Dry Eye & Macular Degeneration Exam #1 – Flashcards
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What are some common eye disorders with aging?
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Cataracts Age related macular degeneration (AMD) Glaucoma Dry eye Decreased vision from any of the above or myopia (near-sightedness) or hyperopia (far-sightedness) Ocular side effects from medications
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Name some eye problems that require a referral to MD.
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Severe eye pain Blurred vision not associated with use of ophthalmic ointments Sensitivity to light History of contact lens wear S/Sx of eyelid or corneal infection Blunt trauma to eye Chemical exposure to eye Eye exposure to heat other than sun exposure Any symptoms persisting for > 72 hours they need to see an eye doctor
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What condition might you suspect if a patient presents with White or mildly red eye Sandy, gritty feeling "Foreign object" feeling Decreased or paradoxical increased tear production Blurred vision Itching Photophobia?
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Dry Eye Disease
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What is dry eye disease?
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Disorder of the tear film
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What are some complications related to dry eye disease?
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Irritation and inflammation Pain Potential damage to the cornea
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T/F There are only internal environmental risk factors associated with dry eye disease.
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False. There are internal and external risk factors
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______ age is an associated risk factor to dry eye disease.
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Increased
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______ chloride ocular products increase the risk of dry eye disease.
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Benzalkonium
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Low intake of __________ could put you at risk for dry eye disease.
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Omega-3 Fatty Acids
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T/F Dry eye disease can be caused by both systemic and/or ocular medications.
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TRUE
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What are some external environmental factors that could increase the risk of dry eye disease?
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Low humidity environment Pollution; Cig. Smoke Extended time on electronic devices, computer screen, TV Post LASIK procedure - at risk for dry eye.
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What is sjorgren's syndrome?
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Dry eye and dry mouth
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What are some causes of aqueous tear deficiency?
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Sjogren's syndrome Lacrimal gland deficiency Tears hypo-secretion
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Which gland disorder produces tear but they evaporate too quickly?
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Meibomian gland disorder
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What are some risk factors for evaporative dry eye causes/ risk factors.
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Meibomian gland disorder Low blink rate Ocular Preservatives Vitamin A deficiency Contact lens use Allergic conjunctivitis
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What is an example of a systemic first generation oral antihistamine that has the potential for causing or worsening dry eye (for anti-cholinergic properties or medication side effects)?
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Benadryl
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What are some medications for urinary incontinence that have the potential for causing or worsening dry eye (for anti-cholinergic properties or medication side effects)?
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Detrol Oxybutnin
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Which acne med. could worsen dry eye?
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Isotretinion
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What are some beta-blockers that could worsen dry eye?
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Metoprolol Propanolol Atenolol
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What is an example of a typical antipsychotic that could worsen dry eye?
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Haldol
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What is an example of a muscle relaxant that could worsen dry eye?
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Flexeril
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What is an example of a TCA that may worsen dry eye?
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Amitriptyline
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What is an example of a diuretic that could worsen dry eye?
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Hydrochlorothiazide
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Which ocular medications may cause dry eye?
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Beta-blockers Carbonic anhydrase inhibitors Adrenergic agonists Prostaglandin analogues Cholinergic agonists Antihistamines with mast cell stabilizing effects - ex: Pataday, Zaditor Decongestants- ex: Nephalozine, Phenylephrine, Tetrahydrolizine Oxymetalozine NSAIDs Ocular Preservatives, especially benzalkonium chloride NOTE: * may not cause dry eye if only ocular med being used, but may cause or worsen dry eye if more than 1 ocular med on this list are being used
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What are the treatment options for dry eye?
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Treat autoimmune and ocular problems if present Modify risk factors/causes, including implicated medications, if possible Lid scrubs and Warm/Cold compresses to eye Diet high in Omega-3 fatty acids or Omega-3 supplementation Artificial Tears products - solutions, gels, ointments Cyclosporine or Lifitegrast ophthalmic for chronic dry eye Autologous serum eye drops, Punctal plugs, special contact lens and other therapies employed by ophthalmologists
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What are the purposes of artificial tears solutions?
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*Improve lubrication *decrease evaporation *Stabilize tear film *Replace insufficient tear film *Objective is to replicate your tears, and try to get pH close to the normal pH of your eye.
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When might you recommend a artificial tears solution?
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Acute or episodic dry or irritated eyes; chronic dry eye
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______ can be irritating to the eye, so it may be good to suggest single packaged items (preservative-free).
