa Blepharitis
• Can be used pre-surgery

Options listed in the CMG for Blepharitis are Chloramphenicol and Azithromycin.

Question 33

Chloramphenicol

Answer 33

• 1% eye ointment
• Rubbed into the lid margin with a clean fingertip BD for 1 week
• Patient must then continue with lid hygiene
• Entry level, available to all optometrists

• Off label use but recommended in guidelines.

Question 34

Azithromycin

Answer 34

• Azyter: eye drops, 1.5% azithromycin dehydrate
• OFF LABEL USE
• Also has mild anti-inflammatory properties
• Research has shown an improvement in signs and symptoms and greater efficacy than hot compresses alone
• BD for 3 days (same as for bacterial conjunctivitis)
• IP qualification required

Question 35

Fusidic Acid

Answer 35

• Unlike chloramphenicol fusidic acid can be used in pregnancy and breast feeding (so can azithromycin).
• Entry level
• Off label use
• £32.29 for 5g (Chloramphenicol ointment is £1.74)
• Twice a day for a week
• Look up all 3 in the BF app to be really familiar with them

Question 36

Level 2 - Systemic Tetracyclines

Answer 36

• Anti-infective
• Also has anti-inflammatory effects
• Long standing blepharitis is characterized by inflamma the eyelids
• IP level intervention or GP may prescribe

Question 37

Level 2 - Systemic Tetracyclines when?

Answer 37

• Considered a second line management option according to the CMG on Blepharitis.
• Recommended for posterior blepharitis
• For chronic cases
• Those that have not responded to standard management.
• When there is associated rosacea (co-management with dermatologist or GP)

Question 38

Types of tetracyclins and difference between:

Answer 38

• Doxycycline
• Minocycline
• Tetracycline
• Oxytetracycline

• Doxycycline and Minocycline obtain a higher concentration in the tissue and longer half life
• There are no randomized, double masked clinical trials that compare tetracyclines with other methods of lid hygiene
• Research is a mix of case reports, unmasked trials or trials comparing tetracyclines to a placebo

Question 39

Dosage for tetracyclins:

Answer 39

• Doxycycline - 100mg twice daily for 2 weeks then once daily for 2-3 months. Or 40mg modified-release for at least 5 months.
• Minocycline - one 50mg tablet for 2 weeks followed by 100mg daily for 10 weeks

• Tetracycline
• Oxytetracycline
When it is for ocular rosacea then the CMG recommends Doxycycline 40mg modified release once daily for up to 6 weeks

Question 40

Contraindications to tetracyclins:

Answer 40

• Hypersensitivity to the drug
• Hypersensitivity to any members of the tetracycline family
• <12 years of age
• Pregnancy or breast feeding - crosses the placenta and expressed in breast milk
• Renal or hepatic impairment
• Systemic lupus erythematosus (SLE)

Question 41

Tetracyclins cautions:

Answer 41

• Photosensitivity
• Caution when using oral contraceptives - may reduce the effect, speak to the GP
• Antacids 2 hours before or after taking tetracyclines - decrease the absorption of the tetracyline
• Use in MG/SLE
• Patients taking anticoagulants, may require a dose reduction

Question 42

Side effects of tetracyclines:

Answer 42

• Can include blurred vision, field loss, diplopia, discoloration of the conjunctiva and lacrimal secretions - these are rare, can indicate BIH

• GI disturbances - common
• Hypersensitivity
• Headache - can indicate BIH
• Photosensitivity

Question 43

Advice to patient taking tetracyclins:

Answer 43

• Limit time in the sun and use high factor suncream
• No tanning equipment
• Alternative forms of contraception should be used during treatment
• To return if they experience any side effects

Question 44

For those where tetracylines are contraindicated:

Answer 44

• consider oral azithromycin
• May improve Meiboman gland function in unresponsive MGD. Much shorter course than tetracyclines.
• 500mg on day one, 250mg for 4 days.

Question 45

Oral Azithromycin Cautions:

Answer 45

• Caution in MG
• Caution in pregnancy and breast feeding
• Caution in hepatic and renal impairement

• There is a long list of potential side effects for all Macrolide antibiotics, please look up your BF.
• The only “common or very common” one with oral azithromycin is arthralgia.

