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an optometrist's review: minocycline rather than doxy
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Nothing really new in this article but it caught my attention since I'm having (i suspect) some issues (skin... urticaria for sure) with doxycycline (in conjunction with light exposure... but not really sunburn). MGD was under control was I was able to reduce the dosage but where's the limit... do I really want to find to out? (will an ulcer define it?)
so maybe I'll consider the suggestion bellow -in bold- on minocycline rather than the good old doxy... while we wait for ALTY (#?) or something more specific for MGD sufferers.
3/4 of DE involves MGD! I remember when I was told that we were a small minority... what happened?... docs started to listen to our symptoms? docs started to press our glands and look closer with slit-lamps?... well something definetly happened!
Well docs (or optometrists) got it, will now pharmas care (meaning... care to sell us something slighty more efficient and less harmful... for shiploads of money)?
Pharmas: the above MGD-specific solution without this serious skin problems is very much awaited and welcome. I really don't have the time to take care of my skin on top of the time required to take care of my corneas, I don't know about you all on DEZ?
take care (therefore avoid benzalkonium... oups, Alcon and Allergan supported this article but still have a look bellow - in bold as well - when talking about plugs and residence time...)
K
PS: One good thing about DE is that one starts to appreaciate rain, Autumn while everyone else looks depressed by it. I've always liked the colour of the trees but there must be something more to it
General Considerations: It seems logical to approach treatment of dry eye in terms of etiology and severity. In the author’s view, approximately 3/4ths of all dry eye will involve meibomian gland dysfunction, and the severity will be mild.
If diagnosis is accomplished by sub-type rather than in a global way (e.g., the eye is “dry”, but specifically due to atrophy of the meibomian glands), the proper management logically follows. The dry eye sub-types and general management can be divided into several broad categories, as follows.
• Deficiency of major components: typically aqueous deficiency (e.g., Sjogrens aqueous tear deficiency (ATD) or non-Sjogrens ATD) or lipid deficiency (e.g., atrophic or non-inflammatory MGD); mucin deficiency is very rare (seen only in ocular surface injury as from acid or alkali burn, or in geographic areas of poor nutrition).
• Management: 1) replace or conserve the missing component, or 2) treat to allow the missing component to re-establish itself (e.g., Restasis to reduce inflammation and allow restoration of aqueous production or warm compresses to promote meibomian gland health).
• Inflammatory MGD: the etiology of the problem appears to be production of bacterial exotoxins, leading to lipid imbalance and ocular surface inflammation(McCulley 1986)
• Management: treat glandular bacterial over-colonization using antibiotics systemically and topically, and promote meibomian gland health using warm compresses
• Lid Surfacing Abnormalities: most commonly lagophthalmos, but also entropion
• Management: night-time lubricants, protective/bandage contact lens
• Allergic Dry Eye: seasonal allergic conjunctivitis or general allergic conjunctivitis
• Management: treat the allergy with topical and/or systemic medication
Deficiency of the Aqueous Component:
Although apparently rare, aqueous deficiency does occur, sometimes in combination with meibomian gland disease. The author has described this latter clinical entity as a “mixture” of ATD and MGD and thus far it represents approximately 5% of the true dry eyes diagnosed in a clinic setting. Sjogren’s syndrome is relatively rare, but is probably the most severe and debilitating dry eye condition. There are numerous methods to manage aqueous deficiency, as follows.
Replace Aqueous Component:
Currently there are many artificial tears available OTC, and they are constantly being optimized. This is great news for patients and practitioners. The effect on the ocular surface is to replace the missing watery component, to thicken the tear film to restore good vision, and to allow healing to take place on the ocular surface. When recommending a specific artificial tear for a patient, it is important to keep in mind several aspects of the drop. These are:
• The effect on vision. Don’t recommend a thick, vision-blurring drop for critical periods such as driving.
