Ocular Surface Wellness The Basics Jack L Schaeffer OD FAAO Marc Bloomenstein OD FAAO Paul Karpecki OD FAAO

Ocular Surface Wellness Ocular surface wellness means re-envisioning our role as eye care practitioners (ECPs) to include helping patients maintain good ocular surface health—not just treating the ocular surface when it’s compromised Wellness requires a proactive stance to maintain ocular surface health Currently we live in a reactive treatment mode 2

Prevention: Action to Maintain Wellness Primary prevention — reducing incidence of disease 1 – Prevent initiation of disease process – Vaccination, healthy habits, smoking cessation Secondary prevention — early detection 1 – Ideally before symptoms occur – Screening, check-ups, early intervention Tertiary prevention — improving outcomes 1 – Help for those with manifest disease 1 – Glycemic control for diabetics, nutritional supplementation for AMD 3

Wellness Today The conventional medical model is disease-oriented Patients interact with medical system to regain health, not to maintain health And that’s a problem! The US is in the midst of a chronic disease epidemic 2 Many costly chronic diseases linked to modifiable lifestyle factors—smoking, diet, activity, sustained stress 2,3 4 Less than ¼ of Americans consume 5 or more servings of fruits and vegetables daily 1 in 5 US adults smokes 1 in 3 US adults is obese

Ocular Surface Wellness: The Opportunity Active maintenance of OS health supports patients’ long-term – Vision quality– Healthy-looking eyes – Ocular comfort– Successful CL wear – Contact lenses change the tear film dynamics and the ocular surface – Young adults are the demographic that will benefit the most 5

Optimizing Vision Efforts to prevent or slow OS pathology help preserve vision Tear film irregularity can affect retinal image quality 16 DE patients experience – Reduced contrast sensitivity 17 – Fluctuating vision – Impact on ease of daily activities (eg, reading, computer, driving, TV) 18 – Discomfort with contact lenses 19 6

Optimizing Vision for Contact Lens Wearers Estimated 37 million US contact lens wearers 20 To perform optimally, CLs need a robust tear film 21 Dissatisfaction with vision is the second most common reason for CL dropout 22,23 Age-related changes to the tear film and OS, combined with changes in refractive needs, can make CL wear more challenging and lead to dropout 20,24 7

Optimizing Vision for Ocular Surgery Candidates Refractive and cataract surgery patients have high expectations for postop comfort and vision Visual outcomes (and postop comfort) influenced by preop OS conditions It is our responsibility to prepare our patients for surgery 8

Threats to Ocular Surface Wellness: Allergy Prevalence of allergic conjunctivitis increasing globally Affects 15% to 40% of US population Typically mild, but interfere with quality of life 42 Significant overlap between presentations of DE and allergy 40 Eye exams may not coincide with seasonal allergy symptoms— proactive questioning important 9 Itch 42.2% Dryness 54.6% 57.7% Itch 45.3% Dryness

Threats to Ocular Surface Wellness: Dry Eye and Blepharitis DE and blepharitis among the most common conditions eye physicians encounter 43,44 – Using a very restrictive definition, DE affects nearly 5 million Americans aged 50 and older 44 – Eye care practitioners may see blepharitis in ~40% of patients 45 10

Threats to Ocular Surface Wellness: Dry Eye and Blepharitis 11 Blepharitis comprises a number of inflammatory eyelid conditions and comorbidities 46 – Dry eye – Chalazion – Hordeolum – Conjunctivitis – Keratopathy MGD (a form of blepharitis) may be the most common cause of evaporative DE 45,47,48

© 2014 Novartis Threats to Ocular Surface Wellness: Medication Use Some common systemic meds increase risk of DE symptoms – Antihistamines – Antianxiety medications 63,64 – Antidepressants 63,64 – Diuretics 62,64 – Oral corticosteroids 63 12

Ocular Surface Wellness In PRACTICE My practice is looking broadly at wellness; our approach includes: – Regular yearly eye exams – Children with refractive error evaluated every 6 months – Comprehensive contact lens exam and follow-up visit for all contact lens patients – Monitoring contact lens compliance – Adopting myopia prevention treatment strategies 13

