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(1) Shared care and ocular therapeutics > Week 3 - Atrifical tears, lubricants and non-pharmacological management of DED > Flashcards

Week 3 - Atrifical tears, lubricants and non-pharmacological management of DED Flashcards

1
Q

Management of DED level 1

A
  • education and environmental/dietary modifications
  • tear supplements
  • eye lid therapy
  • medication changes
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2
Q

Management of DED level 2

A
  • preservative free
  • pharmaceuticals (topical anti-inflammatories, tetracyclines, secretagogues)
  • punctal plugs
  • moisture chamber spectacles
  • Lipiflow
  • demodex
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3
Q

Management of DED level 3

A
  • autologous serum
  • oral secretagogues
  • contact lenses
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4
Q

Management of DED level 4

A
  • amniotic membrane
  • permanent punctal occlusion
  • surgery
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5
Q

Level 1
Education and Environmental/Dietary Modifications

A
  • Chronic nature of the condition
  • Omega 3
  • Omega 6
  • Environmental modifications
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6
Q

Chronic nature of DED

A
  • Is there a cure?
  • Only very occasionally
  • The first visit where you explain the condition is critical
  • Talk about managing, not curing
  • You have to be clear that the patient may be managing this for the rest of their lives
  • Why should they not just ignore it?
  • Risk of reduced vision / infection / scarring (visual loss)
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7
Q

Omega 3 and 6

A
  • Omega 3 (vegetables, nuts, cereals, poultry)
  • Omega 6 (fish such as salmon, mackerel, tuna)
  • Diet or supplements?
  • Research has shown mixed results and the DEWS II report from 2017 reached no firm conclusion
  • “a broad range of systemic anti-inflammatory effects, including inhibiting the production of several key pro-inflammatory cytokines”
  • Contra-indications, including liver disease, atrial fibrillation and bleeding disorders; in these cases, medical advice should be sought prior to commencing supplementation
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8
Q

Environmental Modifications

A

What can the patient change?
* Air conditioning/cigarette smoke
* Wrap around glasses/sunglasses
* Lowering VDU monitor height
* Regular breaks from VDU
* Increase humidity in the home
* Blinking (normally 15-20 per minute)

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9
Q

Level 1
Tear Supplements

A
  • Used to maintain ocular surface hydration and to replace components of the tears, which may be absent or reduced
  • Generally have a short retention time on the ocular surface and require regular use
  • None of these treatments have been shown to be curative, but are used with the aim of improving patient symptoms
  • (better to say “management” to patients, than “treatment”?)
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10
Q

Level 1
Tear Supplements First Line

A

Carbomer 980
Hypromellose
Polyvinyl Alcohol

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11
Q

Carbomer 980

A
  • Common first line option on NHS formularies
  • Research has shown it can be useful for increasing tear film thickness, protecting against desiccation and promoting tear retention at the ocular surface
  • There does not appear to be any substantial difference in effectiveness among the different formulations and products (commonly 0.2%)
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12
Q

Hypromellose

A
  • Still on many formularies
  • Research shows it is safe and effective lubricant for mild to moderate DED
  • Used in combination with lots of other ingredients
  • Concentration can range from 0.2-0.8%
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13
Q

Polyvinyl Alcohol

A
  • Not on every formulary
  • Definitely on Lothian
  • Viscosity enhancing agent (as are the majority of dry eye preparations)
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14
Q

Level 1
Tear Supplements Second Line

A

Carmellose sodium
Sodium Hyaluronate
HP-Guar

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15
Q

Carmellose sodium

A

aka carboxymethylcellulose (CMC)
• Commonly used viscosity enhancing agent
• “Can bind to corneal epi cells and promote epithelial cell healing”
• Research shows success in managing mild to moderate DED

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16
Q

Sodium Hyaluronate

A

aka hyaluronic acid (HA)
• Functions as a tissue lubricant, it is a component of cartilage and found in synovial fluid, the vitreous and the aqueous humour
• Increases viscosity and provides lubrication
• “studies have demonstrated its ability to bind to ocular surface cells and its potential wound healing properties”
• Concentrations from 0.03-0.4%

17
Q

HP-Guar

A
  • Thickener
  • Is dispensed as a drop but on contact with the tears, the reaction changes it into a low viscosity gel
  • (reduction in pH, dilution of sorbitol leads to an increased density of the HP-Guar)
18
Q

Ointments

A
  • Good for night time use to protect the cornea during sleep (avoid recurrent
    erosions)
  • VERY thick
  • Common main ingredient is paraffin
  • Can also include vitamin A (Hydramed night sensitive), lanolin (lacrilube),
    vitamin A and lanolin (Hycosan Night/Hylo Night), mineral oil and lanolin(Xailin night)
  • Carbomer 980 is also a gel and can be used at night time.
19
Q

Lipid Based

A

For primary evaporative dry eye.