• The effect on comfort. The natural, healthy tear film demonstrates a shear-thinning or pseudoplastic behavior(Tiffany 1991), and the ideal tear replacement should behave similarly.(Bron and Tiffany 1991) It has been demonstrated that a shear-thinning drop will be more comfortable compared to a less shear thinning formulation.(Dudinski, Finnin et al. 1983; Paugh 1998)
• Residence Time: the length of time that a drop lasts on the eye is influenced by several major factors, including:
o Drop comfort: If uncomfortable, tearing will result and the drop will be eliminated rapidly.
o Muco-adhesion of the viscolyzers. Several polymers are muco-adhesive (e.g., carboxymethylcellulose (CMC), polyacrylic acid (carbomer), HP-guar and hyaluronic acid (HA)). Mucoadhesion may allow a thin film of supplement to form on the ocular surface, allowing ocular surface healing and the formation of a stable tear film.
o Viscosity: although not always the case, generally thicker drops tend to last longer. The order, shortest to longest residence time relative to viscosity is:
Aqueous preparations < viscous drops < thick gels
There is preliminary data demonstrating residence time for several current drops (see Table 2), that must be interpreted with caution due to the very small sample size. These data were generated using marketed artificial tears, admixed with a fluorescent tracer, and measured in dry eye subjects (n = 5) using a scanning flurometer.(Paugh 2004) The study was funded by Alcon Laboratories, and is continuing to eventually include up to 20 subjects.
Conserve Aqueous Component: Conservation of a limited aqueous component can be achieved by the use of punctal plugs or by a moisture-retention spectacle arrangement.
Punctal Plugs: many are available; temporary, dissolvable should be used first (e.g., collagen type) to determine whether comfort can be improved followed by several month (give example) or permanent plugs (e.g., silicone type). Generally the lower puncta are plugged first, followed by the upper puncta if necessary. Punctal plugs can be very effective in relieving signs and symptoms of dry eye, although approximately 50% extrude within two years.(Tai 2002) Plugs must be monitored for retention over time, whick can be done using a transilluminator through the lid, similar to meibography.
Caution: Aqueous deficiency is relatively uncommon as a cause of dry eye. Thus, the utility of punctal plugs is limited. In addition, plugs will allow both normal waste material and topical solution preservatives to be retained on the ocular surface longer, potentially inducing surface toxicities.
Spectacles and/or Spectacle Side Shields: There is ample evidence that when moisture is retained by a goggle or spectacle set-up the tear film characteristics are improved (see. e.g., Paugh and co-workers(Paugh 2002). Thus, creating a sort of “humidity chamber” may be an acceptable management approach for severe dry eye.
However, wearing a spectacle side shield may not be esthetically acceptable to some patients so a balance between function and appearance can perhaps be made. Pearce and co-workers(Pearce 2003) have demonstrated that a modern, “wraparound” zyl frame can in fact increase humidity in front of an eye whereas a normal spectacle frame does not.
Replace Lipid Component:
There is mounting evidence that lipid replacements are effective in reducing the signs and symptoms in lipid deficient dry eye conditions (e.g., in atrophic meibomian gland disease). For example, Goto et al.(Goto 2002) demonstrated in a cross-over trial that a castor oil emulsion was more effective than saline artificial tears in alleviating signs and symptoms when administered 6 times per day for two weeks. Korb and co-workers have also demonstrated the efficacy of specific oily components in improving the appearance of the lipid layer.(Korb DR 2002)
Several OTC lipid replacements are now available (e.g., Refresh Endura from Allergan and Soothe from Alimera Sciences) and should be considered as an adjunct to warm compress therapy (see below) in cases of lipid insufficiency due to MGD.
Stimulate Aqueous or Lipid Production:
There are current and emerging therapies to stimulate either aqueous or lipid production, either by a therapeutic (drug) approach or holistic means (e.g., essential fatty acid dietary supplement to improve lipid parameters).
