Article Date: 8/1/2005

cover feature
Managing the Ocular Surface
A review of the surface — from disease to co-managing anterior segment surgery.
BY SCOT MORRIS, O.D., F.A.A.O., Conifer, Colo.


IMAGE PROVIDED BY EYEMAGINATION, INC.

As our profession moves towards an increased awareness of ocular surface disease, the question is often posed: How do we manage the ocular surface? There are so many ocular surface diseases that it takes book chapters to fully describe the pathophysiology and various treatment strategies that we can use to treat each individual disease. Here I intend to provide a broad overview and a general "recipe" for treating an assortment of ocular surface diseases.

Get to know the surface

Let's first review some characteristics of the ocular surface so we can better understand how to treat these patients. The ocular surface is composed of the cornea, the bulbar and the palpebral conjunctiva. The corneal surface is composed of the cuboidal epithelium with microvilli that secrete glycocalyx, the protein that covers the epithelium. The glycocalyx makes it possible for the remainder of the tear film to rest on the hydrophobic corneal surface. The microvilli have a ciliary function. They move various antigens and waste products that can be trapped in the surface mucin nasally toward the lacrimal drainage system.

The conjunctiva contains goblet cells that secrete mucins 1 and 4. These mucins are absorbed into the ocular surface and blend with the aqueous component of the tear film. The function of these mucins is to protect the ocular surface from contaminates. The tear prism is a delicate balance of mucin, electrolytes, proteins, pro-inflammatory cytokines, immunoglobulins, and outer meibum lipids that functions to prevent desiccation. It also provides nutrition, removes waste products and protects the ocular surface immunologically.

TABLE 1 - Major Disease Categories
  • Infection
  • Ischemia
  • Inflammation
  • Allergic
  • Immune
  • Mechanical/Trauma
  • Dystrophy
  • Degeneration
  • Neoplastic
  • Congenital/Developmental

Identify the problem

The daunting task every clinician faces is to treat each person promptly and effectively. The first step: Correctly identify the problem. As we review that process, keep in mind that all diseases fall into one or more of the major categories of disease as listed in Table 1, below.

The key is to develop a systematic plan to examine each segment of the ocular surface individually for the presence of each of these major disease categories. This plan will reduce the likelihood of missing any key components. Ask yourself this series of questions:

1. What level of inflammation in the form of chemosis, hyperemia, or hypoxia is present in each part of the ocular surface?

2. Are the lids involved?

a. Are the changes focal, localized, or geographic?

b. Is there a void or change in the normal architecture?

c. Is one or more of the six types of blepharitis present?

d. Is the lid margin keratinized?

3. Is the palpebral conjunctiva involved?

a. Are there inflammatory cysts, deposits or mechanical changes present?

b. Is there a follicular or papillary reaction, or both?

4. Is the bulbar conjunctiva involved?

a. Is there chemosis or focal thickening?

b. Is there focal epithelial loss?

 

 TABLE 2 - OSD Staining Patterns

 

  • Inferior band pattern

  • Poor lid closure

  • Diffuse

  • General ocular conditions

  • Four & eight o'clock

  • Lid conditions

  • Focal

  • Lid lesions, trauma,    epithelial disorders

  • Inferior palpebral conjunctiva

  • Blepharitis

  • Interpalpebral bulbar conjunctiva

  • KCS

5. Is the cornea involved and if so, at what level?

a. Is there any specific corneal staining pattern? (See Table 2, "OSD Staining Patterns.")

b. Is there any epithelial cellular infiltration, edema or opacification?

c. Is there any change in normal cellular architecture?

d. Are these changes local or geographic?

6. What is the status of the tear film?

a. Are there mucous strands or filaments present?

b. Is there sufficient tear film?

Manage the patient

The key to success in treating any disease is effective and honest communication. A few points to keep in mind when talking with your patient:

If your patient doesn't understand, then poor compliance is the likely result, so your chance of success diminishes greatly. Have an honest discussion about the patient's condition, prognosis and various treatment options available. Discuss your treatment strategy. Explain what to expect during the treatment process, including potential drug interactions, side effects and anticipated patient symptoms during the recovery process. Advocate that the patient's compliance is critical to the successful treatment. Emphasize that failure to follow the treatment regimen will prolong the disease, the symptoms and also potentially cause an increased threat to vision and health. Lastly, ask if the patient understands your instructions and if she has any questions.

Manage the problem

When it comes to the true medical management of the ocular surface, there are a few basic rules to keep in mind before embarking on any treatment strategy. Treatment options depend on many conditions including:

Here is a step-by-step guide for treating various ocular surface diseases:

TABLE 3 - Do What You've Got to Do
  • Protect patient health
  • Protect patient vision
  • Make the patient comfortable
  • Prevent the spread of disease
  • Arrest bad inflammation
  • Control secondary mechanical changes
  • Restore normal anatomy and physiology

1. Stop infection. Treat ocular surface infection quickly and aggressively with the most potent antibiotics, antiviral or antifungal available. Currently the fourth-generation fluoroquinolones, Zymar (gatifloxacin ophthalmic solution 0.3%, Allergan) and Vigamox (moxifloxacin hydrochloride ophthalmic solution 0.5%, Alcon), are the drug(s) of choice (DOC) for bacterial infections due to their wide range of coverage, high kill rate and low resistance. Viroptic is the DOC for herpetic infections.

