Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Ophthalmology PPT 4 Dry Eye Lecture Notes
Dry Eye
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Learning Objectives
At the end of this class the students shall be able to :
?Define dry eye disease.
? Understand predisposing and aetiological factors
responsible for dry eye disease
? Comprehend clinical features and tests for the above
condition
? Understand fundamentals of managing dry eye
depending on the severity of disease
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What is Dry Eye Disease?
?Dry eye disease (DED) is a condition caused
by many factors that result in inflammation of
the eye and tear-producing glands.
?Inflammation can decrease the ability of the
eye to produce normal tears that protect the
surface of the eye and keep it moist and
lubricated.
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Definition
qDry eye is not a trivial complaint. It can cause significant
discomfort and affect quality of life significantly.
q In 1995 the National Eye Institute defined dry eye
disease (DED) as " a disorder of the tear film due to tear
deficiency or excessive tear evaporation which causes
damage to the interpalpebral ocular surface and is
associated with symptoms of ocular discomfort".
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Definition
qIn 2007 the International Dry Eye Workshop
defined it as
" 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."
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Dry Eye is more than a red eye.
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Dry Eye
Affects Quality of Life
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The Healthy Eye
Normal tearing
depends on a
neuronal feedback loop Secretomotor
Nerve Impulses
Lacrimal
Glands
Tears Support and Maintain
Ocular Surface
Ocular Surface
Neural Stimulation
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Dry Eye Disease: An Immune-Mediated
Inflammatory Disorder
Inflammation disrupts
normal neuronal
Lacrimal Glands:
control of tearing
? Neurogenic
Inflammation
Interrupted Secretomotor
? T-cell Activation
Nerve Impulses
? Cytokine Secretion into
Tears
Tears Inflame Ocular Surface
Cytokines
Disrupt Neural Arc
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Multiple Factors in Dry Eye
?Transient discomfort
?May be stimulated by
environmental conditions
?Inflammation and ocular
surface damage
?Altered tear film composition
1de Paiva and Pflugfelder. In: Dry Eye and Ocular Surface Disorders.1 02004;
2Pflugfelder et al. In: Dry Eye and Ocular Surface Disorders. 2004.
Role of Inflammation
in Chronic Dry Eye
?Inflammation may be present but not clinically apparent
?Cycle of inflammation and dysfunction
?If untreated, inflammation can damage lacrimal gland and
ocular surface
? Consequences:
?Lower tear production
?Altered corneal barrier function
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Pflugfelder. Am J Ophthalmol. 2004.
Healthy Tears
? A complex mixture of
proteins, mucin, and
electrolytes
?Antimicrobial proteins:
Lysozyme, lactoferrin
?Growth factors &
suppressors of
inflammation: EGF, IL-1RA
?Soluble mucin secreted by
goblet cells for viscosity
?Electrolytes for proper
osmolarity
Stern et al. In: Dry Eye and Ocular Surface Disorders. 2004.
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Image adapted from: Dry Eye and Ocular Surface Disorders. 2004.
Tears in Chronic Dry Eye
? Decrease in many proteins
? Decreased growth factor
concentrations
? Altered cytokine balance
promotes inflammation
? Soluble mucin 5AC greatly
decreased
? Due to goblet cel loss
? Impacts viscosity of
tear film
? Proteases activated
? Increased electrolytes
Solomon et al. Invest Ophthalmol Vis Sci. 2001.
Zhao et al. Cornea. 2001.
Ogasawara et al. Graefes Arch Clin Exp Ophthalmol. 1996.
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Image adapted from: Dry Eye and Ocular Surface Disorders. 2004.
Who Is Likely to Have Dry Eye?
How Do We Diagnose It?