Question 46

Co-management: If tetracyclin

Answer 46

• Who should you inform of your treatment plan?
• A letter should be written to the patient’s GP informing them of any prescriptions issued, this should be done promptly
• Also make sure to be communicating with dermatology if applicable

Question 47

Level 2 - Topical Secretagogues

Answer 47

• Secretagogues are agents that are designed to stimulate the production of aqueous, lipid and/or mucin

• Topical diquafosol tetrasodium (aqueous and mucin - currently not licensed in UK/EU)
• Topical Rebamipide ophthalmic suspension (mucin - currently not licensed in UK/EU)
• Topical testosterone (lipid - currently not licensed in UK/EU)

Question 48

Level 3 - Autologous Serum

Answer 48

• Vials of autologous serum-based eye drops are made from a blood donation from the patient or from a donor

• Believed that autologous serum can better promote healing and growth of corneal epithelial cells

• One full blood donation produces up to 150 vials diluted with 50% saline with a shelf life of 12 months from the date of donation.

• Expensive - £1,100 for 3-5 months’ supply (including delivery to the patient’s home address with same day courier)

Question 49

What are serum drops?

Answer 49

• Autologous Serum ( Auto SE) : SE
Prepared from blood donated by patients: First reported in the 1980s

• Allogeneic SE (Allo SE): Prepared from blood donated from unrelated voluntary blood donors, relatively new.

Question 50

Level 3 - Fingerprick Autologous Blood

Answer 50

• Applying a pin prick of blood onto the conjunctiva 4 x a day.

• Barriers - time required for training, manual dexterity, fear of needles
• Would be initiated by or with oversight from ophthalmology

Question 51

Level 3 - Systemic Secretagogeus

Answer 51

• Oral pilocarpine (aqueous) - licensed in the UK
• Oral cevimeline (aqueous - currently not licensed in UK/EU)

• Oral pilocarpine has been investigated and shown to improve signs and symptoms of DED, but with associated side-effects of nausea and sweating

• Not widely used as there has been limited research and few clinical trials carried out

Question 52

Level 4 - Amniotic Membrane

Answer 52

• Promotes corneal healing in severe dry eye (as well as post surgery or for chemical burns)
• Derived from the inner layer of the amniotic sac - made of an extracellular matrix which has anti-inflammatory, anti-bacterial and anti-scarring properties amongst others
• Similar to a large contact lens
• Length of time varies

Question 53

Neuropathic Pain

Answer 53

• Can present very like dry eye disease or alongside
• Can be post injury, post surgery, diabetes, shingles.
• Standard management options helpful as we want to restore the ocular health and ensure no further nerve damage/reduce inflammation as much as possible

• Patients may benefit from co-management with the GP or referral to a pain management clinic as this may not be confined to the eye.

Question 54

Neuropathic pain treatment:

Answer 54

There may also be a need to target the central issue with nerves and that can require systemic medication.

• Tri-cyclic antidepressants .g. amitriptyline
• Anti-epilepsy e.g. gabapentin

Work by trying to reduce the nerve’s hypersensitivity.

Question 55

When to refer - Dry eye

Answer 55

• normally no referral
(If idiopathic and not associated with systemic disease)

• routine referral if adequate trial of topical treatment (this does not mean just First Line drops) or punctal plugs fails

• secondary complications (vascularisation, corneal scaring, melt, or infection)

• If the condition is not idiopathic, for example if Sjögren’s syndrome or an up entitled underlying disease are suspected, refer (this may be to the GP)

• If lid anatomy or function is abnormal, refer

• if SJS or OCP are suspected, refer urgently (within one week) to ophthalmologist

Question 56

When to refer: Blepharitis

Answer 56

From the Clinical Management Guideline
• alleviation/palliation: normally no referral
• in unilateral cases, if meibomian gland carcinoma is suspected, refer urgently (within one week)

• In patients who do not respond to therapy the possibility of carcinoma or immune mediated diseases should be considered, particularly if the blepharitis is associated with loss of eyelashes and or cicatricial changes

Question 57

Monitoring DED: H&S

Answer 57

• Specific questions
- Symptoms? Any change?
- Have they been carrying out the management? I always say “how often are you using your drops” or “tell me how you have been cleaning your eyelids”
- Any change to GH or medications?

Question 58

Monitoring DED: Assessment

Answer 58

• Slit lamp exam - white light and fluorescein
• Make sure to assess the lids/lashes, conj, cornea and tear stability
• You are wanting to compare to initial visit, grading scales are so important

• Is the situation improving?
• Is it worsening?
• Think about the step by step approach to DED

Question 59

DED: How long between visits?

Answer 59

• If the cornea is clear or only mild staining and I am trying a drop for the symptoms then I will leave it 6-8 weeks. If there is then an improvement in symptoms I will revert to monitoring at the sight test.

• If there is pronounced corneal staining and I am trying intensive lubrication then I will follow up in 1 or 2 weeks (or if it is steroids then 1 week is standard)