Afleveringen
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Mucins play an integral role in ocular surface health. They are the secret ingredient that gives the aqueous its viscosity and moisturizing properties. They entrap pathogens in the tear film to protect the eye. And they provide the glycocalyx anchor that keeps the tear film residing on the ocular surface. In this episode, Anna Tichenor, OD, PhD, of Indiana University explains all this and more in the no-nonsense terms youâd expect from a Midwesterner.
There are two types of mucin: free-floating and membrane-bound. The former are secreted by conjunctival goblet cells into the tear film, where they scavenge for bacteria and pollen while also providing the hydration properties of the tears. Membrane mucins, by contrast, arise from corneal and conjunctival epithelial cells and produce the glycocalyx, âkind of a shag carpetâ on the ocular surface. Dr. Tichenor explains. Functionally, this creates a hydrophilic base that adheres the tear film to the eye.
The discussion then delve into clinical manifestations of these mucin properties, beginning with lissamine staining and what it signifiesâdead or devitalized corneal epithelial cells that also have patches of missing glycocalyx.âThose areas are not going to be wetting very well,â Dr. Tichenor explains, âand would be very prone to infection.â
The team also offers advice on how to identify the Line of Marx at the mucocutaneous junction on lissamine green staining and what it might signify, as well as the role of mucins in lid wiper epitheliopathy.
Although fluorescein patterns are most often interpreted in the context of lipid layer integrity, Dr. Tichenor offers a nice clinical pearl on what they may say about the state of the glycocalyx, too: watch for the fluorescein spreading pattern across the cornea. If you see dark patches form almost immediately after a blink, âI would interpret that as areas where the glycocalyx is not functioning as well as it could.â
Membrane mucins are an effective early warning system. Inflammation is widely recognized as the key driver of dry eye, and research points to mucin as a potential regulator of inflammatory cytokines, Dr. Tichenor explains. Furthermore, overproduction of mucus happens in response to an antigen on the ocular surfaceâa threat that needs to be eliminated. This might be a clue to mucin deficiency in, for instance, Sjögrenâs Syndrome.
This episode emphasizes that mucins contribute to dry eye cases in important ways that shouldn't be overlooked in favor of lipid-based mechanisms and interventions. Other mucin-mediated conditions include ocular cicatricial pemphigoid, mucus fishing syndrome, filamentary keratitis and Stevens-Johnsons Syndrome.
Despite the paucity of mucin-specific treatments available in the US. Dr. Tichenor explains that some artificial tears have âmucomimeticâ properties, especially those containing hyaluronic acid. The potential of topical vitamin A is also touched on, as well as two drugs available internationally: diquafosol and rebamipide.
âHave mucins on your mindâ as you assess dry eye and other ocular surface conditions, is Dr. Tichenorâs takeaway for the episode.
Relevant articles:
A Sticky Subject
As Smooth As Silk
Dry Eye Drop Boosts Ocular Mucins
Regional Conjunctival Differences in Glycocalyx Mucin Expression in Dry Eye and Normal Subjects
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You know the story; it might even be your story. Graduate optometry school with a lot of enthusiasmâand a lot of debt. Pick up all the extra days you can just to stay afloat financially. Now youâre in the high-volume, low-reward daily grind of refraction, primary eye care and the same old conversations with patients about what astigmatism is. Hello, burnout.
What to do? For Ada Noh, OD, the answer was to commit to a specialty concentration in dry eye, forgoing the trappings of routine eye careâbye-bye, phoropter!âfor the intellectual stimulation of advanced care and the risks and rewards of self-employment.
Dr. Noh describes her journey to specialty practice with great anecdotes about how she came to face her fears about starting cold, in an unfamiliar new city to boot. Job one was building a referral base and that meant embracing self-promotion far and wide to optometrists, ophthalmologists, other health care professions and frankly anyone else whoâd hear her out. She says giving up primary care entirely rather than the half-a-loaf approach of adding a dry eye clinic to a general practice was a winning strategy, as other eyecare providers had no reason to see her as a threat. Instead, she became a resource to them.
Addressing the misconception that you need to sink a lot of money into a specialty practice, Dr. Noh reassures listeners that you could start without much more than a slit lamp and a bottle of Fluress if you want. Itâs the extra time and attention you give patients that often makes a decisive difference to them. She does also share her thoughts on the most helpful devices to addânotably, meibography and IPLâas you ramp up over time.
Throughout the episode, Dr. Noh returns to the themes of believing in yourself and having the tenacity to take on whatever comes your way. âDonât wait for âperfectâ because itâs not gonna come,â she counsels. The rewards for all this hard work and risk-taking go beyond the financial. She has more autonomy than ever before.
Amazingly, Dr. Noh is about to take the plunge a second time. Having recently sold the practice she started only a few years ago, sheâs moving to a bigger market and will do it all over again, beginning this fall. Stay tuned for future updates on her second (or maybe third?) act!
