DRY EYE(2006)

PHILIPPINE ACADEMY OF OPTHALMOLOGY

Philippine Academy of Ophthalmology

U-815, Medical Plaza, Amorsolo 1229 MakatiAmorsolo St., corner Dela Rosa St. Makati City, PhilippinesTelephone No: 813-5318, 813-5324; Fax No: 813-5331Email: pao@pao.org.phWebsite: http://www.pao.org.ph

Executive Council 2006-2007

PresidentVice President

SecretaryTreasurer

Councilors

Immediate Past President

Ma. Dominga B. Padilla, M.D.Reynaldo E. Santos, M.D.Carlos G. Naval, M.D.Ruben Lim Bon Siong, M.D.

Teresita R. Castillo, M.D.Rolando Enrique D. Domingo, M.D.Ulysses G. Galang, M.D.Franklin P. Kleiner, M.D.Bernardita C. Navarro, M.D.Mary Rose Pe-Yan, M.D.Vicente O. Santos, Jr., M.D.Harvey S. Uy, M.D.

Marcelino D. Banzon, M.D.

Subspecialty Societies of PAO

1. Cornea Club of the Philippines2. Neuro-Ophthalmology Club3. Philippine Ocular Inflammation Society4. Philippine Glaucoma Society5. Philippine Society of Cataract & Refractive Surgery 6. Philippine Society of Ophthalmic Plastic & Reconstructive Surgery7. Philippine Society of Pediatric Ophthalmology & Strabismus8. Vitreo-Retina Society of the Philippines

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The Cornea Club of the PhilippinesCorrespondence to: The New Medical City, Meralco Complex, Ortigas Ave. Pasig City c/o Victor J. L. Caparas M.D. (President)Telephone No: (632) 635-3202; Fax No: 635-3201Email: viccap@info.com.ph

Officers & Board of Directors 2004-2006

PresidentVice President

Finance OfficerSecretary

DirectorDirector

Director/Immediate Past President

Victor L. Caparas, M.D., MPHCesar R.G. Espiritu, M.D.Reynaldo S. Santos, M.D.Ruben Lim Bon Siong, M.D.

Reuben Aquino, M.D.Ma. Dominga B. Padilla, M.D.Jacinto U. Dy Liacco, M.D.

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defiNitiON

Dry eye, under the unified concept of the disease is now known as Dysfunctional Tear Syndrome (DTS) or Lacrimal Keratoconjunctivitis (LKC) and it refers to a dysfunction of the integrated lacrimal unit that results in the following findings: Unstable tear film, altered tear composition and production, ocular surface and glandular inflammation, ocular surface epithelial disease and symptoms of ocular discomfort.

histOry

In the majority of patients, dry eye syndrome is not sight threatening BUT is characterized by troublesome symp-toms of irritation. In some individuals, exacerbating factors such as systemic medications that decrease tear production or environmental conditions that increase tear evaporation may lead to an acute increase in the severity of symptoms. In other patients in whom the dry eye condition is caused by a nonreversible deficien­cy of tear production (such as cicatrizing ocular surface disease, severe chemical burns, Stevens Johnson Syn-drome, Sjögren’s Syndrome) or by a chronic condition leading to increased evaporation (such as blepharitis and meibomian gland dysfunction), the disease may exhibit chronicity, characterized by waxing and waning severity of symptoms or a gradual increase in symptom severity with time.

Questions about the following elements in the patient history may elicit helpful information:

• Symptoms – dry sensation, irritation/discomfort, burning/stinging, grittiness/sandiness, mild itch-ing, blurring of vision, photophobia, reflex tearing, stickiness, pain/soreness, eye strain or fatigue when reading, using the computer or watching TV, redness, contact lens intolerance, increased frequency of blink-ing, symptoms worse in evening or after prolonged eye use

• Exacerbating conditions – windy conditions, air travel, air conditioned places, low humidity, pro-longed VDT (video display terminal) work

• Duration of symptoms• Topical medications (glaucoma medications, topical

anesthetics and preservative toxicity) used and their effect on symptoms

• Contact lens wear, schedule and care• Past ocular history - Allergic conjunctivitis, chronic

ocular surface inflammation (Sjögren’s Syndrome, Stevens­Johnson Syndrome), infiltrative lacrimal gland disease (lymphoma, sarcoidosis, hemochro-matosis, amyloidosis), chemical trauma, blepharitis,

history of anterior segment surgery which could affect corneal sensitivity (eg, LASIK, PKP or any surgery involving a limbal or corneal incision) and eyelid surgery that could affect lid closure and blinking