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Dry Eye: Multifactorial nature
Elderly woman
Taking
Post
glaucoma
menopausal
medications Contact lens
user
Working for long
Air-conditioned
hours in front of
environment
computer
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Patient Types with High Incidence of
Dry Eye Disease
?Women aged 50 or older
?Women using postmenopausal hormone
replacement therapy
?Those with ocular co-morbidities ?
xerophthalmia, cicatrical pemphigoid,
atopic keratoconjunctivitis, ocular rosacea
?Contact lens wearers
?Smokers
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Dry Eye Disease: Predisposing Factors
?Ageing
?Menopause - Decreased Androgens
?Al ergy Response
?Environmental Stresses
? Contact Lens Wear
? Low Humidity: Heating/AC
? Wind
? Lack of Sleep
? Air Pol ution
? Use of Computer Terminals
?Ocular Surgery (LASIK, Corneal Transplant)
?Medications
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Medications That May Contribute
to Dry Eye Disease
?Systemic
Topical
?Anti-hypertensives
? Preservatives in
?Anti-androgens
Tears
?Anti-cholinergics
?Antidepressants
?Cardiac Anti-arrhythmic Drugs
?Parkinson's Disease Agents
?Antihistamines
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Dry Eye Disease:
Autoimmune Triggers
?Systemic Autoimmunity
?Rheumatoid Arthritis
?Lupus
?Sj?gren's Syndrome
?Graft vs. Host Disease
?All can result in immune-mediated inflammation in the eye.
?Inflammatory mediators secreted into tears.
?Promote inflammation of ocular surface.
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Current Triggers of Dry Eye Disease
Environment
Rheumatoid
Medications
Arthritis
Contact Lens
Irritation
Inflammation
Lupus
Surgery
Sj?gren's
Graft vs Host
Tear
Deficiency/
Postmenopause
Meibomian
Instability
Gland Disease
Symptoms of Ocular Surface Disease
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21
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Dry Eye Disease Symptoms
?Discomfort
?Dryness
?Burning, Stinging
?Foreign-Body Sensation
?Gritty Feeling, Stickiness
?Blurry Vision
?Photophobia, Itching,
?Redness
Note: Symptoms seldom correlate with clinical signs
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Clinical Presentation Can Vary in Severity
Mild
Severe
Slitlamp
Fluorescein
Dye Stain
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Slit lamp examination
?Increased debris/mucin strands in tear film
?Inspection of tear meniscus at lid margin.
?Normal thickness ? 1mm, convex.
? < 0.5mm ? tear deficiency.
?In severe cases ? Marginal tear meniscus is
concave, small & absent.
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Filaments ( comma shaped) over corneal surface which move
on blinking
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Mucous plaques ? semi-transparent, white to grey, slightly
elevated lesions
Stain with rose bengal.
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?Bulbar conjunctival vessels may be dilated Red Eye
?Corneal surface ? irregularity/ dry areas.
?Blinking ? incomplete/infrequent.
?Meibomian gland dysfunction/ blepharitis.
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Diagnostic Tests
?Appropriate choice of test helps the clinician to
arrive at an accurate diagnosis as well as for
individualization of therapy.
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1. Basic Secretion Test
?Purpose ? to measure basal secretion by eliminating
reflex tearing.
?< 5mm hyposecretion.
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2. Schirmer's Test I
?Purpose ? measurement of the total (reflex + basal) tear
secretion.
?Eyes should not be manipulated before starting this test.
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Schirmer Test
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?Normal wetting 10-15 mm
?Dry Eye
?Mild
9-14 mm
?Moderate
4-8 mm
?Severe
< 4 mm
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Schirmer Test II
?Purpose ? to ascertain reflex secretion.
?Measured after 2 minutes.
?After Strips are placed in eye un-anaeasthetized
nasal mucosa is irritated.
?Less than 15 mm failure of reflex secretion.
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Rose Bengal staining
?Purpose - to ascertain indirectly, the presence
of reduced tear volume by the detection of
damaged epithelial cells.
?Useful in early stages of conjunctivitis sicca
and keratoconjunctivitis sicca syndrome.
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Rose Bengal Staining
? Positive test ? show triangular stipple staining of nasal and temporal
bulbar conjunctiva in the interpalpebral area & possible punctate
staining of the cornea (esp. lower 2/3rd).
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Rose Bengal Staining
?False positive ?