Ocular Surface Wellness In PRACTICE DR KARPECKI DR BLOOMENSTEIN

OSW: Revising the Office Medical Strategy In my office: Most of my patients come to the practice for vision care Specifically, they want the glasses or contact lenses their vision plan allows But OSW is essentially medical, which requires that patients and doctors have a new mind-set – ECPs offer more than glasses: we help maintain ocular surface health—which has value – A healthy ocular surface can help optimize vision, comfort, and cosmesis 15

Integrated Health Care Model “Medical model” is overused—“integrated health care model” is a better term Integrated Health Care Model is the essence of proactive vs reactive care Help patients understand use of medical insurance and the value of communication between OD and patient’s other providers, eg: – Primary care physician – Endocrinologist – Dentist – Neurologist – Dermatologist, etc. 16

© 2014 Novartis Start Young, Use Demographic Data The ocular surface changes over a lifetime, and not for the better 1 Goal: keep the ocular surface in optimal condition by changing patient behavior Requires starting as young as possible—ideally before aging changes can create symptoms & signs of ocular surface problems Bring OSW up with young patients, even those without signs or symptoms. OSW is especially important in young contact lens wearers, who may want to wear lenses for the next 50 years—contact lens wear is contraindicated in the presence of an unhealthy ocular surface 17

See Children at Appropriate Intervals In my practice, Children and Teens with vision or ocular surface problems are seen every 6 months – Children’s eyes change rapidly and need reassessment – Frequent monitoring & counseling on compliance (if contact lens wearer) – Instill and reinforce good habits while patients are young 18

Contact Lens Compliance is Important at All Ages Contact lenses affect the tear film and ocular surface 5 Goal is to minimize that effect and maintain long-term ocular health in all patients Choice of contact lens solution is important Appropriate lens care is critical – Rub and rinse – Clean lens cases and replace them as instructed – Lens disposal at the correct interval – On follow-up use fluorescein stain to evaluate lens/solution compatibility 6,7 – Always use the latest technologies and lenses 19

Check for Ocular Surface Conditions in All Patients Ocular surface conditions are very common 2 Provide intervention before signs & symptoms become significant Explain the importance of ocular surface care, including the doctor’s examination – Annual or 6-month visits to check on condition of ocular surface – Have patients report symptoms when they occur – Record changes in ocular surface signs 20

Check for Ocular Surface Conditions in All Patients Understand that although ocular surface issues can affect vision, this is medical care, not vision care Communicate with patient’s primary care physician regarding chronic medical conditions (eg, Sjogren’s syndrome) 21

© 2014 Novartis To Maintain and Restore Wellness Look for and Treat Problems 22 Meibomian gland dysfunction Lagophthalmos Epithelial membrane basement dystrophy Conjunctivochalasis Aqueous-deficient dry eye Blink pattern deficiencies Keratitis Stem cell deficiency Tear film abnormalities

© 2014 Novartis Make Use of New Ocular Surface Diagnostic Technology New tests add useful information – Tear osmolarity – Tear MMP-9 level – Interferometry – Incomplete blink – Gland expression – Sjogren’s antibody testing – Topography – Meibography Enable detection of early-stage disease processes and monitoring of the tear film 23

© 2014 Novartis Treatment Modalities Punctal occlusion Pharmaceuticals (including oral meds) Thermal pulsation/meibomian gland expression Lid hygiene Antibiotics/anti-inflammatories Lipid enhancing and mucomimetic tears 24

© 2014 Novartis Contact Lenses and the Ocular Surface Develop a OSD protocol for your office as part of a comprehensive Contact lens evaluation Medical billing protocol for those with Ocular Surface issues Charge a separate fee for the OSD work up NEVER as part of the vision care managed care exam 25

© 2014 Novartis Contact Lenses and the Ocular Surface Ocular Wellness means understanding of preventive measures and the patients overall Ocular and systemic Health GP lenses are considered the safest lens modality There is an inherent responsibility to ensure long term eye and corneal health There is also a responsibility to create the best Vision possible for our patients 26

Contact Lenses and the Ocular Surface: Challenges Staining Corneal Conjunctival drying/ goblet cell destruction 3 and 9 desication ( nasal temporal) Limbal changes topographical changes Lid abnormalities GPC deposits warped lenses 27

