GP Eye Health Network: Dry Eyes, Mr Y Ghosh



TRANSCRIPTION CITY TYPING SERVICEShttPD://transcriptioncity.co.ukinfo@transcriptioncity.co.uk0208 816 8584TITLE: Presentation 6 Mr Y GhoshDATE: 20th February 2017NUMBER OF SPEAKERS: 1 Numbers SpeakersTRANSCRIPT STYLE: Intelligent VerbatimFILE DURATION: 26 Minutes 31 SecTRANSCRIPTIONIST: Marg Searing SPEAKERSYG:Mr Y GhoshA1:/A2 etc - Audience membersGP Eye Health Network: Dry Eyes, Mr Y GhoshYG: My name is Yaj Ghosh and I am one of the Consultants here at the Eye Hospital. And, thank you very much for asking me to talk here. What this stems from is my speciality interest is ocular plastics. And part of it is watery eyes. So, I run a watery eye clinic every alternate Friday here. And believe me, half of them are actually, mismanaged dry eye conditions, because they present with watery eyes as well.So, one of the pearls for you to take away here, from here, is if you see watery eyes then there might be an element of dry eyes there. So, just a little bit of an overview. Everybody does a test in the end. So, I’ll start off with the small test for you all.So, what conditions do you see with red eyes in the community?[unclear audience responses/mumbled/murmured 00:00:57]YG: Yeah. Anything else?[unclear audience responses/mumbled/murmured 00:01:05]YG: Okay, yeah. Anything else? Okay. So, whatever you have said, they are all here. And believe me, lumps and bumps and cataracts can also cause red eyes. Because if you’ve got a nasty lump and a bump that can cause red eyes and cataracts, if they’re leaking or if they’re causing uveitis, that can cause red eyes as well.So, just a few photographs to take you through. What’s this? If you can see the lid margins?[unclear audience mumbling 00:01:43].YG: Blepharitis, that’s right.What’s this?[unclear audience mumbling 00:01:50]YG: So, this, that it doesn’t have the typical discharge but it’s more watery. So, this is more likely to be a viral conjunctivitis.So, this dry eyes, because see the whole idea of showing these photographs is, they all look the same.[laughing]YG: So, I know your problems. So, what’s this?[unclear audience mumbling 00:02:27]YG: Yeah, can we …[pause to dim lights]A1: It’s normal.A2: That’s much better.YG: See this bit, the reflection from the tear meniscus that’s actually quite high. You wouldn’t normally see this. So, that’s actually a watery eye.[laughing]YG: What’s this?[unclear audience mumbling 00:02:53]YG: So, the idea of showing this is, when you see somebody come in with this, that’s a corneal ulcer or keratitis, always lift the eyelid and turn it because there might be a sub-tarsal foreign body causing that. And that?[unclear audience mumbling 00:03:11]YG: So, that’s a dendritic ulcer. And that’s more likely to be a bacterial one because this is much more severe. What’s that?[unclear audience mumbling 00:03:23]YG: Yeah. So, that’s the hyperopia and that’s an angry red eye. And you could get a similar picture, if you see that after a cataract surgery, that’s endophthalmitis. So, that needs to be referred straightaway. And that? And that? So, these are different grades of cataracts. And this one is my favourite. What’s that?[unclear audience mumbling 00:03:58]YG: Yeah, and what’s that?[unclear audience mumbling 00:04:00]YG: So, that’s a chalazion. And that’s a sty. And we always get, everything is sty. So …[laughing]YG: So, sty is actually a folliculitis whereas chalazion is a swelling of the meibomian gland. Yeah. Again, if you don’t take anything away from this talk, remember that.Okay, so I’ve already said as the preamble that 50% of what I see is actually dry eyes which hasn’t been managed properly. So, it’s a huge subject and it’s not possible to cover it in 20 minutes. So, I’ll try to give you an overview and some pearls to help you diagnose and probably manage them better.So, just a quick run through of the anatomy. The lacrimal gland is present on the outer side of the socket, whereas the sac or the drainage system is on the inner side of the socket. So, if you see any swellings on the outer side that’s from the lacrimal gland system whereas if there is a swelling there and there is mucopurulent discharge from the inner side, then then that’s from the drainage system.So, what does the eyes do. There, you know, the blink is very important to us, because it spreads the tears and it helps protect against infections. It washes away any sort of foreign bodies that come in to the eye and it is rich with glands which secrete the different components of tears.So, it comprises of many structures without going in to the details, the corneal epithelium, it’s integrity. The tear film and the general integrity of the ocular surface is very important which is affected by dry eye conditions. So, the different glands that constitute tears is the lacrimal gland, the meibomian glands which are on the lid margin and the goblet cells on the conjunctiva which produce mucin.So, the tear that you see is actually, a quite complex structure which is made up, simplified in to three layers. The mucus layer which holds it to the surface of the eye. Then there is an aqueous layer