• Past medical history ­ systemic inflammatory disease (Rheumatoid Arthritis, Systemic Lupus Ery-the-matosus, Graft versus Host Disease, etc), diabetes mellitus, vitamin A deficiency, malnutrition, thyroid disease, atopy, rosacea, ovarian disease or oopho-rectomy, radiation or surgery to the orbit, head and neck, Complete Androgen Insufficiency Syndrome (CAIS)

• Systemic medications - cyclosporine, antihistamines (specifically aztemizole or loratadine), cholinergic agents, anticholinergics, antimuscarinics, β−blocking agents, tricyclic antidepressants, phenothiazines, es-trogen-progesterone, and other estrogen derivatives, accutane therapy, anti-androgen therapy

• Menstrual history, onset of menopause• Smoking history

physical examiNatiON

Examination includes visual acuity measurement, exter-nal examination and slit lamp biomicroscopy to:• Document signs of dry eye• Assess presence and severity of deficient aqueous tear

production and/or increased evaporative loss• Exclude other causes of ocular irritation

External examination should pay attention to the fol-lowing:• Skin – atopic dermatitis• Eyelids – lagophthalmos, ectropion, lid margin irre-

gularity, previous blepharoplasty• Proptosis, thyroid eye disease• Cranial nerve function

Slit lamp biomicroscopy should focus on the following:• Tear film – tear meniscus height, tear film debris• Eyelashes – trichiasis, dystichiasis, crusting• Anterior and posterior eyelid margins – blepharitis,

meibomian gland abnormalities, maceration, frothy discharge, keratinization

• Conjunctiva –congestion, mucous strands/discharge, symblepharon, keratinization

• Cornea – superficial punctuate keratitis, filaments, epithelial defects or erosion, corneal melt or ulcer, vascularization, keratinization

Consensus on the Treatment of Dry Eye Disease

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Routine Diagnostic Tests

• Tear break­up time using fluorescein (abnormal/un­stable tear film <10 sec)

• Ocular surface dye staining (cornea and conjunctiva) with fluorescein or lissamine green

• Schirmer test with anesthesia x 5 minutes (abnormal <10 mm).

• Corneal sensation assessed when trigeminal nerve dysfunction is suspected

• Laboratory and clinical evaluation for auto-immune disorders for patients with significant dry eyes

Principles of Management

• Psychological Management - Disease chronic and incurable - Symptoms can be controlled - Adherence to management can be more disruptive

than disease itself - Not likely to lead to serious/permanent ocular da-

mage - If with potential loss of sight, there is need for

minor surgical procedure (tarsorrhaphy, punctual occlusion, etc) in severe tear deficiency states

• Ocular Management - Ocular environmental interventions/computer work

site modification - Tear substitution - Tear preservation - Elimination/substitution of systemic medication

whenever possible - Pharmacologic stimulation of natural tears - Treatment of associated local problems (sympto-

matic mucous strands/filaments, blepharitis, mei­bomian gland dysfunction, ectropion, etc)

• Treatment of Underlying Cause ­ Anti­inflammatories * Topical steroids * Topical cyclosporine * Oral tetracyclines * Topical autologous serum - Nutriceuticals (Essential fatty acids: stabilize

MGD) * Linoleic, gamma linolenic acid * Nutritional supplements

Table 1: Summary of Treatment Recommendation of Delphi Panel of Experts on DTS/LKC

Ocular Surface Condition Treatment Recommendation

Level 1: Level 1:- mild/moderate symptoms - elimination of environmental/drug factor- no corneal signs - preserved tear substitute- mild/moderate conjunctival staining - control allergy­ unstable tear film ­ dietary modification: ↑ omega 3 fatty acid

Level 2: Level 2:- mild corneal staining - unpreserved tear substitutes- ↑ conjunctival staining - gels/PM ointments- visual signs - topical cyclosporine A - topical steroids - secretagogues

Level 3: Level 3:- severe symptoms - oral tetracyclines- marked punctate staining - topical autologous serum­ central corneal staining ­ punctual plugs (after control of inflammation)­ filamentary keratitis

Level 4: Level 4:- severe mucous adherence to epithelium - systemic immunosuppressive- sterile corneal ulceration/persistent epithelial - topical vitamin A defects - bandage soft contact lens - vascularization - moisture goggles - surgery (tarsorrhaphy, amniotic membrane

transplantation)

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· Omega fatty acids · Flaxseed oils, fish oils, evening primrose oils• Surgical Interventions - Correction of lid abnormality ­ Punctual occlusion after control of active inflam­

mation - Tarsorrhaphy for severe cases

Summary of Treatment Recommendation of Del-phi Panel of Experts on DTS/LKC Depending on Severity

See Table 1.