Aqueous Stimulation:
Cyclosporine A was found to stimulate aqueous tear production in KCS dogs(Kaswan 1989), and subsequently became the first therapeutic OSD entity to be developed for humans. Cyclosporine is an immunosuppressant agent when administered systemically, and a partial immunosuppression of ocular surface inflammation may be the mechanism of action in aqueous tear deficiency. Sall and co-workers(Sall 2000) in Phase III trials demonstrated objective (staining and Schirmer results) and subjective (need for artificial tears, investigator assessment of response to treatment) improvements with two concentrations of cyclosporine A (0.05 and 0.1%). Cyclosporine A in a concentration of 0.05% in an emulsion formulation has now been approved as a prescription treatment for moderate to severe dry eye by the FDA. Restasis is the brand name and it is recommended for use BID. Treatment takes up to six months to demonstrate a beneficial effect although the time frame of patient response is likely to vary.
Clinical Pearl: Restasis is moderately expensive and should be perhaps be used only in severe inflammatory ATD situations. The author has never prescribed it, possibly due to the very few cases of Sjogren’s or non-Sjogren’s ATD found in our clinic. Prior to recommending Restasis all other means to manage the dry eye should be explored, including use of the so called “soft steroids” (e.g., loteprednol).
Lipid Stimulation:Although under development at this time by Allergan and perhaps other entities, topically applied androgen (testosterone) appears to have efficacy in stimulating lipid production. There is a large and growing body of evidence that the meibomian gland is an androgen target organ, and that androgen deficiency may lead to MGD.(Sullivan 2002) One report involving one human subject has demonstrated improvement in lipid layer thickness and TBUT following 3 months of treatment with testosterone cream applied to the eyelids TID.(Worda 2001) Given that most dry eye observed in our setting is meibomian gland related, this potential approach appears to be very promising.
Inflammatory MGD/Blepharitis Treatment
1. General Considerations:
Therapy is directed at control rather than cure of the condition due to the chronic nature of these syndromes. There is generally an acute phase of treatment lasting for 2-8 weeks followed by ongoing home (i.e. lid hygiene) and in-office (e.g. forceful expression) as needed.
2. Specific:
The mainstay of therapy is mechanical and hygienic maneuvers (i.e. warm compresses and eyelid scrubs with mild shampoo) to clean lids and lashes and to encourage improved meibomian gland function. Topical antibiotics, perhaps in combination with an anti-inflammatory agent, are indicated when bacteria are suspected. Oral tetracycline (or tetracycline derivatives) is prescribed for meibomitis involvement (the action of tetracycline is likely a decrease in bacterial lipase production rather than simply a reduction of bacteria.(Dougherty, McCulley et al. 1991) Recently, a specific blepharitis protocol has been recommended, as follows.
Background
During the 4th International Conference on Tear Film etc., held in Fajardo, Puerto Rico in November 2004, the topic of blepharitis treatment came up among several clinician investigators. Drs. J Daniel Nelson and Steve Pflugfelder, both leading researchers and clinicians involved with dry eye, recommend the following protocol based on numerous cases.
Recommended Protocol:
• Warm compress therapy, 2 per day, for a minimum of 4-6 weeks. Often treatment will be needed on an ongoing basis.
• Erythromyocin ointment, applied to lashes, QHS for a minimum of 3 months (note: it does not have to be placed in the eye; as Don MacKeen showed(MacKeen 1998), anything applied to the lid skin gets into the eye).
• Lotemax QID until the active phase resolves (4-6 weeks?) (note: A baseline IOP and examination of the optic nerve head with a written note as to the appearance of the optic nerve is important. Remember, although Lotemax has less tendency to raise IOP, it still can happen so a baseline IOP and disc exam is warranted)
• Systemic minocycline for 2 weeks at 50 mg/day, then monthly at 100 mg/day. Minocycline is recommended because it can be taken BID, has the fewest side effects, and induces minimal photosensitization.(Ta 2003)
1. Taper minocycline for long term management (Treatment may need to be continued for months depending on the response. Usually a positive effect will be seen within 8 weeks.)
2. Cautions regarding minocycline: stained teeth, vaginitis in women, and photosentivity (increased sun burn risk) There are other unusual risks that any treating doctor needs to be aware of. These can be found in the PDR.
