Robert Fintelmann MD FACS Kevin Helmuth OD Dr Robert Fintelmann completed his doctorate at the University of Ulm in Germany an ophthalmology residency at Wills Eye Institute in Philadelphia ID: 916680
Download Presentation The PPT/PDF document "Dry Eye update Coordinating teaching, di..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Dry Eye update
Coordinating teaching, diagnosis and therapy
Robert Fintelmann M.D
., FACS,
Kevin Helmuth O.D.
Slide2Dr
. Robert Fintelmann completed his doctorate at the University of Ulm in Germany, an ophthalmology residency at Wills Eye Institute in Philadelphia,
PA,
and a Corneal and Refractive Surgery Fellowship at the University of California, San Francisco. Dr. Fintelmann has performed thousands of cataract surgeries, over 2,000 vision correction procedures (LASIK, PRK, and ICL), & hundreds of corneal transplants. His experience includes: laser-assisted cataract surgery, full corneal transplants, partial thickness corneal transplants (DSAEK, DMEK, DALK), along with minimally invasive transplants of either the anterior or posterior portions of the cornea. In clinic, he enjoys treating ocular surface disease (dry eye), and helping patients achieve relief from their chronic eye irritation. Dr. Fintelmann is a board-certified Diplomate of the American Board of Ophthalmology and serves as an examiner for the oral board exams. He is a fellow of the American College of Surgeons and a member of multiple professional organizations, and he performs research & publishes articles in peer-reviewed journals.
Robert Fintelmann, M.D., FACS
Slide3Dr
. Kevin Helmuth
, received his doctorate from the Pacific University College of Optometry. He currently serves as the Director of Clinic Operations at the AZ College of Optometry where he also works as an Associate Professor.
Prior to coming to Midwestern University, Dr. Helmuth spent nearly 12 years working in Native American health facilities. He previously served as the Director of Optometry for the Gila River Indian Community, Hu Hu Kam Memorial Hospital in Sacaton, Arizona; and the Chief of Optometry for the Creek Nation in Okemah, Oklahoma. He has a clinical and research interest in Dry Eye.Kevin Helmuth O.D.
Slide4Financial Disclosures
Neither Dr. Fintelmann nor Dr. Helmuth have any financial disclosures to report.
<a href='https://newvitruvian.com/image/pocket-clipart-poverty/1092570.html'>Image credit</a>
Slide5Objectives
Discuss new dry eye therapies that will be coming to the marketplace soon
Re-visit Meibomian Gland Dysfunction and therapies to address it
Review the special challenges that are unique to treating dry eyeDiscuss the importance of developing a standardized method of evaluating dry eye patientsReview some effective tools that assist in patient communicationExamine a method for not losing site of the big picture in this complicated conditionUnderstand the importance of incorporating a multi-disciplinary approach
Slide6Medications
New Technology
CEQUA
(cyclosporin A 0.09%)Highest concentration of Cyclosporin AUses a novel nanomiceller technology which allows it to penetrate the tear layer betterPurportedly shows quicker results than either Restasis or Xiidra in corneal staining and tear productionKLARITY-C (cyclosporine/chondroitin sulfate 0.1% ophthalmic emulsion, Imprimis Pharmaceuticals)Compounded, preservative-free, BIDXiidra (lifitegrast 5%)
Multiple Other Meds in Clinical Trials:
KPI-121
(0.25% loteprednol etabonate ophthalmic suspension, Kala Pharmaceuticals)
Thymosin
β
-4.
RGN-259
TearCare
Automated heat device applied to the lids
$5500 after rebate
$250/procedure renewable costs
12-15
minute tx followed by manual expression
New Therapies
Slide7Medications
New Technology
VITAL TEARS
(Autologous Serum)Ordered as a single 2–3 month supply or as an on-going subscription.Provided in 3 ml aliquots. The drops last 1 week in refrigeration and 6 months frozenCOSMESIS DISCUSSION
Digital Heat Inc.
Therapy Update
Slide8Re-visiting MGD treatment
Lipiflow and ILux
Lipiflow is well established
Studies and experience shows improvement of signs and symptoms when glands are presentPromoting it as a silver bullet which would make money hurt its implementationCost is a barrier (definition of success crucial)Results take timeDoes not fix all of the problems
Slide9MGD treatment
Lipiflow and ILux
Price created incentive for competition
Ilux has the same goalWorks in smaller fissuresSmaller device Disposable first cheaper now more expensive than lipiflow
Slide10MGD treatment
Intense Pulsed Light (IPL)
Used for years in dermatology
Suggested use in dry eye to address inflammationExact mechanism of action unknownBest results in patients with rosaceaTreatment parameters varyWith/without expressionMidface versus full faceDifferent machinesWith/without probing?
