Het (droge) oog: OTC druppel of verwijzing naar de (oog)arts?

Just sit down and relax…

Het oog

• The story of the patient (or family…)

• The spot diagnosis bythe pharmacist(check other drugs; know your client)

Different symptoms and degree of ilness…

titel 4 14-6-2017

Oogleden

Stand/sluiting

Ectropion Entropion

Stand/sluiting

lagoftalmie Ptosis

Chalazion Zona Ophtalmica

Xanthelasmata (goedaardig)

Tumoren

• Basocellulair epithelioma = kwaadaardig

Conjunctiva

• Degeneratieve afwijkingen

– Pingueculum

– Pterygium

Het rode oog: subconjunctivale bloeding

conjunctivitis

bacterieel viraal

(Epi)scleritis

banaal ernstig!hardnekkig opname!

Cornea

Ontstekingen cornea

Keratitis Ulcus

Trauma: cornea erosie

• Oorzaken:– Vingernagel– Tak– Plant– Papier

• Klacht:– Pijn ++– Epifora– lichtschuw

Oogverband

Trauma: corpus alienum

iritis/cyclitis

• Klacht: – « diepe » pijn– Tranenvloed– Lichtschuw– Wazig zicht

• Inspectie:– Pericorneale roodheid– Nauwe pupil– Descemet stippen– hypopyon

Anisocorie• Groter in het licht?

=probleem sphincter

• Groter in het donker?=probleem dilatator

Oorzaken anisocorie

• Druppels (verlammen sphincter en/of stimuleren dilatator)

• Ontsteking iris of cornea (miosis)• Traumatisch (sphincter)• Acuut glaucoma (mydriasis)• Neurologisch (corneareflex?)• Corectopie (trauma, HK, verkleving)• Planten! (trompetkelk; datura)

Corectopie

De oogdruk

Klassificatie glaucoom

• a. Chronisch open hoek glaucoma• b. Acuut gesloten hoek glaucoma• c. Infantiel glaucoom• d. Secundair glaucoom

Chronisch open hoek glaucoma

Chronisch open hoek glaucoma

• Klacht: geen « tot het te laat is »: scotomen

• Familiaal• Behandeling:

– 1. oogdruppels: productie, afvoer kamerwater

– 2. lasertherapie– 3. operatie

– …at vitam eternam….

Acuut gesloten hoek glaucoma

• Klacht:– Acuut– Hevige hoofdpijn– Braken– Rood oog– Grote onregelmatig pupil– Wazig zicht (oedeem cornea)

• Behandeling:– Druppels– Vochtafdrijvers:

diamox/mannitol– Laser iridotomie– Operatie (trabeculectomie)

Cataract

Cataract: behandeling

Cataract: Klachten

• Vooral last om VER te kijken• Minder last bij het lezen• “Veraf beter zonder bril”• Sneller verblind als de zon laag staat• Trage evolutie (maanden)

Glasvocht

Glasvochtloslating• Plotse floaters• Flitsen

• Complicatie:– Retinascheuren– Retinaloslating

II: Afwijkingen van de bloedvaten• a: Vaatsclerose• b: Diabetische

retinopathie• c: hypertensieve

retinopathie• d: occlusie a.centralis

retinae• e: occlusie v.centralis

retinae• f: « alle » andere

systeemziekten

diabetische retinopathie

hypertensieve retinopathie

• In fundo:– Vernauwing arteriolen– Overkruisingstekens– Vaatsclerose

– Bloedingen– Exsudaten– papiloedeem

Ziekten van de gele vlekRisicofactoren:

1. leeftijd2. familiaal / genetisch3. diabetes4. slechte voeding (cholesterol,…)5. UV 6. cardiovasculair + roken!

2 vormen:1. Droge vorm2. Natte vorm

Droge vorm van SMD

• Pathologie:– Afzetting van « drusen » (=

vetophoping) onder het pigmentepitheel

• Klacht:– Metamorfopsie (Amsler)– Last voor dichtbij

• Behandeling:– Voedingssupplement– Preventie!

Natte vorm van SMD• Pathologie:

– Loslating pigmentepitheel– Nieuwvatvorming– Exsudatie + Bloeding– Verlittekening macula

• Klacht:– metamorfopsie– Centrale vlek

• Behandeling:– Lasertherapie– Fotodynamische therapie– Intravitreale inspuitingen– chirurgie

Nervus opticus

papiloedeem• Zwelling van de

oogzenuwkop• Oorzaken:

– ICH– Papillitis– Compressie oogzenuw– Hypertensie– AION

Automatische perimetrie (statisch)

Het droge oog

Niet elk droog oog is hetzelfde

International dry eye workshop (DEWS) definition of DED

International Dry Eye Workshop. Ocul Surf 2007;5:75–92.

Dry eye is a multifactorial disease ofthe tears and ocular surface thatresults in symptoms of discomfort,visual disturbance and tear filminstability with potential damage tothe ocular surface. It is accompaniedby increased osmolarity of the tear filmand inflammation of the ocular surface

Prevalence

• About 15% of peopleover 50 years

• 370 million of patients worldwide suffering from DED

From irritation to blindness

DEWS describes two major types of DED

Adapted from International Dry Eye Workshop. Ocul Surf 2007;5:75–92.