GP Lenses and the Ocular Surface Scleral Lenses These modalities create their own challenges and complications Replacement schedules Debri Long term effects on the cornea, Limbus, and Conjunctiva Clearance 28

© 2014 Novartis GP Lenses and the Ocular Surface 3 and 9 staining 10 years ago OK Wellness : Corneal Desiccation is not an acceptable clinical finding What are you going to do 29

© 2014 Novartis GP Lenses and the Ocular Surface Why would anyone wear a GP lenses longer than one year? Structure changes Deposits Scratches What about 6 months 30

© 2014 Novartis Contact Lenses and Vision Multifocals VS Monovision New materials: change yearly Over refractions : every visit :.25 diopter Toric and bitoric designs 31

© 2014 Novartis Involve the Entire Office Success with OSW in the practice requires buy-in from the entire staff Staff buy-in to OSW efforts requires ongoing staff education so they understand: – Types of ocular surface conditions – Ocular surface treatments – Importance of treating ocular surface conditions – Importance of proactive history taking by technicians 32

© 2014 Novartis Advise patients about medications that can cause ocular surface drying Consider diet and potential value of dietary supplements During computer use: – take breaks to rest eyes – blink often – use artificial tears Wear glasses or sunglasses outdoors Look at environment for dryness triggers—eg, sitting all day by an air vent Prescreening with OSDI in reception area before examination Comprehensive pediatric evaluations Prevention Steps 33

Practice Impacts of Preventive Care Additional staff training creates a more skilled staff Staff pride: Staff feels elevated by working in an integrated health care model Increased referrals by patients who appreciate comprehensive approach to health care Greater patient acceptance of lens replacement schedules Increased referrals from primary care physicians as a result of open communications 34

© 2014 Novartis The Future The profession must commit to wellness and providing medical eye care Industry and ECPs must jointly commit to public education about ocular wellness The public needs to hear: “See your eye doctor yearly for wellness!” 35

* Alcon provided sponsorship for a Summit planning meeting and publication * Best Practices in Dry Eye Patient Management Bloomenstein Draft

37 Screening, diagnosing, and treating early signs of dry eye is a relatively new thought process − Most ODs wait for a symptom or significant corneal involvement − Not thinking proactively The multifactorial nature of the disease creates confusion and different interpretations Is a consensus a best practice? Can there be only one? What Is a Best Practice?

38 Is it one that catches the majority of persons with the disease? One that makes it easy for providers to diagnose the disease? One that makes treatment easy and effective? − For the provider? − For the patient? − For both? Should a best practice be one that solves all the problems above? − Simplicity! What Is a Best Practice?

39 LWE OPI TBUT TFOS DED OSDI Ferning MGD CCh − We have made things worse! Not easier! WTF Breaking the Cycle of White Noise

40 AOA Guidelines (2002) Delphi Panel (2006) The Dry Eye Workshop (2007) OD Canadian Consensus (2014) Published Attempts at Best Practices

A Lot Has Changed Since The Last Protocol…

42 Technology Innovations: 2002–2005 Facebook Palm Treo PDABlackBerry

43 New Dry Eye Treatments and Diagnostic Tools: 2002–2005 Meibography

44 Care of the Patient With Dry Eye (AOA Quick Reference Guide). St. Louis, MO: American Optometric Association; : AOA Optometric Clinical Practice Guideline on Care of the Patient With Ocular Surface Disorders

45 Care of the Patient with Dry Eye (AOA Quick Reference Guide). St. Louis, MO: American Optometric Association; Care of the Patient With Dry Eye (AOA Quick Reference Guide). St. Louis, MO: American Optometric Association; AOA 2003: Symptoms List Common Signs, Symptoms, and Complications of Dry Eye ConditionSymptomsSignsComplications Mild Scratchiness, burning, or stinging Mild blurring of vision Decreased tear volume, scanty lower lid tear meniscus Rapid tear film breakup time Debris in tear film Reduced contact lens tolerance Irritation-induced reflex tearing Moderate Marked ocular discomfort Reduced vision All of the above, and: tear film instability Subtle corneal superficial punctate staining Conjunctival staining Reduced antibacterial function of tear film Superficial punctate keratopathy Severe Severe irritation, burning Significantly blurred vision All of the above, and: Mucous strands, filaments, furrows, dellen, staining, or erosion of cornea Lack of corneal luster Hyperemia of conjunctiva Increased viscosity of preocular tear film (POTF) Superficial punctate keratopathy Filamentary keratitis Secondary lid infections