Follow-up

Frequency and extent of follow-up evaluation will de-pend on the severity of disease, therapeutic approach and response to therapy.

Qualifying statements (as adopted & modified from the National Guideline Clearing House of the AAO Cornea/ED Panel & PPP Committee, April 2004)

• The mentioned guidelines in the diagnosis and management of DTS/LKC provide guidance on pat-terns of practice and are not aimed for the care of a particular patient.

• While they should normally meet the needs of most patients, they cannot possibly meet the needs of all patients.

• Adherence to these preferred practice patterns will not ensure a successful outcome in every situa-tion.

• These PPP should not be deemed to include all pro-per methods of care nor should they be interpreted to exclude other methods of care reasonably aimed at obtaining the best results.

• These PPP are not medical standards to be adhered to in all individual situations.

• The Philippine Academy of Ophthalmology, through its affiliate society, the Cornea Club of the Philippines can assist in resolving ethical dilemmas that may arise in the ophthalmic practice of its members as far as the management of DTS/LKC is concerned.

References:1. McCluskey P: Dry Eye – Management Goals and Therapy

Options. In Managing External Eye Disease (MEED) Symposium. Beijing, June 3, 2005.

2. Lemp MA, Conners MS, McCulley JP: Alternative Perspectives in Ocular Surface Health. In Eye World Educational Symposia. 5th World Cornea Congress. Wa-shington DC, April 15, 2005.

3. Tan D, Beuerman RW, Stern ME, Pflugfelder SC, Calogne M: Ophtahlmic Disease Battlefront - Main-taining the Health of the Ocular Surface. In Special Interest Group

Symposia. 2nd SERI-ARVO Meeting on Research in Vision and Ophthalmology. Singapore, February 16, 2005.

4. Pflugfelder SC: Dysfunction of the Lacrimal Functional Unit and Its Impact on Tear Film Stability and Com-position. In Pfulfelder SC, Beuerman RW, Stern ME (eds): Dry Eye and Ocular Surface Disorders. New York, Marcel Dekker, Inc., 2004.

5. National Guideline Clearing House of the American Academy of Ophthalmology, Cornea & External Di-sease Panel, Preferred Practice Pattern Committee on Dry Eye, April 2004.

6. Azar D, Pflugfelder SC, Schein O, Seitz B. Treatment Recommendation for Dysfunctional Tear Syndrome based on the Delphi Consensus Session of a Panel of 17 Experts at Wilmer Ophthalmological Institute. New Orleans, October 2004.

7. Stulting RD, Mader TH, Waring III GO: Diagnosis and Management of Tear Film Dysfunction. In Leibowitz HM (ed): Corneal Disorders, Clinical Diagnosis and Management, 2nd ed. Philadelphia, WB Saunders, 1998.

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Ophthalmic corticosteroidsDexamethasone

Maxidex Santeson 0.1%

Fluorometholone acetate Flarex Flulon 0.1% FML

Fluorometholone/Tetrahydrozo-line Efemoline

Prednisolone acetate Drugmaker's Biotech

Prednisolone Ophthalmic Drops Norsolex-Opta Pred Forte Vistapred

Oral TetracyclinesDoxycycline HCl

Atrax Biocolyn Doryx Doxin Harvellin Vibramycin

Lymecycline Tetralysal

Oxytetracycline HCl Noxebron Terramycin

Tetracycline HCl Moncycline RiteMED Tetracycline

Ocular lubricantsCarbomer/Cetrimide

Vidisic GelCarbomer/Mannitol

LacryviscCarboxymethylcellulose sodium

Cellufresh/Cellufresh MD Celluvisc MD

Dextran/Hypromellose Tears Naturale II

Dextran/Hydroxypropyl methylcellulose

Tears Naturale Hydroxypropylmethyl cellulose Artears

Artelac Eye Drops Genteal

PEG 400/Propylene glycol Systane

Polyvidone Oculotect Fluid/Sine Vidisept N

Retinol palmitate Hypotears

Sodium chloride Larmabak

Other Ophthalmic PreparationsCyclosporine

RestasisSodium hyaluronate

Hialid 0.1%

Nutritional Supplementsβ -Carotene

Afaxin Betavit Ocuvite

Vitalux/Vitalux Plus

Recommended Therapeutics(Drugs Mentioned in the Treatment Guideline)The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's reference, available drugs are listed under each therapeutic class.