Eyeworld Supplements

EW Chicago 2012 Advances in cataract and refractive surgery: A clinical update 9 4-week taper or non-steroidals such as bromfenac daily 4 and topical cyclosporine for chronic phase treatment. Mucin glycocalyx layer dysfunc- tion is associated with skin diseases affecting mucus membranes (usually immune-mediated), including patients with Stevens Johnson syndrome, ocular cicatricial pemphigoid (OCP), and vitamin A deficiency. While patients often have a sufficient aqueous layer, they experience an insufficient mucin layer because the conjunctival goblet cells are attacked. (Five to 20% of conjunctival epithelial cells are mucin-producing goblet cells. Soluble mucins are essential for viscosity of the normal tear film.) Treatment options include a prescription ophthalmic solution that creates an improved oncotic pressure gradient and works at the epithelial cell layer, and topical cyclosporine, which increases goblet Medications such as antihistamines, diuretics, beta blockers, tricyclic antidepressants, anticholinergics, antipsychotics, anxiolytics, antispasmodics, hormone replace- ment therapy, and birth control pills could play a part in DES. Systematic treatment plan The tear layer approach, a systematic treatment plan that evaluates the varied layers of the tear film, is effec- tive in the diagnosis and treatment of dry eye syndrome. It begins with an evaluation of the lipid layer (meibomian gland disease/posterior blepharitis). Problems related to this layer are common in cases of acne rosacea that typically manifests by age 40. About half of the patients have MGD, and patients also usually have inflammation at the sebaceous meibomian gland level. Seborrheic dermatitis patients also may experi- ence lipid layer issues. Warm compresses, lid massage, lid scrubs, topical azithromycyin, tobramycin/ dexamethasone, and ATs that replace the oily layer are effective treatments. Typically oral doxycy- cline (50 mg/d) is used for 4 weeks with topical treatment. The Maskin Meibomian Gland Intraductal Probe (Rhein Medical, St. Petersburg, Fla.) can be used. In addition, the TearScience Thermal Pulsation System (TearScience, Morrisville, N.C.) recently received 510K clearance in the treatment of MGD patients. Aqueous layer treatment is frequently needed for autoimmune disease patients, such as those with Sjogren's syndrome, lupus, and rheumatoid arthritis (RA). Typically these patients have inflammation at the lacrimal and accessory lacrimal glands. Patients with diabetes mellitus may have a neurotrophic component as seen in LASIK. In addition, patients with graft-versus- host disease in bone marrow transplants may also require this treatment. These patients should see their primary care physician, internist/rheumatologist, or oncolo- gist to control systemic inflamma- tion. Steroids are required for the acute phase treatment—loteprednol/ cell density. The underlying skin disease must also be treated. Osmolarity issues Increased osmolarity of the tear film and inflammation of the ocular surface 3 accompanies DES. Artificial tears such as Blink Tears and Blink GelTears (Abbott Medical Optics, Santa Ana, Calif.) can be helpful for dry eye patients, especially those experiencing mucin glycocalyx layer dysfunction, because the viscoadap- tive formula of Blink Tears mimics the natural mucin layer. In addition, studies have shown that Blink Tears is the most hypotonic drop to reduce tear hyperosmolarity, 5 and it provides long-lasting reduction of osmolarity, up to 2.5 hours before returning to baseline. 6 Patients and physicians have reported a reduction in signs and symptoms of dry eye with the use of Blink Tears. Those symptoms include blurred vision, burning, discomfort, dryness, and irritation. 7 Evaluating and treating all of your surgical patients for DES will help them achieve the best possible visual outcomes. References 1. Buznego, C, Luchs, J, Trattler, W. Incidence of Blepharitis in Patients Scheduled for Phacoemulsification. Presented at ASCRS 2010. 2. Trattler, William. AAO 2011. 3. Lemp M, et al. Ocular Surf. 2007;5:75-92. 4. Schechter, B. Comparison of Bromfenac vs. Ketorolac During the Induction Phase of Treat- ment with Topical Cyclosporine for Chronic Dry Eye Patients. Presented at ASCRS 2010. 5. Data on File #114. Blink Formula Grid Comparison. 6. Montani. G. Length of the effect of Blink Intensive on reduction of tear osmolarity. BCLA presentation 2009. 7. Buznego, C, Trattler, W.B. Assessment of Duration of Effect of Commercially Marketed Over-the-Counter Ocular Lubricants. Presented at ASCRS 2011. Dr. Jackson is the founder of Jacksoneye in Lake Villa, Ill. He can be reached at mjlaserdoc@msn.com. AMO Saturday supplement_Chicago 2012-USE THIS ONE_Layout 1 4/20/12 4:25 PM Page 9

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