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Dry Eye Continuum of Care

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           Dry Eye
The Eye Centers of Racine and
          Kenosha

      Dr. Kanwar A. Singh MD
        Dr. I. Paul Singh MD
      Dr. Stephen J. Pruett OD
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Prevalence of Dry Eye Disease
 • 60 million affected worldwide.
 • 1 to 2 million suffer from severe, chronic
   symptoms.
 • 7 to 10 million Americans have some form
   of dry eye needing artificial tears.
 • 33 million adults may be undiagnosed.
 • Sjögren’s - associated dry effects 1% to
   2% of the population.
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Prevalence of Dry Eye Disease

• Average age of a dry eye patient is
  54; most are women.
• 59 million Americans may be
  suffering from Dry Eye Syndrome.
• Dry Eye Syndrome affects 75% of
  people over age 65.
• Common reason for ophthalmologist
  visits.
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What is Dry Eye Disease?

Chronic dry eye disease (CDED) is a
condition caused by many factors that
result in inflammation of the eye and the
tear-producing glands. Inflammation can
decrease the eye’s ability to produce
normal tears that protect the surface of
the eye and keep it moist and lubricated.
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Dry Eye is more than a red eye.
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Dry Eye Is a Continuum of
         Disease
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The Healthy Eye

     Normal tearing
      depends on a
 neuronal feedback loop Secretomotor
                        Nerve Impulses


 Lacrimal
  Glands           Tears Support and Maintain
                         Ocular Surface


                                                 Ocular Surface
                                                Neural Stimulation


                                                  Stern et al, Cornea. 1998:17:584
                                                                                         8


Dry Eye Disease: An Immune-
Mediated Inflammatory Disorder
                                                       Inflammation disrupts
                                                          normal neuronal
                                                         control of tearing.
 Lacrimal Glands:
 • Neurogenic              Interrupted Secretomotor
   Inflammation                 Nerve Impulses
 • T-cell Activation
 • Cytokine Secretion into
   Tears

                        Tears Inflame Ocular Surface

                                                            Cytokines
                                                        Disrupt Neural Arc


                                                           Stern et al, Cornea. 1998:17:584
                                                                 9




Dry Eye Disease Continuum
• Continuum of severity
    ranges from mild to
    severe1
•   Chronic dry eye is the
    result of disease
    progression




                             1Pflugfelder.   Am J Ophthalmol. 2004.
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Multiple Factors in Dry Eye
• Transient discomfort
• May be stimulated by
    environmental
    conditions1
•   Inflammation and
    ocular surface
    damage
•   Altered tear film
    composition2
                 1de   Paiva and Pflugfelder. In: Dry Eye and Ocular Surface Disorders. 2004;
                           2Pflugfelder et al. In: Dry Eye and Ocular Surface Disorders. 2004.
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Role of Inflammation
in Chronic Dry Eye
• Inflammation may be present but not
  clinically apparent
• Cycle of inflammation and dysfunction
• If untreated, inflammation can damage
  the lacrimal gland and ocular surface
• Consequences:
  – Lower tear production
  – Altered corneal barrier function
                                       Pflugfelder. Am J Ophthalmol. 2004.
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  Causes of
  Chronic Dry Eye
                                                           Disruption of normal
Lacrimal Glands:                                        neuronal control of tearing
• Chronic irritation
• T-cell activation
                             Interrupted Secretomotor
• Cytokine secretion into          Nerve Impulses
  tears                                                                   Lacrimal
                                                                          Damage


                            Tears Damage Ocular Surface


                                                                 Cytokines
                                                             Disrupt Neural Arc



                                                                   Stern et al. Cornea. 1998.
                                                                Nelson et al. Adv Ther. 2000.
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  Healthy Tears
• A complex mixture of
 proteins, mucin, and
 electrolytes
   – Antimicrobial proteins:
     Lysozyme, lactoferrin
   – Growth factors &
     suppressors of
     inflammation: EGF, IL-1RA
   – Soluble mucin 5AC secreted
     by goblet cells for viscosity
   – Electrolytes for proper
     osmolarity

                                     Stern et al. In: Dry Eye and Ocular Surface Disorders. 2004.

                               Image adapted from: Dry Eye and Ocular Surface Disorders. 2004.
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  Tears in Chronic Dry Eye
• Decrease in many proteins
• Decreased growth factor
 concentrations
• Altered cytokine balance
 promotes inflammation
• Soluble mucin 5AC greatly
 decreased
   – Due to goblet cell loss
   – Impacts viscosity of
     tear film
• Proteases activated                           Solomon et al. Invest Ophthalmol Vis Sci. 2001.

• Increased electrolytes                                              Zhao et al. Cornea. 2001.
                                      Ogasawara et al. Graefes Arch Clin Exp Ophthalmol. 1996.
                               Image adapted from: Dry Eye and Ocular Surface Disorders. 2004.
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Who Is Likely to Have Dry Eye?

