Ocular Surface Diseases

The Fourth Affiliated Hospital of CMU Eye Centre

Overview

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Roles and Characteristics of the eyelids

Eye protection Regular blink: protection and stability of the tear film Rich of glands

Adequate blood supply

No venous valve

Conception
Corneal epithelium Conjunctival epithelium Tear film Clinical ocular surface consist of conjunctiva cornea eyelids lacrimal gland lacrimal passages

Tear and the Tear Film

Function :
1.Cleaning 2.Wetting ocular surface 3.Bacteriostasis 4.Supporting the cornea (oxygen supply)

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Origin of Epithelium
Stem cells, SC
Corneal epithelium derived from the Limbal stem cells. Conjunctival epithelium derived from forniceal and palpebral regions.

Ocular Surface Disease

Conception
The ocular surface is a complex biological continuum responsible for the maintenance of corneal clarity, elaboration of a stable tear film for clear vision, as well as protection of the eye against microbial and mechanical insults. Comprising a variety of disorders on cornea, eyelid, conjunctiva, lacrimal apparatus and tear film.

Classification
Corneal, conjunctival lesion
Squamous epithelization type Limbal stem cell deficiency type

Tear film disorders

Aqueous tear deficiency Lipid tear deficiency Mucoprotein deficiency Kinetic disorders of lacrimal fluid

Treatment
Reconstruction
Epithelium, limbal stem cells Lacrimal secretion, tear film Innervation (nerve restore)

Structure and function of eyelid

Surgical operation
To re-establish conjunctiva, cornea, tear film and eyelid.

Dry Eye
Healthy tear film

Dry eye

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Conception
Dry eye (known by doctors as keratoconjunctivitis sicca) is a chronic lack of sufficient lubrication and moisture in the eye. Its consequences range from subtle but constant irritation to ocular inflammation of the anterior (front) tissues of the eye.

Tear Secretion
Lacrimal gland
Producing the watery part of the tear film called the aqueous.

Meibomian glands
Producing lipids which keep the tear film from evaporating.

Goblet cells of the conjunctiva

Producing mucin which allows the wetting of the ocular surface as well as stabilizes the tear film.

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Etiological factor & Classification

Aqueous tear deficiency Lipid tear deficiency Mucoprotein deficiency

Kinetic disorders of lacrimal fluid

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Clinical Manifestation
Dry eye symptoms
asthenopia
irritation, grittiness

dryness burning ophthalmalgia

light sensitivity

pink-eye Do you regularly experience one or several symptoms above?

Some diseases and conditions (like rheumatoid arthritis, lupus and Sjgrens Syndrome) also cause chronic Dry Eye in many patients.
On the other hand, activities like reading, Wearing contact lenses or working at the computer may cause Dry Eye.

Diagnostic Tests for Dry Eye

Dry Eye questionnaire

Lacrimal river width Schirmer test uses paper strips under eyelid to measure the wetness that collects over a specific period of time. Break-up time of tear film (BUT) Staining uses special dyes to highlight areas of possible damage to the eye surface.
Tear ferning test Lactoferrin contents Tear penetration pressure test Corneal tonographic map Impression cytology

Diagnosing
Schirmer test, BUT, Staining Foundation
Symptom Instability of tear film Damage on epithelium Tear penetration pressure increasing

Treatment
According to the clinical category For tear deficiency: Maintain moisture in the eyes;
reducing the evaporation; increasing the secretion; controlling inflammation & immunoreaction.

For over-evaporation: Therapy the Meibomian gland

dysfunction; controlling inflammation; cleaning eyelid; decreasing the evaporation; lipid replacement.

According to the eye conditions For intermittent symptoms: Artificial tears add volume to
the tear film as long as they remain in contact with the surface of the eye.

For midrange dry eye: Artificial tears and punctal

occlusion.

For Severe dry eye: Appending cyclosporin, surgery.

Summary
Eliminating the etiological factors Tears replacement therapy Maintain moisture in the eyes Increasing the tear secretion Immune inhibition therapy Re-establish the tear film Other supporting treatment

Meibomian Gland Dysfunction

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Etiological Factor
Failure of the glands to produce or secrete lipids. Wax ester declining and cholesterol increasing make the symptoms worse . Lack of tears and tear penetration pressure increasing. Lupus, brandy nose etc.

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Clinical Manifestation
Common in aged people and who lived in cold region.

No specific symptoms. Lid-margin mostly thickening; abnormal secretion while pressurizing. Disorder in Meibomian gland, eyelid, conjunctiva.

Figure: Notching of the lid caused by loss of meibomian glands.

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Diagnosing
Absence of Meibomian gland.

The gland orifices are often compromised due to stenosis or closure.

A declining quality and quantity of lipid secretion.

Anyone of the physical signs can make the diagnosis of Meibomian gland dysfunction if the patient has clinical symptoms.

Figure: No visible meibomian gland orifices: Eversion of the lower lids in both eyes showed atresic meibomian glands. http://www.ophmanagement.com

Treatment
Clearing
Hot fomentation on eyelids for 5~10mins. Massaging the eyelids.

Swabbing the lid-margin with mild cleaning solution.

Treatment
Antibiotics oral administration. Local Medication Antibiotic eye drops Glucocorticoid eye drops (short term) Artificial tears

The End

Lacrimal river width

Schirmer Test
Normal 10mm/5min

Tear break-up time, BUT

Staining
Using special dyes to highlight areas of possible damage to the eye surface.