Ocular Surface Wellness
The Basics
Jack L Schaeffer OD FAAO
Marc Bloomenstein OD FAAO
Paul Karpecki OD FAAO
Ocular Surface Wellness
• Ocular surface wellness means re-envisioning our role
as eye care practitioners (ECPs) to include helping
patients maintain good ocular surface health—not just
treating the ocular surface when it’s compromised
• Wellness requires a proactive stance to maintain ocular
surface health
• Currently we live in a reactive treatment mode
2
Prevention: Action to Maintain Wellness
• Primary prevention — reducing incidence of disease1
– Prevent initiation of disease process
– Vaccination, healthy habits, smoking cessation
• Secondary prevention — early detection1
– Ideally before symptoms occur
– Screening, check-ups, early intervention
• Tertiary prevention — improving outcomes1
– Help for those with manifest disease1
– Glycemic control for diabetics, nutritional supplementation
for AMD
3
Wellness Today
• The conventional medical model is
disease-oriented
• Patients interact with medical system to
regain health, not to maintain health
And that’s a problem!
• The US is in the midst of a chronic disease
epidemic2
• Many costly chronic diseases linked to
modifiable lifestyle factors—smoking,
diet, activity, sustained stress2,3
1 in 3 US adults is obese
1 in 5 US adults smokes
Less than ¼ of Americans consume
5 or more servings of fruits and
vegetables daily
4
Ocular Surface Wellness: The Opportunity
• Active maintenance of OS health supports patients’
long-term
– Vision quality
– Healthy-looking eyes
– Ocular comfort
– Successful CL wear
– Contact lenses change the tear film dynamics and the ocular
surface
– Young adults are the demographic that will benefit the most
5
Optimizing Vision
• Efforts to prevent or slow OS pathology
help preserve vision
• Tear film irregularity can affect retinal
image quality16
• DE patients experience
– Reduced contrast sensitivity17
– Fluctuating vision
– Impact on ease of daily activities (eg,
reading, computer, driving, TV)18
– Discomfort with contact lenses19
6
Optimizing Vision for
Contact Lens Wearers
• Estimated 37 million US contact lens wearers20
• To perform optimally, CLs need a robust tear film21
• Dissatisfaction with vision is the second most common
reason for CL dropout22,23
• Age-related changes to the tear film and OS, combined
with changes in refractive needs, can make CL wear
more challenging and lead to dropout20,24
7
Optimizing Vision for
Ocular Surgery Candidates
• Refractive and cataract surgery patients
have high expectations for postop
comfort and vision
• Visual outcomes (and postop comfort)
influenced by preop OS conditions25-29
• It is our responsibility to prepare our
patients for surgery
8
Threats to Ocular Surface Wellness: Allergy
• Prevalence of allergic conjunctivitis
increasing globally
• Affects 15% to 40% of US
population40-42
• Typically mild, but interfere with
quality of life42
Itch
• Significant overlap between
42.2%
presentations of DE and allergy40
• Eye exams may not coincide with
seasonal allergy symptoms—
proactive questioning important
57.7% Itch
45.3% Dryness
Dryness
54.6%
9
Threats to Ocular Surface Wellness:
Dry Eye and Blepharitis
• DE and blepharitis among the
most common conditions eye
physicians encounter43,44
– Using a very restrictive definition,
DE affects nearly 5 million
Americans aged 50 and older44
– Eye care practitioners may see
blepharitis in ~40% of patients45
10
Threats to Ocular Surface Wellness:
Dry Eye and Blepharitis
• Blepharitis comprises a number of inflammatory eyelid
conditions and comorbidities46
–
–
–
–
Dry eye
Chalazion
Hordeolum
Conjunctivitis
– Keratopathy
• MGD (a form of blepharitis) may be the most common
cause of evaporative DE45,47,48
11
Threats to Ocular Surface Wellness:
Medication Use
• Some common systemic meds increase risk of DE
symptoms
–
–
–
–
–
Antihistamines62-64
Antianxiety medications63,64
Antidepressants63,64
Diuretics62,64
Oral corticosteroids63
12
© 2014 Novartis
Ocular Surface Wellness In PRACTICE
• My practice is looking broadly at wellness; our approach
includes:
– Regular yearly eye exams
– Children with refractive error evaluated every 6 months
– Comprehensive contact lens exam and follow-up visit for all
contact lens patients
– Monitoring contact lens compliance
– Adopting myopia prevention treatment strategies
13
Ocular Surface Wellness In PRACTICE
• DR KARPECKI
• DR BLOOMENSTEIN
OSW: Revising the Office Medical Strategy
In my office:
• Most of my patients come to the practice for vision care
• Specifically, they want the glasses or contact lenses
their vision plan allows
• But OSW is essentially medical, which requires that
patients and doctors have a new mind-set
– ECPs offer more than glasses: we help maintain ocular
surface health—which has value
– A healthy ocular surface can help optimize vision, comfort,
and cosmesis
15
Integrated Health Care Model
• “Medical model” is overused—“integrated health care
model” is a better term
• Integrated Health Care Model is the essence of proactive vs
reactive care
• Help patients understand use of medical insurance and the
value of communication between OD and patient’s other
providers, eg:
–
–
–
–
–
Primary care physician
Endocrinologist
Dentist
Neurologist
Dermatologist, etc.