• Thera Tears Capsules with omega 3 and 6 fatty acids are useful. The dose is two capsules BID. It may take months, however, to see a beneficial effect.
MGD Therapy: Does It Work?
Paugh et al.(Paugh, Knapp et al. 1990) examined this question in a group of problematic contact lens wearers wherein MGD was the only likely candidate for the symptoms of dryness and burning. Lid scrubs and warm compresses were prescribed twice a day for one eye only (both eyes were equally affected at the outset) for two weeks. Symptomatology and fluorescein breakup time were assessed by a masked observer. The results demonstrated a highly statistically significant increase in FBUT of ~ 4 seconds in the treated eye and no change in the control (i.e., the no lid therapy) eye after the two week period. The BUT results are presented below (Figure 8).
Summary, Dry Eye Diagnosis and Management
This is an exciting time for clinicians and dry eye sufferers alike due to the wealth of new information and treatment options now available. The key to diagnosis lies in trying to assess not only the traditional global signs of dry eye/OSD, but in trying to classify the disease by specific sub-type. If etiology can be determined, effective treatments logically follow. The majority of sub-types commonly encountered appear to be those related to meibomian gland dysfunction (75%; either inflammatory or non-inflammatory MGD). Treatment for these and aqueous deficient conditions involve stimulating, conserving or replacing the deficient component. Adjunctive therapy is employed as needed, such as warm compresses, topical and systemic antibiotics, and possibly systemic nutritional supplements such as flax seed oil. The future holds the promise of increasingly efficacious treatments as new therapeutic entities are developed (e.g., androgen to treat MGD) and optimized palliative artificial tears.
Acknowledgements: The author thanks Dr. Alan Sasai, Principal Clinical Scientist (Allergan Inc) for his help in producing the gland expression video. The author also thanks both Allergan Inc (for financial support) and Alcon Laboratories (for materiel support) relative to the ongoing dry eye screening project at S.C.C.O.
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© 2005 Copyright, SCCO. All rights reserved.
Nothing really new in this article but it caught my attention since I'm having (i suspect) some issues (skin... urticaria for sure) with doxycycline (in conjunction with light exposure... but not really sunburn). MGD was under control was I was able to reduce the dosage but where's the limit... do I really want to find to out? (will an ulcer define it?)
so maybe I'll consider the suggestion bellow -in bold- on minocycline rather than the good old doxy... while we wait for ALTY (#?) or something more specific for MGD sufferers.
3/4 of DE involves MGD! I remember when I was told that we were a small minority... what happened?... docs started to listen to our symptoms? docs started to press our glands and look closer with slit-lamps?... well something definetly happened!
Well docs (or optometrists) got it, will now pharmas care (meaning... care to sell us something slighty more efficient and less harmful... for shiploads of money)?
Pharmas: the above MGD-specific solution without this serious skin problems is very much awaited and welcome. I really don't have the time to take care of my skin on top of the time required to take care of my corneas, I don't know about you all on DEZ?
take care (therefore avoid benzalkonium... oups, Alcon and Allergan supported this article but still have a look bellow - in bold as well - when talking about plugs and residence time...)
K
PS: One good thing about DE is that one starts to appreaciate rain, Autumn while everyone else looks depressed by it. I've always liked the colour of the trees but there must be something more to it
General Considerations: It seems logical to approach treatment of dry eye in terms of etiology and severity. In the author’s view, approximately 3/4ths of all dry eye will involve meibomian gland dysfunction, and the severity will be mild.
If diagnosis is accomplished by sub-type rather than in a global way (e.g., the eye is “dry”, but specifically due to atrophy of the meibomian glands), the proper management logically follows. The dry eye sub-types and general management can be divided into several broad categories, as follows.
• Deficiency of major components: typically aqueous deficiency (e.g., Sjogrens aqueous tear deficiency (ATD) or non-Sjogrens ATD) or lipid deficiency (e.g., atrophic or non-inflammatory MGD); mucin deficiency is very rare (seen only in ocular surface injury as from acid or alkali burn, or in geographic areas of poor nutrition).
