Dry Eye 2020

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Meibomian Gland Dysfunction (MGD), also known as Evaporative Dry Eye or Lipid Deficiency Dry Eye. CONTRAINDICATIONS:Do not use the LipiFlow System in patients with the following conditions. Use of the device in patients with these conditions may cause injury. Safety and effectiveness of the device have not been studied in patients with these conditions. •Ocular surgery within prior 3 months, including intraocular, oculo-plastic, corneal or refractive surgery procedure •Ocular injury within prior 3 months Ocular herpes of eye or eyelid within prior 3 months •Active ocular infection (e.g., viral, bacterial, mycobacterial, protozoan, or fungal infection of the cornea, conjunctiva, lacrimal gland, lacrimal sac, or eyelids including a hordeolum or stye) •Active DRY EYE 2020 INDICATIONS FOR USE:The LipiFlow System is intended for the application of localized heat and pressure therapy in adult patients with chronic cystic conditions of the eyelids, including Treat The epidemiology of dry eye disease By Dr Michael Wang DRY EYE DISEASE (DED) as a highly prevalent and often debilitating condition has recognised impacts on ocular comfort, visual function, work productivity, psychological well-being and quality of life¹ - ³. The 2017 TFOS DEWS II Epidemiology report highlighted the paucity of studies in the literature investigating the risk factors and natural history of DED. As part of my PhD studies within the Ocular Surface Laboratory (OSL), we assessed the systemic risk factors of DED subtypes in a cohort of 372 community residents, using the global consensus TFOS DEWS II diagnostic criteria⁴. Multivariate regression analysis showed that systemic rheumatological disease and antidepressant medication use were associated with increased odds of aqueous tear deficiency. Independent risk factors for meibomian gland dysfunction (MGD), the primary cause of evaporative dry eye disease, included advancing age, East Asian ethnicity, migraine headaches, thyroid disease and use of oral contraceptive therapy. These results highlight the importance of eye care practitioners routinely enquiring about systemic health when evaluating patients with DED. Opportunistic screening and timely inter-disciplinary referral, arising as a result of such inquiry, would then enable optimisation of modifiable systemic risk factors, including disease activity and medication use, wherever necessary. Our associated, second study evaluated the impacts of ageing on the natural history of DED in a cohort of 1331 community residents⁵. In agreement with the trends reported in previous studies, the results demonstrated positive associations between ageing and clinical markers of DED, aqueous tear deficiency and MGD. On average, each decade of life was associated with 25% increased odds of developing dry eye disease. Of note, clinical signs of MGD emerged earlier in the natural history of DED progression, with the optimal prognostic cut-off ages for meibomian gland dropout, reduced meibum expressibility and diminished tear film lipid layer thickness occurring in the third decade of life, between the ages of 24 to 29 years. Interestingly, a transient delay was detected between the appearance of clinical signs of MGD and other markers of DED, including tear film instability, hyperosmolarity, lid wiper Omega fatty acids for DED By Lesley Springall FOLLOWING THE SURPRISING findings from the Dry Eye Assessment and Management (DREAM) Research Group study in 2018, which concluded that omega-3 was no better than olive oil for managing moderate to severe dry eye disease (DED), a Cochrane Systematic Review suggests there might still be a role for the popular fish oil supplement. Led by Australian TFOS ambassador, Associate Professor Laura Downie, from the Department of Optometry and Vision Sciences at the University of Melbourne, the Cochrane review set out to assess the effects of polyunsaturated fatty acid supplements omega-3 and omega-6 on dry eye signs and symptoms. A search of five national and international