16
See Children at Appropriate Intervals
• In my practice, Children and Teens with vision or ocular
surface problems are seen every 6 months
– Children’s eyes change rapidly and need reassessment
– Frequent monitoring & counseling on compliance (if contact
lens wearer)
– Instill and reinforce good habits while patients are young
18
Contact Lens Compliance is
Important at All Ages
• Contact lenses affect the tear film and ocular surface5
• Goal is to minimize that effect and maintain long-term
ocular health in all patients
• Choice of contact lens solution is important
• Appropriate lens care is critical
–
–
–
–
Rub and rinse
Clean lens cases and replace them as instructed
Lens disposal at the correct interval
On follow-up use fluorescein stain to evaluate lens/solution
compatibility6,7
– Always use the latest technologies and lenses
19
Check for Ocular Surface
Conditions in All Patients
• Understand that although ocular surface issues can
affect vision, this is medical care, not vision care
• Communicate with patient’s primary care physician
regarding chronic medical conditions (eg, Sjogren’s
syndrome)
21
To Maintain and Restore Wellness Look for
and Treat Problems
•
•
•
•
•
•
•
•
•
Meibomian gland dysfunction
Lagophthalmos
Epithelial membrane basement dystrophy
Conjunctivochalasis
Aqueous-deficient dry eye
Blink pattern deficiencies
Keratitis
Stem cell deficiency
Tear film abnormalities
22
© 2014 Novartis
Make Use of New Ocular Surface Diagnostic
Technology
• New tests add useful information
–
–
–
–
–
–
–
–
Tear osmolarity
Tear MMP-9 level
Interferometry
Incomplete blink
Gland expression
Sjogren’s antibody testing
Topography
Meibography
• Enable detection of early-stage disease processes and
monitoring of the tear film
23
© 2014 Novartis
Treatment Modalities
•
•
•
•
•
•
Punctal occlusion
Pharmaceuticals (including oral meds)
Thermal pulsation/meibomian gland expression
Lid hygiene
Antibiotics/anti-inflammatories
Lipid enhancing and mucomimetic tears
24
© 2014 Novartis
Contact Lenses and the Ocular Surface
• Develop a OSD protocol for your office as part of a
comprehensive Contact lens evaluation
• Medical billing protocol for those with Ocular Surface
issues
• Charge a separate fee for the OSD work up
• NEVER as part of the vision care managed care exam
25
© 2014 Novartis
Contact Lenses and the Ocular Surface
• Ocular Wellness means understanding of preventive
measures and the patients overall Ocular and systemic
Health
• GP lenses are considered the safest lens modality
• There is an inherent responsibility to ensure long term eye
and corneal health
• There is also a responsibility to create the best Vision
possible for our patients
26
© 2014 Novartis
Contact Lenses and the Ocular Surface:
Challenges
• Staining
• Corneal
• Conjunctival drying/ goblet cell destruction
• 3 and 9 desication ( nasal temporal)
• Limbal changes
• topographical changes
• Lid abnormalities
• GPC
• deposits
• warped lenses
27
GP Lenses and the Ocular Surface
• Scleral Lenses
• These modalities create their own challenges and
complications
• Replacement schedules
• Debri
• Long term effects on the cornea , Limbus, and
Conjunctiva
• Clearance
28
GP Lenses and the Ocular Surface
• Why would anyone wear a GP lenses longer than one
year?
