wk4: AED Dry eye Mx Flashcards
How can you classify dysfunctional tear syndrome patients? (3)
With lid margin disease
Tear distribution problems
Without lid margin disease
How can you classify dysfunctional tear syndrome patients with lid margin disease? (2)
anterior lid margin
posterior lid margin
How can you classify dysfunctional tear syndrome patients with tear distribution problems? (5)
conjunctivochalasis lid + lash malposition elevated surface lesions reduced or incomplete blinking other
How can you classify dysfunctional tear syndrome patients without lid margin disease? (4)
severity level 1-4
How can we treat dysfunctional tear syndrome patients with anterior lid disease? (2)
lid hygeine
topical antibiotic
How can we treat dysfunctional tear syndrome patients with posterior lid disease? (3)
Hot compresses and massage, and, it that doesn’t work:
tetracyclines or
topical steroids
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: lubrication/contact lenses
B: lubrication/steroids
C: lubrication/contact lenses
D: lubrication/steroids
And if none of these works, surgery
How do we grade level 1 dysfunctional tear syndrome? (2)
1 or more of:
mild/moderate symptoms + no signs
mild/moderate conjunctival signs
How can we manage level 1 dysfunctional tear syndrome? (4)
education/counselling
environmental modifications
control of systemic modifications
perserved tears/allergy control
How do we grade level 2 dysfunctional tear syndrome? (5)
moderate/severe symptoms tear film signs mild PEE conj. staining visual signs
How can we manage level 2 dysfunctional tear syndrome with no inflammation present? (3)
If no inflammation: unpreserved tears/gels/ointment
How can we manage level 2 dysfunctional tear syndrome with inflammation? (4)
If inflammation: steroids/cyclosprine/nutritional supplements/secretagogues
How do we grade level 3 dysfunctional tear syndrome? (4)
severe symptoms
marked SPK
central corneal stain
filamentary keratitis
How can we manage level 3 dysfunctional tear syndrome? (3)
tetracyclines autologous serum punctal plugs (after inflammatory control)
How do we grade level 4 dysfunctional tear syndrome? (3)
severe symptoms
severe corneal staining/erosion
conjunctival scarring
How can we manage level 4 dysfunctional tear syndrome? (5)
topical vitamin A contact lenses acetylcysteine moisture goggles surgery
List examples of dry eye treatment options for the following categories:
A: Palliative/protective treatment (2)
Supplements
Soidum Hyaluronate
Autologous serum eye drops (also is anti-inflamm)
List examples of dry eye treatment options for the following categories:
B: Anti-inflammatory (4)
Flaxseed oil/fish oil
Topical corticosteroids
Oral tetracycline (MMP9)
Autologous serum eye drops
List examples of dry eye treatment options for the following categories:
C: immunomodulation (1)
Topical cyclosporine
Other than palliative, anti-inflammatory and immunomodulation, what other type of treatment option exists for dry eye? (1)
Biomechanical tx
What differences are there between commercial eye drops?
No real differences. Any differences stated by companies are from in vitro studies and don’t represent what happens in humans
What is the role of tear supplements? (3)
used to hydrate ocular surface, counteract dehydration, and reduce lid friction
What is the major problem we face with tear supplements? (2)
Not instilled frequently enough or
necessity of long term use not understood by patient (education important)
How can liquid tear supplements vary? (4)
can vary in: viscosity contact time friction wetting properties
How do the mechanisms of action for liquid tear supplements vary? (2)
some improve adherence to glycocalyx
others absorb water and improve tear distribution
How do gel tear supplements differ from liquids (1) and ointments? (1)
Increased contact time across cornea than liquid
Less profound effect on vision than ointments
Between liquids, gels and ointments, which has the better contact time?
ointments (however they severely disrupt visual performance)
When is ointment best used? (2)
at night before bed (due to the poor vision), or
in an eye with already poor vision
Name 2 disadvantages of ointments?
disruption of visual performance
thickeness of ointments can get annoying
How can you improve your vision faster after using a gel tear supplement? (1)
rub the gel layer across the eye to get better vision faster
What happens to gel viscosity when entering the eye?
changes
What side effect might occur with use of preserved tear supplements?
if preserved: more than around 8 drops a day may disrupt epithelium and may cause irritation dry eye symptoms
What tear supplement preservative is the most toxic to the ocular surface? (1)
Benzoalkonium chloride (BAK)
How do newer tear supplement preservatives compare to older ones? (in terms of toxicity)
less toxic but not infallible
What is pulse dosing?
the admin of drugs, usually antibiotics or corticosteroids, in a single, large dose which might be repeated after an interval of days.
