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OD2 Semester 2 - Applied Clinical Training > wk4: AED Dry eye Mx > Flashcards

wk4: AED Dry eye Mx Flashcards

1
Q

How can you classify dysfunctional tear syndrome patients? (3)

A

With lid margin disease
Tear distribution problems
Without lid margin disease

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2
Q

How can you classify dysfunctional tear syndrome patients with lid margin disease? (2)

A

anterior lid margin

posterior lid margin

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3
Q

How can you classify dysfunctional tear syndrome patients with tear distribution problems? (5)

A 
conjunctivochalasis
lid + lash malposition
elevated surface lesions
reduced or incomplete blinking
other
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4
Q

How can you classify dysfunctional tear syndrome patients without lid margin disease? (4)

A

severity level 1-4

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5
Q

How can we treat dysfunctional tear syndrome patients with anterior lid disease? (2)

A

lid hygeine

topical antibiotic

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6
Q

How can we treat dysfunctional tear syndrome patients with posterior lid disease? (3)

A

Hot compresses and massage, and, it that doesn’t work:
tetracyclines or
topical steroids

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7
Q 
How do we treat the following tear distribution problems:
A: reduced/incomplete blinking (2)
B: elevated surface lesions (2)
C: lid and lash malposition (2)
D: conjunctivochalasis (2)
What if these tx don't work? (1)
A

A: lubrication/contact lenses
B: lubrication/steroids
C: lubrication/contact lenses
D: lubrication/steroids

And if none of these works, surgery

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8
Q

How do we grade level 1 dysfunctional tear syndrome? (2)

A

1 or more of:
mild/moderate symptoms + no signs
mild/moderate conjunctival signs

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9
Q

How can we manage level 1 dysfunctional tear syndrome? (4)

A

education/counselling
environmental modifications
control of systemic modifications
perserved tears/allergy control

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10
Q

How do we grade level 2 dysfunctional tear syndrome? (5)

A 
moderate/severe symptoms
tear film signs
mild PEE
conj. staining
visual signs
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11
Q

How can we manage level 2 dysfunctional tear syndrome with no inflammation present? (3)

A

If no inflammation: unpreserved tears/gels/ointment

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12
Q

How can we manage level 2 dysfunctional tear syndrome with inflammation? (4)

A

If inflammation: steroids/cyclosprine/nutritional supplements/secretagogues

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13
Q

How do we grade level 3 dysfunctional tear syndrome? (4)

A

severe symptoms
marked SPK
central corneal stain
filamentary keratitis

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14
Q

How can we manage level 3 dysfunctional tear syndrome? (3)

A 
tetracyclines
autologous serum
punctal plugs (after inflammatory control)
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15
Q

How do we grade level 4 dysfunctional tear syndrome? (3)

A

severe symptoms
severe corneal staining/erosion
conjunctival scarring

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16
Q

How can we manage level 4 dysfunctional tear syndrome? (5)

A 
topical vitamin A
contact lenses
acetylcysteine
moisture goggles
surgery
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17
Q

List examples of dry eye treatment options for the following categories:
A: Palliative/protective treatment (2)

A

Supplements
Soidum Hyaluronate
Autologous serum eye drops (also is anti-inflamm)

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18
Q

List examples of dry eye treatment options for the following categories:
B: Anti-inflammatory (4)

A

Flaxseed oil/fish oil
Topical corticosteroids
Oral tetracycline (MMP9)
Autologous serum eye drops

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19
Q

List examples of dry eye treatment options for the following categories:
C: immunomodulation (1)

A

Topical cyclosporine

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20
Q

Other than palliative, anti-inflammatory and immunomodulation, what other type of treatment option exists for dry eye? (1)

A

Biomechanical tx

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21
Q

What differences are there between commercial eye drops?

A

No real differences. Any differences stated by companies are from in vitro studies and don’t represent what happens in humans

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22
Q

What is the role of tear supplements? (3)

A

used to hydrate ocular surface, counteract dehydration, and reduce lid friction

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23
Q

What is the major problem we face with tear supplements? (2)

A

Not instilled frequently enough or

necessity of long term use not understood by patient (education important)

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24
Q

How can liquid tear supplements vary? (4)

A 
can vary in:
viscosity
contact time
friction
wetting properties
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25
Q

How do the mechanisms of action for liquid tear supplements vary? (2)

A

some improve adherence to glycocalyx

others absorb water and improve tear distribution

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26
Q

How do gel tear supplements differ from liquids (1) and ointments? (1)

A

Increased contact time across cornea than liquid

Less profound effect on vision than ointments

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27
Q

Between liquids, gels and ointments, which has the better contact time?

