Ocular Surface Wellness The Basics Jack L Schaeffer OD FAAO Marc Bloomenstein OD FAAO Paul Karpecki...

Ocular Surface Wellness The Basics

Jack L Schaeffer OD FAAOMarc Bloomenstein OD FAAOPaul Karpecki OD FAAO

Ocular Surface Wellness

• Ocular surface wellness means re-envisioning our role as eye care practitioners (ECPs) to include helping patients maintain good ocular surface health—not just treating the ocular surface when it’s compromised

• Wellness requires a proactive stance to maintain ocular surface health

• Currently we live in a reactive treatment mode

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Prevention: Action to Maintain Wellness

• Primary prevention — reducing incidence of disease1

– Prevent initiation of disease process– Vaccination, healthy habits, smoking cessation

• Secondary prevention — early detection1 – Ideally before symptoms occur– Screening, check-ups, early intervention

• Tertiary prevention — improving outcomes1

– Help for those with manifest disease1 – Glycemic control for diabetics, nutritional supplementation

for AMD

3

Wellness Today

• The conventional medical model is disease-oriented

• Patients interact with medical system to regain health, not to maintain health

And that’s a problem!• The US is in the midst of a chronic disease

epidemic2

• Many costly chronic diseases linked to modifiable lifestyle factors—smoking, diet, activity, sustained stress2,3

4

Less than ¼ of Americans consume 5 or more servings of fruits and

vegetables daily

1 in 5 US adults smokes

1 in 3 US adults is obese

Ocular Surface Wellness: The Opportunity

• Active maintenance of OS health supports patients’ long-term– Vision quality – Healthy-looking eyes– Ocular comfort – Successful CL wear

– Contact lenses change the tear film dynamics and the ocular surface

– Young adults are the demographic that will benefit the most

5

Optimizing Vision

• Efforts to prevent or slow OS pathology help preserve vision

• Tear film irregularity can affect retinal image quality16

• DE patients experience– Reduced contrast sensitivity17

– Fluctuating vision – Impact on ease of daily activities (eg,

reading, computer, driving, TV)18

– Discomfort with contact lenses19

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Optimizing Vision for Contact Lens Wearers

• Estimated 37 million US contact lens wearers20

• To perform optimally, CLs need a robust tear film21

• Dissatisfaction with vision is the second most common reason for CL dropout22,23

• Age-related changes to the tear film and OS, combined with changes in refractive needs, can make CL wear more challenging and lead to dropout20,24

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Optimizing Vision for Ocular Surgery Candidates

• Refractive and cataract surgery patients have high expectations for postop comfort and vision

• Visual outcomes (and postop comfort) influenced by preop OS conditions25-29

• It is our responsibility to prepare our

patients for surgery

8

Threats to Ocular Surface Wellness: Allergy

• Prevalence of allergic conjunctivitis increasing globally

• Affects 15% to 40% of US population40-42

• Typically mild, but interfere with quality of life42

• Significant overlap between presentations of DE and allergy40

• Eye exams may not coincide with seasonal allergy symptoms—proactive questioning important

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Itch42.2%

Dryness54.6%

57.7% Itch45.3% Dryness

Threats to Ocular Surface Wellness: Dry Eye and Blepharitis

• DE and blepharitis among the most common conditions eye physicians encounter43,44

– Using a very restrictive definition, DE affects nearly 5 million Americans aged 50 and older44

– Eye care practitioners may see blepharitis in ~40% of patients45

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Threats to Ocular Surface Wellness: Dry Eye and Blepharitis

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• Blepharitis comprises a number of inflammatory eyelid conditions and comorbidities46

– Dry eye – Chalazion– Hordeolum– Conjunctivitis– Keratopathy

• MGD (a form of blepharitis) may be the most common cause of evaporative DE45,47,48

© 2014 Novartis

Threats to Ocular Surface Wellness: Medication Use

• Some common systemic meds increase risk of DE symptoms– Antihistamines62-64 – Antianxiety medications63,64

– Antidepressants63,64

– Diuretics62,64

– Oral corticosteroids63

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Ocular Surface Wellness In PRACTICE

• My practice is looking broadly at wellness; our approach includes:– Regular yearly eye exams

– Children with refractive error evaluated every 6 months

– Comprehensive contact lens exam and follow-up visit for all contact lens patients