• Structure changes
• Deposits
• Scratches
• What about 6 months
30
© 2014 Novartis
Contact Lenses and Vision
• Multifocals VS Monovision
• New materials: change yearly
• Over refractions : every visit : .25 diopter
• Toric and bitoric designs
31
© 2014 Novartis
Involve the Entire Office
• Success with OSW in the practice requires buy-in from
the entire staff
• Staff buy-in to OSW efforts requires ongoing staff
education so they understand:
–
–
–
–
Types of ocular surface conditions
Ocular surface treatments
Importance of treating ocular surface conditions
Importance of proactive history taking by technicians
32
© 2014 Novartis
Practice Impacts of Preventive Care
• Additional staff training creates a more skilled staff
• Staff pride: Staff feels elevated by working in an integrated
health care model
• Increased referrals by patients who appreciate
comprehensive approach to health care
• Greater patient acceptance of lens replacement schedules
• Increased referrals from primary care physicians as a result
of open communications
34
Bloomenstein Draft 12-4-14
Best Practices in Dry Eye
Patient Management
*
*Alcon provided sponsorship
for a Summit planning meeting
and publication
What Is a Best Practice?
• Screening, diagnosing, and treating early signs of dry eye is a
relatively new thought process
− Most ODs wait for a symptom or significant corneal involvement
− Not thinking proactively
• The multifactorial nature of the disease creates confusion and
different interpretations
• Is a consensus a best practice?
• Can there be only one?
37
What Is a Best Practice?
• Is it one that catches the majority of persons with the disease?
• One that makes it easy for providers to diagnose the disease?
• One that makes treatment easy and effective?
− For the provider?
− For the patient?
− For both?
• Should a best practice be one that solves all the problems above?
− Simplicity!
38
Breaking the Cycle of White Noise
•
•
•
•
•
•
•
•
•
LWE
OPI
TBUT
TFOS
DED
OSDI
Ferning
MGD
CCh
− We have made things worse! Not easier!
• WTF
39
Published Attempts at Best Practices
• AOA Guidelines (2002)
• Delphi Panel (2006)
• The Dry Eye Workshop (2007)
• OD Canadian Consensus (2014)
40
A Lot Has Changed Since
The Last Protocol…
Technology Innovations: 2002–2005
Palm Treo PDA
BlackBerry
Facebook
42
New Dry Eye Treatments and Diagnostic Tools:
2002–2005
Meibography
43
2003: AOA Optometric Clinical Practice Guideline on Care
of the Patient With Ocular Surface Disorders
Care of the Patient With Dry Eye (AOA Quick Reference Guide). St. Louis, MO: American Optometric Association; 2003.
44
AOA Had It Going in the Right Direction…
• What happened?
− Were the protocols too simple?
• Why was this not adopted?
− Who failed? The AOA? The “experts”?
• The AOA protocol, in 2003, did not change behavior!
− Let’s not make the same mistake
47
Technology Innovations: 2006–2007
iPhone
Fingerprint Reading
Technology
Human Genome Project
codes last gene sequence
Nintendo Wii
48
New Dry Eye Treatments: 2006–2007
49
2006: Dysfunctional Tear Syndrome: A Delphi Approach to
Treatment Recommendations (Delphi)
•
•
•
•
17 preselected international dry eye specialists
2-round Delphi panel approach
Used a 2/3 majority for consensus building on the responses
Treatment algorithms were calculated as the primary endpoint
− Treatment recommendations for different types and severity levels of
dry eye disease
• New terminology
− Dysfunctional tear syndrome (DTS)
Behrens A et al. Cornea. 2006;25:900-907.
50
Delphi Recommendations
• More detailed treatment
• Cherry-picking screening tools and treatment
− TOO TIME CONSUMING
− DIFFICULT TO DIFFERENTIATE
− NOT ADOPTED BY ALL EXPERTS
NO BEHAVIOR CHANGES!
54
2007 Report of the International Dry Eye
WorkShop (DEWS)
• The Management and Therapy Subcommittee of the International
Dry Eye WorkShop (DEWS)
• Reviewed the Delphi Panel approach to the treatment of dry eye
disease and suggested some modifications
• The DEWS treatment recommendations are stratified according to
the severity of the disease
International Dry Eye WorkShop. 2007 Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5:61-204.
55
Dry Eye Defined (DEWS)
“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”
International Dry Eye WorkShop. 2007 Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5:61-204.
56
Cycle of Ocular Surface Inflammation (DEWS)
Dry eye
Altered tear
film stability
and composition
Dysfunction
of lacrimal
functional unit
Inflammation and
apoptosis on
ocular surface
International Dry Eye WorkShop. 2007 Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5:61-204.
57
DEWS
• Where is the widespread acceptance?