Dry eye disease

Excess evaporation in the presence of

normal lacrimalsecretory function

Reduced lacrimal tear secretion

and tear volume

Aqueous deficiency Evaporative

The ocular surface

Kanski & Bowling. Clinical Ophthalmology, 7th edn. Elsevier, 2011.Figure adapted from Gipson. IOVS 2007;48:4391–8Image is for illustrative purposes only.

Epithelium

Tear film

Meibomian gland

Main lacrimal gland

Accessory lacrimal gland

Glycocalyx

Goblet cells

Pre-ocular tear film

Lacrimal glands

Meibomian glands

EpitheliumAqueous layer

7-8 μm Lipid layer

0.1 μm Mucine layer

0.8 μm

Meibomian gland dysfunction

• Associated with dermatoses such as acne rosacea, seborrhoeic dermatitis and atopic dermatitis1

• Diagnosis based on morphological features2

– Acini and duct orifices, – Presence of orifice plugging,– Thickening or absence of expressed meibum_ Irregular lid margin

Clinical features of MGD

1. Tomlinson et al. MGD Workshop. IOVS 2011;52:2006–49.2. International Dry Eye Workshop. Ocul Surf 2007;5:75–92.

Photographs courtesy of Professor P Aragona

The healthy tear film

Water evaporation from tears is normally ~33% of the total tear flow1

1. Rolando et al. Br J Ophthalmol 2009;94(Suppl. 1):i1–9.Image is for illustrative purposes only.

Lipid layer

Aqueous/ mucin layer

Epithelial cells

In DED, the tear film and ocular surface are damaged

Water evaporation is now ~75% of the total tear flow1

Compromised tear film• Lipid layer

defective• Cells dehydrated• Osmotic balance

disrupted

Lipid layer

Aqueous/ mucin layer

Epithelial cells

1. Rolando et al. Br J Ophthalmol 2009;94(Suppl. 1):i1–9.Image is for illustrative purposes only.

Evaporation of the aqueous layer may lead to hyperosmolarity

Aqueous layer

Lipid layer

Mucin layer

Conjunctival cells

Compatible solutes

Evaporation Evaporation

Water

Apoptosis

WaterHyperosmolarity

Image is for illustrative purposes only.

Cellular response to hyperosmolarity

Exposure to hypertonic environment

Water loss

Regulatory volume increase

Uptake of inorganic solutes

Decreased cell function, stress

activation

Normal cell

Adapted from Strange et al. Adv Physiol Educ 2004;28:155–9.

Dehydratedcell

Restoredcell volume

Hyperosmolarity

Cell damageand death

In DED, quantity of water in tear film is decreased, due to either increased evaporation or insufficient water production

Image is for illustrative purposes only.

Fuorescein staining

Severity Level 1 2 3 4

Treatment

• Patient education• Environmental and

dietary modifications

• Eliminate offending systemic medications

• Artificial tear substitutes, gels/ointments

• Eyelid therapy

• Anti-inflammatories• Oral tetracyclines• Punctal plugs• Secretagogues• Moisture chamber

spectacles

• Serum• Contact lenses• Permanent punctal

occlusion

• Systemic anti-inflammatory therapy

• Surgery (lid surgery, tarsorrhaphy; mucus membrane, salivary gland, amniotic membrane transplantation)

If no improvement, add level-2 treatments

If no improvement, add level-1 and -3 treatments

If no improvement, add level 4 treatments

1. Management and Therapy Subcommittee. Ocul Surf. 2007.

Dry Eye WorkShop (DEWS) Treatment Guidelines1

Artificial Tears are a widely recognized First-Line Treatment

The ideal drop….• Protects cells of

cornea and conjunctiva

• Improves mucin layer• Adds volume• Limits evaporation• Feels good• Limited instillations• Easy instillation• Non toxic

The ideal artificial tear• Protects cells of

cornea andconjunctiva

• Improves mucin layer• Adds volume• Limits evaporation• Feels good• Limited instillations• Easy instillation• Non toxic

• Osmoprotectants

• mucine (like) substance

• lipids• Not too viscous, shear

thinning

• preservatives!

• Many products contain a single osmoprotectant but…

Osmoprotectants are thought to be most effective when several are combined into one formulation

No Treatment PURITE® Benzalkonium chloride

PolyquadSodium perborate

Preservatives…or not?6

Transplantation of labial salivary glands

• Subtarsal incision of conjunctiva

• Dissection+Recession of conjunctiva

• Suturing the graft with two submucosal running Prolene sutures entering the skin nasally and leaving it temporally

1 day and 2 weeks postop

How do they help?

- via direct secretion of “tears” or essential tear components (mucins,…)??

- via secretion of molecules that stimulate the lacrimal gland, the goblet cells of cornea and conjunctiva (TFF, Lacritin,…)??

Mass Spec

• Quadrupole Orbitrap(ThermoFischerQ Exactive PlusTM)

• Thousands (!) of proteinspecies detected

• Much more sensitiveanalysis of small and lessabundant proteins

The smile of a tear by Joan Miró

Dank!