Replace/enhances the lipid layer to prevent evaporation of the aqueous layer. Therefore interrupting the feedback loop that leads to excessive aqueous production.

Examples include:
* Castor oil
* Mineral oil
* Soybean oil

20
Q

Combination Drops

A
  • Drops that contain multiple ingredients to try and improve the tear film.
  • Examples include
  • Optive Fusion – mixture of CMC, sodium hyaluronate and glycerine
  • Thealoz Duo – mixture of sodium hyaluronate and trehalose (an osmoprotectant)
  • Hylo-Care – mixture of sodium hyaluronate and dexpanthenol (aids corneal healing)
  • Systane Balance – mixture of HP-Guar and mineral oil
  • Visu-XL – crosslinked sodium hyaluronate and co-enzymes
21
Q

Mucus

A
  • On slit lamp you may see mucus filaments or a mucus plaque
  • Patient may report sticky/stringy discharge
  • Ilube: eye drops, 5% acetylcysteine, 0.35% Hypromellose
  • Instil one or two drops into the affected eye three or four times daily
    (CMG on Dry Eye)
  • Stings on installation
  • Contains BAK
  • Not available to entry level, must be IP
22
Q

Acetylcysteine

A
  • Mucolytic
  • “has been shown to dramatically reduce the viscosity and tenacity of sputum”
  • Combined with hypromellose
23
Q

Acetylcysteine dosage

A
  • Standard dosage is 3-4 x a day
  • But with preservative free formulations this can be increased to as often as the patient feels necessary
  • If there is significant corneal staining I will ask for 1-2 hourly application until the staining is controlled then it can be reduced
    to a maintenance dose
  • Overuse of preserved drops can lead to a toxic reaction
24
Q

Level 1
Medication Changes

A
  • When did the symptoms start?
  • Does this coincide with any changes to existing or new medications?
  • DO NOT CHANGE MEDS WITHOUT CONSULTING WITH THE APPROPRIATE DOCTOR

Common examples – NSAIDs, diuretics, vasodilators, antihistamines, antidepressants, beta blockers, HRT

25
Q

Level 2
Preservative free

A
  • Using preserved drops more than 4 x a day and long term can lead to a toxic reaction (particularly BAK, not just dry eye drops)
  • DED patients can also be particularly sensitive to preservatives
  • Check if the drop is available preservative free or change formulation
  • Think of this when a patient is reporting discomfort after previously being on the drops without problems or has increased the frequency.
26
Q

NHS Formulary

A
  • Within Scotland this varies health board to health board. You
    must know what is available in the area you work in.
  • Also be careful with the names of products when requesting a
    repeat Rx from the GP
27
Q

Level 2
Punctal Plugs

A
  • Punctal plugs are designed to improve retention of the tears on the
    ocular surface, by preventing the normal drainage via the punctum
  • Temporary plug made of collagen, which is gradually absorbed over a
    period of 3 days to 6 months – usually intercanilicular
  • Semi-permanent plug made of silicone, which can stay in place for
    around a year
  • Contraindications – EDE, CL wear, bleph/MGD
  • Risks – infection, epiphora, loss, migration
28
Q

Level 2
Moisture Chamber Spectacles

A
  • Reduce the evaporation rate of the tears from the ocular surface by increasing the humidity within the chamber area
  • Addition of side panels to the side of spectacles, to prevent relatively dry air flowing in from the outside. Small moist sponges can also be placed on the inside of the frames to increase humidity further
29
Q

Level 3
Contact Lenses

A
  • Proposed that lenses can be used to reduce the tear evaporation rate
  • Rigid gas permeable lens or a low water content soft lens
  • Increased risk of corneal vascularisation and infection, and possible corneal ulceration
  • Generally only tried in more severe cases of DED, for which all other strategies have proved unsuccessful
30
Q

Level 4
Permanent Punctal Occlusion

A
  • Following a successful trial of temporary or semi-permanent punctal
    plugs
  • Consider when plugs are knocked out regularly
  • Most common methods are argon laser and thermal cautery
  • Another method is to stitch the punctum closed or use a punctal patch
31
Q

Level 4
Surgery

A
  • Lid tarsorrhaphy
  • Autologous submandibular gland transplantation (most common
    of salivary gland transplant options)
  • Amniotic membrane transplantation
32
Q

When to refer?

A
  • 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 unidentified 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 1 week) to ophthalmology.

(1) Shared care and ocular therapeutics (20 decks)

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