or the watery component which is not really water but it has got lots of minerals in it as well. Which is secreted from the lacrimal gland. And the final layer is secreted from the lid margin which is the oily layer which prevents it from evaporating. And so, any of these being affected will cause dry eyes.So, that is how it looks. This is the biggest or the thickest layer which is the aqueous layer. That’s the oily layer on top and this is the mucus layer which holds it to the surface. So, as I said, it cleans it supports the cornea and it takes the oxygen supply in to the cornea because it doesn’t have any vascular supply and it keeps the eye comfortable.So, just an idea how a healthy tear film looks like and when it breaks down it just totally anatomically wrong. So, what are the different types of dry eye disease? Broadly, it’s classified into aqueous deficient, which means that the watery component is deficient and evaporated which means that it’s there but it’s not staying in the eye for long. And the reason for that is, that the oily layer is deficient and it’s not allowing it to stay in the eye for long. And we’ll come to the causes in a minute.So, aqueous deficient most of the time is because of the Sjogren’s type of disease where they will also complain of: What other symptoms do they complain of?[unclear audience mumbling 00:08:02]YG: Dry eyes and dry mouth mostly. But they can complain of dryness wherever there is a mucus surface. And the non-Sjogren’s type is where the lacrimal gland itself has got a problem. So, these, there the bulk of the tears is not present.Whereas in the evaporative type which is this group, so this is mainly due to the meibomian glands not functioning properly. So, if somebody has got blepharitis, they will suffer with these. If somebody has severe posterior lid margin disease they will suffer with this. And then there is you know vitamin A deficiency which we don’t see in this country that much. And another big offender is people on eyedrops which have preservatives. So, that is becoming increasingly known as a big problem.So, as I said, there are three types of mainly broad dry eye conditions and the kinetic disorders is obviously if their tears are being impeded. So, if somebody has got a blocked tear duct then they can have problems as well.Any questions so far? No?Okay, so, what do they present with? How do we diagnose them? There are tests and we will come to that in a minute but their symptoms are very characteristic. And the first thing that they come and tell us is, I’ve got grit in the eye. And if somebody says that, they’ve got dry eyes. Whether it’s severe, moderate or mild, that comes next.But the other symptom which is becoming increasingly popular is asthenopia. Do you know what asthenopia is? This is a sense of tiredness of the eyes and this is because, if the eyes are dry, a lot of people nowadays are dependent on their computer screens. And when you are looking at computer screens for long hours, you stop blinking. There is a very good video on YouTube, go and have a look. Normally, we blink 12 to 14 times in a minute. There is a guy who is watching television and he blinks once in a minute. So, you can imagine what happens to the tear film. And that’s so important.The more severe ones will present with burning sensations, stinging sensation and in extreme cases they’ll present with a red eye which I have already shown you. And if they suffer from disorders like rheumatoid arthritis and Sjorgen’s Syndrome they are bound to have some symptoms associated with dry eyes.The other thing which we need to be careful about is contact lens wearers. And again, as I said, earlier on, glaucoma patients because they are on so many drops and most of the drops still have preservatives in it, they cause problems with the tear film. So, another common term that we use is tear film dysfunction.So, how can we diagnose dry eyes. So, these are the common tests that we do. So, lacrimal river width. I’ll show you each of these in a minute which I showed you in one of the first photographs where the actual tear meniscus is higher if they have a problem. The Schirmer test actually measures the amount, of tears being secreted into the eye. The tear break-up time is valuable to assess if somebody has got evaporative eye disease and again I’ll show how to do that. Staining shows us if the corneal epithelium is intact or if there is drying anywhere. And the tear lab, this is the latest toy we have. It’s complicated and essentially it measures the osmolarity of the tears which gives an idea of whether it’s a good tear or bad tear.So, Schirmer test, BUT, is tear break-up. And it’s based on … the tear breakup time is obviously, based on, the fact that there is a time span for which the tear film should stay in the eye. And if you ask the patient to keep the eye open and it breaks up before that, that means it’s unstable.So, that’s the Schirmer’s test which is, if you see these are the two papers that we put in. Some do it with drops, some do it without the drops and the measurements are different. Normally, you would get 10 to 15 within two