Relevant articles worth reading:
âWhy Isnât My Dry Eye Therapy Working?â
By Ada Noh, OD
Dive Into Dry Eye
With advice from Cory Lappin, OD, Hamza Shah, OD, Michelle Hessen, OD, and Erica Udell, OD
Pathways to Specialization: Findâand FollowâYour Calling
With advice from Kelly Cohen, OD, Emilie Seitz, OD, Rami Aboumourad, OD, Joseph Sowka, OD, Cory Lappin, OD, Marie Homa-Palladino, OD, Langis Michaud, OD, Michael Cymbor, OD, Erin Tomiyama, OD, PhD, and Diane T. Adamcyzk, OD
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Zijn er afleveringen die ontbreken?
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With renowned dry eye expert Milton Hom, OD, as this episodeâs guest, hosts Kaleb Abbott, OD, and Andrew Pucker, OD, PhD, lead a spirited discussion of so-called âartificial tearsâ and contact lens rewetting drops as distinct product categories. They begin by exploring whether or not FDA definitions align with the perception of clinicians and their recommendations to patients, noting that much of the terminology and categorization structure of these products stems from the original FDA product monograph, which dates to 1988.
Dr. Abbott argues that these categories are outdated and should rightly be combined and renamed âlubricating dropsâ to reflect real-world use. He also points out that thereâs less than 1% similarity between artificial and human tears, as the latter contains thousands of proteins and growth factors, so the term âartificial tearsâ creates unrealistic expectations with patients.
The conversation then turns to ingredients in tear products and their role in product selection. Dr. Hom favors drops containing hyaluronic acid when wound healing or improved contact lens comfort is needed, a trehalose-containing drop if he sees corneal staining and an emulsion-based product (mineral oil or castor oil) for evaporative dry eye. The trio are intrigued by newer products that aim to mimic natural tears by including vitamin C, vitamin B12, amino acids and other ingredients but we need to see the data supporting their efficacy.
They return to the topic of the FDA monograph when discussing why Meibo is considered an artificial tear in Europe, and sold over the counter, but not in the US; its formulation doesnât meet the FDA criteria for OTC status and so the product was developed as an Rx drug. The experts point out that Meibo has a much longer ocular surface retention time than regular artificial tearsâroughly 6-8 hours vs. 30 minâand thus does perform differently.
The episode ends with a discussion of how to approach patients with overlapping allergy and dry eye, and a general wrap-up on the debate over whether certain artificial tear products truly have properties that distinguish them from others. The consensus is that some indeed do but none truly replicate the natural tear film.
Relevant articles worth reading:
It's time to retire the terms artificial tears and rewetting drops: A call for accurate terminology and updated clinical usage in eye care
By Kaleb Abbott, OD, MS, and Andrew Pucker, OD, PhD
Over the counter (OTC) artificial tear drops for dry eye syndrome
By Andrew Pucker, OD, PhD, Sueko Ng, MHS, and Jason Nichols, ODArtificial Tears: What Matters and Why
With advice from Jennifer S. Harthan, OD, Suzanne Sherman, OD, Cecilia Koetting, OD, and Meaghan Horton, OD
Artificial Tears: Looking Beneath the Surface
By Mike Christensen, OD, PhD, and Tressa Larson, OD
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Dry eye specialist Cory Lappin, OD, of Cincinnati shares insights on IPL that heâs developed from many years of performing the procedure. Dr. Lappin begins with a clear and concise explanation of how light interacts with pigment at the cellular level to âkick-startâ meibocyte activity and target telangiectatic blood vessels. He addresses common misconceptions about IPL, taking care to explain that it is a non-laser and non-thermal procedure, as a way of understanding where it fits in among dry eye interventions.
From there, Drs. Lappin, Abbott and Pucker discuss ideal candidatesâmost notably those with ocular rosacea but also many typical MGD patientsâand how to discern their suitability based on Fitzpatrick skin type. The trio also delves into cautions and contraindications in patients on doxycycline, those with active herpetic outbreaks, epilepsy patients, people with skin conditions like melasma and the hazards posed by eyeliner tattoos.
A discussion on technique explains the three main protocols for IPLâToyos (high fluence), Epstein (overlapping lower-fluence pulses) and Periman (full-face treatment)âand how choice of light filter can affect results.
The conversation concludes with practical tips for patient education on IPL and how to establish a schedule for treatment (beginning with four sessions at a minimum) and long-term monitoring (ideally every three to six months thereafter). Dr. Lappin also gives advice for clinicians who are interested in adding IPL but apprehensive: gain confidence by thoroughly understanding it first, start with ocular rosacea patients and others likely to get great results, and donât feel you have to sell the patientâeducate, donât attempt to âconvince,â and let them decide for themselves.
Relevant articles worth reading:
Ocular Rosacea: How to Recognize and React
By Kaleb Abbott, OD, MS
The Role of Intense Pulsed Light in OSD Management
By Harriette Canellos, OD, and Christina Canellos, OD
When IPL Prevails
Edited by Paul C. Ajamian, OD
Tackle MGD with These Hands-on Interventions
By Mila Ioussifova, OD, and Hardeep Kataria, OD
