(droge) oog: OTC druppel of verwijzing naar de

Het (droge) oog: OTC druppel of
verwijzing naar de (oog)arts?
Just sit down and relax…
Het oog
• The story of the
patient (or family…)
• The spot diagnosis by
the pharmacist
(check other drugs;
know your client)
Different symptoms and degree of
ilness…
titel
4
14-6-2017
Oogleden
Stand/sluiting
Ectropion
Entropion
Stand/sluiting
lagoftalmie
Ptosis
Chalazion
Zona Ophtalmica
Xanthelasmata (goedaardig)
Tumoren
• Basocellulair epithelioma = kwaadaardig
Conjunctiva
• Degeneratieve
afwijkingen
– Pingueculum
– Pterygium
Het rode oog: subconjunctivale
bloeding
conjunctivitis
bacterieel
viraal
(Epi)scleritis
banaal
hardnekkig
ernstig!
opname!
Cornea
Ontstekingen cornea
Keratitis
Ulcus
Trauma: cornea erosie
• Oorzaken:
–
–
–
–
Vingernagel
Tak
Plant
Papier
• Klacht:
– Pijn ++
– Epifora
– lichtschuw
Oogverband
Trauma: corpus alienum
iritis/cyclitis
• Klacht:
–
–
–
–
« diepe » pijn
Tranenvloed
Lichtschuw
Wazig zicht
• Inspectie:
–
–
–
–
Pericorneale roodheid
Nauwe pupil
Descemet stippen
hypopyon
Anisocorie
• Groter in het licht?
=probleem sphincter
• Groter in het donker?
=probleem dilatator
Oorzaken anisocorie
• Druppels (verlammen sphincter en/of
stimuleren dilatator)
• Ontsteking iris of cornea (miosis)
• Traumatisch (sphincter)
• Acuut glaucoma (mydriasis)
• Neurologisch (corneareflex?)
• Corectopie (trauma, HK, verkleving)
• Planten! (trompetkelk; datura)
Corectopie
De oogdruk
Klassificatie glaucoom
•
•
•
•
a. Chronisch open hoek glaucoma
b. Acuut gesloten hoek glaucoma
c. Infantiel glaucoom
d. Secundair glaucoom
Chronisch open hoek glaucoma
Chronisch open hoek glaucoma
• Klacht: geen « tot het te laat is »:
scotomen
• Familiaal
• Behandeling:
– 1. oogdruppels: productie, afvoer
kamerwater
– 2. lasertherapie
– 3. operatie
– …at vitam eternam….
Acuut gesloten hoek glaucoma
• Klacht:
–
–
–
–
–
–
Acuut
Hevige hoofdpijn
Braken
Rood oog
Grote onregelmatig pupil
Wazig zicht (oedeem cornea)
• Behandeling:
– Druppels
– Vochtafdrijvers:
diamox/mannitol
– Laser iridotomie
– Operatie (trabeculectomie)
Cataract
Cataract: behandeling
Cataract: Klachten
•
•
•
•
•
Vooral last om VER te kijken
Minder last bij het lezen
“Veraf beter zonder bril”
Sneller verblind als de zon laag staat
Trage evolutie (maanden)
Glasvocht
Glasvochtloslating
• Plotse floaters
• Flitsen
• Complicatie:
– Retinascheuren
– Retinaloslating
II: Afwijkingen van de bloedvaten
• a: Vaatsclerose
• b: Diabetische
retinopathie
• c: hypertensieve
retinopathie
• d: occlusie a.centralis
retinae
• e: occlusie v.centralis
retinae
• f: « alle » andere
systeemziekten
diabetische retinopathie
hypertensieve retinopathie
• In fundo:
– Vernauwing arteriolen
– Overkruisingstekens
– Vaatsclerose
– Bloedingen
– Exsudaten
– papiloedeem
Ziekten van de gele vlek
Risicofactoren:
1. leeftijd
2. familiaal /
genetisch
3. diabetes
4. slechte voeding
(cholesterol,…)
5. UV
6. cardiovasculair +
roken!
2 vormen:
1. Droge vorm
2. Natte vorm
Droge vorm van SMD
• Pathologie:
– Afzetting van « drusen » (=
vetophoping) onder het
pigmentepitheel
• Klacht:
– Metamorfopsie (Amsler)
– Last voor dichtbij
• Behandeling:
– Voedingssupplement
– Preventie!
Natte vorm van SMD
• Pathologie:
–
–
–
–
Loslating pigmentepitheel
Nieuwvatvorming
Exsudatie + Bloeding
Verlittekening macula
• Klacht:
– metamorfopsie
– Centrale vlek
• Behandeling:
–
–
–
–
Lasertherapie
Fotodynamische therapie
Intravitreale inspuitingen
chirurgie
Nervus opticus
papiloedeem
• Zwelling van de
oogzenuwkop
• Oorzaken:
–
–
–
–
–
ICH
Papillitis
Compressie oogzenuw
Hypertensie
AION
Automatische perimetrie (statisch)
Het droge
oog
Niet elk droog
oog is
hetzelfde
International dry eye workshop
(DEWS) definition of DED
Dry eye is a multifactorial disease of
the tears and ocular surface that
results in symptoms of discomfort,
visual disturbance and tear film
instability with potential damage to
the ocular surface. It is accompanied
by increased osmolarity of the tear film
and inflammation of the ocular surface
International Dry Eye Workshop. Ocul Surf 2007;5:75–92.