• Management: 1) replace or conserve the missing component, or 2) treat to allow the missing component to re-establish itself (e.g., Restasis to reduce inflammation and allow restoration of aqueous production or warm compresses to promote meibomian gland health).
• Inflammatory MGD: the etiology of the problem appears to be production of bacterial exotoxins, leading to lipid imbalance and ocular surface inflammation(McCulley 1986)
• Management: treat glandular bacterial over-colonization using antibiotics systemically and topically, and promote meibomian gland health using warm compresses
• Lid Surfacing Abnormalities: most commonly lagophthalmos, but also entropion
• Management: night-time lubricants, protective/bandage contact lens
• Allergic Dry Eye: seasonal allergic conjunctivitis or general allergic conjunctivitis
• Management: treat the allergy with topical and/or systemic medication
Deficiency of the Aqueous Component:
Although apparently rare, aqueous deficiency does occur, sometimes in combination with meibomian gland disease. The author has described this latter clinical entity as a “mixture” of ATD and MGD and thus far it represents approximately 5% of the true dry eyes diagnosed in a clinic setting. Sjogren’s syndrome is relatively rare, but is probably the most severe and debilitating dry eye condition. There are numerous methods to manage aqueous deficiency, as follows.
Replace Aqueous Component:
Currently there are many artificial tears available OTC, and they are constantly being optimized. This is great news for patients and practitioners. The effect on the ocular surface is to replace the missing watery component, to thicken the tear film to restore good vision, and to allow healing to take place on the ocular surface. When recommending a specific artificial tear for a patient, it is important to keep in mind several aspects of the drop. These are:
• The effect on vision. Don’t recommend a thick, vision-blurring drop for critical periods such as driving.
• The effect on comfort. The natural, healthy tear film demonstrates a shear-thinning or pseudoplastic behavior(Tiffany 1991), and the ideal tear replacement should behave similarly.(Bron and Tiffany 1991) It has been demonstrated that a shear-thinning drop will be more comfortable compared to a less shear thinning formulation.(Dudinski, Finnin et al. 1983; Paugh 1998)
• Residence Time: the length of time that a drop lasts on the eye is influenced by several major factors, including:
o Drop comfort: If uncomfortable, tearing will result and the drop will be eliminated rapidly.
o Muco-adhesion of the viscolyzers. Several polymers are muco-adhesive (e.g., carboxymethylcellulose (CMC), polyacrylic acid (carbomer), HP-guar and hyaluronic acid (HA)). Mucoadhesion may allow a thin film of supplement to form on the ocular surface, allowing ocular surface healing and the formation of a stable tear film.
o Viscosity: although not always the case, generally thicker drops tend to last longer. The order, shortest to longest residence time relative to viscosity is:
Aqueous preparations < viscous drops < thick gels
There is preliminary data demonstrating residence time for several current drops (see Table 2), that must be interpreted with caution due to the very small sample size. These data were generated using marketed artificial tears, admixed with a fluorescent tracer, and measured in dry eye subjects (n = 5) using a scanning flurometer.(Paugh 2004) The study was funded by Alcon Laboratories, and is continuing to eventually include up to 20 subjects.
Conserve Aqueous Component: Conservation of a limited aqueous component can be achieved by the use of punctal plugs or by a moisture-retention spectacle arrangement.
Punctal Plugs: many are available; temporary, dissolvable should be used first (e.g., collagen type) to determine whether comfort can be improved followed by several month (give example) or permanent plugs (e.g., silicone type). Generally the lower puncta are plugged first, followed by the upper puncta if necessary. Punctal plugs can be very effective in relieving signs and symptoms of dry eye, although approximately 50% extrude within two years.(Tai 2002) Plugs must be monitored for retention over time, whick can be done using a transilluminator through the lid, similar to meibography.
Caution: Aqueous deficiency is relatively uncommon as a cause of dry eye. Thus, the utility of punctal plugs is limited. In addition, plugs will allow both normal waste material and topical solution preservatives to be retained on the ocular surface longer, potentially inducing surface toxicities.