databases and three trial registries highlighted 34 randomised controlled trials, involving more than 4,300 dry eye patients from 13 countries, where omega-3 and omega-6 supplements were compared with placebo, artificial tears or no treatment. “Although much of the evidence was uncertain, long‐chain omega‐3 supplements may have little to no benefit, relative to placebo, on dry eye symptoms, but did improve some clinical signs,” wrote A/Prof Downie and her team. The researchers also found there was some beneficial effect on dry eye symptoms epitheliopathy and dry eye symptoms, which predominantly emerged during the fourth decade of life, between the ages of 33 and 38 years. This brief delay potentially represents a degree of functional reserve in the ocular surface, as well as a potential window of opportunity for preventative intervention in the younger adult group to attempt to halt the progression of DED. Finally, and of importance to clinicians relying on ocular surface staining in dry eye diagnosis, corneal and conjunctival staining were among the last clinical signs of DED to emerge in the natural history of progression. Such signs of ocular surface damage typically arose between the ages of 46 and 52 years and were more likely to represent moderate-to-severe dry eye disease. 86% MGD has been shown to affect 86% of patients with dry eye 1 References 1. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II Epidemiology Report. Ocul Surf. 2017;15(3):334-365. 2. Uchino M, Schaumberg DA. Dry Eye Disease: Impact on Quality of Life and Vision. Curr Ophthalmol Rep. 2013;1(2):51-57. 3. Belmonte C, Nichols JJ, Cox SM, et al. TFOS DEWS II Pain and Sensation Report. Ocul Surf. 2017;15(3):404-437. 4. Wang MTM, Vidal-Rohr M, Muntz A, Diprose WK, Ormonde SE, Wolffsohn JS, Craig JP. Systemic risk factors of dry eye disease subtypes: a New Zealand cross-sectional study. Ocul Surf. 2020;18(3):374-380. 5. Wang MTM, Muntz A, Lim J, Kim JS, Lacerda L, Arora A, Craig JP. Ageing and the natural history of dry eye disease: a prospective registrybased cross-sectional study. Ocul Surf. 2020 Aug 3; doi: 10.1016/j. jtos.2020.07.003. Online ahead of print.. Dr Michael Wang is an neuro-ophthalmology clinical research fellow and a PhD student in the Department of Ophthalmology at the University of Auckland. within prior 3 months, including intraocular, oculo-plastic, corneal or refractive surgery procedure •Ocular injury within prior 3 months Ocular herpes of eye or eyelid within prior 3 months conditions. Use of the device in patients with these conditions may cause injury. Safety and effectiveness of the device have not been studied in patients with these conditions. •Ocular surgery Treat following the with patients in System LipiFlow the use not CONTRAINDICATIONS:Do Eye. Dry Deficiency Lipid or Eye Dry Evaporative as known also (MGD), Dysfunction Gland Meibomian including eyelids, the of conditions cystic chronic with patients adult in therapy pressure and heat localized of application the for intended is System LipiFlow USE:The FOR INDICATIONS when omega-3 was combined with standard dry eye treatments, such as artificial tears, warm compresses and corticosteroid eye drops, compared to the standard treatments alone. “Effects on other clinical measures, including dry eye symptoms and side effects, could not be clearly determined. It is also unclear whether other types of supplement combinations are effective for treating dry eye. We have low to moderate confidence in the evidence for all outcomes,” said the authors, concluding that current evidence remains uncertain and inconsistent, but that the review findings did suggest a possible role for omega‐3 supplements in DED treatment. “A core outcome set would work toward improving the consistency of reporting and the capacity to synthesize evidence.” For the full review go to, www.cochranelibrary. com/cdsr/doi/10.1002/14651858.CD011016. pub2/full to affect 86% of shown been has MGD 86% patients with dry eye 1 ocular inflammation or history of chronic, recurrent ocular inflammation within prior 3 months (e.g., retinitis, macular inflammation, choroiditis, uveitis, iritis, scleritis, episcleritis, keratitis) or stye) •Active hordeolum a including eyelids or sac, lacrimal gland, lacrimal conjunctiva, cornea, the of infection fungal or protozoan, mycobacterial, bacterial, viral, (e.g., infection ocular •Active compromise corneal integrity (e.g., prior chemical burn, recurrent corneal erosion, corneal epithelial defect, Grade 3 corneal fluorescein staining, or map dot fingerprint dystrophy) may that abnormality surface •Ocular ptosis) severe trichiasis, severe lagophthalmos, blepharospasm, edema, tumor, ectropion, entropion, (e.g., function lid affect that abnormalities •Eyelid result in reduced treatment effectiveness because these conditions may cause ocular symptoms unrelated to cystic meibomian glands and require other medical management. Safety and with the following conditions may patients in System LipiFlow the of Use fornices. palpebral small with eyes as such eyes, all fit not may (Disposable) II Activator or Activator PRECAUTIONS:The inflammation(e.g., blepharochalasis, staphylococcal blepharitis or seborrheic blepharitis). Patients with severe eyelid inflammation should be treated medically prior to device use •Systemic disease conjunctivitis •Severe (Grade 3 or 4) eyelid papillary giant or vernal allergic, 2-4) (Grade severe to •Moderate conditions. these with patients in studied been not have device the of effectiveness erythematosus, Sjögren's syndrome) •Taking medications known to cause dryness (e.g., isotretinoin (Accutane®) and systemic antihistamines) •Esthetic eyelid and eyelash procedures (e.g., lupus systemic syndrome, Riley-Day leukemia, sarcoidosis, granulomatosis, Wegener’s arthritis, rheumatoid deficiency, A vitamin syndrome, Stevens-Johnson eye(e.g., dry cause that conditions Reference: 1. Lemp, M. A., Crews, L. A., Bron, A. J., Foulks, G. N., & Sullivan, B. D. (2012). Distribution of Aqueous-Deficient and Evaporative Dry Eye in a Clinic-Based Patient Cohort. Cornea, 31(5), symptoms. eye dry patient’s the worsen may which plugs, punctal inserted previously loosen may procedure treatment the addition, In tattooing). eyelid extensions, lash blepharoplasty, Ltd. 507 Mount Wellington Hwy, Mount Wellington, Auckland 1060, New Zealand. Phone: 0800 266 700. PP2018OTH4191 266 111. New Zealand: AMO Australia Pty. 1800 Phone: Australia. 2113, NSW Ryde, North Road, Khartoum 1-5 Ltd, Pty Australia AMO Australia: doi:10.1097/ico.0b013e318225415a. 472-478. 24 | NEW ZEALAND OPTICS SEPTEMBER 2020
conditions. Use of the device in patients with these conditions may cause injury. Safety and effectiveness of the device have not been studied in patients with these conditions. •Ocular surgery within prior 3 months, including intraocular, oculo-plastic, corneal or refractive surgery procedure •Ocular injury within prior 3 months Ocular herpes of eye or eyelid within prior 3 months INDICATIONS FOR USE:The LipiFlow System is intended for the application of localized heat and pressure therapy in adult patients with chronic cystic conditions of the eyelids, including Meibomian Gland Dysfunction (MGD), also known as Evaporative Dry Eye or Lipid Deficiency Dry Eye. CONTRAINDICATIONS:Do not use the LipiFlow System in patients with the following 86% MGD has been shown •Active ocular infection (e.g., viral, bacterial, mycobacterial, protozoan, or fungal infection of the cornea, conjunctiva, lacrimal gland, lacrimal sac, or eyelids including a hordeolum or stye) •Active Treat Treat Treat to affect 86% of patients with dry eye 1 86% MGD has been shown to affect 86% of 86% patients with dry eye MGD has has been shown 1 86% to to affect 86% of of MGD patients has with with been dry dry eye shown eye 1 1 to affect 86% of patients with dry eye Treat 1 INDICATIONS FOR USE:The LipiFlow System is intended for the application of localized heat and pressure therapy in adult patients with chronic cystic conditions of the eyelids, including Meibomian Gland Dysfunction (MGD), also known as Evaporative Dry Eye or Lipid Deficiency Dry Eye. CONTRAINDICATIONS:Do