THE PARAOPTOMETRIC – MARCH 2016

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Refresh Optive Gel Drops from Allergan are for people with DES who need a more viscous artificial tear to relieve their symptoms.

The optometric assistant can help the doctor with the diagnosis and treatment of patients with dry eye. Here’s how. 

Dry eye syndrome (DES) is a condition that affects close to five million people in the U.S. Also known as keratoconjunctivitis sicca,  it is caused by insufficient tears to lubricate the eye or from an imbalance in the tear composition.

COMPONENTS OF TEAR FILM
The tear film of the eye is responsible for lubrication, which helps the eye maintain its vision by providing nutrition to the anterior portion of the eye, creating a clear corneal optical surface, reducing the risk of infection and flushing away debris. It is made up of three components:

Oily Layer: The outmost layer is produced by the meibomian glands of the upper and lower eye lids. Its role is reducing the evaporation of the tear film and to smooth the tear surface.

Aqueous Layer: Produced by the lacrimal glands, this middle layer comprises 90% of the tear film volume. It supplies the cornea with oxygen and makes the corneal surface smooth.

Mucin Layer: The innermost layer is produced by the goblet cells of the conjunctiva and is responsible for the even spread of the tear film over the surface of the eye.

Each component of the tear film serves an important function in protecting and nourishing the eye. An imbalance of the tear film can cause the tears to evaporate too quickly and result in the patient developing DES. More commonly seen are patients who experience inadequate tear supply which also can contribute to dry eye symptoms.

CAUSES OF DES
Patients with dry eye experience a variety of symptoms. Some patients complain of pain, a gritty sensation and stinging, while others experience itchy, irritated eyes. There are many causes, including:

Medications. Antihistamines, decongestants, oral contraceptives, blood pressure medications””just to name a few””can cause a decrease in the amount of tears the eye produces and contribute to dry eyes.

Medical History. Certain medical conditions, such as diabetes, rheumatoid arthritis and thyroid disease, have all been shown to contribute to DES symptoms.

Age. Dry eyes are more prevalent in people over the age of 65.

Gender. Women tend to develop DES more often than men. That is because women may be more likely to have dry eyes secondary to hormonal changes from pregnancy, menopause and the use of oral contraceptives.

Environment. People living in dry climates, or those who are constantly exposed to windy or smoke conditions, may be more likely to develop dry eyes.

DIAGNOSING DES
First, the paraoptometric performs a complete and thorough patient history. To properly diagnose dry eyes, the patient should be asked to describe any and all symptoms he or she may be experiencing. All medical conditions, medications and/or environmental factors should be documented since they may contribute to the  problem.

Next, measurements of the patient’s tear quantity and quality are taken. The paraoptometric can assist the optometrist by performing many of the diagnostic tests associated with the diagnosis of dry eyes.

A special test called the “Schirmir Test” measures the amount of tears being produced by the eye. This test is performed by placing a strip of porous paper in the lower cul-de-sac after first placing topical anesthetic into the patient’s eyes. The anesthetic will numb the eye so it will not tear reflexively due to irritation from the test strip. After insertion of the test strip, the patient is then instructed to keep their eyes closed for five minutes. The test strip is then removed, and the amount of wetting is measured. Wetting of the test strip of less than 10mm may indicate the presence of dry eyes.

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InflammaDry from RPS Diagnostics detects the presence of elevated inflammatory proteins in the tear film.

Tear quality can be measured by using the TearLab Osmolarity Test and/or the InflammaDry Test. The TearLab Osmolarity Test requires only nanoliters of fluid to analyze the osmolarity of the tear film, a key indicator of dry eye disease. Tears with high osmolarity can determine the severity of the dry eye. As hyperosmolarity leads to visual fluctuations and tear film instability, it is key to identify and manage early before damage to the cornea can occur. The test is fast and easy to perform; all technicians are trained by TearLab representatives, and from collection to results the test takes only seconds.

Ocular surface inflammation can be detected using the InflammaDry test. This single-use, disposable test is able to detect an elevated inflammatory protein (matrix metalloproteinase 9 or MMP-9) in the tear film, which is a marker for dry eyes. The technician collects the tears with the InflammaDry sample collector, then activates the test using the provided buffer solution and waits 10 minutes. Elevated levels of the inflammatory protein are indicated by the appearance of a red result line.

TREATING DES
There are several treatments for dry eyes depending on the severity of the case.

Lid hygiene. The first course of action is advising the use of lid hygiene, which involves applying warm compresses to open the meibomian glands and scrupulous cleaning of the lids and lashes with baby shampoo. The paraoptometric can help the doctor by explaining the process of lid hygiene.

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The TearLab Osmolarity Test requires only nanoliters of fluid to analyze the osmolarity of the tear film.

Artificial tears. The dry-eye patient is often advised to use artificial tear supplements. These drops or ointments, such as Refresh Optive Gel Drops from Allergan, are available over the counter, and the patient can be advised to purchase either preserved or non-preserved drops, or how often the drops should be used. The assistant can review proper technique for drop insertion.
Supplements. Patients may also be instructed to start taking vitamin supplements, such as ProDHA Eye from Nordic Naturals, that include omega-3 fatty acids, which have been shown to provide some DES relief.

Punctal plugs. For those patients with more severe dry eyes, the doctor may recommend the use of punctal plugs made from either silicone or collagen, which keep more tears in the eyes by blocking the punctum, allowing tears to drain from the eye. Companies such as Lacrivera, Beaver-Visitec and Eagle are just a few that offer plugs.

Topical steroids. For patients with severe symptoms, prescription steroids may be prescribed to  reduce inflammation.

Janet Hunter, COMT, president of Eye Source, LLC, specializes in ophthalmic technician training.

 

WHERE TO FIND IT
Allergan
800.416.8780 | Refreshbrand.com

Eagle Vision Inc.
800.222.7584 | dryeye.org

Lacrivera
855.857.0518 | lacrivera.com

Nordic Naturals
800.662.2544 | nordicnaturals.com

Odyssey Medical Inc.,/Beaver-Visitec
888.905.7770 | beaver-visitec.com

RPS Diagnostics
877.921.0080 | RPSdetectors.com
info@inflammadry.com

TearLab
855.TEARLAB | TearLab.com
marketing@TearLab.com

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