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Dr. Zia.ul.Mazhry
FRCS(Edin), FRCS(Glasgow),
Assistant Professor Central Park medical college Lahore Consultant Surgeon & Head of Ophthalmology Department WAPDA Teaching Hospital Complex Lahore
Ocular Surface-Overview
http://www.virtualcancercentre.com
Conception
Corneal epithelium Conjunctival epithelium Tear film Clinical ocular surface consist of conjunctiva cornea eyelids lacrimal gland lacrimal passages
Origin of Epithelium
Stem cells, SC
Corneal epithelium derived from the Limbal stem cells. Conjunctival epithelium derived from forniceal and palpebral regions.
Aqueous Insufficiency
Inflammation CTDs, Sjogrens Trauma, neurological, congenital
Mucin Abnormalities
Stevens-Johnson, pemphigoid, radiation, vitamin A deficiency, trachoma
Hormonal changes
menopause, oral contraceptives, pregnancy, lactation
Medications
antidepressants, decongestants, antihistamines, antihypertensives, diuretics
Environmental
smoke, air pollution, wind, heat/AC, VDT, light, dry climate, air travel
Blink disorder
anatomical, surgical (LASIK)
Irritation
Inflammation
Ocular Surface
Mechanical
ATD
Blepharospasm
Blepharitis
Toxic
Allergic
1o OSD
Conjunctivochals is Dermatochalasis
Although, percent of individuals who experience signs and symptoms of dry eye at one time or another due to environmental factors = 100%
Prause JU, Norn M. Relation Between Blink Frequency and Break-Up Time. Acta Ophthalmol. 1983 61: 108-116. Cho P, Cheung P, Leung K, Ma V, Lee V. Effect of Reading on Non-Invasive Tear Break-Up Time and Inter-Blink Interval. Clin. Exp. Optom. 1997 80: 62-8. Tsubota K, Seiichiro H, Okusawa Y, Egami F, Ohtsuki T, Nakamori K. Quantitative Videographic Analysis of Blinking in Normal Subjects and Patients with Dry Eye. Arch. Ophthalmol. 1996 114(6): 715-720. Nally L, Ousler GW, Abelson MB. Ocular discomfort and tear film break-up time in dry eye patients: a correlation. IOVS 2000 41(4): 1436. Collins M, Seeto R, Campbell L, Ross M. Blinking and Corneal Sensitivity. Acta Ophthalmologica 1989 67(5): 525-531. Abelson MB, Holly FJ. A tentative mechanism for inferior punctate keratopathy. Am. J. Ophthalmol. 1977 83: 866-869. Doane MG. Dynamics of the Human Blink. Ber. Disch. Ophthalmol. Ges. 1980 77: 13-17. Kaneko K, Sakamoto K. Spontaneous Blinks as a Criterion of Visual Fatigue During Prolonged Work on Visual Display Terminals. Perceptual and Motor Skills 2001 92(1): 234-250..
1977 - <8g
1997 30-40g
Altered lifestyle
PATIENT SYMPTOMS
Dryness Itchiness or scratchiness Photophobia Contact lens intolerance Burning or stinging Foreign body sensation Grittiness Fluctuating visual acuity Tired eyes General discomfort
CLINICAL SIGNS
Hyperemia Low tear meniscus Tear debris Abnormal tear osmolarity Fast tear break up time Conjunctival staining Blepharitis Increased cytokines Corneal surface damage
Symptoms
May be confusing (i.e. reduced VA)
Clinical history
Critical for the diagnosis! Helps pinpoint the cause and the effect
Clinical tests
Vision
Fluctuation Blurring
Artificial Tears
Frequency of Use
Discomfort
Stinging Burning Painful
less than or equal to 5 mm wetting over 5 minutes Tear Breakup time less than or equal to 10seconds Tear Meniscus height less than or equal to 0.2 mm Fluorescein staining more than 3 out of 15 Rose Bengal staining more than 3 out of 18 Tear film osmolarity more than 316 mOsm/L Impression cytology more than 1 Brush cytology more than 1 Tear lactoferrin less than or equal to 0.9 ug/mL
Schirmer Test
Normal 10mm/5min
Staining
Using special dyes to highlight areas of possible damage to the eye surface.