?Chronic conjunctivitis
?Acute chemical conjunctivitis, secondary to hair spray
use and drugs such as tetracaine & cocaine
?Exposure keratitis
?Superficial punctate keratitis, secondary to toxic or
idiopathic phenomena.
?Foreign bodies in conjunctiva.
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Modified van Bijsterveld conjunctival rose bengal grading map.
The density of rose bengal staining is recorded on a scale of 0-3 for
each of 6 areas of the conjunctiva, and then summed for each eye.
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Fluoroscein Dye Test
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Tear film Break-up time (BUT)
? Time of appearance of first dry spot from the last
blink.
? Tests for stability of tear film.
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Tear film Break-up time (BUT)
?Wetting time > 20 s Normal Tear film stability.
?BUT Averages b/w 25-30 s in Normal individuals.
?Women < Men
?Less in elderly
?BUT < 10 s significant tear film instability.
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NEI Workshop grading
Efron Scale
? Grade 0 = no staining
? Grade 1 = trace staining
? Grade 2 = mild staining
? Grade 3 = moderate
staining
? Grade 4 = severe
staining
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Other tests
? Practical Double Vital Staining for Ocular Examination
? Corneal Residence Time Test or Tear Clearance Rate (TCR)
? Tear Function Index
? Tear Film Osmolarity Test
? Tear Lactofer in Test
? Tear Lysozyme Test
? Impression Cytology
? Biopsy of Labial Accessory Salivary Glands
? Ocular Ferning Test
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Tear Film Osmolarity Test
?Tear Samples are collected with hand-drawn micropippete
from inferior marginal tear strip, without disturbing the
ocular surface.
?Tear osmolarity is determined by a freezing point
depression osmometer.
?Normal ? 295 to 309 mOsm/litre
?Elevated in Dry Eyes.
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Impression Cytology
?To determine the goblet cell density of bulbar & palpebral
conjunctiva.
?A strip of filter paper is gently pressed against the bulbar &
palpebral conjunctiva with a glass end.
?Staining with Schiff's agent & counter staining with
haemotoxylin graded with microscope.
?Dry Eyes goblet cell counts.
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DEWS Dry eye severity grading scheme
Dry Eye Severity
Level
1
2
3
4
Discomfort,
Mild and/or
Moderate
Severe frequent Severe and/or
severity
episodic;
episodic or
or constant
disabling
& frequency
occurs under
chronic, stress or without stress
and constant
environmental
no
stress
stress
Visual symptoms None or episodic Annoying and/or Annoying,
Constant and/or
mild fatigue
activity-limiting
chronic
possibly disabling
episodic
and/or constant,
limiting activity
Conjunctival
None to mild
None to mild
+/-
+/++
injection
Conjunctival
None to mild
Variable
Moderate to
Marked
staining
marked
Corneal staining
None to mild
Variable
Marked central
Severe punctuate
severity/location
erosions
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Dry Eye Severity
Level
1
2
3
4
Corneal/tear
None to mild
Mild debris,
Filamentary
Filamentary
signs
meniscus
keratitis,
keratitis,
mucus clumping, mucus clumping,
increased tear
increased tear
debris
debris, ulceration
Lid/meibomian
MGD variably
MGD variably
Frequent
Trichiasis,
glands
present
present
keratinization,
symblepharon
TBUT (sec)
Variable
10
5
Immediate
Schirmer score
Variable
10
5
2
(mm/5 min)
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Left Untreated, Chronic Dry Eye
May Become a Progressive Disorder
?Patients suffering from dry eye disease may move
between severity levels and can become worse, if
untreated.
?Disease management options can be adjusted for
individual patients depending on disease severity
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1Nelson et al. Adv Ther. 2000.
Management
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Aims of Treatment
?Relieve discomfort
?Provide smooth optical surface
?Prevent structural ocular surface damage
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Modalities of treatment
?Preservation of existing tears
?Reduction of tear drainage
?Tear substitutes
?Treat any other associated eye disease which
predisposes to dry eye
?Other options
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Preservation of existing tears
? Environmental modifications such as humidification,
avoidance of wind/dusty or smoky environment, avoid
central heating
? Lifestyle/workplace modifications
? taking regular breaks from reading or computer use
? lowering computer monitor below eye level
? increasing blink/fast blinking exercise
? discontinuing medications that exacerbate DED
?A small lateral tarsorrhaphy ? useful in incomplete lid
closure.