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Preservative
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Bion Tears™ Refresh Plus™ Soothe PF™ Systane™ Tears Naturale Free™ These are all examples of what types of products?
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Tears Solution Products. SOLUTIONS!
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Patient counseling points for tears solution. Start with _____ dosing, and adjust quantity based on response. Often use ____-_____ times daily. Preservative-free or mild preservative products preferrred when using _____ times daily or more. NOTE: Consider switching production solution if using QID or more or consider a gel product (longer lasting than solution) or the addition of an ointment at bedtime.
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BID 3-4 FOUR
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Advantage to ophthalmic gels and ointments over solutions is the _____ _____.
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Retention Time. Stay in the eye longer
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Most ophthalmic gels and ointments are ______-_____.
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Preservative free
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How frequently do you apply ointments?
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QHS Can be applied during the day, but does cause some mild blurred vision.
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What is cyclosporine ophthalmic emulsion indicated for and what is the brand name?
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Restasis Indicated for chronic MODERATE to SEVERE dry eye disease **Reduces dry eye symptoms and signs from chronic inflammation
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How does Restasis work?
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It is a T-cell mediated anti-inflammatory effect
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Can patients continue to use their OTC artificial tears products with Restasis?
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Absolutely.
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Cyclosporin reduces the ______.
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Inflammation
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Full clinical benefit of cyclosporine emulsions can be seen in how long?
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Full Clinical benefit usually seen in 4-8 weeks but may take 3-6 months
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If using artificial tears, it is best to wait _____ _____ after instilling Restasis.
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One Hour
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How long should you wait to reinsert contact lens after administration of Restasis?
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You should wait 15 minutes.
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What techniques should be used when using Restasis? What is the dose for Restasis?
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Close eye and occlusion Instill one drop into each eye every twelve hours. One vial for both eyes
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What are some adverse effects of Restasis?
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Ocular burning and stinging upon instillation administration; eye pain and foreign body sensation upon instillation
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The use of Restasis should improve what type of symptoms?
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Dry eye symptoms
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If a patient complains of stinging in the eye upon administration of Restasis, what might you recommend?
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Artificial Tears products
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T/F Restasis has a high systemic concentration.
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False. Systemic exposure is minimal, blood concentration undetectable after ocular administration.
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What are two contraindications with Restasis?
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Active ocular infection, hypersensitivity to any ingredient
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What is the generic name for Xiidra?
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Lifitegrast
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What is Xiidra indicated for?
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Indicated for chronic moderate to severe dry eye. **Reduces signs and symptoms of dry eye from chronic inflammation
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How does Xiidra work?
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T-cell mediated anti-inflammatory action much like Restasis.
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What is the clinical benefit to Xiidra compared to Restasis?
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Clinical benefit may be seen as early as 14 days (faster benefit than Restasis)and increases for 6-12 weeks
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What is the dosage for Xiidra?
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Instill one drop into each eye twice daily (Approximately 12 hours apart)
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What are some side-effects of Xiidra?
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eye irritation, discomfort, decreased visual acuity, dysgeusia when instill drops
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__________ (From Xiidra) can be minimized with lacrimal occlusion.
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Dysgeusia
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What is the term for: the small central part of the retina that is responsible for central, high level visual acuity
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Macula
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With AMD, the _______ pigment epithelium + ________ of the macula center (fovea) deteriorate which causes loss of central, high resolution vision
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Retinal Photoreceptors
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What are some causes of Age-related Macular Degeneration?
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Increased levels of vascular endothelial growth factor (VEGF), inflammation, inflammatory cytokines
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What are the two types of Advanced Age related Macular degeneration?
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Advanced non-neovascular Advanced neovascular
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Advanced non-neovascular - Termed ______ AMD - atrophy of macula, multiple large drusen (small yellow deposits), slow _____ vision loss over many years
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DRY Central
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Advanced Neovascular - Termed _____ AMD - overgrowth of leaking blood vessels, large _____ plus sub-retinal fluid, scars, hemorrhage leading to profound central vision loss (more rapid than Dry) and perhaps eventual blindness
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WET Drusen What is a drusen? Drusen are yellow deposits under the retina, the light-sensitive tissue at the back of the eye. Drusen are made up of lipids, a fatty protein. While drusen likely do not cause age-related macular degeneration (AMD), their presence increases a person's risk of developing AMD
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What is the number one risk factor for age-related Macular Degeneration?