S T C I
OD
S N N C I
OS
18 Points Possible
Symptoms Less Morning Dryness Less End of Day Dryness Eyes Felt Refreshed Longer Less Frequent Foreign Body Sensation
Pseudo-Dry Eye Dry eye symptoms in contact lens wearers that are not due to a true dry eye state
Injection
Fluorescein Staining
Blink Rate
Flourophotometry
Osmolarity
Which dry eye diagnostic tools are you using currently and in which order?
thorough slit-lamp examination Uneven or scanty tear meniscus Vital staining Tear film break-up time Schirmer lacrimation test Lack of goblet cells The lid functioning, Mucous shreds and strings Lid parallel folds
Blepharitis
Lid Swelling, vasodilation of lid margin, lid thickening, lid notches, loss of lashes, blurring of vision, mucous discharge, and crusts
Toxic reaction due to antibiotics, antivirals, sympathomimetics, miotics, beta-blockers, topical anesthetics, etc. with no underlying immune dysfunction Persistent burning and feeling of grittiness in the eyes, inflamed and swollen eyelids with small inflamed bumps, bloodshot eyes. Pain and photophobia may be present. It is instructive to ask rosacea patients how their eyes react to bright sunlight
Many patients after cataract surgery tell us they () are having real problems with dry eye syndrome
Juan Duran De la Colina; EuroTimes, dec 2005
Cataract surgery
Clear cornea incision
How to Treat
Ask for symptoms Determine the primary source of symptoms Avoid drying situations and drugs Local therapy is preferred No toxic preservatives Do not hurt Use the agent most effective and safe Combinations Depending on severity Time: no cure but usually mild
Severity Level
Level 1: Mild to moderate symptoms; mild to moderate conjunctival signs; no staining Level 2: Moderate to severe symptoms; tear film signs; visual signs; mild corneal punctate staining; conjunctival staining Level 3: Severe symptoms; corneal filamentary keratitis; marked corneal punctate staining; central corneal staining Level 4: Extremely severe symptoms/altered lifestyle; conjunctival scarring; corneal Making erosions; severe corneal Dry Eyes Wet staining
Principles of treatment
Treat the Symptoms Treat the Cause Treat the complications
Level Two
Unpreserved tears Gels and nighttime ointments Nutritional support Cyclosporine Topical steroids Secretagogues
Level Four
Systemic antiinflammatory therapy Acetylcysteine Moisture goggles Punctal cautery
Ph Value around 7
Thixotropy The property of becoming fluid when shaken and then becoming semisolid again Preservatives/preservative free/disappearing BAK, Polyquad Gen Aqua Sodium Perborate
Patient satisfaction
NO
A tear drop
Requirements
Minimal Blurring
SYSTANE
Demulcents
HP-Guar
Large gel-forming polysaccharide
Essential Ions (K, Ca, Mg, Na, Zinc) At pH 7.0 it is fluid in the bottle but in the eye @ ~7.5 7.8
Forms chemical x-links w/ borate Soft gel forming matrix Bioadhesive properties Very lubricous
Mechanism of Action
Systane - Preservative
Polyquaternium-1 (Polyquad) Quaternary ammonium Used in contact lens care solutions Less corneal damage Corneal uptake of carboxyfluorescein:
BAK: 9-99 fold increase Polyquad: 0-4 fold increase
7.1
7.2
7.3
7.4
7.5
7.6
7.7
pH of Tear Film
10.000
pH 7.4
VISCOSITY, cp x10-3
pH 7.8
1.000
0.100
0.010
Thinner
SHEAR STRESS, Pa
Systane effects:
in-eye gelling effect adjust pH tear creates an ocular shield decrease the evaporation on tear film increase the stability of tear film allow the epithelial repair in a healthy environment
What Is Restasis?
Ophthalmic emulsion of cyclosporine 0.05%.
Prescription therapy for dry eye disease. Restasis is FDA approved to increase tear production in patients whose tear production may be reduced by inflammation of the eye associated with keratoconjunctivitis sicca.
Acceptability Summary
Question My eyes feel dry in the morning. My eyes feel dry at the end of the day. My eyes feel comfortable upon instillation of drops. My eyes feel refreshed when I use the drops. My eyes feel refreshed longer than expected when I use the drops. I frequently forgot my symptoms during the use of the drops. Delta % Change -0.8* 19% -0.9* +0.5* +0.6* 22% 13% 17%
+0.8*
+0.7*
28%
26%
* p<0.0001
Message
Subjective Symptoms and objective signs are both important in the diagnosis and management of dry eye, with the patients symptoms and history playing a critical role. Most clinicians use objective signs in dry eye management. However, currently available diagnostic tests do not correlate reliably with symptom severity. Research aimed at developing accurate, objective, responsive measures of dry eye severity is needed.
Smith, Nichols, and Baldwin, 2008
THANK YOU!