2. Stop cicatricial changes, mechanical agents, antigen contact, etc. Remove any mechanical force that is causing damage to the surface, including foreign body in the lid margin, conjunctiva or cornea. In some instances this may even indicate removal of metaplastic or degenerating tissue. Include aggressive lubricant therapy to irrigate the surface and wash away localized antigens, foreign bodies and inflammatory mediators. In allergic disease this may also mean taking aggressive avoidance strategies to decrease or eliminate antigen exposure.

3. Treat associated inflammation. Often overlooked but crucial to a successful outcome, you must treat inflammation deriving from the ocular surface disease. The inflammatory process in ocular surface disease is very complex and often engaged at multiple levels. Effective treatment may call for concomitant use of multiple anti-inflammatory medications along the continuum (see Table 4, "Anti-inflammatory Treatments"). The goal is to impede negative inflammatory changes that can lead to patient discomfort or visual loss as well as permanent changes in the cellular architecture of the ocular surface. Being initially aggressive will cause a quicker mediation of the irritating agent and allow for a faster overall recovery.

 

 TABLE 4 - Anti-inflammatory Treatments

 

  • Avoidance strategies

  • Cold compresses

  • Decongestants/vasoconstrictors

  • Antihistamine/Mast cell stabilizers

  • NSAIDs (oral & topical)

  • Steroids (oral & topical)

  • Other immunomodulating agents

  • Restasis (cyclosporin A, Allergan)

  • Doxycycline

  • Omega-3 fatty acids

  • Vitamin combinations

  • Hormone modulation

On the opposite side of the spectrum is a more generalized "shotgun" approach. It may temporarily calm the clinical signs but prolong the actual recovery time while allowing for a chronic sub-clinical inflammatory process to develop on the ocular surface. Chronic inflammation results in degenerative or atrophic morphological changes of the ocular surface cellular structures.

4. Control patient discomfort. Patients want to feel better and often gauge their success by their symptoms. Provide adequate pain management techniques including both oral and topical alternatives when necessary. Use lubricant therapy, cold compresses and topical analgesia in the form of Acular (ketorolac tromethamine ophthalmic solution 0.4%, Allergan) or Voltaren (diclofenac sodium ophthalmic solution 0.1%, Novartis). It's essential to control photophobia so cycloplegia, preferably homatropine 5% ophthalmic solution, should be employed when there is an impending or active intraocular involvement. Be judicious in using oral agents in the form of non-narcotic or narcotic analgesics. Start aggressively and taper as needed.

5. Restore normal anatomy and physiology. Once you have arrested the progression of the ocular surface disease, the secondary challenge is to restore the ocular surface to its original state. Think clinically: Begin at the external surface and work inward.

Remember these steps

I hope this has provided you with a conceptual idea of how to treat the wide array of OSDs. Identify the etiology of the disease through careful analysis and astute clinical skills. Treat aggressively, stop infection or other mechanical event, treat inflammation, control patient discomfort, and restore normal physiology and anatomy. 

 

Co-Managing Anterior Segment Surgery

A decade ago ocular surface disease (OSD) rarely received mention on the cover of the major optometric and ophthalmic journals. Now, however, OSD is the centerpiece of multiple issues across the professional spectrum. A primary reason is the advancement of corneal refractive procedures, modern cataract surgery, and the ensuing complications. Its prevalence has brought optometrists into the picture as co-managers.

A few tips on co-management:

1.   Be proactive in diagnosing and treating OSD prior to any ocular surgery. Treat all forms of lid margin disease with the appropriate therapy to decrease risk of surgical field contamination or intraocular inoculation. Pay special attention to LASIK and PRK patients with any presenting symptoms of dry eye disease. It is advised that the patient be asymptomatic and void of any clinical signs before proceeding with surgery. This may result in postponement of surgery; however, the postoperative recovery and patient comfort will be much faster by abiding by this rule.

2.   Prophylactically treat all patients aggressively for OSD immediately post-op, regardless of the presence of symptoms and signs.

It is now considered the standard of care to prescribe a fourth-generation fluoroquinolone with any anterior segment surgery. These drugs have been demonstrated to be very effective against Gram +, Gram -, and the atypicals. Topical steroids are also recommended to decrease the inflammatory reaction present on the surface as a result of surgical trauma. Additionally, frequent lubrication of the ocular surface (up to q1h or more) with an artificial tear supplement is recommended. This will not only assist in lubrication, but also clear any foreign particles or inflammatory mediators.

3.   Treat short-term postoperative complications with the appropriate and aggressive therapy.

The most prominent reason for postoperative issues with OSD is the failure to stay aggressive until the disease is mediated. The second most common reason is the failure to treat the correct problem with the proper drug. Be diligent in your diagnosis and choose the right therapy.

 

Dr. Morris is the director of Eye Consultants of Colorado, LLC, and Morris Education & Consulting Associates. He is a member of the American Optometric Association and is a Fellow of the American Academy of Optometry.

 

Optometric Management, Issue: August 2005