Spectacles and/or Spectacle Side Shields: There is ample evidence that when moisture is retained by a goggle or spectacle set-up the tear film characteristics are improved (see. e.g., Paugh and co-workers(Paugh 2002). Thus, creating a sort of “humidity chamber” may be an acceptable management approach for severe dry eye.
However, wearing a spectacle side shield may not be esthetically acceptable to some patients so a balance between function and appearance can perhaps be made. Pearce and co-workers(Pearce 2003) have demonstrated that a modern, “wraparound” zyl frame can in fact increase humidity in front of an eye whereas a normal spectacle frame does not.
Replace Lipid Component:
There is mounting evidence that lipid replacements are effective in reducing the signs and symptoms in lipid deficient dry eye conditions (e.g., in atrophic meibomian gland disease). For example, Goto et al.(Goto 2002) demonstrated in a cross-over trial that a castor oil emulsion was more effective than saline artificial tears in alleviating signs and symptoms when administered 6 times per day for two weeks. Korb and co-workers have also demonstrated the efficacy of specific oily components in improving the appearance of the lipid layer.(Korb DR 2002)
Several OTC lipid replacements are now available (e.g., Refresh Endura from Allergan and Soothe from Alimera Sciences) and should be considered as an adjunct to warm compress therapy (see below) in cases of lipid insufficiency due to MGD.
Stimulate Aqueous or Lipid Production:
There are current and emerging therapies to stimulate either aqueous or lipid production, either by a therapeutic (drug) approach or holistic means (e.g., essential fatty acid dietary supplement to improve lipid parameters).
Aqueous Stimulation:
Cyclosporine A was found to stimulate aqueous tear production in KCS dogs(Kaswan 1989), and subsequently became the first therapeutic OSD entity to be developed for humans. Cyclosporine is an immunosuppressant agent when administered systemically, and a partial immunosuppression of ocular surface inflammation may be the mechanism of action in aqueous tear deficiency. Sall and co-workers(Sall 2000) in Phase III trials demonstrated objective (staining and Schirmer results) and subjective (need for artificial tears, investigator assessment of response to treatment) improvements with two concentrations of cyclosporine A (0.05 and 0.1%). Cyclosporine A in a concentration of 0.05% in an emulsion formulation has now been approved as a prescription treatment for moderate to severe dry eye by the FDA. Restasis is the brand name and it is recommended for use BID. Treatment takes up to six months to demonstrate a beneficial effect although the time frame of patient response is likely to vary.
Clinical Pearl: Restasis is moderately expensive and should be perhaps be used only in severe inflammatory ATD situations. The author has never prescribed it, possibly due to the very few cases of Sjogren’s or non-Sjogren’s ATD found in our clinic. Prior to recommending Restasis all other means to manage the dry eye should be explored, including use of the so called “soft steroids” (e.g., loteprednol).
Lipid Stimulation:Although under development at this time by Allergan and perhaps other entities, topically applied androgen (testosterone) appears to have efficacy in stimulating lipid production. There is a large and growing body of evidence that the meibomian gland is an androgen target organ, and that androgen deficiency may lead to MGD.(Sullivan 2002) One report involving one human subject has demonstrated improvement in lipid layer thickness and TBUT following 3 months of treatment with testosterone cream applied to the eyelids TID.(Worda 2001) Given that most dry eye observed in our setting is meibomian gland related, this potential approach appears to be very promising.
Inflammatory MGD/Blepharitis Treatment
1. General Considerations:
Therapy is directed at control rather than cure of the condition due to the chronic nature of these syndromes. There is generally an acute phase of treatment lasting for 2-8 weeks followed by ongoing home (i.e. lid hygiene) and in-office (e.g. forceful expression) as needed.
