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Tear film

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  • 1. NALIN NAYAN B.OPTM 006 NSHM KNOWLEDGE CAMPUS . DURGAPUR
  • 2. PREFACE • The main aspect of this project is to show the different tear function test to show any abnormality in the tear film or tear film dysfunction. • This give us a brief idea about the abnormality and proper care to be taken in ocular surface disorders. This project has been explained in simple and illustrative manner about the different condition of tear film dysfunction. This project has explained about the different test that has to be done to assess the tear film dysfunction.
  • 3. ACKNOWLEDGEMENT • THIS PROJECT HAS BEEN COMPLETED IN SUPPORT OF MANY PEOPLE, OTHERWISE IT WAS NOT POSSIBLE FOR ME TO PREPARE THIS PROJECT . I WANT TO GIVE MY SINCERE THANKS TO DR.AGRAWALS’ EYE HOSPITAL FOR ALLOWING ME TO COMPLETE MY INTERNSHIP HERE. • I WOULD LIKE TO THANK NSHM KNOWLEDGE CAMPUS, DURGAPUR FOR GIVING ME SUPPORT. • LAST BUT NOT THE LEAST I WOULD LIKE TO THANKS MY FACULTIES, MY SENIORS , FRIENDS AND MY COLLEAGUES FOR THEIR SUPPORT.
  • 4. Tear Film- introduction It covers the exposed part of the globe i.e., the cornea and the bulbar conjunctiva It remains most directly in contact with the environment Imp for protecting the eye from external influences aqueous
  • 5. Function of Tear Film For maintaining health of the underlying structures To maintain the optical stability Antibacterial Function Provides Corneal Nutrition Mechanical function by flushing cellular debris, FB from cornea & conjunctival sac & by lubricating the surface
  • 6. Structural components of Tear film: Outer lipid layer Middle aqueous layer Inner mucin layer To retard the evaporation of the aqueous To lower the surface tension of the tear film To lubricate the eyelids To supply atmospheric O2 to the avascular corneal epithelium Antibacterial function To wash away debris and allow the passage of leucocytes after injury Lubrication Protection by covering FB with a slippery coating Converts hydrophobic into Hydrophilic surface
  • 7. Physical properties of Tear film 98.2% H2O 1.8% solids pH 7.3-7.7 310-334 mOsm RI 1.37
  • 8. Bio-chemical components Solutes( Protiens -Na120-160 -Cl 118-135 -HCO3 20-25 -K 20-42 -Mg 0.7-0.9 -Ca 0.5-1.1 -Glucose 0.5-1.1 -Retinol -Urea -Lysozyme -Lactoferrin -lipocalin -IgA, IgG -Albumin •Enzymes -Glycolytic enz -Amylase -Plasminogen activator -Latent proteanases -Latent Collegenase
  • 9. Healthy Tear film Tear film in dry eye
  • 10. Deficit aq. production Evaporative Sjogren’s syndrome Non Sjogren’s syndrome Meibomian Gland Disease Exposure Keratopathy CL AbnormalityPrimary 2ndary Lac. Gland Disease Lac. Gland Obstruction Loss of Reflex Tearing Ocular irritation Tear film instability Ocular surface dysfunction s Age Related
  • 11. Lac glands Brain Neuronal feedback loop for tear production Ocular surf produces neural stimulation Secretomotor nerve impulses Ocular surfaceTear supports and maintains ocular surface
  • 12. Change in the neuro-secretory arc/ Changes in immunomodulation of the lac gland Disruption of the feedback loop Diminution of neural tear stimulus Sensory nerves will adapt to prolonged sureface irritation Decrease the stimulus for reflex tearing Ocular surface dessication
  • 13. Mechanism of Tear Film Break up
  • 14. Condition in Dry Eye vs. Normal Eye
  • 15. Chief C/O the patients with Tear Film dysfunction  Burning or Itching  Fluctuating Vision  Foreign Body Sensation  Grittiness or irritation  Watering or excessive tearing  Sore or tired eyes  History of Styes  Ocular Discharge  Light sensitivity  Contact Lens Discomfort
  • 16. History taking for a Dry Eye(DE) patient….. Duration of reading or computer use Whether using contact lens Living in arid condition Living in air conditioned environment Frequent air traveling Addiction to cigarettes Exposure to environmental allergans or systemic allergies Any recent diagnosed hormonal change Autoimmune diseases CRx (sply oral antihistaminic, antidepressants, hormone replacement therapy,etc.)