A

ointments (however they severely disrupt visual performance)

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28
Q

When is ointment best used? (2)

A

at night before bed (due to the poor vision), or

in an eye with already poor vision

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29
Q

Name 2 disadvantages of ointments?

A

disruption of visual performance

thickeness of ointments can get annoying

30
Q

How can you improve your vision faster after using a gel tear supplement? (1)

A

rub the gel layer across the eye to get better vision faster

31
Q

What happens to gel viscosity when entering the eye?

A

changes

32
Q

What side effect might occur with use of preserved tear supplements?

A

if preserved: more than around 8 drops a day may disrupt epithelium and may cause irritation dry eye symptoms

33
Q

What tear supplement preservative is the most toxic to the ocular surface? (1)

A

Benzoalkonium chloride (BAK)

34
Q

How do newer tear supplement preservatives compare to older ones? (in terms of toxicity)

A

less toxic but not infallible

35
Q

What is pulse dosing?

A

the admin of drugs, usually antibiotics or corticosteroids, in a single, large dose which might be repeated after an interval of days.

36
Q

What is the main advantage to pulse dosing when using steroids? (1)

A

fewer undesirable side effects associated with frequent dosing

37
Q

When and how should you use topical steroids for dry eye? (5)

A 
No evidence based treatment regimes (only clinical based)
Suggest start FML iBD to iQID
Taper slowly
No repeat scripts - prescribe on review
Write to GP
38
Q

Name an example of an effective steroid against ocular surface disease with a good side effect profile (1)

A

Loteprednol. (I’d also accept cyclosporin A honestly)

39
Q

How can dietary supplements help against dry eye? Provide an example

A

The balance between omega 3 and omega 6 helps modulate inflammation in the body

40
Q

What is the ideal ratio of omega 6 to omega 3? What is the ratio of the omegas with the current western diet?

A

Ideal: 15:1

Western diet: 4:1

41
Q

When can dietary supplements be contraindicated? (3)

A

In patients with:
liver disease
arterial fibrillation
bleeding disorders

42
Q

Describe the following features of Cyclosporin A:
A: what type of drug is it?
B: does it have anti-inflammatory effects?
C: Is it used topically or systemically?
D: When is it NOT effective? (1)

A

A: immunomodulatory drug
B: yes, it has anti-inflammatory properties
C: can be used both topically or systemically
D: not effective in iatrogenic dry eye (i.e. dry eye assoc. with corneal surgery and contact lenses)

43
Q

Is cyclosporin A available in australia?

A

Only for Dogs (woof). Vets can prescribe it to a dog.

44
Q

How long does treatment of patients with DED using topical cyclopsorine need to be continued for?

A

extended periods of time, as evidenced by the rarity of a clinical “cure”

45
Q

What is an autologous serum? What is the main advantage of this? (1)

A

it’s where you compound the patients own blood into eye drops. I.e. we create a lubricant that patients (typically i’d assume) don’t become allergic to. Because it’s themselves. Another advantage is favourable biochemical factors (pH, nutrients, etc.)

46
Q

What do autogolous serum eye drops contain? (5) (note: this is an advantage I guess)

A 
Epithelial growth factor
vitamin A
Fibronectin
IgG
Lysomzymes
47
Q

List the disadvantages of autogolous serum eye drops (4)

A

Cost
Useful in severe DED only
Shelf life
Variability in manufacture

48
Q

How does autologous serum enhance epithelial viability? (2)

A

either directly by supporting proliferation and migration of epithelial cells or indirectly by binding and neutralizing inflammatory cytokines

49
Q

Name and briefly describe the 3 types of punctal plugs (3 x 2 pts)

A
  1. Collagen plugs: dissolve over a period of a week (7-10 days), Used diagnostically (may be suggested by a doctor to see how the plugs help and can then later be replaced by more long term plugs)
  2. Silicon plugs: long term dry eye tx - therapeutic (essentially lasts until removed)
  3. Intracanalicular plugs: longest lasting. Go further into the duct. Removal may require surgery. Not relevant to this lecture. [It appears we don’t really use these ones anymore]
50
Q

How does the size and width of collagen plugs compare to silicon plugs?

