Download MBBS Ophthalmology PPT 4 Dry Eye Lecture Notes

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1

Learning Objectives

At the end of this class the students shall be able to :

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?Define dry eye disease.

? Understand predisposing and aetiological factors

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responsible for dry eye disease

? Comprehend clinical features and tests for the above

condition

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? Understand fundamentals of managing dry eye

depending on the severity of disease

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2
What is Dry Eye Disease?

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?Dry eye disease (DED) is a condition caused

by many factors that result in inflammation of

the eye and tear-producing glands.

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?Inflammation can decrease the ability of the

eye to produce normal tears that protect the

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surface of the eye and keep it moist and

lubricated.

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Definition

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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

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disease (DED) as " a disorder of the tear film due to tear

deficiency or excessive tear evaporation which causes

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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

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" 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

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depends on a

neuronal feedback loop Secretomotor

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Nerve Impulses

Lacrimal

Glands

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Tears Support and Maintain

Ocular Surface

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Ocular Surface

Neural Stimulation

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Dry Eye Disease: An Immune-Mediated

Inflammatory Disorder

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Inflammation disrupts

normal neuronal

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Lacrimal Glands:

control of tearing

? Neurogenic

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Inflammation

Interrupted Secretomotor

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? T-cell Activation

Nerve Impulses

? Cytokine Secretion into

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Tears

Tears Inflame Ocular Surface

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Cytokines

Disrupt Neural Arc

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Multiple Factors in Dry Eye

?Transient discomfort

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?May be stimulated by

environmental conditions

?Inflammation and ocular

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surface damage

?Altered tear film composition

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1de Paiva and Pflugfelder. In: Dry Eye and Ocular Surface Disorders.1 02004;

2Pflugfelder et al. In: Dry Eye and Ocular Surface Disorders. 2004.

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Role of Inflammation

in Chronic Dry Eye
?Inflammation may be present but not clinically apparent

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?Cycle of inflammation and dysfunction

?If untreated, inflammation can damage lacrimal gland and

ocular surface

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? Consequences:

?Lower tear production

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?Altered corneal barrier function

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Pflugfelder. Am J Ophthalmol. 2004.

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Healthy Tears

? A complex mixture of

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proteins, mucin, and

electrolytes

?Antimicrobial proteins:

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Lysozyme, lactoferrin

?Growth factors &

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suppressors of

inflammation: EGF, IL-1RA

?Soluble mucin secreted by

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goblet cells for viscosity

?Electrolytes for proper

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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

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? Decrease in many proteins
? Decreased growth factor

concentrations

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? Altered cytokine balance

promotes inflammation

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? Soluble mucin 5AC greatly

decreased

? Due to goblet cel loss

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? Impacts viscosity of

tear film

? Proteases activated

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? Increased electrolytes

Solomon et al. Invest Ophthalmol Vis Sci. 2001.

Zhao et al. Cornea. 2001.

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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

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Taking

Post

glaucoma

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menopausal

medications Contact lens

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user

Working for long

Air-conditioned

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hours in front of

environment

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computer

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Patient Types with High Incidence of

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Dry Eye Disease

?Women aged 50 or older

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?Women using postmenopausal hormone

replacement therapy

?Those with ocular co-morbidities ?

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xerophthalmia, cicatrical pemphigoid,

atopic keratoconjunctivitis, ocular rosacea

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?Contact lens wearers

?Smokers

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Dry Eye Disease: Predisposing Factors

?Ageing

?Menopause - Decreased Androgens

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?Al ergy Response

?Environmental Stresses

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? Contact Lens Wear

? Low Humidity: Heating/AC

? Wind

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? Lack of Sleep

? Air Pol ution

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? Use of Computer Terminals

?Ocular Surgery (LASIK, Corneal Transplant)

?Medications

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Medications That May Contribute

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to Dry Eye Disease

?Systemic

Topical

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?Anti-hypertensives

? Preservatives in

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?Anti-androgens

Tears

?Anti-cholinergics

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?Antidepressants
?Cardiac Anti-arrhythmic Drugs
?Parkinson's Disease Agents
?Antihistamines

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Dry Eye Disease:

Autoimmune Triggers

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?Systemic Autoimmunity

?Rheumatoid Arthritis

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?Lupus

?Sj?gren's Syndrome

?Graft vs. Host Disease

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?All can result in immune-mediated inflammation in the eye.

?Inflammatory mediators secreted into tears.

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?Promote inflammation of ocular surface.