– Monitoring contact lens compliance

– Adopting myopia prevention treatment strategies 13

Ocular Surface Wellness In PRACTICE

• DR KARPECKI

• DR BLOOMENSTEIN

OSW: Revising the Office Medical Strategy

In my office:• Most of my patients come to the practice for vision care• Specifically, they want the glasses or contact lenses their

vision plan allows

• But OSW is essentially medical, which requires that patients and doctors have a new mind-set

– ECPs offer more than glasses: we help maintain ocular surface health—which has value

– A healthy ocular surface can help optimize vision, comfort, and cosmesis

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Integrated Health Care Model

• “Medical model” is overused—“integrated health care model” is a better term

• Integrated Health Care Model is the essence of proactive vs reactive care

• Help patients understand use of medical insurance and the value of communication between OD and patient’s other providers, eg:– Primary care physician– Endocrinologist– Dentist– Neurologist– Dermatologist, etc.

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See Children at Appropriate Intervals

• In my practice, Children and Teens with vision or ocular surface problems are seen every 6 months

– Children’s eyes change rapidly and need reassessment– Frequent monitoring & counseling on compliance (if contact

lens wearer)– Instill and reinforce good habits while patients are young

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Contact Lens Compliance is Important at All Ages

• Contact lenses affect the tear film and ocular surface5 • Goal is to minimize that effect and maintain long-term

ocular health in all patients• Choice of contact lens solution is important• Appropriate lens care is critical

– Rub and rinse– Clean lens cases and replace them as instructed– Lens disposal at the correct interval – On follow-up use fluorescein stain to evaluate lens/solution

compatibility6,7 – Always use the latest technologies and lenses

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Check for Ocular Surface Conditions in All Patients

• Understand that although ocular surface issues can affect vision, this is medical care, not vision care

• Communicate with patient’s primary care physician regarding chronic medical conditions (eg, Sjogren’s syndrome)

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© 2014 Novartis

To Maintain and Restore Wellness Look for and Treat Problems

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• Meibomian gland dysfunction• Lagophthalmos• Epithelial membrane basement dystrophy• Conjunctivochalasis • Aqueous-deficient dry eye• Blink pattern deficiencies• Keratitis• Stem cell deficiency• Tear film abnormalities

© 2014 Novartis

Make Use of New Ocular Surface Diagnostic Technology

• New tests add useful information– Tear osmolarity– Tear MMP-9 level– Interferometry– Incomplete blink– Gland expression– Sjogren’s antibody testing– Topography– Meibography

• Enable detection of early-stage disease processes and monitoring of the tear film

23

© 2014 Novartis

Treatment Modalities

• Punctal occlusion• Pharmaceuticals (including oral meds)• Thermal pulsation/meibomian gland expression• Lid hygiene• Antibiotics/anti-inflammatories• Lipid enhancing and mucomimetic tears

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© 2014 Novartis

Contact Lenses and the Ocular Surface

• Develop a OSD protocol for your office as part of a comprehensive Contact lens evaluation

• Medical billing protocol for those with Ocular Surface issues

• Charge a separate fee for the OSD work up

• NEVER as part of the vision care managed care exam

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© 2014 Novartis

Contact Lenses and the Ocular Surface

• Ocular Wellness means understanding of preventive measures and the patients overall Ocular and systemic Health

• GP lenses are considered the safest lens modality

• There is an inherent responsibility to ensure long term eye and corneal health

• There is also a responsibility to create the best Vision possible for our patients

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Contact Lenses and the Ocular Surface: Challenges

• Staining• Corneal • Conjunctival drying/ goblet cell destruction • 3 and 9 desication ( nasal temporal)• Limbal changes • topographical changes• Lid abnormalities• GPC• deposits• warped lenses

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GP Lenses and the Ocular Surface

• Scleral Lenses• These modalities create their own challenges and

complications• Replacement schedules• Debri• Long term effects on the cornea , Limbus, and

Conjunctiva• Clearance

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© 2014 Novartis

GP Lenses and the Ocular Surface

• Why would anyone wear a GP lenses longer than one year?• Structure changes• Deposits• Scratches