not use the LipiFlow System in patients with the following conditions. Use of the device in patients with these conditions may cause injury. Safety and effectiveness of the device have not been studied in patients with these conditions. •Ocular surgery within prior 3 months, including intraocular, oculo-plastic, corneal or refractive surgery procedure •Ocular injury within prior 3 months Ocular herpes of eye or eyelid within prior 3 months •Active ocular infection (e.g., viral, bacterial, mycobacterial, protozoan, or fungal infection of the cornea, conjunctiva, lacrimal gland, lacrimal sac, or eyelids including a hordeolum or stye) •Active ocular inflammation or history of chronic, recurrent ocular inflammation within prior 3 months (e.g., retinitis, macular inflammation, choroiditis, uveitis, iritis, scleritis, episcleritis, keratitis) •Eyelid abnormalities that affect lid function (e.g., entropion, ectropion, tumor, edema, blepharospasm, lagophthalmos, severe trichiasis, severe ptosis) •Ocular surface abnormality that may INDICATIONS compromise FOR corneal FOR USE:The integrity USE:The LipiFlow (e.g., LipiFlow prior System System chemical is intended is burn, intended for recurrent the for the corneal application erosion, of localized of localized corneal heat heat epithelial and pressure and pressure defect, therapy Grade therapy in 3 adult corneal in adult patients fluorescein patients with with chronic staining, chronic cystic or cystic map conditions dot conditions fingerprint of the of eyelids, the dystrophy) eyelids, including including Meibomian PRECAUTIONS:The Gland Gland Dysfunction Activator (MGD), or (MGD), Activator also also known II known (Disposable) as as Evaporative may Dry not Dry Eye fit all or Eye eyes, Lipid or Lipid such Deficiency Deficiency as eyes Dry with Dry Eye. small Eye. palpebral CONTRAINDICATIONS:Do fornices. Use of the not LipiFlow use not the use System LipiFlow the LipiFlow in System patients System in with patients in the patients following with with the conditions following the following may conditions. result in Use reduced Use of the of treatment device the device in patients effectiveness in patients with with because these these conditions these conditions may may cause may cause injury. cause injury. Safety ocular Safety and symptoms and effectiveness unrelated of the of to device the cystic device have meibomian have not been not glands been studied studied and in require patients in patients other with medical with these these management. conditions. •Ocular Safety •Ocular surgery and surgery within within effectiveness prior prior 3 months, 3 of months, the including device including have not intraocular, been studied oculo-plastic, in patients corneal corneal with these refractive or refractive conditions. surgery surgery •Moderate procedure procedure to •Ocular severe •Ocular (Grade injury injury within 2-4) within allergic, prior prior 3 vernal months 3 months or Ocular giant Ocular papillary herpes herpes of conjunctivitis eye of or eye eyelid or eyelid •Severe within within prior (Grade prior 3 months 3 or 3 months 4) eyelid •Active •Active inflammation(e.g., ocular ocular infection infection blepharochalasis, (e.g., (e.g., viral, viral, bacterial, bacterial, staphylococcal mycobacterial, blepharitis protozoan, protozoan, or seborrheic fungal fungal infection blepharitis). infection of the Patients of cornea, the cornea, with severe conjunctiva, eyelid lacrimal inflammation lacrimal gland, gland, lacrimal should lacrimal sac, be treated or sac, eyelids or medically eyelids including including prior a to a device hordeolum use •Systemic stye) or stye) •Active •Active disease ocular INDICATIONS ocular conditions inflammation that cause FOR or history dry USE:The history eye(e.g., of chronic, LipiFlow of chronic, Stevens-Johnson recurrent System recurrent ocular is intended syndrome, ocular inflammation for vitamin the application within A deficiency, within prior of prior localized 3 months rheumatoid 3 months heat (e.g., and (e.g., arthritis, retinitis, pressure