ocular surface

How to Manage Ocular Surface Disease

Although OSD may present asymptomatically, employ a strategy that includes early treatment.

Marc Bloomenstein, O.D., F.A.A.O. Scottsdale, Ariz.

IMAGE OF CORNEAL STAINING COURTESY OF GREG DENAEYER, O.D.

The notion of an annual examination is a foreign idea to me. Our patients live such busy lives that an interruption, like going to the doctor or an eye doctor, usually is not on the top of their list. Let's be honest, many of us do not make regular pilgrimages to our doctors, so they can tell us that our non-symptomatic organs are working as we expect them too. Yet, we think our patients are venturing to our practices for that exact reason — a wellness check with no symptoms?

Reality check: Patients make appointments because subconsciously or consciously, their eyes are not working as they have in the past. With the exception of some obvious pathology or significant change in refraction, we can often trace their ocular problem to an ocular surface disease (OSD). Yet, many of us don't address the problem or give our patients the strategies to avoid the inevitable-worsening and eventual symptoms of OSD.

The ocular surface is a complicated living system that needs nourishment and constant care. If we can provide early treatment to our OSD patients, we can help them stay healthy. Much of what we do should be designed to prevent conditions from worsening (e.g. the early treatment of myopia or current use of corneal cross-linking for keratoconus patients).

OSD is often times broken down into three distinct and separate entities: allergic conjunctivitis, blepharitis and keratoconjunctivitis sicca. However, these entities are all linked by inflammation, and the symptoms of one condition may mirror the symptoms of another.

To truly prevent OSD from having visual and quality-of-life consequences, we must design a treatment regiment to decrease the inflammatory load that is hampering the patient. Most over-the-counter regiments work to help mask the symptoms, yet they lack the ability to stop the condition in its tracks. Much like the way we treat our glaucoma patient with a treatment plan and regular follow-up visits, our “eye” on the health of their OSD vision requires the same attention, as this article will discuss.

Allergic conjunctivitis

Allergies are on the rise and with more than 50 million Americans suffering, according to the Asthma and Allergy Foundation of America, with at least 30% of those having eye-related symptoms, we have a large pool of patients who will need our help. All it may take to diagnose allergic conjunctivitis is to simply ask your patient whether his eyes are ever itchy. Recognize the opportunities to treat allergy when you see signs of concomitant allergic reaction, such as a runny nose and congestion, especially during peak pollen/hay fever season or when you discover the patient has come in contact with any known allergens.

The allergy-reacting conjunctiva will often times have varying degrees of papillary reaction, mucous discharge and hyperemia. This is also relative to the papillary reaction driven by the sheer force of the lid on contact lenses. However, the patient may not be in your chair during their allergic attack. Since the initial onset of the allergen creates the mast cell-driven cascade of inflammatory mediators that leads to the eventual symptoms, we need to get the medication in our patient's hands prior to an attack. Diluting the allergen can be useful with patients, and, therefore, prescribing an artificial tear during the height of the allergy season is beneficial. Moreover, the comorbidity of dry eye is high here and, thus, the treatment regiment for dry eye will help with your allergy patients.

Regarding therapy for ocular allergy, you should be aware of the following:

► Response time. Certain drops have been shown to reduce the itch response quickly.
► Dosage. For patients with an on-the-go lifestyle, q.i.d. or b.i.d. dosing may not be the optimal choice. Two mast cell-stabilizing antihistamines are approved by the FDA for q.d. dosing.
► All drops are not indicated for use with contact lenses.
► Pediatric use. Allergies are often times seen in younger patients, and they may only present with ocular symptoms. Knowing that you are prescribing a medication that is approved for use in pediatric patients as young as age two gives you peace of mind.

And for your patients who are of childbearing years, consider a drop that carries a pregnancy category B approval, thus making it a safe choice.

Posterior blepharitis

Meibomian gland dysfunction (MGD) is defined by The International Workshop on Meibomian Gland Dysfunction as “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.” However, the condition can also be defined as one of the most common eye complications that our patients deal with on a daily basis.