Slide11MGD treatment
IPL
Broad spectrum light source
xenon bulbs500-1200nm wavelength FDA approval 1995Taken up by pigment (melanin, hemoglobin, artificial pigment e.g. eyeliner tattoo)Different filters and pulsesGood safety profile when used as intended
Slide12MGD treatment
IPL
Complementary to lipiflow
Works in inflammatory conditionsImprovement in more advanced casesNo renewables/Price pointSeveral treatments necessaryImprovement noted earlier# of treatments done at MWU
Slide13Multiple probes are available 1mm, 2mm, 2.5mm, 4mm or 6mm. Start with 2mm.
For clogged meibomian glands, particularly those inducing a feeling of pressure/discomfort.
Takes 5-30 minutes
Use lidocaine on the lid marginProvides both immediate and long-term effects on symptoms and signsLongevity of effect variable, retreat in 6-18 month time frame or possibly beyond.Price considerations
Probing of the Meibomian Glands
Maskin Meibomian Gland
Intraductal
Probe
Slide14The Difficulty of Treating Dry Eye
Glaucoma Treatments
Prostaglandin analogs
Beta BlockersCarbonic anhydrase inhibitorsAlpha AgonistsRho khinase inhibitorsCombination DrugsLPIALT/SLTTrabeculectomyMIGS
Slide15Cyclosporin A variants
Xiidra
Warm compresses/Heat mask
Moisture gogglesArtificial tears (preserved)Artificial tears (non-preserved)Gels OintmentsSleep shieldsNutraceuticalsIntense Pulsed Light (IPL)LipiflowiLuxTearCareAqueous secretagoguesMucin secretagoguesIntraductal Gland ProbingLid debridementManual gland expressionTopical NSAIDSTetracyclinesMacrolidesTopical antibioticsTarsorrhaphyConjunctivochalasis repairEnvironmental considerationsBlinking exercisesIncreased fluid intake
The Difficulty of Treating Dry Eye
Dry Eye Treatments
Slide16The Difficulty of Treating Dry Eye
Addressing
other pathology is crucial
Conjunctivochalasis variable in presentation and contribution to symptomsCan be addressed in clinic with cauteryImproving surface prior to intervention results in smoother recoveryEBMD, radial keratotomy, pterygium and scarsAffect test resultsMay need to be addressed surgically to get desired outcomeLid positionCan be underlying pathologyWork with surgeon who understands dry eyeLimbal stem cell deficiencyMistaken for dry eye
Slide17InTEGRATING new treatments
Both short and long-term views are important
Slide18Standardizing approach
Consistency improves care and learning
Slide19Standardization
Evaluation
The Diagnosis of Dry Eye is mostly based on symptoms
Our template standardizes approach to the patient, teaching, treatment and outcome evaluation.standardized grading scales e.g. staining, meibomian gland expression, redness scales, NIKTBUT, lissamine green, fluorescein etc. Immediate availability of these scales e.g. pictures within the E.H.R. that provide grading assistance for doctors and students alike.better teaching environment by synchronizing exam protocol and messaging to students/patients.Improved assessment of therapy success since both signs and or symptoms can improve
Slide20Standardization
Use of technology
MeibographyNIKTBUTTear film analysis Ocular surface analysisProvides communication tools to convey diagnosis and problems to patientsProvides visualization of findings to students and doctorsUnderlines multifactorial and interconnected nature of Dry Eyes and its effects on vision and surgical outcomes
Slide21Standardization
Treatment
Treatment tablesStandardize treatment, facilitate decision makingGraphical analysis over timeEmphasize treatment effect, enhance complianceChronological record of treatmentWhat has been done? What worked?Easier to integrate new treatment options while keeping established options on everybody’s mind.Provides framework for better and more impactful research opportunities.
Slide22Case history
Personal ocular/medical History
OSDI / SPEED questionnaire
Oculus 5M Meibography (dropout/truncation) NIKTBUT Tear meniscus Conjunctival InjectionTears Zone Quick and/or Schirmers Fl-TBUTCornea/Conjunctiva Corneal staining (Fluorescein/Lissamine) Conjunctival staining (Fluorescein/Lissamine) Conjunctivochalasis Corneal/Conjunctival filaments Other corneal pathology
Lids
Floppy eyelids
Blepharitis (Cylindrical?)
Lid position
Lid retraction
Lagophthalmos
Blink type
Blink rate
Meibomian gland expression
Meibum quality
Line of Marx
Telangiectasia
Other
Dry Mouth Rosacea Contact lenses
Systemic meds score Compliance rating
Standardizing your Evaluations
For Dry Eye
Work-Ups
Slide23Case history
Personal ocular/medical History
OSDI / SPEED questionnaire
Tears Fl-TBUTCornea/Conjunctiva Corneal staining (Fluorescein/Lissamine) Conjunctival staining (Fluorescein/Lissamine) Lids
Blepharitis
(Cylindrical?)