retinitis, Wegener’s macular therapy macular granulomatosis, inflammation, adult patients sarcoidosis, with choroiditis, chronic uveitis, leukemia, uveitis, cystic iritis, conditions iritis, scleritis, Riley-Day scleritis, of syndrome, the episcleritis, eyelids, keratitis) systemic including keratitis) lupus •Eyelid Meibomian •Eyelid erythematosus, abnormalities Gland Sjögren's that Dysfunction that affect syndrome) affect lid function (MGD), lid function •Taking (e.g., also (e.g., known medications entropion, entropion, as Evaporative ectropion, known ectropion, to Dry tumor, cause Eye tumor, dryness edema, Lipid edema, (e.g., Deficiency blepharospasm, isotretinoin Dry (Accutane®) Eye. lagophthalmos, CONTRAINDICATIONS:Do and severe systemic severe trichiasis, antihistamines) trichiasis, severe not severe ptosis) use •Esthetic ptosis) •Ocular LipiFlow •Ocular eyelid surface System and surface eyelash in abnormality patients procedures that with that may the (e.g., may following conditions. compromise blepharoplasty, corneal Use corneal lash of integrity the extensions, integrity device (e.g., in (e.g., prior patients eyelid prior chemical tattooing). with chemical these burn, In burn, conditions recurrent addition, recurrent the corneal may treatment corneal cause erosion, injury. erosion, procedure corneal Safety corneal epithelial may and epithelial effectiveness loosen defect, previously defect, Grade of the Grade inserted 3 device corneal 3 corneal have punctal not fluorescein plugs, been staining, studied which staining, may or patients map worsen map dot with the dot patient’s these fingerprint conditions. dry dystrophy) eye symptoms. •Ocular surgery within PRECAUTIONS:The Reference: prior 1. 3 Lemp, months, Activator M. Activator including A., Crews, Activator intraocular, L. Activator A., Bron, II A. II oculo-plastic, (Disposable) J., Foulks, may G. N., corneal may not & fit not Sullivan, all or fit eyes, refractive all B. eyes, such D. (2012). such surgery as eyes as Distribution eyes with procedure with small small of palpebral •Ocular Aqueous-Deficient palpebral injury fornices. fornices. within Use and prior Use of Evaporative the of 3 LipiFlow months the LipiFlow Dry Ocular System Eye System in herpes a in Clinic-Based patients of patients eye with or Patient eyelid with the following Cohort. the within following Cornea, prior conditions 3 conditions months 31(5), may may result •Active result 472-478. in reduced in ocular reduced doi:10.1097/ico.0b013e318225415a. treatment infection treatment (e.g., effectiveness viral, bacterial, because because these mycobacterial, these Australia: conditions conditions protozoan, AMO may may cause Australia cause or ocular fungal Pty ocular symptoms Ltd, infection symptoms 1-5 Khartoum unrelated of the unrelated cornea, Road, to cystic to conjunctiva, North cystic Ryde, meibomian NSW lacrimal glands 2113, glands gland, Australia. require and lacrimal require Phone: other sac, other or medical 1800 eyelids medical 266 111. including management. New Zealand: a hordeolum Safety Safety AMO and or and Australia stye) •Active Pty. ocular effectiveness Ltd. 507 inflammation Mount of the of device Wellington the device or have history Hwy, have not been not of Mount chronic, been studied Wellington, studied recurrent patients in Auckland patients ocular with 1060, inflammation with these these New conditions. Zealand. within •Moderate Phone: prior •Moderate 30800 months to severe to 266 severe (e.g., 700. (Grade retinitis, (Grade PP2018OTH4191 2-4) 2-4) allergic, macular allergic, vernal inflammation, vernal or giant or giant papillary choroiditis, papillary uveitis, conjunctivitis iritis, •Severe scleritis, •Severe (Grade episcleritis, (Grade 3 or 34) or keratitis) eyelid 4) eyelid •Eyelid inflammation(e.g., abnormalities blepharochalasis, that affect lid function staphylococcal (e.g., blepharitis entropion, blepharitis or ectropion, seborrheic seborrheic tumor, blepharitis). edema, Patients blepharospasm, Patients with with severe severe lagophthalmos, eyelid eyelid inflammation severe