In a 2008 survey-based perspective on prevalence and treatment, published in The Ocular Surface, optometrists reported diagnosing blepharitis in 47% of their patients. Further, in a 2011 abstract from the American Society of Cataract and Refractive Surgery (Luchs, Buznego, Trattler), which assessed the frequency of occurrence and the severity of blepharitis in 100 cataract patients, the prevalence was as high as 59%.

Yet, many of our patients are unaware this condition exists because we tend not to act until they become symptomatic. Patients who have MGD present with dryness, a sandy or sticky feeling, watering/tearing, redness and most notably, burning. These symptoms vary in degree and often times are overlooked due to their transient nature. During certain times of the year, such as winter when the air is much drier or when your patient has a sinus infection, these symptoms may be more prominent than others.

The tools needed to diagnose MGD are in every optometrist's armamentarium: their eyes and their ears. The earliest clinical sign may be saponification, or bubbling on the lid margin, indicating a change in the meibum's composition. The International Workshop on Meibomian Gland Dysfunction attempted to stage MGD so as to give treatment options and help us see the progression of this condition:

► Stage 1 is no symptoms and a clinical sign of altered secretions. The meibomian secretion should appear smooth and golden, much like olive oil.
► In Stage 2, mild symptoms of discomfort, itching or photophobia with signs of scattered lid margin features and more altered secretions, though still easily expressible glands, are present.
► Stage 3 is comprised of an increase in the aforementioned symptoms, and limitations on personal activities increase in conjunction with vascularity and plugging. Gland expressibility is more difficult, and mild-to-moderate corneal staining is present.
► Stage 4 MGD is characterized by marked ocular discomfort with definite limitations of personal activities, gland drop out and displacement. Further, severely altered secretions (much like the tooth paste analogy) and more increased signs of inflammation on the lid margin are present.

Pictured is meibomian gland dysfunction (MGD). As MGD progresses through stages, it becomes more challenging to treat.

The treatment of MGD must begin much earlier than we, as clinicians, are accustomed. This is because as the progression of this condition moves from stages, it also becomes more challenging to treat. The mind-set should not be of removing the condition, but helping maintain the condition. The analogy of brushing your teeth to manage the plaque is a good example for patients. If you were to cease brushing your teeth, the plaque would build up.

The recommended staged therapy starts with warm compresses and gland expression. I prefer to keep this as simple as possible. I instruct my patients to use the shower to heat their lids, with frequent water dunking and a commercially available lid foam scrub. I also prescribe cyclosporine 0.05%, (Restasis, Allergan) to increase the lubrication of the ocular surface and help to remove any potential increase in inflammation.

The International Workshop on Meibomian Gland Dysfunction then states that at Stage 2, the introduction of an oral tetracycline derivative or topical azithromycin is needed in concurrence with the treatment for Stage 1.

For a longer use of the macrolides, you should consider a low dose doxycycline. Since gastritis is a concern for patients who take doxycycline, tell patients to avoid using this medication on an empty stomach or right before going to bed. Further, educate these patients that they should avoid milk products to preclude any stomach issues related to the dosing. The reason: Macrolides tend to chelate.

A 25mg-to-50mg q.d. dose of doxycycline can be enough to ensure an anti-inflammatory effect for the lids. Since this is a staged therapy, using the warm water treatment and lid foam is still recommended.

The International Workshop on Meibomian Gland Dysfunction defined treatment for Stage 3 as the addition of an anti-inflammatory (e.g. steroids) and Stage 4 as the continuation of steroids, use of a bandage contact lens and/or surgery. New treatments for Stage 3 and 4 MGD patients now exist that involve adding heat to the glands. (See “New Devices to Manage Dry Eye,” page 32.)

Another treatment to open those recalcitrant glands: an intraductal probe. In any of the stages of MGD, opening the orifice is important to the viability of this important gland. In the office, break off the capped glands, massage the lashes to ensure meibum flow, and, if necessary, use a probe to break the surface of the gland, which may have hypertrophied.

