Dr. Leukoma wrote:

[snip]

Very valid points, all, of course.

Wednesday was the f/u app't. One week sans cl's, no drops, no
fish/flax seed/cod liver supp's, no nightly ointments, etc. Cold
turkey. Won $ at Vegas, but it was a pyrrhic victory....

Doc sees virtually identical corneal and conjunctival staining, good
Schirmer's, 3s t-buts, despite rainy morning and absolutely -0- air
moving in the exam room. Assumes tbut must drop down to -0- with wind,
dry air, pollution, dust, etc.

Interferometry looks good. Meibography looks good. MGs seem to work
just fine.

He's still stumped re: serious instability of tear film. Doesn't see a
reason to try steroids or Restasis. Recommends I stay the course on
the palliative treatments and check back in six months. Hmm.

Still thinking about this. I'll surf around to see what Atropine
toxicity looks like. I'm also trying to understand more about BAK
toxicity. I've certainly found citations that explain what the
superficial damage from BAK looks like, but:

1) I've never seen anything that studies LONG-term use. Perhaps the
superficial problems DO self-repair. I'm curious whether there's
potential--over years--to decimate the healing mechanism;
2) Most of the studies use steroid or lubricant drops which likely have
a mild buffering effect;
3) The literature points to more frequent, more severe problems in
existing dry eye Pts, which, perhaps, I was;

Question: When you evaluate DES Pts over time, do you see differing
levels of staining, and in different parts of the cornea/conjunctiva?
In other words, is the staining static or variable? My staining--at
least in these first two visits--seems not to have changed at all;

I also talked with the doc about Hyaluronic Acid--a recommendation from
my ophthalmologist. I'm trying to score some in 3-4% concentration.
Not easy. Anybody have any experience with this alleged ambrosia??

TIA,

Neil

Neil Brooks wrote:

- quote -


More evidence, then, to reject the BAK hypothesis, since the effects
apparently were not cumulative.

- quote -


Epithelial cells are rapidly replaced. Besides, you apparently don't
have one of the hallmarks of BAK toxicity, which is SPK.

- quote -


The fact that you don't have accommodative paralysis does not mitigate
against atropine toxicity on a different level.

- quote -

Shouldn't have hurt, either.

DrG

LarryDoc <larrybic[at]yahoo.remove.com> wrote:

Dr. B-

I responded via e-mail last night, thinking I'd have left for a
weekend vacation by now ;-)

Thanks much. Good to have you dropping in again/still.
--
Live simply so that others may simply live

"Dr. Leukoma" <drg[at]leukoma.com> wrote:

- quote -

I'm equally eager to have it (rejected or) replaced as I am to have it
confirmed....

- quote -

(trying to run out of here, but...) I found another few cites last
evening that are intriguing:

1) The cationic detergent and quaternary ammonium compound
benzalkonium chloride (BAK) is especially damaging to the ocular
epithelium. BAK emulsifies the cell membrane lipids and breaks down
their intercellular junctions (Calonge). The use of preserved
artificial tears in patients with closed puncta causes increased
damage to the ocular surface due to the longer contact time (decreased
tear clearance) and undiluted preservative build-up. [1]

[during the vast majority of the time that I used BAK, I had either
full plugs or full cautery]

2) The most widely used preservative, benzalkonium chloride (BAC), is
retained within epithelial cell membranes for several days. High
concentrations of this cationic detergent lead to cell necrosis,
whereas concentrations as low as 0.0001% induce growth arrest and
apoptotic cell death. [2]

If the qd use of cycloplegics was /always/ last thing before bedtime
(because of the pain on instillation and how debilitated I was when
cycloplegia set in), then the drops--coupled with cautery--had no
place to go....

As my primary care ophthalmologist continually reminds me, "Your eyes
break all the rules."

- quote -

I'd welcome accommodative paralysis with open arms. In fact, my docs
continue to consider a monofocal IOL procedure /if/ we can control the
dry eye.

I'm trying to get in to see Dr. Pflugfelder. My concern at the moment
is some reasonably definitive diagnosis that will inform a narrowly
focused course of treatment. Throwing the kitchen sink at my eyes may
not have always helped me.

Thanks, as always, Dr. G.


[1] http://www.clsa.info/ContinuingEduca...2_article1.pdf
[2] http://www.iovs.org/cgi/content/full/42/5/948
--
Live simply so that others may simply live

Neil, I hate to say this, but I have to reject your hypothesis.

BAK is present in most topical eye medications, including drugs that
are used on a chronic basis for many years, such as glaucoma
medications. BAK cytotoxicity is dose-dependent. You were using the
atropine q.d. for a number of years, and never more than twice daily,
which is the same dosing as topical glaucoma medications. Yet, most
patients with glaucoma tolerate their medications fairly well. BAK got
a really bad rap with contact lens solutions because the chemical
became concentrated on the lens surface, exposing the cornea over a
much longer period. It also got a really bad rap when used as a
preservative in viscoelastic solutions used in cataract surgery due to
toxicity to the endothelial cells. Unlike the epithelium, endothelial
cells are not replaced.

It is possible that the cause of your dry eye is totally independent of
the BAK, and due to permanent anticholinergic effects. Long-term use
of atropine has been known to cause accommodative paralysis. It may be
the case that molecules of atropine are still sitting on the receptor
sites of some of the accessory tear glands.

DrG
http://www.coppellfamilyeyecare.com

Great post, as usual,Doc. I have read that Restasis is the first of 4
meds that are going through the FDA approval process for thw treatment
of dry eyes. When these meds hit the market I hope more of our
colleagues treat dry eye as a true pathology (which it is) and not just
a nuisance side effect of aging and allergy.

In article <110tv1d6fufo0vf4i1vpphuomjlq1umm4j[at]4ax.com> ,
Neil Brooks <Neil0502[at]yahoo.com> wrote:

- quote -

Were you off the BAK at the time of the Restasis trial? If so, then 6
months of Restasis pretty much addresses the issue of whether or not
that is an appropriate treatment, eh?

Did your research indicate permanent lacrimal system affects from BAK?
Permanent cornea nerve de-innervation? (How is your cornea sensitivity?
If the nerves don't connect to signal dryness, then the lacrimal system
wont repond.)

If not, then an attempt at anti-inflamatory/cyclosporin trial is
reasonable. One protocol many find effective is: one week of high
potency steroid, then second through tapering off by 6th week of low
potency/ dose steroid, Restasis beginning second week. The thinking is
of rapid anti-inflammatory response while waiting for the Restasis to
kick in.

Meanwhile, have a written report of your situation and hypothisis in
hand next time you're at the SCCO clinic and ask that the case be
presented to one of the profs there. There are two or three who are
pretty up on cornea/anterior segment disorders. Hey, maybe you'll make
the "Some Favorite Cases" segment in the continuing ed program next
weekend! I may even be there!

Best,
(but I actually mean it)

LB, O.D.

"doctor_my_eye[at]msn.com" <doctor_my_eye[at]msn.com> wrote:

- quote -

I gotcha. I'll talk with the doc about it next week.

I've been through two restasis trials in the past, though--six months
each time--with no clear improvement. Maybe things are different this
time.

Thanks again....
--
Live simply so that others may simply live

Damn, I can't spell on the fly. That was cyclosporine.

You do not have to show the signs of in inflammatory process to benefit
from Restasis. As a matter of fact, the literature from Allergan from
their clinical investigations show that they simply don't know what the
"true" mechanism of action of cytosporine. You should run a 30 day
trial of Restasis twice daily and wait for your body's subjective
response.