This is why… People are still self treating. OCULAR SURFACE DISEASE AND DRY EYE SYNDROME why are we still talking about this? The 2008 Gallup Survey of Dry Eye Sufferers Reports That Patients Are Frustrated With Their Dry Eye Condition Blepharitis Prevalence Study 3  This survey of dry eye sufferers indicated that  72% of patients had physicians recommend artificial tears for their dry eye problem (n=541)  82% of patients somewhat agree or strongly agree that they wish there was something more effective to treat their dry eye (n=751)  97% of patients report that their dry eye condition is frustrating (n=751) Methodology: • Computer-assisted telephone interviewing using a questionnaire designed to elicit information on symptoms suggestive of blepharitis • N = 5,019 • Questions were asked regarding past 12 months: – – – – Itching/burning eyelids Crusts or flakes on eyelids upon awakening Eyelids heavy / puffy Eyelids red upon awakening Lemp MA, Nichols KK. Blepharitis in the United States 2009: A survey‐based perspective on prevalence and treatment. Ocular Surface 2009;7(2): S1‐14 The 2008 Gallup Study of Dry Eye Sufferers. Patient Impact 2007 International Dry Eye Workshop Prevalence and Frequency of Symptoms % Extrapolated Prevalence* At least 1 symptom in past 12 months 79 182 million More than 1 symptom in past 12 months 63 145 million At least 1 symptom in past 12 months at least half the time 32 74 million Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface. *Based on percentage of US population of ~229 million ≥18 years of age in 2008. Lemp MA, Nichols KK. Blepharitis in the United States 2009: A survey‐based perspective on prevalence and treatment. Ocular Surface 2009;7(2): S1‐14. DEWS Delphi Panel Causes and Exacerbations of Ocular Surface Disease Environmental It is important to make sure we are asking about work, home and sleeping environment. Treat ocular inflammation    Restasis Soft steroid gtts NSAID orals and gtts Inflammation: CD4+ T-Cells   Inflammatory mediated response cascade Can live for 6 months on the ocular surface Helps explain the chronic progressive nature of the disease  No quick fixes  Combined treatment modalities  Allergies    Allergies The ocular allergic reaction is an IgE antibodydependent hypersensitivity response. Inflammatory response Causes disruption of the mucin, aqueous, lipid layers Lid disease Mast cell degranulates releasing histamine Meibomian gland dysfunction (MGD) is now considered the leading cause of dry eye according to the published findings of the 2011 International Workshop on MGD. DOI:10.1167/iovs.10-6997 Investigative Ophthalmology & Visual Science, Special Issue 2011, Vol. 52, No. 4 Copyright 2011 The Association for Research in Vision and Ophthalmology, Inc. Lid disease Patients with Lid Disease Chief Complain or reason for exam. Percentage of patients who of some sort of lid disease present Patients Patients may may not not seek seek treatment treatment specifically specifically for for blepharitis blepharitis Lemp MA, Nichols KK. Blepharitis in the United States 2009: A survey‐based perspective on prevalence and treatment. Ocular Surface 2009;7(2): S1‐14. Graph reproduced with permission from Campbell Alliance group. Lid Disease Cascade “The lack of concordance between signs and symptoms presents a problem in the diagnosis of the disease and the assessment of severity”Dr. Michael Lemp Diagnostic Testing      Diagnostic: TearLab History/ OSDI index Vital dyes- quality Schirmers- tear production Tear Lab- osmolarity InflammaDry- MMP (not available in the US at this time) osmolarity values above 308 mOsms/L are generally indicative of dry eye disease. Will we ever diagnose and treat ocular surface disease like we treat glaucoma? Covered by VSP Diagnostic: InflammaDry RPS Treatment  Elevated MMP may be the best indicator of dry eye Decreased MMP (matrix metalloproteinase-9) activity  Elevated MMP may be the best indicator of dry eye     Normal Level of MMP is 0-40ng/mL Doxycycline or Azasite Lid Wash/Wipes Steroid or combo for acute phase Omega 3: EPA anti-inflammatory effect Autologous Serum  Blood Draw: Virology Testing HIV  Hep A IGM  Hep B Core Antibody IGM  Hep D Surface Antigen  Hep C Virus Antibody  O’brien Pharmacy Custom Compounding   Fax: 913-322-0002  Ph: 913-322-0001  Scleral Lenses  Moisture Chamber Fill with preservative free Optive  9% sodium chloride inhalation solution  5% Transdermal Cream in a Versa Base.   BID DHEA (Dehydroepiandrosterone) 1% TID  anabolic properties that upregulate cell division and repair   0.1% vitamin A ointment (retinoic acid)  cell membrane repair and speeds epithelial growth Lacrisert sustained release Plugs… Why don’t we do them more? Plugs… Why don’t we do them more?   Can make the condition worse Complications Awareness  Ejection  pyogenic granuloma  Dacryocystitis  Plugs 1. 2. 3. 4. Temporary collagen Standard long term plug of choice Oasis Form Fit Lacrimedics Medium term occlusion Maskin Probe Procedure Gush of sequestered meibum Takes me about 30 minutes to do upper and lower lids of both eyes. I was able to open about 12 glands upper and lower lids OD,OS with multiple resulting in a gush of meibum being released. MASKIN PROBE Theory Intraductal fibrotic and neovascular membranes. Disposable and Inexpensive These were able to be opened up by probing allowing sequestered plug of meibum to escape. Anesthetize the lids  Topical: Leiter’s Compounding Pharmacy  8% lidocaine with 25% jojoba in a petrolatum ointment base. Place a drop of proparacaine 0.5% or tetracaine 0.5% solution in the conjunctival sac.  Place a generous amount of anesthetic ointment on the lower lid margin using a sterile cotton tipped applicator.  Repeat application every 5 minutes for 15-20 minutes  Procedure TIP Procedure Procedure Even with topical anesthetic the patient usually jumps a little when the probe breaks through the membrane. Supply List     Maskin Aluminum Handle, Male Fitting $99 Starter Kit with 3-1mm probes 2-2mm probes $79 10 of any size for $150 Anesthetic Gel $37 Supply Information 3360 Scherer Drive North, Suite B St. Petersburg, FL 33716 Office: (727) 209-2244 / (800) 637-4346 Fax: (727) 341-8123 Leiter’s Compounding pharmacy. 1700 Park Avenue . Suite 30 San Jose . California 95126 Ph. 800-292-6773 . Ph. 408-292-6772 . Fx. 408-288-8252 Leiterrx.com