A

Pretty similar honestly, silicon plugs typically a bit wider though on average

51
Q

As silicon plugs are typically wider than collagen, what is a useful thing we can do prior to insertion of the plugs? (1)

A

punctal dilation and measurement

52
Q

How can we reduce the patient’s blink reflex when performing punctal plug insertion? (1)

A

use anaesthetic

53
Q

What sort of complications can occur with the use of punctal plugs? (8)

A 
rupture of punctum from over dilation (very rare)
discomfort in canthus
cornea/conj abrasion
epiphora
loss of silicone plug
breakage of plug (during insertion/removal)
distal migration of plug 
canaliculatis or dacryocystitis
54
Q

What must you do if the plug migrates distally? (1)

A

requires surgical removal

55
Q

In what type of scenario might a punctal plug cause discomfort in the canthus? (1)

A

if plug doesn’t sit properly, it can cause a bump that can rub and cause discomfort

56
Q

Why might epiphora occur with the use of punctal plugs? (2)

A

hypersecretion due to FB sensation

insufficient drainagae

57
Q

Why don’t we like using intracanalicular plugs anymore?

A

These plugs were installed further beyond the punctum, this meant that if there were an infection, the full cannuliculus would have to be removed

58
Q

How can the patient help us best assess how they are faring with/without punctal plugs? (1) Provide questions they can answer (4)

A

Real time judgement - daily commentary by px, noting: How did it feel? What drops were used? How often used? What environment were they in? (aircon, weather)

59
Q

Should we tell patients how long the colalgen plugs will last? (1) Why? (1.5)

A

No. This would affect their daily diary commentary. Don’t tell them just expect to see a change in the diary notes around the 1 week mark - IF there is NO difference, this means the plugs likely are NOT doing anything

60
Q

Name 4 drug treatments that can be used for dry eye

A

Tear/lipid stimulation preparations
Acetylcysteine
Vitamin A
Tetracyclines

Note: there are others

61
Q

How does acetylcysteine help tx dry eye?

A

reduces tear viscosity in patients with mucous preventing tear distribution

62
Q

How does vitamin A help tx dry eye? (2)

A

specifically used for goblet cell loss and primary vitamin A deficiency

63
Q

How do tetracyclines help tx dry eye? (2)

A

promote posterior lid function and play role in inflammatory control

64
Q

Other than punctal plugs, what are the 4 types of treatments we can use for dry eye?

A

Drugs
Control of lid disease
Contact lenses
Environment (changing environment)

65
Q

How can we change the environment to help tx dry eye? (3)

A

reduce evaporation
room humidifiers (increase humidity, promote moist ocular surface)
spectacles, with/without side shields and moist pads (at night) [reduces air flow over eyes, humidify immediate ocular environment]

66
Q

What is Lipiflow and how does it work?

A

A treatment device specifically designed for effectively removing blockages from the meibmomian glands. Single-use lipiflow activators are placed on the eyes to begin tx, where they deliver a combo of heat and gentle pressure to the inner lids

note: still in trials basically

67
Q

List important factors involved in step 1 of DED management (7)

A

education (about mx, tx, + prognosis)
education (about potential dietary modifications, incl fatty acid supplements)
modify local environment
identification/potential elimination of offending systemic/topical meds
ocular lubricants
lid hygeine + warm compress

68
Q

List important factors involved in step 2 of DED management (7)

A

non-preserved lubricants
tea tree oil tx (for demodex)
tear conservation (punctal occlusion, moisture goggles)
overnight tx (ointment, moisture chamber)
in-office healing/expression of meibomian glands
in-office intense pulsed light therapy (for MGD)
prescription drugs to manage DED

69
Q

List important factors involved in step 3 of DED management (3)

A

oral secretagogues
autologous/allogenic serum eye drops
therapeutic contact lens options (soft bandage lenses, rigid scleral lenses)

70
Q

In step 2 of DED, what prescription drugs can you use to manage? (6)

A

Topical antibiotic or antibiotic/steroid combo applied to lid margins for anterior blepharitis (if present)
Topical corticosteroid (limited duration)
Topical secretagogues
Topical non-glucocorticoid immunomodulatory drugs (e.g. cyclosporin)
Topical LFA-1 antagonist drugs
Oral macrolide or tetracycline antibiotics

OD2 Semester 2 - Applied Clinical Training (63 decks)

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