Prevalence
• About 15% of people
over 50 years
• 370 million of
patients worldwide
suffering from DED
From irritation to blindness
DEWS describes two major
types of DED
Dry eye disease
Aqueous
deficiency
Evaporative
Reduced lacrimal
tear secretion
and tear volume
Excess evaporation
in the presence of
normal lacrimal
secretory function
Adapted from International Dry Eye Workshop. Ocul Surf 2007;5:75–92.
The ocular surface
Main
lacrimal
gland
Accessory
lacrimal gland
Epithelium
Meibomian
gland
Pre-ocular tear film
Epithelium
Mucine layer
0.8 μm
Aqueous layer
7-8 μm
Lipid layer
0.1 μm
Lacrimal
glands
Meibomian
glands
Tear
film
Glycocalyx
Goblet
cells
Kanski & Bowling. Clinical Ophthalmology, 7th edn. Elsevier, 2011.
Figure adapted from Gipson. IOVS 2007;48:4391–8
Image is for illustrative purposes only.
Meibomian gland dysfunction
Clinical features of MGD
• Associated with dermatoses such as acne rosacea,
seborrhoeic dermatitis and atopic dermatitis1
• Diagnosis based on morphological features2
–
–
–
_
Acini and duct orifices,
Presence of orifice plugging,
Thickening or absence of expressed meibum
Irregular lid margin
Photographs courtesy of Professor P Aragona
1. Tomlinson et al. MGD Workshop. IOVS 2011;52:2006–49.
2. International Dry Eye Workshop. Ocul Surf 2007;5:75–92.
The healthy tear film
Lipid
layer
Aqueous/
mucin layer
Epithelial
cells
Water evaporation from tears is normally ~33% of the total tear flow1
1. Rolando et al. Br J Ophthalmol 2009;94(Suppl. 1):i1–9.
Image is for illustrative purposes only.
In DED, the tear film and ocular
surface are damaged
Lipid
layer
Aqueous/
mucin layer
Epithelial
cells
Compromised
tear film
• Lipid layer
defective
• Cells dehydrated
• Osmotic balance
disrupted
Water evaporation is now ~75% of the total tear flow1
1. Rolando et al. Br J Ophthalmol 2009;94(Suppl. 1):i1–9.
Image is for illustrative purposes only.
Evaporation of the aqueous layer may
lead to hyperosmolarity
Evaporation
Evaporation
Lipid layer
Compatible
solutes
Water
Aqueous layer
Hyperosmolarity
Water
Mucin layer
Apoptosiscells
Conjunctival
Image is for illustrative purposes only.
Cellular response to hyperosmolarity
Hyperosmolarity
Normal
cell
Dehydrated
cell
Restored
cell volume
Exposure to hypertonic
environment
Regulatory volume
increase
Water loss
Uptake of
inorganic solutes
Cell damage
and death
Decreased cell
function, stress
activation
In DED, quantity of water in tear film is decreased, due to either
increased evaporation or insufficient water production
Image is for illustrative purposes only.
Adapted from Strange et al. Adv Physiol Educ 2004;28:155–9.
Fuorescein staining
Artificial Tears are a widely
recognized First-Line Treatment
Dry Eye WorkShop (DEWS) Treatment Guidelines1
Severity Level
Treatment
1
2
3
• Patient education
• Anti-inflammatories
• Serum
• Environmental and
dietary
modifications
• Oral tetracyclines
• Contact lenses
• Punctal plugs
• Permanent punctal
occlusion
• Eliminate offending
systemic
medications
• Secretagogues
• Moisture chamber
spectacles
• Artificial tear
substitutes,
gels/ointments
• Eyelid therapy
If no improvement,
add level-2 treatments
1. Management and Therapy Subcommittee. Ocul Surf. 2007.
If no improvement, add
level-1 and -3 treatments
If no improvement,
add level 4 treatments
4
• Systemic antiinflammatory
therapy
• Surgery (lid surgery,
tarsorrhaphy;
mucus membrane,
salivary gland,
amniotic
membrane
transplantation)
The ideal drop….
• Protects cells of
cornea and
conjunctiva
• Improves mucin layer
• Adds volume
• Limits evaporation
• Feels good
• Limited instillations
• Easy instillation
• Non toxic
The ideal artificial tear
• Protects cells of
cornea and
conjunctiva
• Improves mucin layer
• Adds volume
• Limits evaporation
• Feels good
• Limited instillations
• Easy instillation
• Non toxic
• Osmoprotectants
• mucine (like) substance
• lipids
• Not too viscous, shear
thinning
• preservatives!
• Many products contain a single
osmoprotectant but…
Osmoprotectants are thought to be
most effective when several are
combined into one formulation
6
Preservatives…or not?
No Treatment
PURITE®
Sodium perborate
Polyquad
Benzalkonium
chloride
Transplantation of labial salivary
glands
• Subtarsal incision of
conjunctiva
• Dissection+Recession of
conjunctiva
• Suturing the graft with
two submucosal running
Prolene sutures entering
the skin nasally and
leaving it temporally
1 day and 2 weeks postop
How do they help?
- via direct secretion of “tears” or essential
tear components (mucins,…)??
- via secretion of molecules that stimulate the
lacrimal gland, the goblet cells of cornea and
conjunctiva (TFF, Lacritin,…)??
Mass Spec
• Quadrupole Orbitrap
(ThermoFischer
Q Exactive PlusTM)
• Thousands (!) of protein
species detected
• Much more sensitive
analysis of small and less
abundant proteins
The smile of a tear by Joan Miró
Dank!