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Current Triggers of Dry Eye Disease

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Environment

Rheumatoid

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Medications

Arthritis

Contact Lens

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Irritation

Inflammation

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Lupus

Surgery

Sj?gren's

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Graft vs Host

Tear

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Deficiency/

Postmenopause

Meibomian

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Instability

Gland Disease

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Symptoms of Ocular Surface Disease

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Dry Eye Disease Symptoms

?Discomfort

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?Dryness

?Burning, Stinging

?Foreign-Body Sensation

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?Gritty Feeling, Stickiness

?Blurry Vision

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?Photophobia, Itching,

?Redness

Note: Symptoms seldom correlate with clinical signs

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Clinical Presentation Can Vary in Severity

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Mild

Severe

Slitlamp

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Fluorescein

Dye Stain

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Slit lamp examination

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?Increased debris/mucin strands in tear film

?Inspection of tear meniscus at lid margin.

?Normal thickness ? 1mm, convex.

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? < 0.5mm ? tear deficiency.

?In severe cases ? Marginal tear meniscus is

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concave, small & absent.

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Filaments ( comma shaped) over corneal surface which move

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on blinking

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Mucous plaques ? semi-transparent, white to grey, slightly

elevated lesions

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Stain with rose bengal.

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?Bulbar conjunctival vessels may be dilated Red Eye

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?Corneal surface ? irregularity/ dry areas.

?Blinking ? incomplete/infrequent.

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?Meibomian gland dysfunction/ blepharitis.

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Diagnostic Tests

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?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

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reflex tearing.

?< 5mm hyposecretion.

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2. Schirmer's Test I

?Purpose ? measurement of the total (reflex + basal) tear

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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

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?Mild

9-14 mm

?Moderate

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4-8 mm

?Severe

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< 4 mm

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Schirmer Test II

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?Purpose ? to ascertain reflex secretion.

?Measured after 2 minutes.

?After Strips are placed in eye un-anaeasthetized

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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

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of reduced tear volume by the detection of

damaged epithelial cells.

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?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

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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 ?

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?Chronic conjunctivitis

?Acute chemical conjunctivitis, secondary to hair spray

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use and drugs such as tetracaine & cocaine

?Exposure keratitis

?Superficial punctate keratitis, secondary to toxic or

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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

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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.

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? Tests for stability of tear film.

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Tear film Break-up time (BUT)

?Wetting time > 20 s Normal Tear film stability.

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?BUT Averages b/w 25-30 s in Normal individuals.

?Women < Men

?Less in elderly

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?BUT < 10 s significant tear film instability.

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NEI Workshop grading

Efron Scale
? Grade 0 = no staining
? Grade 1 = trace staining

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? Grade 2 = mild staining
? Grade 3 = moderate

staining

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? Grade 4 = severe

staining

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Other tests

? Practical Double Vital Staining for Ocular Examination

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? Corneal Residence Time Test or Tear Clearance Rate (TCR)
? Tear Function Index
? Tear Film Osmolarity Test
? Tear Lactofer in Test
? Tear Lysozyme Test

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? 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

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from inferior marginal tear strip, without disturbing the

ocular surface.

?Tear osmolarity is determined by a freezing point

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depression osmometer.

?Normal ? 295 to 309 mOsm/litre

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?Elevated in Dry Eyes.

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Impression Cytology

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?To determine the goblet cell density of bulbar & palpebral

conjunctiva.

?A strip of filter paper is gently pressed against the bulbar &

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palpebral conjunctiva with a glass end.

?Staining with Schiff's agent & counter staining with

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haemotoxylin graded with microscope.

?Dry Eyes goblet cell counts.

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DEWS Dry eye severity grading scheme

Dry Eye Severity

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Level

1

2

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3

4

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Discomfort,

Mild and/or

Moderate

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Severe frequent Severe and/or

severity

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episodic;

episodic or

or constant

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disabling

& frequency

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occurs under

chronic, stress or without stress

and constant

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environmental

no

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stress

stress

Visual symptoms None or episodic Annoying and/or Annoying,

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Constant and/or

mild fatigue

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activity-limiting

chronic

possibly disabling

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episodic

and/or constant,

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limiting activity

Conjunctival

None to mild

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None to mild

+/-

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+/++

injection
Conjunctival

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None to mild

Variable

Moderate to

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Marked

staining

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marked

Corneal staining

None to mild

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Variable

Marked central

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Severe punctuate

severity/location

erosions

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Dry Eye Severity

Level

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1

2

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3

4

Corneal/tear

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None to mild

Mild debris,

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Filamentary

Filamentary

signs

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meniscus

keratitis,

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keratitis,

mucus clumping, mucus clumping,

increased tear

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increased tear

debris

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debris, ulceration

Lid/meibomian

MGD variably

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MGD variably

Frequent

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Trichiasis,

glands

present

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present

keratinization,

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symblepharon

TBUT (sec)

Variable

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10

5

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Immediate

Schirmer score

Variable

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10

5

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2

(mm/5 min)

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Left Untreated, Chronic Dry Eye

May Become a Progressive Disorder

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?Patients suffering from dry eye disease may move

between severity levels and can become worse, if

untreated.

