Notes on Dr. Peter C. Donshik's 10/2 SJS Seminar Presentation on Dry Eyes

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Dr. Peter C. Donshik: "Treatment of Dry Eye in SJS"

What is dry eye disease?  It gets redefined every few years
Can relate to deficient tear production or evaporative loss
SJS (tear deficiency)
Meibmian gland disease (evaporative)
Unstable tear film leads to ocular irritation and inflammation, which leads to ocular damage

Utility of moderate dry eye on quality of life is similar to that of moderate angina

Tears are produced in three areas: lacrimal glands (fluid/aqueous), meibomian (lipid), and mucin layer; they are a soup

Tears are necessary for good vision

Sequence of treatment determined by severity of dryness and response to treatment: there is no universal approach

Artificial tears do not contain all of the ingredients of tears

Artificial tears:
If used more than 2-3 times/day should really use non-preservative
Using drops with preservatives more than 4 times a day can cause eye irritation and make things worse

Ointments: Genteal Gel has less viscosity than others (less blurring) than others; good for night

Inserts:
Lacriserts: need to make some tears for them to work (slow releasing inserts); problem that can happen is at the end of the cycle, you can get too many tears and vision can blur (can just flip it out and wait to put in another the next day or put in another)
Goggles: moist chamber goggles, Panoptic (tight seal), Tranquileyes
Decrease outflow of tears: punctal plugs (upper, lower, or both) made of collagen and lasts 3 days to a few 56
Silicon plugs last longer than collagen, though they can sometimes fall out; reversible; can be removed w/ forceps

Evoxac and salagen more helpful for dry mouth than eye, but can help somewhat with dry eye

Autologuous serum: severe ocular surface disease and haven't responded to other methods; contains more ingredients of tears than standard artificial tears; taken for 4-5 mnth; needs to be refrigerated

Omega-3s and Omega-6s: must be eaten; essential fats; American diet high in 6s and low in 3s
What does Omega-3 do?  Helps increase oily layer-meibomian secretions
Can help w/ joints and lid/meibomian gland disease
Leads to an anti-inflammatory response in the body and a potential stimulation of tears
No good study to prove it, but most doctors find that more patients report a beneficial response than those who say it doesn't help.
Ratio of EPA and DHA is important
Increase amount of fish in diet
Patients on blood thinners need to consult doctors

Topical corticosteroids or Restasis:
Restasis: decrease lymphocytic invasion; will not work if there is no viable tissue to stimulate (if glands are overrun with lymphocytes); good candidate is able to make some tears and is using artificial tears 3-4 times a day and not finding relief; can take 1-3 months to have an affect; overall success rate or 70-75% (improvement, not necessarily total relief of symptoms)

Natural treatments: warm compresses, clean lid, massage

No way of determining what kind of treatment to use; must look at signs and symptoms, try to start w/ minimally invasive therapies and work up