Lecture 2 OcSurface Pharm 80.pdf

Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation Reduce evaporation – Ointment – Environmental control – Goggles, moisture chambers – Humidifiers – Tarsorrhaphy Obstruction of lacrimal drainage system à putting a stop – Surgery, cautery, laser – Canalicular occlusion, Punc...

Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation Reduce evaporation – Ointment – Environmental control – Goggles, moisture chambers – Humidifiers – Tarsorrhaphy Obstruction of lacrimal drainage system à putting a stop – Surgery, cautery, laser – Canalicular occlusion, Punctal plugs 46 Diane T. Adamczyk, OD, FAAO Copyright © 2024 40 -top pic is tarsorrhaphy which is joining of part or all of the upper and lower eyelids to partially close the eye so that there is less exposure to the ocular surface -this procedure is still a viable option in some pt’s as a means of treating and managing severe dry eye problems 40 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation: Reduce Evaporation Ointments – Petrolatum, mineral oil, lanolin à all help to prevent evaporation – Retard evaporation – Useful also: aqueous, mucin deficiency – Side effect: blurred vision – Bedtime use 48 Diane T. Adamczyk, OD, FAAO Copyright © 2024 41 -side effect of ointments à gives blurred vision so we would prescribe that for evening time use before the pt goes to bed 41 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation: Lacrimal Occlusion Therapy Who do we Occlude? Patients with: Aqueous deficiency Ocular surface problems Neurotropic related (e.g. s/p refractive surgery) Who do we best consider not to Occlude? Patients with inflammatory etiology to dry eye (at least initially) 49 Diane T. Adamczyk, OD, FAAO Copyright © 2024 42 -purpose of punctal occlusion is to try to keep tears on the ocular surface a little bit longer -good for pt with aqueous deficiency, ocular surface problems and neurotropic related -neurotropic related: refractive surgery such as lasik à making flap on cornea, decreasing/disrupting neuronal supply where you end up getting tear production is diminished, the nerves regenerate so it doesn’t last forever that’s why when you punctal occlude this pt you wouldn’t have to do it for a long time, probably 3-6 months would be optimal bc that’s how long the regeneration will occur -people you don’t want to occlude are pt with inflammatory etiology initially until you get inflammation under control using a steroid on the ocular surface and once it’s under control then you can punctal occlude the pt -when you punctual occlude someone who has an inflammatory issue, the inflammatory mediators such as cytokines are stuck at the ocular surface instead of draining out 42 Ocular Surface Diesease Treatment Options Pharmacology II 50 Diane T. Adamczyk, OD, FAAO Copyright © 2024 43 -diff types of refractive surgery -PRK: corneal epithelium is wiped off and then zapped with the laser -LASIK: remove flap and then put it back can result in DED -SMILE less disruption in the cornea and the corneal nerves à less likely to develop DED problems -depending on the type of refractive surgery pt has may influence if the patient may suffer from DED 43 Ocular Surface Diesease Treatment Options Pharmacology II Take Home Punctal plugs do not relieve inflammation – May result in retention of pro-inflammatory proteins – Leading to pooling in lower fornix – Result in ongoing damage and inferior corneal staining Conclude: Suggest a benefit from earlier treatment or concurrent tx with anti-inflammatory agent (before or with punctal occlusion) THE OCULAR SURFACE / APRIL 2016, VOL. 14 NO. 2 53 Diane T. Adamczyk, OD, FAAO Copyright © 2024 44 -SPK will be seen in the inferior aspect bc tis is where inflammatory agents are pooling 44 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation Lacrimal Occlusive Devices/Procedures – Temporary Collagen rods Extended dissolvable – Permanent Silicone plugs – Intracanalicular – Freeman plug Smart Plugs, Form Fit Surgery/Cautery 54 Diane T. Adamczyk, OD, FAAO Copyright © 2024 45 -cuaterize the puncta will burn the skin of the puncta and cause it to close à permanent but will cause tissue damage -permanent but puncta can still open in the future -the other options are good bc if you want to remove the temporary punctal occlusions, they’re much easier and won’t cause any damage to the tissues 45 Ocular Surface Diesease Treatment Options Pharmacology II Punctal Occlusion Temporary Short Term Collagen (Diagnostic) (< 1 Week) Temporary Extended Extend Dissolvable Polymer (2-6 months) Freeman Type (Multiple Varieties) (Multiple Sizes) (“Stopper”) Permanent Silicone Intracanular Herrick (Multiple Sizes) Other Intracanular Smart Plug Cautery or Laser Intracanular Form Fit 55 Diane T. Adamczyk, OD, FAAO Copyright © 2024 46 -summary of what we will talk about 46 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation Lacrimal Occlusive Devices/Procedures – Temporary Collagen rods Extended dissolvable – Permanent Silicone plugs – Intracanalicular – Freeman plug Smart Plugs, Form Fit Surgery/Cautery 56 Diane T. Adamczyk, OD, FAAO Copyright © 2024 47 47 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation: Lacrimal Occlusion - Collagen Lacrimal Occlusive Devices – Collagen rods Dissolve 4- 7 days 0.2-0.6 mm diameter 1.75-2.0 mm long 57 Diane T. Adamczyk, OD, FAAO Copyright © 2024 48 -push into plug using forceps in the puncta -punctually occlude pt for trial bases and do one eye to want to know if the pt benefited from it when they come back in a week -pt should say that it was good the first few days then slowly the effects diminished which makes sense bc the collagen plug is dissolving throughout the week -although the pt may report what is stated about that doesn’t mean the pt didn’t benefit from it but shows that they still might benefit from a more permanent occlusion 48 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation Lacrimal Occlusive Devices/Procedures – Temporary Collagen rods Extended dissolvable à temporary and different à lasts 2-6 months – Permanent Silicone plugs – Intracanalicular – Freeman plug Smart Plugs, Form Fit Surgery/Cautery 59 Diane T. Adamczyk, OD, FAAO Copyright © 2024 49 49 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation: Temporary Synthetic Plugs Lacrimal Occlusive Device: – Dissolve over extended time (2-6months) Absorbable copolymers – Use: post surgical, dry eye – Examples: UltraPlug Extended Wear Synthetic Absorbable Plug – E-Caprolactone-L-Lactide copolymer – Duration: 2-6 month Extended Duration Absorbable Plug (Oasis) – Copolymer of glycolic acid and trimethylene carbonate – Duration: 3 months 60 Diane T. Adamczyk, OD, FAAO Copyright © 2024 50 -extended lasts 2-6 months -these are optimal for pt with post refractive surgery that were concerned that their DE is going to exacerbate -2 examples in red that are still available in the market for extended 50 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation Lacrimal Occlusive Devices/Procedures – Temporary Collagen rods Extended dissolvable – Permanent Silicone plugs à permanent bc once you put them in unless they fall out or are removed so its permanent but reversible – Intracanalicular à put inside the canula so you can’t see it looking externally – Freeman plug à sit like a stopper for a sink so if you look thru slit lamp you can see it Smart Plugs, Form Fit Surgery/Cautery 61 Diane T. Adamczyk, OD, FAAO Copyright © 2024 51 - 51 Ocular Surface Diesease Treatment Options Pharmacology II Tear Conservation: Lacrimal Occlusion - Silicone Silicone based plugs – Types: Intracanalicular (e.g. may vary=0.3-0.7) Freeman (e.g. may vary=0.3-1) – Permanent, but can be removed Intracanalicular – irrigation Freeman - forceps – Contraindication: chronic dacryocystitis 62 Diane T. Adamczyk, OD, FAAO Copyright © 2024 52 -freeman plugs are shown -there is no best one when comparing the intracanalicular or freeman, it depends on the pt -all have diff gages and there's not one universal gage so you have to measure the puncta and bc these plugs come in diff sizes measure the puncta bc if you put a plug that’s too small, it will push into the puncta and end up being intracanalicular and if it’s too big then the plug will pop out -intracanalicular à fit inside the canula -blunted needle is put in the puncta about 3 mm and that’s attached to syringe filled with saline and you have to push the saline into the canula and that’s to remove the plug -why do you want to remove the plug, bc the pt has epiphora (excessive tearing) -she discussed how she was once irrigating a pt and the saline squirted out and she couldn’t push thru any further bc the punctal plug was at the common canalicular and the saline solution squired from the superior canalicular -the con of intracanalicular plugs is that although it doesn’t happen frequently, there can be scarring, and the only way to fix that is using a topical steroid and if that doesn’t help then you have to do a DCR surgery -DCR: major surgical procedure that bypasses the common canalicular area and creates a new path for tears to drain between your eyes and your nose 52 Ocular Surface Diesease Treatment Options Pharmacology II Plugs included punctal, intracanalicular, and dissolving types 63 Diane T. Adamczyk, OD, FAAO Copyright © 2024 53 53 Ocular Surface Diesease Treatment Options Pharmacology II Improvement (in ≥50%): in dry eye symptoms, ocular surface status, artificial tear use, CL comfort, TBUT Complications – infrequent – Plug loss (most common = 40%) à pt rubs their eyes and falls out – Epiphora (9%) à excessive tearing – Irritation (10%) – Canaliculitis (most common in intracanalicular plugs = 8%) – Tearing, discomfort, pyogenic granuloma, dacryocystitis (