Keratoconjunctivitis sicca

Another of the ocular surface diseases, keratoconjunctivitis sicca (KCS), or dry eye, is a main stay in the optometric practice. How many patients do you have using an artificial tear? What percent of your contact lens patients are using drops to keep their eyes lubricated? How many of your MGD patients must concomitantly add lubrication? Shockingly, the numbers are large in our practices, so we must work hard to properly diagnose this condition and prevent it from worsening.

The risk factors for KCS: age (elderly patients are at greater risk), gender (females are at an increased risk), medications, such as anti-histamines, birth control pills and anti-depressants, and systemic medical conditions, such as diabetes, inflammatory conditions and rosacea.

Since we are attempting to help keep dryness in check, we need to look at our patient's environment (air travel presents the driest environment), time in front of the computer and time outside in inhospitable weather conditions. Also, contact lenses, those thin pieces of plastic placed on the eye, can cause inflammation, and, thus, induce a chronically dry environment for the ocular surface.

The conventional way to diagnose dryness was to use tear break-up time, the Schirmer's test and/or look for corneal fluorescein staining. However, these methods can often times be misleading, especially when it comes to waiting for staining. The International Task Force (ITF), or Delphi panel, created guidelines, much like the Meibomian Gland Workshop, to help doctors define and treat KCS. Ironically, the Delphi panel guidelines focus mainly on symptoms and place little emphasis on the diagnostic testing of the condition.

However, with new technology, such as an osmolarity tester and an as-yet-to-be-approved device that detects elevated levels of MMP-9, an enzyme which has been observed in the tear fluid of dry eye patients, doctors may have a number to help guide them in their treatment plans. (See “New Devices to Manage Dry Eye,” page 32.) We must also conduct a thorough evaluation of the lids, since MGD is a major culprit in the dry eye patient.

The ITF guidelines are designed as a planned treatment that starts with artificial tears. A large portion of our patients are already on a drop (albeit the wrong drop and often times to reduce the redness), and this treatment is palliative at best. In a recent survey, almost 50% of all adults said they felt they had dry eyes, and 50% of these adults said they are treating it with artificial tears.

More problematic is that not all tears are created equally. As stated earlier, the presence of MGD can have a negative impact on the osmolarity and inflammation of the eye. Therefore, recent tears are formulated to help replace those insufficient oils. The ITF guidelines specify that mild MGD patients can continue using a non-preserved tear, but advancing dry eye patients should use preservative-free tears.

Even with all the great advancements in artificial tears, 63% of patients using tears routinely do not feel that the tears are managing their symptoms successfully, according to a recent Harris Interactive poll. Therefore, Restasis is the next recommended treatment modality in this patient population. Restasis has been shown to increase the tear production, goblet cell density (which in turn induces more mucin) and, when combined with the emulsion created from castor oil, stabilize all three of the major components of the tears. Since this medication works to improve the inflammatory environment, it is a maintenance drop to alleviate the chronic nature of KCS.

Faced with increased symptoms and a concurrent increase in corneal staining, the ITF recommends punctal plugs and dietary supplementation (omega-3 essential fatty acids), along with the concomitant use of Restasis and artificial tears.

Decisions with impact

Through the next few decades as the baby boomers “boom,” we, as clinicians, will be inundated with ocular surface disease patients. The decisions we make as we see these patients will have a long-lasting impact on their quality of vision. Although OSD may present asymptomatically, the signs and risk factors are obvious. We need to increase our diligence in treating these patients. Every O.D. who walks into an exam lane is an OSD specialist; we just have to make sure that our patients know that. OM

Dr. Bloomenstein is the director of Optometric Services at Schwartz Laser Eye Center in Scottsdale, Ariz. E-mail him at drbloomenstein@schwartzlaser.com. To comment on this article, e-mail optometricmanagement@gmail.com.