46 Care of the Patient With Dry Eye (AOA Quick Reference Guide). St. Louis, MO: American Optometric Association; AOA 2003: Evaluation and Management Frequency and Composition of Evaluation and Management Visits for Dry Eye Degree of Involvement Frequency of Evaluation History External Evaluation and Slit Lamp Biomicroscopy Supplemental TestingManagement Plan Mild Annually or as necessary Yes Fluorescein staining, Rose Bengal staining, BUT Preserved or unpreserved tear supplement p.r.n. Patient counseling and education Moderate Every 6–12 months or as necessary Yes Fluorescein staining, Rose Bengal staining, BUT, Schirmer test Unpreserved tear supplements 4–5 times a day up to p.r.n. Patient counseling and education Severe Every 3–6 months or as necessary Yes Fluorescein staining, Rose Bengal staining, BUT, Schirmer test Unpreserved tear supplements p.r.n., ointment h.s. Punctal occlusion Patient counseling and education Associated with systemic disease Every 1–6 months or as necessary Yes Fluorescein staining, Rose Bengal staining, BUT, Schirmer test Unpreserved tear supplements p.r.n., ointment h.s. Punctal occlusion Refer to primary physician Patient counseling and education

47 What happened? − Were the protocols too simple? Why was this not adopted? − Who failed? The AOA? The “experts”? The AOA protocol, in 2003, did not change behavior! − Let’s not make the same mistake AOA Had It Going in the Right Direction…

48 Technology Innovations: 2006–2007 Nintendo Wii Fingerprint Reading Technology Human Genome Project codes last gene sequence iPhone

49 New Dry Eye Treatments: 2006–2007

50 Behrens A et al. Cornea. 2006;25: preselected international dry eye specialists 2-round Delphi panel approach Used a 2/3 majority for consensus building on the responses Treatment algorithms were calculated as the primary endpoint − Treatment recommendations for different types and severity levels of dry eye disease New terminology − Dysfunctional tear syndrome (DTS) 2006: Dysfunctional Tear Syndrome: A Delphi Approach to Treatment Recommendations (Delphi)

51 Behrens A et al. Cornea. 2006;25: Level 1 − Mild to moderate symptoms, no signs − Mild to moderate conjunctival signs Level 2 − Moderate to severe symptoms − Tear film signs − Mild corneal punctate staining − Conjunctival staining − Visual signs Levels of Severity Without Lid Margin Disease (Delphi)

52 Behrens A et al. Cornea. 2006;25: Level 3 − Severe symptoms − Marked corneal punctate staining − Central corneal staining − Filamentary keratitis Level 4 − Severe symptoms − Severe corneal staining, erosions − Conjunctival scarring Levels of Severity Without Lid Margin Disease ( cont’d )

53 a With clinically evident inflammation. Behrens A et al. Cornea. 2006;25: Treatment (Delphi) Level 1 Education and environment modification Preserved artificial tears Allergy control Level 2 Unpreserved tears/Gel ointment at night Steroids/Cyclosporine A/Secretagogues/Nutritional supplements a Level 3 Tetracyclines Autologous serum Punctal plugs Level 4 Contact lenses Acetylcysteine Moisture goggles Surgery

54 More detailed treatment Cherry-picking screening tools and treatment − TOO TIME CONSUMING − DIFFICULT TO DIFFERENTIATE − NOT ADOPTED BY ALL EXPERTS NO BEHAVIOR CHANGES! Delphi Recommendations

55 International Dry Eye WorkShop Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5: The Management and Therapy Subcommittee of the International Dry Eye WorkShop (DEWS) Reviewed the Delphi Panel approach to the treatment of dry eye disease and suggested some modifications The DEWS treatment recommendations are stratified according to the severity of the disease 2007 Report of the International Dry Eye WorkShop (DEWS)

56 International Dry Eye WorkShop Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5: “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” Dry Eye Defined (DEWS)

