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A New Vision for Women
Michelle Hessen, OD, FAAO
The Wilmer Eye Institute
Johns Hopkins University School of Medicine
Financial Disclosures
I have no financial disclosures to report
The Healthy Tear Film:
A Delicate Balance Outer lipid layer prevents
evaporation Secreted by meibomian glands
Aqueous component – a complex mixture of proteins, mucins, electrolytes Secreted by main & accessory
lacrimal glands
Mucins provide viscosity and stability during the blink cycle Mucin gel decreases in density
toward tear film surface
Mucin Layer: Goblet CellsMucins – “glue”
Aqueous Layer: Lacrimal Gland
98% water; washes away debris, irritants and provide moisture to the eye surface
Lipid Layer: Meibomian Glands
Functions of Tear Film Optical clarity and refractive power
Ocular surface comfort – lubrication
Protection from environmental and infectious
insults
– Antibacterial proteins, antibodies, complement
– Reflex tears to flush away particles
Trophic environment for corneal epithelium
– Necessary electrolytes, correct pH
– Protein factors for growth and wound healing
Epidemiology of Dry Eye
Global prevalence: 3.5% to 33.7%
Variability due to differences in:
Ages studied
Diagnostic criteria utilized
Higher prevalence
Women
Increasing age2007 Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5:65-204; Moss et
al. Arch Ophthalmol. 2004;122:369-373; Schaumberg et al. Am J Ophthalmol. 2003;136:318-326.
Epidemiology of Dry Eye
One-fourth of patients seen in outpatient clinics present with dry eye symptoms
Prevalence is greater in women, especially after menopause (80% of dry eye patients are females)
Increases with age
Incidence of Dry Eye
Dry eye incidence per 100 fee-for-service Medicare beneficiaries increased from 1.22 in 1991 to 1.92 in 1998 (57.4%)
Cataract incidence increased from 23.44 to 27.29 (16.4%)
Diabetic retinopathy from 1.36 to 2.55 (87.5%)
Ellwein LB et al. Arch Ophthalmol. 2002;120(6):804-811.
Future Considerations
Changes in demographics
By 2050, ~100% increase in population aged 65 to 84 years and ~333% increase in population aged 85 years and older
http://www.census.gov/ipc/www/usinterimproj/natprojtab02b.pdf
Lifestyle factors
Computer use, CL wear, refractive surgery
Heightened awareness/expectations
Dry Eye: Epidemiology
Challenges
Difficulty in diagnosis (no single diagnostic test)
Lack of correlation between clinical tests and patient symptoms
Dry Eye: Symptoms
Eye irritation
“gritty/sandy/scratchy” sensation
Itching
Burning
Redness
Fluctuating/blurred vision
Excessive tearing
Light Sensitivity
Why Should Dry Eye Be Treated?
Dry Eye
Extremely common
Major negative impact on quality of life
Quality of Life Patients describe vast array of
symptoms
Survey of 640 patients
389 unique symptom descriptions
Different words for “same” symptom
Most bothersome symptom is often not the most frequent
Severity increases as day progresses
Begley et al. Cornea. 2002;21:664-670.
SF-36: Dry Eye vs Normals
SF-36 Section Mild DED
Moderate
DED
Severe
DED
Physical functioning +2 +2 -5
Physical role -3 -4 -23
Bodily pain -1 -1 -13
General health +6 -1 -12
Vitality +1 -4 -11
Social functioning +4 +4 -8
Emotional role +8 +2 -9
Mental health +5 +1 -2
Mertzanis et al. Invest Ophthalmol Vis Sci. 2005;46:46-50.
Dry Eye and Quality of Life
Severe dry eye disease has an impact on quality of life comparable to:
Severe angina
Dialysis
Schiffman et al. Ophthalmology. 2003; Buchholz et al. Ocul Surf. 2006
Visual Impact
Visual acuity does not always correlate with self-assessed visual performance
Among those with normal visual acuity, dry eye symptoms were associated with increased difficulty:
Navigating stairs
Recognizing friends
Reading road signs
Reading the newspaper
Watching TV
Cooking
Driving at night
Tong et al. Eye . 2010;24:1486-1491.
Visual Impact: Dry Eye vs Normals
Patients Reporting
Difficulty With Odds Ratio
95%
Confidence Interval
Reading 3.64 2.45 – 5.40
Professional work 3.49 1.72 – 7.09
Computer use 3.37 2.11 – 5.38
Television 2.84 1.05 – 7.74
Driving (day) 2.80 1.58 – 4.96
Driving (night) 2.20 1.48 – 3.28
Miljanović et al. Am J Ophthalmol. 2007;143:409-415.
Dry Eye and Visual Function
Keratitis sicca and unstable tear film degrade visual function:
↓ Contrast sensitivity
Rolando et al. Cornea. 1998
Tutt et al. Invest Ophthalmol Vis Sci. 2000
Puell et al. Acta Ophthalmol Scand. 2006
Chotikavanich et al. Invest Ophthalmol Vis Sci. 2009
↑ Higher order optical aberrations
Koh et al. Invest Ophthalmol Vis Sci. 2008
Montes-Mico et al. Invest Ophthalmol Vis Sci. 2005
Dry Eye and Contrast Sensitivity
P < 0.05
Low (10%) Contrast
High Contrast
Chotikavanich et al. Invest Ophthalmol Vis Sci. 2009
Blepharitis
Classification
Anterior
Posterior
Blepharitis
Anterior
Infectious
Seborrheic
Allergic
Autoimmune
Posterior
MGD
Wu E, Akpek EK. BMJ In Practice
Distribution of Bacteria Isolated from Blepharitis (1993-2001) (N=224)
Staphylococcusaureus - 26%
Other GramPositives - 7%
Streptococcuspneumoniae - 2%
Coagulase NegativeStaphylococcus - 57%
Acinetobacter - 1%Moraxella - 1%
Haemophilus - 2%
Other GramNegatives - 4%
Increased Risk for Endophthalmitis
Ocular surface is an important source of infecting organisms that adversely affect surgical outcomes (Speaker, 1991)
Endophthalmitis results from patients own lid and conjunctival flora
Surgical outcome adversely affected Procedures must be
postponed/cancelled due to status of lid margin
Meibomian Gland Dysfunction
Subset of posterior blepharitis
Functional abnormalities of the MG
Emphasizes the important role of MG
Meibomian gland disease
Broader range of meibomian gland
disorders
Neoplasia and congenital disease
Definition of MGD
Meibomian gland dysfunction (MGD) is a chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in the glandular secretion. This may result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease..