  How Do We Diagnose It?
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Dry Eye Disease: Predisposing
Factors
 • Aging
 • Menopause - Decreased Androgens
 • Allergy Response
 • Environmental Stresses
   – Contact Lens Wear – Low Humidity: Heating/Air Cond.
   – Wind              – Lack of Sleep
   – Air Pollution     – Use of Computer Terminals
 • Ocular Surgery (LASIK, Corneal
  Transplant)
 • Medications
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Medications That May Contribute
to Dry Eye Disease
• Systemic
                             • Topical
  – Antihypertensives
  – Antiandrogens              – Preservatives in
                                 Tears
  – Anticholinergics
  – Antidepressants
  – Cardiac Antiarrhythmic
    Drugs
  – Parkinson’s Disease
    Agents
  – Antihistamines
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Dry Eye Disease:
Autoimmune Triggers
• Systemic Autoimmunity
    – Rheumatoid Arthritis
    – Lupus
    – Sjögren’s Syndrome
    – Graft vs. Host Disease
• All can result in immune-mediated
    inflammation in the eye.
•   Inflammatory mediators secreted into tears.
    – Promote inflammation of ocular surface.
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Current Triggers of Dry Eye
Disease
Environment                                  Rheumatoid Arthritis
Medications                                  Lupus
Contact Lens   Irritation   Inflammation     Sjögren’s
Surgery                                      Graft vs Host



                        Tear
                     Deficiency/   Postmenopause
                                   Meibomian
                     Instability   Gland Disease



       Symptoms of Ocular Surface Disease
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Dry Eye Disease Symptoms
• Discomfort
• Dryness
• Burning, Stinging
• Foreign-Body Sensation
• Gritty Feeling, Stickiness
• Blurry Vision
• Photophobia, Itching, Redness

Note: Symptoms seldom correlate with clinical
  signs.                                Lemp CLAO J 1995;21:221
                                                                                         21


Patient Types with High Incidence
of Dry Eye Disease
  • Women aged 50 or older1
  • Women using postmenopausal hormone
      replacement therapy2
  •   Those with ocular comorbidities3
  •   Contact lens wearers3
  •   Smokers4
  •   Users of artificial tears ≥ 3 times/day

                                                 1Schaumberg  et al. Am J Ophthalmol. 2003;
                                                            2Schaumberg   et al. JAMA. 2001;
                                                                      3Lemp. CLAO J. 1995;
              4Multi-Sponsor Surveys, Inc. The 2005 Gallup Study of Dry Eye Sufferers. 2005.
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Identifying Potential Dry Eye Patients




            1. Do your eyes feel dry, painful, or sore?
       No
            2. Do you experience episodes or periods
              of blurred vision?

            3. How often are your eyes sensitive to light?
            4. Do you have problems with your eyes when
              you are working on a computer, watching TV,
              or reading?

            5. Do you use artificial tears three or more
              times a day?
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Diagnosing Dry Eye Disease

• Patients who answer “yes” to any one of
  the previous questions should be evaluated
  for dry eye disease
• Many clinicians use clinical tests plus
  symptoms and patient history to diagnose1




                                  1Nichols   et al. Cornea. 2000.
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Clinical Presentation Can Vary in
Severity
                  Mild     Severe


    Slitlamp



    Fluorescein
     Dye Stain

                               Lemp, 1995; Marsh et al, 1999
                                    25




Schirmer Test
                Without
                  Anesthesia
                • Measures reflex
                  tear secretion.

                With Anesthesia
                • Eliminates
                  stimulated
                  tearing.
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Potential Severe Consequences
of Untreated Dry Eye Disease




   Sterile Melting   Bacterial Keratitis
                                                                                            27


    Symptoms of Dry Eye
Dry Eye Severity
                               1              2               3                  4
Level

                            Mild         Moderate          Severe            Severe
General Symptoms
                          Symptoms       Symptoms        Symptoms          Symptoms

Symptoms: Itchy, Sandy,     Never to
                                          Sometimes        Frequent           Always
Gritty, Dry                 Seldom


Discomfort: Stinging,
                              No             Yes             Yes                Yes
Burning, Pain


Vision: Blurring,
                              No              No          Sometimes           Usually
Interrupted


                          Less than 2X   Several times   Several times     Several times
Use of Artificial Tears
                            per day        per day         per day           per day

                                                             McDonnell et al. ARVO. 2004.
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What Is    Restasis ™?


• Ophthalmic emulsion of cyclosporine
  0.05%.
  – Prescription therapy for dry eye disease.
  – Restasis™ is FDA approved to increase tear
    production in patients whose tear
    production may be reduced by
    inflammation of the eye associated with
    keratoconjunctivitis sicca.
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Left Untreated, Chronic Dry Eye
May Become a Progressive Disorder
 • Patients suffering from dry eye disease
  may move between severity levels and
  can become worse, if untreated1
   – Disease management options can be adjusted
     for individual patients depending on disease
     severity



                                     1Nelson   et al. Adv Ther. 2000.
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Summary
• Dry eye is a prevalent yet underdiagnosed disease
    ranging from mild to severe, episodic or chronic
•   Episodic dry eye can be due to external factors
•   Chronic dry eye can be a progressive disease with
    underlying pathophysiology of inflammation and altered
    tear composition
•   Certain patient types have a high incidence of dry eye
    and should be diagnosed with a combination of signs
    and symptoms
•   A continuum of care is available to treat both episodic
    and chronic dry eye across the range of severity levels
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Do you think you have dry eyes?

Make an appointment.

• We can examine your eyes to see which
 treatment is correct for you.
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Thank You.

				
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