What is the main advantage to pulse dosing when using steroids? (1)
fewer undesirable side effects associated with frequent dosing
When and how should you use topical steroids for dry eye? (5)
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
Name an example of an effective steroid against ocular surface disease with a good side effect profile (1)
Loteprednol. (I’d also accept cyclosporin A honestly)
How can dietary supplements help against dry eye? Provide an example
The balance between omega 3 and omega 6 helps modulate inflammation in the body
What is the ideal ratio of omega 6 to omega 3? What is the ratio of the omegas with the current western diet?
Ideal: 15:1
Western diet: 4:1
When can dietary supplements be contraindicated? (3)
In patients with:
liver disease
arterial fibrillation
bleeding disorders
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: 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)
Is cyclosporin A available in australia?
Only for Dogs (woof). Vets can prescribe it to a dog.
How long does treatment of patients with DED using topical cyclopsorine need to be continued for?
extended periods of time, as evidenced by the rarity of a clinical “cure”
What is an autologous serum? What is the main advantage of this? (1)
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.)
What do autogolous serum eye drops contain? (5) (note: this is an advantage I guess)
Epithelial growth factor vitamin A Fibronectin IgG Lysomzymes
List the disadvantages of autogolous serum eye drops (4)
Cost
Useful in severe DED only
Shelf life
Variability in manufacture
How does autologous serum enhance epithelial viability? (2)
either directly by supporting proliferation and migration of epithelial cells or indirectly by binding and neutralizing inflammatory cytokines
Name and briefly describe the 3 types of punctal plugs (3 x 2 pts)
- 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)
- Silicon plugs: long term dry eye tx - therapeutic (essentially lasts until removed)
- 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]
How does the size and width of collagen plugs compare to silicon plugs?
Pretty similar honestly, silicon plugs typically a bit wider though on average
As silicon plugs are typically wider than collagen, what is a useful thing we can do prior to insertion of the plugs? (1)
punctal dilation and measurement
How can we reduce the patient’s blink reflex when performing punctal plug insertion? (1)
use anaesthetic
What sort of complications can occur with the use of punctal plugs? (8)
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
What must you do if the plug migrates distally? (1)
requires surgical removal
In what type of scenario might a punctal plug cause discomfort in the canthus? (1)
if plug doesn’t sit properly, it can cause a bump that can rub and cause discomfort
Why might epiphora occur with the use of punctal plugs? (2)
hypersecretion due to FB sensation
insufficient drainagae
Why don’t we like using intracanalicular plugs anymore?
These plugs were installed further beyond the punctum, this meant that if there were an infection, the full cannuliculus would have to be removed
How can the patient help us best assess how they are faring with/without punctal plugs? (1) Provide questions they can answer (4)
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)
Should we tell patients how long the colalgen plugs will last? (1) Why? (1.5)
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
Name 4 drug treatments that can be used for dry eye
Tear/lipid stimulation preparations
Acetylcysteine
Vitamin A
Tetracyclines
Note: there are others
How does acetylcysteine help tx dry eye?
reduces tear viscosity in patients with mucous preventing tear distribution
How does vitamin A help tx dry eye? (2)
specifically used for goblet cell loss and primary vitamin A deficiency
How do tetracyclines help tx dry eye? (2)
promote posterior lid function and play role in inflammatory control
Other than punctal plugs, what are the 4 types of treatments we can use for dry eye?
Drugs
Control of lid disease
Contact lenses
Environment (changing environment)
How can we change the environment to help tx dry eye? (3)
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]
What is Lipiflow and how does it work?
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
List important factors involved in step 1 of DED management (7)
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
List important factors involved in step 2 of DED management (7)
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
List important factors involved in step 3 of DED management (3)
oral secretagogues
autologous/allogenic serum eye drops
therapeutic contact lens options (soft bandage lenses, rigid scleral lenses)
In step 2 of DED, what prescription drugs can you use to manage? (6)
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