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Reduction of tear drainage
Done by punctual occlusion
?Preserves natural tears & prolongs effect of
artificial tears
?Greatest value in severe KCS who have not
responded to frequent use of topical treatment.
?May be ?
o Short term occlusion
o Permanent occlusion
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Temporary occlusion
?Collagen plugs are used.
?Dissolve in 1-2 weeks time.
?Initially all four puncta are
occluded
?If epiphora occurs, then upper
two plugs removed
If patient is asymptomatic, then
lower puncta are permanently
occluded
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Reversible occlusion
?Reversible prolonged occlusion with silicone/ long
acting collagen plugs (that dissolve in 2-6 wks).
?Problems ?
?Extrusion
?Granuloma formation
?Distal migration.
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Permanent occlusion
?
Done in severe KCS &
repeated Schirmer < 2mm
?
Should not be done in ?
?
Patients who develop
epiphora fol owing
temporary occlusion of
lower puncta
?
Young patients as their
tear production tends
to fluctuate
?
Done by cautery
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Tear substitutes
?Artificial Tear Drops used.
?Stabilize & thicken pre-corneal tear film .
?Prolongs tear film B.U.T.
?Keeps ocular surface wet & lubricated .
?Helps to repair ocular surface damage
?Keeps ocular surface smooth
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Tear substitutes
?
Drops - Frequent instil ation is required
Preservative free drops are bet er
?
Gels ? Consists of carbomers
Less frequent instil ation required
?
Ointments ? Contains petroleum mineral oil & used at bedtime
Mucolytic agents ? 5 % acetylcysteine drops QID to disperse
corneal filaments & mucous plaques.
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Eye Drops
?
Cel ulose derivatives ?
o Hydroxypropyl methylcellulose
o Carboxymethylcel ulose [more useful in lipid or mucous
deficiency]
o
Appropriate for mild cases.
?
Polyvinyl alcohol ? Bet er in aqueous deficiency
o Dose
?
QID in mild cases
?
? hrly ? 2 hrly in severe cases
?
Povidone
?
Sodium chloride
?
Hypromel ose
?
Sodium hyaluronate
?
Polyethylene and propylene glycol
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Treatment of associated diseases
?Meibomian gland disease/ Blepharitis ?
?Lid hygiene ? warm compresses, lid massage
?Lid scrubs
?Systemic Doxycycline/ Azithromycin/ Roxitromycin
?Correction of eyelid abnormalities ? blepharoptosis,
lagophthalmos
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Other options
? Topical cyclosporine [0.05%, 0.1%]
? Reduces cell-mediated inflammation of lacrimal tissue
increase in goblet cells, reversal of squamous metaplasia
of conjunctiva.
? Oral cholinergic agents (M3) like pilocarpine , cevimeline
? Effective in xerostomia & about 40% of KCS patients
also obtain relief
? Botulinum toxin injection to orbicularis muscle ? controls
blepharospasm in severe dry eye.
? Sub-mandibular gland transplantation ? for extreme dry eye.
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The DEWS treatment recommendations were based on the
modified severity grading (based on severity level)
Level 1:
Education and counselling
Environmental management
Elimination of offending systemic medications
Preserved tear substitutes, allergy eye drops
Level 2:
If Level 1 treatments are inadequate, add:
Unpreserved tears, gels, ointments
Steroids
Cyclosporine A
Secretagogues
Nutritional supplements
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Level 3:
If Level 2 treatments are inadequate, add:
Tetracyclines
Autologous serum tears
Punctal plugs (after control of inflammation)
Level 4:
If Level 3 treatments are inadequate, add:
Topical vitamin A
Contact lenses
Acetylcysteine
Moisture goggles
Surgery-Amniotic Membrane Transplanatation
Limbal stem cell graft
Keratoplasty
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Thank You
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This post was last modified on 07 April 2022