• What about 6 months

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© 2014 Novartis

Contact Lenses and Vision

• Multifocals VS Monovision

• New materials: change yearly

• Over refractions : every visit : .25 diopter

• Toric and bitoric designs

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© 2014 Novartis

Involve the Entire Office

• Success with OSW in the practice requires buy-in from the entire staff

• Staff buy-in to OSW efforts requires ongoing staff education so they understand:– Types of ocular surface conditions– Ocular surface treatments– Importance of treating ocular surface conditions– Importance of proactive history taking by technicians

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Practice Impacts of Preventive Care

• Additional staff training creates a more skilled staff • Staff pride: Staff feels elevated by working in an integrated

health care model

• Increased referrals by patients who appreciate comprehensive approach to health care

• Greater patient acceptance of lens replacement schedules

• Increased referrals from primary care physicians as a result of open communications

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*Alcon provided sponsorship for a Summit planning meeting and publication

*

Best Practices in Dry Eye Patient Management

Bloomenstein Draft 12-4-14

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• Screening, diagnosing, and treating early signs of dry eye is a relatively new thought process Most ODs wait for a symptom or significant corneal involvement Not thinking proactively

• The multifactorial nature of the disease creates confusion and different interpretations

• Is a consensus a best practice?

• Can there be only one?

What Is a Best Practice?

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• Is it one that catches the majority of persons with the disease?• One that makes it easy for providers to diagnose the disease?• One that makes treatment easy and effective?

For the provider? For the patient? For both?

• Should a best practice be one that solves all the problems above? Simplicity!

What Is a Best Practice?

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• LWE

• OPI

• TBUT

• TFOS

• DED

• OSDI

• Ferning

• MGD

• CCh We have made things worse! Not easier!

• WTF

Breaking the Cycle of White Noise

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• AOA Guidelines (2002)

• Delphi Panel (2006)

• The Dry Eye Workshop (2007)

• OD Canadian Consensus (2014)

Published Attempts at Best Practices

A Lot Has Changed Since The Last Protocol…

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Technology Innovations: 2002–2005

Facebook

Palm Treo PDA BlackBerry

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New Dry Eye Treatments and Diagnostic Tools: 2002–2005

Meibography

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Care of the Patient With Dry Eye (AOA Quick Reference Guide). St. Louis, MO: American Optometric Association; 2003.

2003: AOA Optometric Clinical Practice Guideline on Care of the Patient With Ocular Surface Disorders

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• What happened? Were the protocols too simple?

• Why was this not adopted? Who failed? The AOA? The “experts”?

• The AOA protocol, in 2003, did not change behavior! Let’s not make the same mistake

AOA Had It Going in the Right Direction…

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Nintendo WiiFingerprint Reading

Technology

Human Genome Project codes last gene sequence

iPhone

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New Dry Eye Treatments: 2006–2007

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Behrens A et al. Cornea. 2006;25:900-907.

• 17 preselected international dry eye specialists• 2-round Delphi panel approach• Used a 2/3 majority for consensus building on the responses• Treatment algorithms were calculated as the primary endpoint

Treatment recommendations for different types and severity levels of dry eye disease

• New terminology Dysfunctional tear syndrome (DTS)

2006: Dysfunctional Tear Syndrome: A Delphi Approach to Treatment Recommendations (Delphi)

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• More detailed treatment

• Cherry-picking screening tools and treatment TOO TIME CONSUMING DIFFICULT TO DIFFERENTIATE NOT ADOPTED BY ALL EXPERTS

NO BEHAVIOR CHANGES!

Delphi Recommendations

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International Dry Eye WorkShop. 2007 Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5:61-204.

• The Management and Therapy Subcommittee of the International Dry Eye WorkShop (DEWS)

• Reviewed the Delphi Panel approach to the treatment of dry eye disease and suggested some modifications

• The DEWS treatment recommendations are stratified according to the severity of the disease

2007 Report of the International Dry Eye WorkShop (DEWS)

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“Dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film

instability, with potential damage to the ocular surface. It is accompanied by increased osmolarity

of the tear film and inflammation of the ocular surface”

Dry Eye Defined (DEWS)

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Cycle of Ocular Surface Inflammation (DEWS)

Dry eye Altered tear film stability

and composition

Dysfunction of lacrimal

functional unit

Inflammation and apoptosis on ocular surface

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• Where is the widespread acceptance?

• Which of us is adhering to these protocols? Telling our colleagues to adhere to this?

NO CHANGE IN BEHAVIOR…AGAIN!