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?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

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?Provide smooth optical surface

?Prevent structural ocular surface damage

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Modalities of treatment

?Preservation of existing tears

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?Reduction of tear drainage

?Tear substitutes

?Treat any other associated eye disease which

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predisposes to dry eye

?Other options

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Preservation of existing tears

? Environmental modifications such as humidification,

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avoidance of wind/dusty or smoky environment, avoid

central heating

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? Lifestyle/workplace modifications

? taking regular breaks from reading or computer use

? lowering computer monitor below eye level

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? increasing blink/fast blinking exercise

? discontinuing medications that exacerbate DED

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?A small lateral tarsorrhaphy ? useful in incomplete lid

closure.

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Reduction of tear drainage

Done by punctual occlusion

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?Preserves natural tears & prolongs effect of

artificial tears

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?Greatest value in severe KCS who have not

responded to frequent use of topical treatment.

?May be ?

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o Short term occlusion

o Permanent occlusion

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Temporary occlusion

?Collagen plugs are used.

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?Dissolve in 1-2 weeks time.

?Initially all four puncta are

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occluded

?If epiphora occurs, then upper

two plugs removed

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If patient is asymptomatic, then

lower puncta are permanently

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occluded

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Reversible occlusion

?Reversible prolonged occlusion with silicone/ long

acting collagen plugs (that dissolve in 2-6 wks).

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?Problems ?

?Extrusion

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?Granuloma formation

?Distal migration.

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Permanent occlusion

?

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Done in severe KCS &

repeated Schirmer < 2mm

?

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Should not be done in ?

?

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Patients who develop

epiphora fol owing

temporary occlusion of

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lower puncta

?

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Young patients as their

tear production tends

to fluctuate

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?

Done by cautery

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Tear substitutes

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?Artificial Tear Drops used.

?Stabilize & thicken pre-corneal tear film .

?Prolongs tear film B.U.T.

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?Keeps ocular surface wet & lubricated .

?Helps to repair ocular surface damage

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?Keeps ocular surface smooth

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Tear substitutes

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?

Drops - Frequent instil ation is required

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Preservative free drops are bet er

?

Gels ? Consists of carbomers

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Less frequent instil ation required

?

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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 ?

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o Hydroxypropyl methylcellulose
o Carboxymethylcel ulose [more useful in lipid or mucous

deficiency]

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o

Appropriate for mild cases.

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?

Polyvinyl alcohol ? Bet er in aqueous deficiency

o Dose

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?

QID in mild cases

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?

? hrly ? 2 hrly in severe cases

?

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Povidone

?

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Sodium chloride

?

Hypromel ose

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?

Sodium hyaluronate

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?

Polyethylene and propylene glycol

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Treatment of associated diseases

?Meibomian gland disease/ Blepharitis ?

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?Lid hygiene ? warm compresses, lid massage

?Lid scrubs

?Systemic Doxycycline/ Azithromycin/ Roxitromycin

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?Correction of eyelid abnormalities ? blepharoptosis,

lagophthalmos

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Other options

? Topical cyclosporine [0.05%, 0.1%]

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? Reduces cell-mediated inflammation of lacrimal tissue

increase in goblet cells, reversal of squamous metaplasia

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of conjunctiva.

? Oral cholinergic agents (M3) like pilocarpine , cevimeline

? Effective in xerostomia & about 40% of KCS patients

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also obtain relief

? Botulinum toxin injection to orbicularis muscle ? controls

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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:

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Education and counselling

Environmental management

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Elimination of offending systemic medications

Preserved tear substitutes, allergy eye drops

Level 2:

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If Level 1 treatments are inadequate, add:

Unpreserved tears, gels, ointments

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Steroids

Cyclosporine A

Secretagogues

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Nutritional supplements

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Level 3:

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If Level 2 treatments are inadequate, add:

Tetracyclines

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Autologous serum tears

Punctal plugs (after control of inflammation)

Level 4:

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If Level 3 treatments are inadequate, add:

Topical vitamin A

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Contact lenses

Acetylcysteine

Moisture goggles

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Surgery-Amniotic Membrane Transplanatation

Limbal stem cell graft

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Keratoplasty

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Thank You

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