Grading of MGD
Normal MG Orifices,
Clear Oil
Cloudy Meibum
MG Orifice Opacification
Periductal Fibrosis
“Toothpaste” Meibum
Tomlinson et al. Invest Ophthalmol Vis Sci. 2011;52:2006-2049.
Treatment of Blepharitis
Lid hygene measures
Treatment of associated aqueous dry eye
Medical treatment
Surgical treatment
Eyelid Hygene
1. Apply hot compress
2. Stretch lid taut
3. Apply pressure to lid with palmar
surface of finger in lateral motion
Treatment of Blepharitis Artificial tears
Topical lipid supplements
Topical antibiotics/Oral antibiotics
Topical calcineurin inhibitors
Oral essential FA supplements
Surgical Treatment
Probing of MG, IPL, Lipiflow (level III)=>
Symptoms?
Treatment of MGD-associated conditions
Courtesy of Stephen C. Pflugfelder, MD.
Meibomian Gland Disease Aqueous Tear Deficiency
Akpek et al. Am J Ophthalmol 2009
The Tear Film is an Important Refracting Element of the Eye
Minimal Disruption of the Ocular Surface can Severely Degrade Visual Acuity
Today’s Cataract Patient
Large, rapidly growing demographic
(i.e., baby boomers)
Educated, financially secure
Increased life expectancy
Longer working careers
Today’s Cataract Patient
Are unwilling to compromise active lifestyle
Embrace demand-driven healthcare
Demand high quality vision (e.g., reading, distance, night)
Have new requirements for intermediate vision (e.g., computers)
More Surgeons are Implanting Refractive IOLs
2009 ASCRS/ESCRS Member Survey (Leaming Report)
Refractive IOLs
Multifocal and accommodating lenses are dramatically changing the way ophthalmologists practice cataract surgery
Ocular surface and Cataract surgery
The incidence and severity of dry eye symptoms increase after cataract surgery
Phacoemulsification has been shown to reduce tear meniscus height and TBUT and increase squamous metaplasia on conjunctival impression cytology
Moderate-severe ocular surface disease are also at higher risk of postoperative complications (infections, corneal melt)
Exacerbation of Dry eye post-operatively
Mechanisms:
increased inflammatory mediators due to post-operative inflammation
toxicity from the use of benzalkonium chloride containing eye drops
damage to corneal nerves from limbal incisions
Post-operative care Reduce prolonged use of postop meds
Topical nonsteroidal anti-inflammatory drugs
Reported to cause corneal melt, mainly in the presence of epithelial breakdown.
Complications perhaps more likely in severe ocular surface disease
Suggestion of reduced risk with concomitant use of topical steroids
Multifocal IOL designs and OSD
Goal: improve spectacle independence with satisfactory distance and near vision
Visual outcomes depend on:
Appropriate patient selection
Eliminating astigmatism
Accurate biometry
IOL power calculation
Multifocal IOLs
Patient dissatisfaction due to:
Glare and halos
Dysphotopsias
Reduced contrast sensitivity
Decreased night vision
Diagnose/Manage OSD
Failure to identify ocular surface disease may result in an unhappy patient secondary to exacerbation of their underlying conditions
Dry eye
Meibomian gland dysfunction
Epithelial basement membrane dystrophy
May be asymptomatic preoperatively
Thorough clinical examination is critical
Ocular surface abnormalities does not exclude patients as candidates for multifocal IOLs
Effective treatment of preexisting condition
Accurate biometric analysis/Topography
Failure to diagnose ocular surface disease can potentially impact IOL calculations predominately due to inaccurate corneal power calculation.
OSD may interfere with accurate keratometry measurements
Use >1 keratometry method
Repeat readings if there is a significant discrepancy
Perform all readings prior to instillation of eye drops or applanation tonometry
Smoothness and spacing of the reflected topography images may give additional clues to the ocular surface status
Accurate biometric analysis/Topography
Residual ametropia is an important cause of patient dissatisfaction after insertion of advanced technology IOLs
>0.75 D of residual astigmatism may result in dissatisfaction
Enhancement procedures for Residual refractive error
Laser assisted insitu keratolmileusis
Surface ablation (preferred)
Treat OSD preoperatively
Aggressive treatment of ocular surface disease before cataract surgery is important as these conditions may reduce quality of vision
Delay surgery until ocular surface is optimized due to risk of postoperative complications
Improves patient comfort and vision postoperatively
Avoids situation of patient mistakenly blaming their symptoms as due to their surgery
1.1 D @ 74
Manifest +.50+.50 at 160
Ks:
IOLM 42.40/44.94*98 (2.54 at 98)
Lenstar 43.00/46.25*91 (3.25 at 91)
Manual 42.50/44.75*90 (2.25 at 90)
Orbscan 43.20/46.10*96 (2.90 at 96
IOL chosen
SN6AT7 24.5D
6 week P/O
UVVA 20/50
BCVA -1.00 sph= 20/25-
Recommended