57 International Dry Eye WorkShop Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5: Cycle of Ocular Surface Inflammation (DEWS) Dry eye Altered tear film stability and composition Dysfunction of lacrimal functional unit Inflammation and apoptosis on ocular surface

58 Etiopathogenesis of Dry Eye Disease (DEWS) Altered lipid, aqueous, protein, and mucin distribution Increase cytokine production T-cell activation Matrix metalloproteinases ApoptosisDiscomfort Tear film instability Dry eye disease Altered tear compositionOcular surface inflammation LFU dysfunction LFU, lacrimal function unit. International Dry Eye WorkShop Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5:

59 Diagnosis of Dry Eye Disease (DEWS) The DEWS Dry Eye Diagnosis Grid* (modified from The Ocular Surface 2007 ) Dry Eye Severity Level1234 Discomfort, severity, and frequency Mild/Episodic environmental stress Moderate/Episodic/Chronic environmental stress or no stress Severe/Frequent/ Constant without stress Severe and disabling, constant Visual symptoms None or episodic mild fatigue Annoying and/or activity- limiting episodic Annoying, chronic, and/or constant limiting activity Constant and/or possibly disabling Lid/meibomian glands MGD variably present FrequentTrichiasis, keratinization, symblepharon TFBUT (sec) Variable≤10≤5Immediate Corneal staining (NEI Scale 0–15) None to mildVariableCentralSevere punctate erosions Conjunctival staining (NEI Scale 0–18) None to mildVariableModerate to markedMarked Schirmer test (no anesthesia) (mm/5 min) Variable≤10≤5≤2 Recommended management Patient education, diet modification and lid therapy, artificial tear/ gel supplements, environmental control Add anti-inflammatories, tetracyclines, punctal plugs, moisture chamber spectacles Add autologous serum, bandage or large- diameter rigid contact lenses, permanent punctal occlusion Add systemic anti- inflammatory agents, surgical intervention *The order of the tests represents a common dry eye exam sequence. Recommended management is listed below each grade. International Dry Eye WorkShop Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5:

60 Severity Level1234 Symptoms Mild to moderateModerate to severeSevere Conjunctival Signs Mild to moderateStaining Scarring Corneal Staining Mild punctate staining Marked punctate staining; central staining; filamentary keratitis Severe staining; corneal erosions Other Signs Tear film; vision (blurring) Treatment Options Patient education Environmental modification Preserved tears Control allergy Unpreserved tears Gels, ointments Topical prescription therapies Secretagogues Nutritional support Oral tetracyclines Punctal plugs (once inflammation is controlled) Systemic anti- inflammatory therapy Oral cyclosporine Acetylcysteine Moisture goggles Surgery (punctal cautery) If no improvement, add level-2 treatments If no improvement, add level 1-3 treatments If no improvement, add level-4 treatments Meibomian gland disease treatment options: lid hygiene, thermomassage, oral tetracyclines. International Task Force (ITF) Dry Eye Treatment Recommendations 1. Behrens et al. Cornea

61 a Treatments in bold are DEWS modifications. In general, DEWS recommends more aggressive treatments at lower severity levels than did ITF. International Dry Eye WorkShop Report of the International Dry Eye WorkShop (DEWS). Ocul Surf. 2007;5: Dry Eye Workshop (DEWS) Treatment Guidelines Build Upon the ITF Recommendations 1. Management and Therapy Subcommittee of the International Dry Eye Severity Level1234 Treatment a Patient education Environmental and dietary modifications Eliminate offending systemic medications Artificial tears, gels/ointments Eyelid therapy Anti-inflammatories Oral tetracyclines Punctal plugs Secretagogues Moisture chamber spectacles Serum Contact lenses Permanent punctal occlusion Systemic anti- inflammatory therapy Surgery (lid surgery, tarsorrhaphy; mucous membrane, salivary gland, amniotic membrane transplantation ) If no improvement, add level-2 treatments If no improvement, add level 1-3 treatments If no improvement, add level-4 treatments

62 Where is the widespread acceptance? Which of us is adhering to these protocols? Telling our colleagues to adhere to this? NO CHANGE IN BEHAVIOR…AGAIN! DEWS

