Dry eye

Dr. Anumeha

Defination
Dry eye syndrome is a clinical condition characterized by deficient tear production or excessive tear evaporation Multifactorial disease of the tears and the ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface.

Classification: Based on pathophysiology of tear film 1. Aqueous tear deficiency( ATD) a. Senile or idiopathic atrophy of lacrimal gland b. Menopause c. Hypofunction of lacrimal gland associated with autoimmune diseases like Sjogrens Syndrome,KCS 2 Lacrimal Surfactant( Mucin ) deficiency a. Trauma to conjunctiva b. Vitamin A deficiency c. Conjunctival infections : trachoma, diphtheria d. Pempigoid, erythema, Stevens Johnsons Syndrome e. Chemical, thermal, radiation injury f. Drug induced : sulpha, epinephrine

 3.Lipid Layer Abnormality : a. Chronic Blepharitis b. Acne rosaecea 4 Impaired Lid Function or Blinking Neuropralytic lesions of Trigeminal, Facial, Greater Superficial Petrosal Nerve etc. 5 Epitheliopathy Disease of corneal epithelium 6. Other Causes a. Drugs b. VDTS : Visual Display Terminal Syndrome, Computer vision syndrome c. Contact Lenses

 Causes of Decreased Corneal Sensation Neurotrophic keratitis (damage to the fifth nerve)Corneal surgery Limbal incisions Penetrating keratoplasty Lamellar keratoplasty Radial keratotomy Excimer laser surgery Herpes simplexTopical medications b-Blockers Atropine DiabetesContact lens wearAging

Hyposecretive causes (KCS) 1. Sjgren syndrome: Primary - no associated connective tissue disease Secondary - associated connective tissue disease (e.g. rheumatoid arthritis) 2. Non Sjgren syndrome: Age-related Hormonal (including oral contraceptives) Drugs (e.g. anti-histamines) Vitamin A deficiency Infiltrative process (e.g. lymphoma) Neurological lesions (e.g. Riley-Day syndrome) Absence / abnormality of lacrimal gland / ductules Idiopathic

Evaporative causes Deficiency of oily component of tear film (e.g. meibomian gland dysfunction) Defective corneal resurfacing (e.g. lid malaposition) Blink disorders Contact lens wear

Symptoms: Irritation Redness Burning/ Stinging Itchy eyes Sandy- gritty feeling (foreign body sensation) Blurred vision Tearing Contact lens intolerance. Increased frequency of blinking Mucous discharge. Photophobia (less frequent symptom)
Symptoms worsen in windy or air-conditioned environments. As day progresses. After prolonged reading, working on computers

Signs Non-corneal signs:decreased meniscus and a reduced tear break-up time mucous discharge and strands of mucin on the corneal surface. Corneal signs: signs of keratopathy, punctate epithelial erosions, filament and plaque depositions.When severe, frank ulceration, leading to perforation, can occur.predisposition to bacterial infections.

Diagnosis:
HISTORY Character. sandy-gritty feeling, burning, foreign body sensation, or increased awareness of the eyes, eyes itch Location. Irritation on the surface of the eye, in the eye, on the lid margin, or on the skin Diurnal variation. Onset. start suddenly, or develop gradually? episodes or continuous problem Duration. How long have the symptoms been present? Aggravating factors. Is there anything that makes the symptoms worsewind, smoke, low humidity (i.e., airplane cabins), reading, watching TV, contact lens wear, artificial tears? Alleviating factors. Is there anything that makes the symptoms betterhot compresses, eye closure, high humidity, artificial tears?

Tear break-up time: A tear break-up time of less than 10 seconds suggests a dry eye. Schirmer test: Measure the amount of wetting after 5 minutes: 13-15mm normal 6-10mm borderline < 6mm indicates dry eye.

 Rose Bengal Stain. Rose Bengal (solution 1 % or strip) stains the damaged devitalized epithelial cells of the conjunctiva and cornea. It can detect even mild cases of Keratoconjunctivis Sicca (KCS) by staining the palpabral conjunctiva in the form of two triangles with their base towards limbus. Rose Bengal gives stinging sensations but anesthetic drug should not be used as it may give false results.

Rose bengal staining typical for moderate KCS. The conjunctiva stains more than the cornea, and the nasal conjunctiva stains more than the temporal conjunctiva

Rose bengal staining in early, moderate, and late keratoconjunctivitis sicca

Rose bengal staining in early, moderate, and late meibomitis and meibomian gland dysfunction

Laboratory Studies Conjunctival impression cytology can be used to monitor the progression of ocular surface changes. Serology for circulating autoantibodies, including ANA or SS antibodies (ie, SS-A, SS-B), anti-Ro, anti-La, anti-M3 receptor, and anti-fodrin, as well as ANCA and RhF, may be indicated.

Others a. Tear Function Index (TFI) test. It is a more specific and sensitive test to quantitatively measure the tears. The higher the value of TFI, the better the ocular surface. Values below 96 suggest dry eyes. b. Fluophotometery. measure tear secretions. It uses decay of sodium fluorescein to measure the tear flow and the tear volume. This test is costly and not very informative. c. Tear Osmolarity. It provides qualitative assessment of tear formation. The reference value is 312 mosm/L. This value increases with the severity of the dry eye. d. The tear ferning test (TFT) can be used to help diagnose the quality of tears (electrolyte concentration),

Differential diagnosis Blepharitis Blocked nasolacrimal duct Floppy eyelid syndrome

Treatment aims Ease discomfort Protect and preserve the cornea Treat any underlying conditions Treatment recommendations are based on disease severity

Ophthalmic agents and lubricants 1) HPMC ,CMC,PVA glycerine artificial tear 2) White petrolatum, castor oil, hydroxypropyl-guar, mineral oil 3) Ocular inserts:Hydroxypropyl cellulose (Lacrisert):Acts to stabilize and thicken precorneal tear film
and to prolong tear film breakup time

4) Mucolytic agents: 10% N-acetylcysteine drops

(Mucomyst

5) Immunomodulators: Cyclosporine 6) Autologous serum eye drops: Autologous serum (20%) and umbilical cord serum (20%) eye drops 7) Dietary supplements:Omega-3 fatty acid

Surgical Management Canalicular Obstruction by Punctal Plugs Canalicular Obstruction by cautry Punctal Patch Technique: This is most efficacious surgical technique for long lasting occlusion of the lacrimal drainage system Lid surgery Tarsorrhaphy Mucous membrane grafting Salivary gland duct transposition Amniotic membrane transplantation

Punctal plug

 Level 1
Education and environmental/dietary modifications Elimination of offending systemic medications Preserved artificial tear substitutes, gels, and ointments Eyelid therapy

Level 2 If level 1 treatment is inadequate, add the following:

Nonpreserved artificial tear substitutes Anti-inflammatory agents
Topical corticosteroids Topical cyclosporine A Topical/systemic omega-3 fatty acids

Tetracyclines (for meibomianitis, rosacea) Punctal plugs (after control of inflammation) Secretagogues: Diquafoso Moisture chamber spectacles

 Level 3 - If level 2 treatment is inadequate, add the following:

Autologous serum, umbilical cord serum Contact lenses Permanent punctal occlusion

Level 4 If level 3 treatment is inadequate, add the following:

Systemic anti-inflammatory agents Surgery
Lid surgery Tarsorrhaphy Mucous membrane grafting Salivary gland duct transposition Amniotic membrane transplantation