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-