63

64 Technology Innovations: 2008–2014 Tesla Roadster iPad CERNS Hadron Collider HTC Dream (1 st Android Phone)

65 New Dry Eye Treatments and Diagnostic Tools: 2008–2014 MiBoFlo

Solution for Early Diabetes Detection More Appeal than Blood Draw Non-Invasive 6 Seconds Immediate Results Diabetes & Eye-Care 100M eye exams in US annually Diabetes = changing vision Medical model of optometry Can Avoid Complications Can identify diabetes 7 years prior to complications Disclaimer: For investor use only ClearPath DS-120 is the only FDA- cleared non- invasive diabetes detection system available for sale in the United States. The only other way is invasive blood draw.

67 National Dry Eye DISEASE Guidelines for Canadian Optometrists Canadian Journal of Optometry Revue Canadienne d’Optométrie Vol. 76, Suppl ISSN

68 CASE HISTORY including 4 specific questions 1. Do your eyes feel uncomfortable? 2. Do you have watery eyes? 3. Does your vision fluctuate, especially in a dry environment? 4. Do you use eye drops? Canadian Dry Eye Consensus Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Can J Optom. 2014;76(Suppl. 1):1-32.

69 Canadian Dry Eye Consensus TypeManagement Episodic Tear supplements/ lubricants Consider composition of available agents (lipid-based, products that restore the mucin layer, overall) Ocular Hot compresses, lid hygiene, moisture chamber glasses, modifications to CL wear (switch to daily disposables) Non-ocular considerations Environmental (ambient humidity, air movement, computer use), systemic medications and supplements, alcohol, smoking, hormonal status, sleep apnea Chronic Episodic management + Short-termTopical corticosteroid Long-term Topical cyclosporine Essential fatty acids Supportive Oral tetracycline/macrolide, lacrimal occlusion, meibomian gland expression (in-office), sleep mask/lid taping Recalcitrant Ocular Scleral lenses, filament removal, autologous serum eye drops, amniotic membranes, tarsorrhaphy, other surgical techniques SystemicSecretagogue, systemic immunosuppressive therapies Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Can J Optom. 2014;76(Suppl. 1):1-32.

70 Canadian Dry Eye Consensus Canadian Association of Optometrists. National Dry Eye Disease Guidelines for Canadian Optometrists. Can J Optom. 2014;76(Suppl. 1):1-32.

* Alcon provided sponsorship for a Summit planning meeting and publication * Improving the Screening, Diagnosis, and Management of Dry Eye Disease

72 Current guidelines (eg, DEWS, AOA) are perceived as being too complex or inaccessible Limited awareness of guidelines Recommendations from “the experts” are not being incorporated into everyday practice by community ECPs for multiple reasons Need to SIMPLIFY by setting minimum recommendations that all ECPs can commit to Why Do We Need Recommendations for Dry Eye Disease?

73 Discussed clinical data on dry eye disease and the role of ocular surface wellness Identified current gaps in management through survey sent to “experts” and >1000 ECPs 1.5-day discussion and debate (ECPs and industry) on best practices for screening, diagnosing, and managing dry dye disease Used interactive polling system to establish consensus (minimum 2/3 agreement needed) The Dry Eye Summit 2014: How Did We Develop Recommendations?

74 Experts are much more likely to recommend treatment for dry eye disease. Identifying Gaps in Care: “Expert” vs Community ECP Practices For What Percentage of Your Dry Eye Disease Patients Do You Recommend Any Treatment?

75 Disease − Diabetes − Allergies Contact lens wear Medications − Antihistamines/Decongestants Age Digital device use − Cell phones − Tablets − Computers Know the Risk Factors

76 1. Do you think your eyes look healthy ? 2. Do your eyes feel healthy ? 3. Are there times when your vision is not as clear as you want it to be? 4. Do your eyes ever feel dry or uncomfortable ? Consensus on Screening Questions

77 1. Detailed patient history 2. Staining 3. Osmolarity levels Consensus on Baseline Diagnostic Options for Entry Level Dry Eye Disease

78 1. For all patients: A. Ocular lubrication B. Lid hygiene C. Nutrition 2. Topical anti-inflammatories Consensus on Baseline Management