Dry Eye


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The EBAI CME 2013 - 21st and 22nd of September 2013, Golden Valley Resort, Ghodbunder Road, Thane West, Mumbai.

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Dry Eye

  1. 1. DRY EYE Dr Sheetal Deolekar MS DNB FCPS DOMS Fellow Disha Eye Hospitals
  2. 2. DEFINITION  NEI/Industry definition: A syndrome in which an unstable tear film inadequately supports the health of ocular surface epithelium, promotes ocular surface inflammation, and stimulates eye pain.  International DEWS Report : 2007 Dry eye is a multifactorial disease of the tears and ocular surface that results in symptom of discomfort and visual disturbance, and tear film instability with potential damage to ocular surface.  It is accompanied by increased osmolarity of tear film and inflammation of the ocular surface.
  4. 4. PATHOGENESIS Secretory dysfunction Ocular surface inflammation Altered tear composition Tear film instability Ocular surface disease Ocular discomfort Chronic pain symptoms Lacrimal keratoconjunctivitis sicca
  6. 6. OCULAR SURFACE MANIFESTATION Corneal epithelial disease •Tear film unstability •Disrupted epithelial barrier •Increased corneal permeability •Sterile keratolysis Conjunctival epithelial disease •Squamous metaplasia – decreased mucin and number of goblet cells •Increased expression of genes- increased apoptosis of conj. Epithelial cells inflammation •Cellular and soluble inflmmatory mediators •Increased number of T lymphocytes and change in their distribution •Immune activation- increased proinflammatory cytokines DRY EYE
  7. 7. SEVERITY GRADING SCHEME Dry eye severity level 1 2 3 4 Discomfort:severity &frequency Mild, episodic under stress Mod episodic/ chronic Severe frequent/ constant Severe &/or disabling & constant Visual symptoms -/ mild episodic Annoying and/or activity limiting Annoying chronic/ constant Constant &/ or disabling Conj injection -/ mild -/mild +/- +/++ Conj staining -/ mild Variable Mod/ marked Marked Corneal staining -/ mild Variable Mod/ marked Punctate erosions Corneal & tear signs -/ mild Mild debris, variable meniscus Filamentary keratitis, mucous clumps 3+ ulceration Lid & meb glands + variable + variable Frequent Trichiasis, keratinisation TBUT Variable < 10 < 5 Immidiate Shirmer score variable <10 < 5 <2
  8. 8. TREATMENT Treatment 1 2 3 4 Education Enviornmental factors Offending medications Preserved tear substitutes Unpreserved tears Anti-inflammatory Secretogauges Tetracyclines Autologous serum Punctal plugs Topical vit A Moisture goggles Surgery
  9. 9. ANTI-INFLAMMATORY THERAPY  Cyclosporin A- 0.5%, 1% and 2%  Inhibits T cell activation and cytokine production  Topical tacrolimus increases aqueous tear secretion and can be used in keratoconjunctivitis sicca refractory to topical cyclosporin.  Severe dry eye  Stevens-Johnson Syndrome  Ocular cicatrical pemphigoid  Post transplant immunosuppression
  10. 10. TOPICAL TACROLIMUS  Available as Ointment in 0.1% and 0.03 % concentrations for dermatological use.  100 times more potent in inhibiting IL2 than cyclosporine A  Not approved by FDA for use in children < 2yrs  Contraindicated in  Pregnancy  Lactation  Active ocular infection  Patient on phototherapy  Patient on other immunosuppressive drugs  Children less than 2 yrs
  11. 11. DOSAGE  5mm ribbon of ointment to be applied in the conjunctival fornix  Twice a day application  Continuous application for 3 months after a washout period of 2 weeks  Decrease the frequency to once a day or alternate day application  Long term intermittent use up to 4 yrs seen to be safe in clinical trials 12
  12. 12. AUTOLOGOUS SERUM  Serum = fluid component of full blood which remains after clotting  Use first described in 1984 by Fox et al (for keratoconjunctivitis sicca)  Unpreserved, non-antigenic  Biomechanical and biochemical properties similar to natural tears
  13. 13. AUTOLOGOUS SERUM  Contains epithelio-trophic / modulating factors  Promotes growth and migration of ocular surface epithelial cells in vitro  Maintains corneal epithelial cell morphology and function better than pharmaceutical tear substitutes (Geerling et al)  Increases transcription of RNA for nerve growth factor and transforming growth factor-beta in cultured human keratocytes (Ebner et al)
  14. 14. PRE-OP CONSIDERATION IN TRANSPLANT Adequate stem cell supply Anatomically functioning lids Adequate tear film function LSCT AMT Punctal occlusion Tarsorraphy Botulinum injection in LPS Correction of entropion Ectropion
  15. 15. SURGICAL OPTIONS  Sealing of the perforation or descemetocele with corneal cyanoacrylate tissue adhesive  Tarsorrhaphy  Surgical occlusion of the lacrimal drainage system  Amniotic membrane transplantation
  16. 16. TARSORRHAPHY  To reduce the area of exposed ocular surface indicated in  Severe epitheliopathy  Persistent epithelial defects  Frank stromal ulceration  Corneal perforation
  17. 17. TRANSPLANT IN DRY EYE  Good donor epithelium with no sloughing  Shortest donor tissue preservation time  Check teflon cutting block for irregularities before harvesting donor button  Keeping the epithelial surface well lubricated preferably by viscoelastics
  18. 18. Thank You All!!! We all know… when to operate and when NOT to!