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SMOKING! Some other risk factors: Increasing Age Heredity Obesity Race: Caucasian Hypertension, Atherosclerosis High intake of saturated fat and cholesterol
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Risk factors for AMD: Low intake of lutein, zeaxanthin, and ___________ (Docosahexanoic acid (DHA) and Eicosapentaenoic acid (EPA)
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Omega 3 Fatty-Acids
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What are some patient symptoms of intermediate or advanced NEOVASCULAR AMD?
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Words on a page look blurred in the center Straight lines look distorted, especially toward the center of the vision Dark or empty area appears in the center of the vision Colors look dim Difficulties in reading road signs, watching TV, seeing faces
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What some QOL issues related to AMD? Which issue with AMD is most complained about?
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Adverse effects on daily activities such as reading, driving, watching televisionImpaired orientation Reduction in mobility Impaired balance Increase risk of falls Depression MOST COMPLAINED ABOUT: Decreased facial recognition What are some non-pharmacological strategies to aid in better QOL for these patients? Bright light Magnifying devices Reading glasses Large print reading materials Patient education materials available on web sites and thru the ophthalmologist
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For patients without AMD and those with Early and Intermediate AMD should undergo regular eye examinations by which type of physician?
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Ophthalmologist
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What are some preventative strategies for patients without AMD and those with Early and Intermediate AMD?
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Stop smoking if smoke Control Blood Pressure Wear sunglasses Eat plenty of __fruits and vegetables __ Increase intake of dietary antioxidants, lutein, zeaxanthin, and omega-3 fatty acids (DHA, EPA) Consider an eye health supplement based upon AREDS or AREDS2
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What are some food items that contain Omega-3 fatty-acids
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Fatty fish Walnuts Soy Oil Flaxseed Canola Oil Fortified Milk Rich Eggs? WTH is a rich egg? Who knows?
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What are some food sources that contain Lutein and Zeaxanthin?
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GREENS! Kale Romaine lettuce Spinach Turnip greens Garden peas Brussel sprouts Zucchini Broccoli Eggs Orange peppers Honey dew melons Winter squash Oranges and Orange juice
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In the study presented in class for AREDs, what was determined to be the most effective therapy?
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Antioxidants plus Zinc (plus copper) formulation
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Smokers should not take supplements with ______-_______ increases the risk of lung cancer!
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Beta-carotene Smokers that are hoping to protect their eyes, but are not willing to quit smoking should NOT be recommended a product containing beta-carotene.
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********IMPORTANT************ WHAT IS THE PRODUCT IN THE AREDS2 STUDY? WHAT ARE THE INGREDIENTS?
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PreserVision AREDS 2 formula™ Nutrients per Daily dosage (2gels = ): Vitamins C (500 mg) and E (400 IU) Zinc (80 mg) and Copper (2 mg) Lutein (10mg) and Zeaxanthin (2mg)
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ICAPS AREDs Formula is not recommended for ______ due to beta-carotene.
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Smokers
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Name some ophthalmic gels and ointments.
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Example Gels: GenTeal Gel, Refresh Celluvisc Gel™ Example Ointments: Tears Naturale PM, Systane Night ointment ™
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Name four Vascular Endothelial Growth Factor Inhibitors. Which is NOT FDA approved?
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Ranibizumab - Lucentis® Pegaptanib - Macugen® * Aflibercept - Eylea® Bevacizumab - Avastin® - not FDA approved
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How are Vascular Endothelial Growth Factor Inhibitors administered?
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Intra-vitreal by ophthalmologist Injection
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Which Vascular Endothelial Growth Factor Inhibitor should not be used because it is not effective?
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Pegaptanib - Macugen® *
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What does the efficacy of Vascular Endothelial Growth Factor Inhibitors look like?
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Stabilization and even improvement in vision; Mean visual acuity gain of up to 6-10 letters on the ETDRS or Snellen Charts
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What are some ocular AEs with VEGF Inhibitors?
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Ocular AEs Incr. IOP (transient) Pain/object in eye* Endophthalmitis Retinal detachment Small hemorrhage in the eye* Floaters* *Most common
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What are some patient consultation points for VEGF Inhibitors?
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In days after treatment - If eye becomes: Red Sensitive to light Very Painful Has a change of vision or purulent discharge See your ophthalmologist ASAP!
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Patient monitoring of VEGF inhibitors should be by an ophthalmologist and should consist of:
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Check for appropriate optic nerve perfusion immediately after medication injection IOP measurement within 30 minutes after injection Examination for infection within one week after injection Periodic visual acuity testing