should trichiasis, should be severe treated be treated ptosis) medically medically •Ocular prior prior surface to device to abnormality device use •Systemic use •Systemic that disease may disease conditions compromise conditions that that cause corneal cause dry integrity eye(e.g., dry eye(e.g., (e.g., Stevens-Johnson prior chemical syndrome, burn, syndrome, recurrent vitamin vitamin corneal A deficiency, A deficiency, erosion, corneal rheumatoid epithelial arthritis, arthritis, defect, Wegener’s Wegener’s Grade 3 corneal granulomatosis, fluorescein sarcoidosis, staining, leukemia, or leukemia, map Riley-Day dot Riley-Day fingerprint syndrome, syndrome, dystrophy) systemic systemic lupus lupus PRECAUTIONS:The erythematosus, Sjögren's Sjögren's syndrome) Activator syndrome) or •Taking Activator •Taking II medications (Disposable) known known may to cause not to cause fit dryness all dryness eyes, (e.g., such (e.g., as eyes isotretinoin with small (Accutane®) palpebral and systemic and fornices. systemic Use antihistamines) of the LipiFlow •Esthetic •Esthetic System eyelid in eyelid patients and eyelash and with eyelash the following procedures (e.g., conditions (e.g., may result blepharoplasty, in reduced lash lash treatment extensions, eyelid effectiveness eyelid tattooing). tattooing). because In addition, these In addition, conditions the treatment the treatment may cause procedure procedure ocular may symptoms may loosen loosen previously unrelated previously to inserted cystic inserted meibomian punctal punctal plugs, glands plugs, which and which may require may worsen worsen other the medical patient’s the patient’s management. dry eye dry eye symptoms. Safety and effectiveness Reference: 1. Lemp, 1. of Lemp, the M. A., device M. Crews, A., have Crews, L. A., not L. Bron, been A., Bron, A. studied J., A. Foulks, J., in Foulks, patients G. N., G. & N., with Sullivan, & these Sullivan, B. conditions. D. B. (2012). D. (2012). •Moderate Distribution Distribution to of severe of Aqueous-Deficient (Grade 2-4) and allergic, and Evaporative vernal Dry giant Eye Dry in Eye papillary a a Clinic-Based conjunctivitis Patient Patient Cohort. •Severe Cohort. Cornea, (Grade Cornea, 31(5), 3 or 31(5), 4) eyelid 472-478. inflammation(e.g., 472-478. doi:10.1097/ico.0b013e318225415a. blepharochalasis, staphylococcal Australia: Australia: blepharitis AMO AMO Australia or seborrheic Australia Pty Ltd, Pty blepharitis). Ltd, 1-5 Khartoum 1-5 Khartoum Patients Road, with Road, North severe North Ryde, eyelid Ryde, NSW inflammation NSW 2113, 2113, Australia. Australia. should Phone: be Phone: treated 1800 1800 266 medically 111. 266 111. New prior New Zealand: to Zealand: device AMO use AMO Australia •Systemic Australia Pty. disease Pty. Ltd. 507 conditions Ltd. 507 Mount Mount Wellington that Wellington cause dry Hwy, eye(e.g., Hwy, Mount Mount Stevens-Johnson Wellington, Auckland Auckland syndrome, 1060, 1060, New vitamin New Zealand. A Zealand. deficiency, Phone: Phone: 0800 rheumatoid 0800 266 266 700. arthritis, 700. PP2018OTH4191 Wegener’s granulomatosis, sarcoidosis, leukemia, Riley-Day syndrome, systemic lupus erythematosus, Sjögren's syndrome) •Taking medications known to cause dryness (e.g., isotretinoin (Accutane®) and systemic antihistamines) •Esthetic eyelid and eyelash procedures (e.g., blepharoplasty, lash extensions, eyelid tattooing). In addition, the treatment procedure may loosen previously inserted punctal plugs, which may worsen the patient’s dry eye symptoms. Reference: 1. Lemp, M. A., Crews, L. A., Bron, A. J., Foulks, G. N., & Sullivan, B. D. (2012). Distribution of Aqueous-Deficient and Evaporative Dry Eye in a Clinic-Based Patient Cohort. Cornea, 31(5), 472-478. doi:10.1097/ico.0b013e318225415a. Australia: AMO Australia Pty Ltd, 1-5 Khartoum Road, North Ryde, NSW 2113, Australia. Phone: 1800 266 111. New Zealand: AMO Australia Pty. Ltd. 507 Mount Wellington Hwy, Mount Wellington, Auckland 1060, New Zealand. Phone: 0800 266 700. PP2018OTH4191 WWW.EYEONOPTICS.CO.NZ | 25
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