minutes. And in some it doesn’t even take two minutes to get to that stage.Tear break-up time, as I said. So, what we do is we put a fluorescein and ask them to blink and then hold. And if you see these black spots appearing within 10 seconds, that means they have an unstable tear film. Now the point of me showing all this is, you can do this in your practice and you can actually, make a diagnosis of these. So, they don’t then need to be referred on to the ophthalmologist. It saves you money and it saves us time. Because ultimately, they will be sent back to you for looking after them. And it’s very easy to diagnose this. We are more than happy to deal with the more complex ones which we will come to in a minute. But this is a very simple test. All you need is a filter which you can put it on the top of a torch which is an ultraviolet filter and a drop of fluorescein. That’s all you need.So, that’s the staining again. You put fluorescein in and as you can see the areas which are dry will take it up because the epithelium is not wet properly and then you can actually make a drawing of the areas.And that’s the lacrimal river that’s as you see, normally you should not be able to see this. And that’s the toy.So, that brings us to meibomian gland dysfunction which means essentially, if you see patients who are presenting who are saying that the lids are really, red and at the margin of the lid, you see these kind of meibomian gland openings are swollen, they have an inflammation, an active inflammation of the meibomian glands. And you have, to treat that. If you just give them artificial tear drops and send them away they will not get better and they’ll keep coming back.So, the theory behind this is that the meibomian glands secrete an oily secretion and there are bugs at the root of the eyelashes as well which secrete a toxin. It sets up an inflammatory reaction and that just compounds the problem. So, you have to treat the Meibomitis or the inflammation of the glands and then you also have to treat the tear film dysfunction.So, I’m sure you see this every day, that people come in with a lid margin like that. A lot of people who have rosacea would present like that because they are more prone. And so, you will see this, the meibomian gland opening sometimes, the atrophy due to chronic inflammation. Can you see? Am I in your way? And as you can see notching of the lid caused by the … because the meibomian gland is virtual … you know dead. So, it’s not functioning.So, because the top layer of the tear is deficient, so the patients would complain that they do not get relief from whatever drops they put in. So, they present with red eyes as a result.The next group of disorders which cause problems, is ocular surface disease. So, if I should you this, what is this? [unclear audience mumbling 00:16:44]. It looks like a [unclear ? ipcoasis 00:16:46] doesn’t it? But this particular one was actually Penfigoide. So, when you’ve got something like this, as you can see. The lids are ectropic because they are being pulled down by the skin condition. The whole surface is ulcerated. So, that’s going to have a definite effect on the corneal surface as well.So, to treat the meibomian glands, three things again, you can do from primary care. Hot fomentation which is you know dry fomentation. So, flannel, ask them to warm it up on the radiators that’s the right temperature. Ask them to hold it over the eye with a bit of pressure and that liquefies the secretions there so that they can then discharge and they don’t get clogged up. Because if they get clogged up, then you get the chalazions which is another problem.And the second thing is lid toilet. Again, you will hear different stories, tea tree oil, sodium bicarbonate and lots. You will hear the latest advice on the NHS website is, don’t use baby shampoo. I still feel that if you get a baby shampoo which does not have any essences in them or you know the flavouring material and all that, they’re still the best. It’s the way you do the lid toilet that is important. And what I always say, is take an egg cup full of water, two to three drops of baby shampoo, take a cotton bud, dip in that solution and use that as if you are putting make up on your eyelashes. And that way you are actually scrubbing the lid which is what you need and not just you know putting the make up on. So, essentially you are getting rid of the toxins and that helps with the inflammation.And the third thing is they need a course of Doxycycline or Lymecycline depending upon what, you know, they can tolerate. Because Doxycycline some people have stomach upsets.