• Which of us is adhering to these protocols? Telling our
colleagues to adhere to this?
NO CHANGE IN BEHAVIOR…AGAIN!
62
63
Technology Innovations: 2008–2014
Tesla Roadster
HTC Dream
(1st Android Phone)
iPad
CERNS Hadron Collider
64
New Dry Eye Treatments and Diagnostic Tools:
2008–2014
MiBoFlo
65
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• Can identify diabetes 7 years
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Diabetes & Eye-Care
•
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•
Disclaimer: For investor use only
100M eye exams in US
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Diabetes = changing vision
Medical model of optometry
National Dry Eye DISEASE Guidelines
for Canadian Optometrists
Canadian Journal of Optometry
Revue Canadienne d’Optométrie
Vol. 76, Suppl. 1
2014
ISSN 0045-5075
67
Canadian Dry Eye Consensus
CASE HISTORY including 4 specific questions
1. Do your eyes feel uncomfortable?
2. Do you have watery eyes?
3. Does your vision fluctuate, especially in a dry
environment?
4. Do you use eye drops?
Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Can J Optom. 2014;76(Suppl.
1):1-32.
68
Canadian Dry Eye Consensus
Type
Management
Episodic
Tear supplements/
lubricants
Consider composition of available agents (lipid-based, products that restore the
mucin layer, overall)
Ocular
Hot compresses, lid hygiene, moisture chamber glasses, modifications to CL
wear (switch to daily disposables)
Non-ocular considerations
Environmental (ambient humidity, air movement, computer use), systemic
medications and supplements, alcohol, smoking, hormonal status, sleep apnea
Episodic management +
Chronic
Recalcitrant
Short-term
Topical corticosteroid
Long-term
Topical cyclosporine
Essential fatty acids
Supportive
Oral tetracycline/macrolide, lacrimal occlusion, meibomian gland expression
(in-office), sleep mask/lid taping
Ocular
Scleral lenses, filament removal, autologous serum eye drops, amniotic
membranes, tarsorrhaphy, other surgical techniques
Systemic
Secretagogue, systemic immunosuppressive therapies
Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Can J Optom. 2014;76(Suppl.
1):1-32.
69
Canadian Dry Eye Consensus
Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Can J Optom. 2014;76(Suppl.
1):1-32.
70
Improving the Screening,
Diagnosis, and Management
of Dry Eye Disease
*
*Alcon provided sponsorship
for a Summit planning meeting
and publication
Why Do We Need Recommendations
for Dry Eye Disease?
• Current guidelines (eg, DEWS, AOA) are perceived as being too
complex or inaccessible
• Limited awareness of guidelines
• Recommendations from “the experts” are not being incorporated into
everyday practice by community ECPs for multiple reasons
• Need to SIMPLIFY by setting minimum recommendations that all
ECPs can commit to
72
The Dry Eye Summit 2014:
How Did We Develop Recommendations?
• Discussed clinical data on dry eye disease and the role of ocular
surface wellness
• Identified current gaps in management through survey sent to
“experts” and >1000 ECPs
• 1.5-day discussion and debate (ECPs and industry) on best
practices for screening, diagnosing, and managing dry dye disease
• Used interactive polling system to establish consensus
(minimum 2/3 agreement needed)
73
Identifying Gaps in Care:
“Expert” vs Community ECP Practices
100%
For What Percentage of Your Dry Eye Disease
Patients
Experts (n = 28)
OD community (n = 658)
Do You Recommend Any Treatment?
% of ECPs
80%
60%
40%
20%
0%
<5%
5%-10%
11%-25%
% of Patients
26%-50%
>50%
Experts are much more likely to recommend treatment for dry eye disease.
74
Know the Risk Factors
• Disease
− Diabetes
− Allergies
• Contact lens wear
• Medications
− Antihistamines/Decongestants
• Age
• Digital device use
− Cell phones
− Tablets
− Computers
75
Consensus on Screening Questions
1. Do you think your eyes look healthy?
2. Do your eyes feel healthy?
3. Are there times when your vision
is not as clear as you want it to be?
4. Do your eyes ever feel dry or
uncomfortable?
76
Consensus on Baseline Diagnostic Options for
Entry Level Dry Eye Disease
1. Detailed patient history
2. Staining
3. Osmolarity levels
77
Consensus on Baseline Management
1. For all patients:
A. Ocular lubrication
B. Lid hygiene
C. Nutrition
2. Topical anti-inflammatories
78