2. Specific:
The mainstay of therapy is mechanical and hygienic maneuvers (i.e. warm compresses and eyelid scrubs with mild shampoo) to clean lids and lashes and to encourage improved meibomian gland function. Topical antibiotics, perhaps in combination with an anti-inflammatory agent, are indicated when bacteria are suspected. Oral tetracycline (or tetracycline derivatives) is prescribed for meibomitis involvement (the action of tetracycline is likely a decrease in bacterial lipase production rather than simply a reduction of bacteria.(Dougherty, McCulley et al. 1991) Recently, a specific blepharitis protocol has been recommended, as follows.
Background
During the 4th International Conference on Tear Film etc., held in Fajardo, Puerto Rico in November 2004, the topic of blepharitis treatment came up among several clinician investigators. Drs. J Daniel Nelson and Steve Pflugfelder, both leading researchers and clinicians involved with dry eye, recommend the following protocol based on numerous cases.
Recommended Protocol:
• Warm compress therapy, 2 per day, for a minimum of 4-6 weeks. Often treatment will be needed on an ongoing basis.
• Erythromyocin ointment, applied to lashes, QHS for a minimum of 3 months (note: it does not have to be placed in the eye; as Don MacKeen showed(MacKeen 1998), anything applied to the lid skin gets into the eye).
• Lotemax QID until the active phase resolves (4-6 weeks?) (note: A baseline IOP and examination of the optic nerve head with a written note as to the appearance of the optic nerve is important. Remember, although Lotemax has less tendency to raise IOP, it still can happen so a baseline IOP and disc exam is warranted)
• Systemic minocycline for 2 weeks at 50 mg/day, then monthly at 100 mg/day. Minocycline is recommended because it can be taken BID, has the fewest side effects, and induces minimal photosensitization.(Ta 2003)
1. Taper minocycline for long term management (Treatment may need to be continued for months depending on the response. Usually a positive effect will be seen within 8 weeks.)
2. Cautions regarding minocycline: stained teeth, vaginitis in women, and photosentivity (increased sun burn risk) There are other unusual risks that any treating doctor needs to be aware of. These can be found in the PDR.
• Thera Tears Capsules with omega 3 and 6 fatty acids are useful. The dose is two capsules BID. It may take months, however, to see a beneficial effect.
MGD Therapy: Does It Work?
Paugh et al.(Paugh, Knapp et al. 1990) examined this question in a group of problematic contact lens wearers wherein MGD was the only likely candidate for the symptoms of dryness and burning. Lid scrubs and warm compresses were prescribed twice a day for one eye only (both eyes were equally affected at the outset) for two weeks. Symptomatology and fluorescein breakup time were assessed by a masked observer. The results demonstrated a highly statistically significant increase in FBUT of ~ 4 seconds in the treated eye and no change in the control (i.e., the no lid therapy) eye after the two week period. The BUT results are presented below (Figure 8).
Summary, Dry Eye Diagnosis and Management
This is an exciting time for clinicians and dry eye sufferers alike due to the wealth of new information and treatment options now available. The key to diagnosis lies in trying to assess not only the traditional global signs of dry eye/OSD, but in trying to classify the disease by specific sub-type. If etiology can be determined, effective treatments logically follow. The majority of sub-types commonly encountered appear to be those related to meibomian gland dysfunction (75%; either inflammatory or non-inflammatory MGD). Treatment for these and aqueous deficient conditions involve stimulating, conserving or replacing the deficient component. Adjunctive therapy is employed as needed, such as warm compresses, topical and systemic antibiotics, and possibly systemic nutritional supplements such as flax seed oil. The future holds the promise of increasingly efficacious treatments as new therapeutic entities are developed (e.g., androgen to treat MGD) and optimized palliative artificial tears.
Acknowledgements: The author thanks Dr. Alan Sasai, Principal Clinical Scientist (Allergan Inc) for his help in producing the gland expression video. The author also thanks both Allergan Inc (for financial support) and Alcon Laboratories (for materiel support) relative to the ongoing dry eye screening project at S.C.C.O.
Back to Course Table of Contents
Online CE Home | SCCO Home | VWI Home | Contact Us
© 2005 Copyright, SCCO. All rights reserved.
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