[unclear audience 00:19:06]YG The cleaning, depending upon how severe it is, even once a day in the morning is good enough. Sometimes you have to do it twice.Now, in terms of local treatment, there is another element to dry eyes which is inflammation. If the corneal surface is inflamed like I showed you in necrosis or StevenJohnson’s type disorders then you have to treat the inflammation because otherwise the tear film is not going to get stable. And the only drop available so far is, cyclosporine drops which you may have heard about. So, if it is going in to that domain then obviously, the patients need to be in the hospital.This is, in advanced cases where you might have to reconstruct the corneal surface altogether. But again, there are simpler things that we do, which is like, putting in a punctal plug which is a piece of plastic which blocks the tear duct openings and thereby retains the natural tears that are being secreted. Because no matter how many types of eye drops we have in the market, nothing comes even close to your natural eye drops. So, if you can have that in the eye, patients get instantaneous relief.The second step further, if that’s not helping is, you can actually have inserts put in which are continuous release and secrets tears. You can use eye drops which stimulate the eye glands … the tear glands to secrete more tears.Now, whatever I am saying is based on International Dry Eye Disease Workshop. They last met November last year and all the classifications, all the treatment modalities are based on their recommendations. And this is just sort of like an aide memoire of what you should be doing in your practice. And as I said, for mild to moderate disease, just eye drops are good enough. Whereas moderate to severe they need more intensive management. And for the really severe ones they need sometimes even immunosuppression amongst other things.So, this is just a simple treatment chart to show you how to manage. And I thought this was quite a good one because there is an overlap of all the different types and it gives you an idea, about, like it says or oil deficiency dry eyes, meibomian gland dysfunction, so, you manage that. But that overlaps with aqueous and obviously, that falls within the mixed dry eye conditions. And, for those who are computer users, make sure you take that in the history because they need to take breaks when they’re working. No matter how much eye drops you give them, it’s not going to get any better if they don’t look away from the screen and blink.For those who want to read up on this there is probably about 100 different types of dry eye products in the market. And it was a very interesting paper, sorry, where they compared whether one was better than the other and they found that there was virtually no difference between the different products. Unless you are looking at obviously, if somebody has got evaporative eye disease and you’re giving them condition … drops for aqueous deficient eye disease, then that makes a difference. But amongst the other eye drops there’s hardly anything.These are the different groups, can I just ask, how many people still use hypromellose eye drops. Show of hands? Come on, don’t be shy. Right. Again, when you go away from here, please throw that away because it doesn’t work. And they will come back, you’ll have to give them more. Hypromellose doesn’t work. So, that’s this group here.These others, the most popular ones are hyaluronic acid because they are closest to body secretions and they stay in the eye longer. So, that’s the reason. And increasingly we are going away from preserved ones. Because again, we are finding out the hard way the ill effects of preservatives. So, that’s the kind of choices.The other thing that really, works well, particularly in meibomitis is omega-3s and there’s enough evidence now and literature to say that those help.Again, this is a very short pathway which I find very useful of how to start your treatment. So, for the mild ones, like I was saying, you can start with hyaluronic acid, the least concentrated one. And then you can go up in stages depending upon the severity of the condition.So, what’s the future? We have so far looked only at the aqueous component or the oily component. Nobody has looked at the mucus side of things. So, this is in stage three trials now which actually causes increased secretion of mucus. And platelet rich plasma is for people who have the severe dry eye conditions. So, that, again is like a tear analogue. And when you cut onions, how many people cry? So, that is what is being done with this one. They are developing a stimulator which stimulates the nasal epithelium and thereby makes you cry.[laughing]YG: I found this very interesting pathway which was developed in Suffolk, where they were referring it to primary eye car triage service which is the ophthalmic … optom led service. And again, obviously to economise things. And if they couldn’t get a result then only the patient was referred on to the hospital. What I couldn’t find out, is their audit of how successful this was. But I thought it was interesting because that’s the way things are going at, the moment.So, to summarise, dry eyes is a complex thing but there are simple things that you can do to help the patient. And in extreme cases obviously, hospital care is essential. But there are simple things which can help the patient both symptomatically and management wise. And sometimes they might need supportive treatment for which we are more than happy to give advice.That’s all folks. Thank you.END OF TRANSCRIPT ................
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