Meibomian
gland expression
Meibum quality
Other
Systemic meds score
Compliance rating
Standardizing your Evaluations
For Dry Eye
Follow-Ups
Slide24Exam
Slide25Technology
Slide26Managing the Chronic PatientThe value of graphical analysis
Slide27Estrogen
Progesterone
Loratadine
(Claritin)Chlorpheniramine (Chlor-Trimetan)Diphenhydramine (Benadryl)Furosemide (Lasix)HydrochlorothiazideIsoretinoinIsoTretinoinCyclophosphamide (Cytoxan)Cetirizine (Zyrtec)Desloratadine (Clarinex)Sertraline (Zoloft)Paroxetine (Paxil)Amitriptyline (Elavil/Endep)Doxepin (Adapin/Sinequan)IbuprofenPropoxyphene Napsylate + Acetomeniphen (Darvocet-N)Hydrocodone (Lortab)Lansoprazole (Prevacid)
Esomeprazole (Nexium)
Omeprazole (Prilosec)
Ranitidine (Zantac)
Cidetidine
(Tagamet)
Thioridazine
(
Mellaril
)
Chlorpromazine (
Thorazine
)
Systemic Medication Score
Dry Eye Inducing Systemic Drugs
Slide28Managing the Chronic PatientThe value of graphical analysis
Slide29The importance of a treatment table
Managing the Chronic PatientNot losing the forest for the trees
Slide30The personalized treatment planManaging the Chronic PatientBuilding Compliance Through Improved Patient Communication
Slide31Interdisciplinary approach
Rheumatology
Psychology
Dry Eye patients suffer from greater depression, anxiety and one case reported higher suicidal ideationDry Eye patients have shown reduced quality of life in multiple studiesTwo Depression Screening Questions to ask your patients.1) During the past 2 weeks, have you often been bothered by feeling down, depressed, or hopeless? 2) During the past 2 weeks, have you often been bothered by little interest or pleasure in doing things?
Slide32References
J Vis Exp. 2019 Apr 1;(146). doi: 10.3791/57811
Toyos R, et al.
Photomed Laser Surg. 2015;(33)1:41-46Clin Ophthalmol. 2019 Jan 22;13:189-198. doi: 10.2147/OPTH.S191588. eCollection 2019Graefes Arch Clin Exp Ophthalmol. 2019 Mar;257(3):591-599. doi: 10.1007/s00417-019-04241-1. Epub 2019 Jan 15.Cornea. 2019 Mar;38(3):311-317. doi: 10.1097/ICO.0000000000001854Eye Contact Lens. 2018 Nov;44 Suppl 2:S404-S409. doi: 10.1097/ICL.0000000000000550
The British Journal of Dermatology. 2018;179(2):282-289
BMC Psychiatry. 2018 May 16;18(1):131. doi: 10.1186/s12888-018-1715-x
Brain Behav. 2016 Oct 13;6(12):e00586. doi: 10.1002/brb3.586. eCollection 2016 Dec.
Sci Rep. 2016 Mar 1;6:22480. doi: 10.1038/srep22480.
Curr Eye Res. 2016 Aug;41(8):1044-1049. Epub 2015 Dec 7.
Curr Eye Res. 2016 May;41(5):590-9. doi: 10.3109/02713683.2015.1056804. Epub 2015 Sep 4
Canadian Agency for Drugs and Technologies in Health
; 2018 Feb 8
www.webmd.com/skin-problems-and-treatments/news/20120830/are-mites-causing-your-rosacea#1
Joint Bone Spine, 2016 Dec;83(6):681-685. doi: 10.1016/j.jbspin.2015.10.005. Epub 2016 Jan
13
Mickles,Chandra
OD,
MS, Review
of Optometry,
Dry Eye Drugs: New Approaches to an Old
Problem, March 15, 2019
Maskin SL. Intraductal meibomian gland probing relieves symptoms of obstructive meibomian gland dysfunction. Cornea 2010;29(10):1145–1152.
Fermon S, Hindi Zaga I, Alvarez Melloni D. Intraductal meibomian gland probing for the treatment of blepharitis. Arch Soc Esp Oftalmol 2015;90(2):76–80.
Nakayama N, Kawashima M, Kaido M, Arita R, Tsubota K. Analysis of Meibum Before and After Intraductal Meibomian Gland Probing in Eyes With Obstructive Meibomian Gland Dysfunction. Cornea 2015;34(10):1206–1208
.
https://dryeyeandmgd.com/dry-eye-and-mgd-treatments/lipiflow-treatment-leading-cause-dry-eye
/
http://www.eyelidsurgery.co.uk/ectropionentropion-surgery
/
https://
www.atlasophthalmology.net/photo.jsf;jsessionid=0AC5E47D464510B839F301A57DA39A59?node=625&locale=pt
https://psychologybenefits.org/2015/01/29/4-tips-for-preventing-and-coping-with-hiv-related-short-term-memory-loss
/
http://shine365.marshfieldclinic.org/wellness/feeling-anxious-worried-or-panicky
/
https://www.dawn.com/news/1454338
https://www.seebetterflorida.com/lumenis-optima-ipl/
Slide33