DEWS

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Tesla Roadster iPad

CERNS Hadron Collider

HTC Dream (1st Android Phone)

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New Dry Eye Treatments and Diagnostic Tools: 2008–2014

MiBoFlo

Solution for Early Diabetes Detection

More Appeal than Blood Draw

• Non-Invasive• 6 Seconds

• Immediate Results

Diabetes & Eye-Care• 100M eye exams in US

annually• Diabetes = changing vision• Medical model of optometry

Can Avoid Complications

• Can identify diabetes 7 years prior to complications

Disclaimer: For investor use only

ClearPath DS-120 is the only

FDA-cleared

non-invasive diabetes detection system

available for sale in the United States. The only other

way is invasive

blood draw.

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National Dry Eye DISEASE Guidelines for Canadian Optometrists

Canadian Journal of OptometryRevue Canadienne d’OptométrieVol. 76, Suppl. 12014ISSN 0045-5075

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CASE HISTORY including 4 specific questions1. Do your eyes feel uncomfortable? 2. Do you have watery eyes? 3. Does your vision fluctuate, especially in a dry

environment? 4. Do you use eye drops?

Canadian Dry Eye Consensus

Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Can J Optom. 2014;76(Suppl. 1):1-32.

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Type Management

Episodic

Tear supplements/lubricants

Consider composition of available agents (lipid-based, products that restore the mucin layer, overall)

Ocular Hot compresses, lid hygiene, moisture chamber glasses, modifications to CL wear (switch to daily disposables)

Non-ocular considerations Environmental (ambient humidity, air movement, computer use), systemic medications and supplements, alcohol, smoking, hormonal status, sleep apnea

Chronic

Episodic management +

Short-term Topical corticosteroid

Long-term Topical cyclosporineEssential fatty acids

Supportive Oral tetracycline/macrolide, lacrimal occlusion, meibomian gland expression (in-office), sleep mask/lid taping

RecalcitrantOcular Scleral lenses, filament removal, autologous serum eye drops, amniotic

membranes, tarsorrhaphy, other surgical techniques

Systemic Secretagogue, systemic immunosuppressive therapies


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*Alcon provided sponsorship for a Summit planning meeting and publication

*

Improving the Screening, Diagnosis, and Management

of Dry Eye Disease

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• Current guidelines (eg, DEWS, AOA) are perceived as being too complex or inaccessible

• Limited awareness of guidelines

• Recommendations from “the experts” are not being incorporated into everyday practice by community ECPs for multiple reasons

• Need to SIMPLIFY by setting minimum recommendations that all ECPs can commit to

Why Do We Need Recommendations for Dry Eye Disease?

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• Discussed clinical data on dry eye disease and the role of ocular surface wellness

• Identified current gaps in management through survey sent to “experts” and >1000 ECPs

• 1.5-day discussion and debate (ECPs and industry) on best practices for screening, diagnosing, and managing dry dye disease

• Used interactive polling system to establish consensus (minimum 2/3 agreement needed)

The Dry Eye Summit 2014: How Did We Develop Recommendations?

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Experts are much more likely to recommend treatment for dry eye disease.

Identifying Gaps in Care: “Expert” vs Community ECP Practices

<5% 5%-10% 11%-25% 26%-50% >50%0%

20%

40%

60%

80%

100%Experts (n = 28) OD community (n = 658)

% of Patients

% o

f EC

Ps

For What Percentage of Your Dry Eye Disease Patients

Do You Recommend Any Treatment?

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• Disease Diabetes Allergies

• Contact lens wear• Medications

Antihistamines/Decongestants

• Age• Digital device use

Cell phones Tablets Computers

Know the Risk Factors

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1. Do you think your eyes look healthy?

2. Do your eyes feel healthy?

3. Are there times when your vision is not as clear as you want it to be?

4. Do your eyes ever feel dry or uncomfortable?

Consensus on Screening Questions

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1. Detailed patient history

2. Staining

3. Osmolarity levels

Consensus on Baseline Diagnostic Options for Entry Level Dry Eye Disease

http://www.dreamstime.com/stock-image-patient-history-image14810781

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1. For all patients:

A. Ocular lubrication

B. Lid hygiene

C. Nutrition

2. Topical anti-inflammatories

Consensus on Baseline Management

Ocular Surface Wellness The Basics Jack L Schaeffer OD FAAO Marc Bloomenstein OD FAAO Paul Karpecki...

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