  • 17. External Evaluation  Palpebral Aperture Size  Blink Patterns  Lid Closure  Lid Margin Evaluation  Lid/punctal Apposition Tear Volume  Subjective Tear Meniscus  Schirmer  Phenol Red Thread  Meibomian Gland Evaluation  Gland Observation  Lipid Expression Ocular Surface Evaluation  Temporal Bulbar Conjunctiva  Cornea  Nasal Bulbar Conjunctiva  Inferior Palpebral Conjunctiva  Staining with Sodium Fluorescein  Tear Break Up Time (TBUT)/Tear Stability  Rose Bengal Staining Drainage Mechanism 6-sector examination 1 2 3 4 5 6
  • 18. Diseases related to dysfunction in tear film Evaporative Dry Eye Oil deficiency- secondary to obstructive meibomian gland dysfunction Defective resurfacing of the eye by the tear film (result of poor blinking or abnormal lid-globe congruity)
  • 19. Dry Eye: Multifactorial nature Elderly woman Contact lens user Post menopausal Taking glaucoma medications Working for long hours in front of computer Air-conditioned environment
  • 20. Diseases related to dysfunction in tear film Lacrimation from excess tearing Obstructive epiphoria as a result of failure of tear drainage ( Schirmer’s value)
  • 21. Early Signs of Tear Dysfunction Precorneal Tear Film Presence of an increased amount of mucin strands and debris In Chronic Dry Eye(CDE) lipid contaminated mucin accumulates Marginal Tear Strip MTS is reduced in height (0.3mm) Attains concave shape In CDE it can be absent
  • 22. Tear Film Break-up Time(BUT) It is the difference b/w the last blink and the first randomly appearing dry spots Assessed with fluorescein and cobalt blue filter in broad beam Avg of three reading is taken Suspect Dry Eye when BUT<10secs
  • 23. Causes of Tear Film Destability Tear Film rupture occurs when hydrophobic lipid diffuses from the superficial layer and contaminates the underlying hydrophilic mucin layer Epithelial change (like poor secretion of glycocalyx) can cause poor adherence of tearfilm
  • 24. Schirmer’s Test  Rate of tear formation is estimated  Whatman filter paper no 41 is used  Dimension 5mm X 35mm  5mm tab is folded at one end  The bent end is placed at the junction of the lateral 1/3rd and medial 2/3rd of the lower conjunctival sac  The test is performed in dim light with fans and ACs switched off
  • 25. Schirmer test  Without Anesthesia Measures Reflex Tear Secretion (dry eye = < 6mm wetting)  With Anesthesia Measures Basal Tear Secretion (dry eye =< 3mm wetting)
  • 26. Rose Bengal staining  Rose Bengal solution 1% placed into the conjunctival sac.  After a wait of 2 mins, degree of rose bengal staining on bulbar conjunctiva and cornea is quantitated by microscopic exam.  Stains devitalized cells.  Also stains mucous strands (very often present in KCS) J Am Optom Assoc 1991, 62:187-199
  • 27. Rose Bengal staining in Early, Moderate and Late KCS EARLY MODERATE LATE
  • 28. Phenol Red Thread test A sterile cotton thread is draped over the non-anesthetized lid margin It changes color upon aqueous contact and the length of colored thread is measured This test is used to evaluate the tear secretion quantity without inducing significant reflex tearing The normative value is 13±4 mm of wetting over a fifteen second period
  • 29. Impression cytology  Removal of superficial layers of conjunctival epithelium  Application of circular discs of cellulose acetate filter paper for a certain period of time.  Obtained specimen observed under microscope for signs and symptoms of squamous metaplasia or presence of inflammatory cells.  In CDE conditions the cells appear fewer, irregular in size & shape and takes up stain less uniformly J Am Optom Assoc 1991, 62: 187-99
  • 30. Impression Cytology Mapping Healthy Mild Moderate Severe
  • 31. Lysozyme Assay Hyposecretion of tears may be due to the reduction in the concentration of lysozyme Wetted filter strip is placed into an agar plate containing specific bacteria The plate is incubated for 24 hrs and the zone of lysis is measured The zone will be reduced if the concn of lysozyme in tears is decreased
  • 32. Tear Globulin Assay Decreased tear formation may be due to dec IgA Performed on spl tripartigan immunodiffusion plates containing specific agar gel in wells Twenty microliters of tear samples is put into these wells and the plates are incubated for 48 hrs The diffusion of rings around wells are measured to nearest 0.1mm with partigen ruler The ring will be reduced if the concn of Iga in tears is decreased
  • 33. To check the outflow mechanism Jones test
  • 34. Jones-I (primary) test Differentiates excessive watering due to blockage in lacrimal passage with primary hypersecretion of tears 1 drop of 2% fluorescein in instilled in the conjunctival sac After 5mins a cotton tipped bud (moistened with 4%proparacaine) is inserted under the inferior turbanate Fluorescein if recovered from the nose then the excretory system is patent Otherwise should go for Jones-II test
  • 35. Jones-II (Secondary) Test  Helps to identify the probable site of partial obstruction  4% xylocaine in instilled in the conjunctival sac  Any residual fuorescein is washed out  NLD is irrigated with normal saline  The patient is positioned his/her down by 45deg  +ve –fluorescein stained saline recovered from the nose showing functional patency of upper lac passage  -ve- unstained saline recovered from the nose shows block in the upper lac passage or defective lacrimal pump mechanism
  • 36. Jones Dye-I Jones Dye-II
  • 37. Tearscope Assess patient's tear film quantity, quality and stability Non invasive method Tear quantity is assessed with one full-length view along the tear meniscus Tear quality is assessed by matching the patient's tear film with the equivalent pattern in the Guillon- Keeler Tear Film Grading System, and by viewing the tear film flow dynamics. Tear stability is assessed by directly viewing the tear film on the contact lens or corneal surface and measuring the non invasive break up time
  • 38. Cold cathode illumination Timer Star/stop button On/off High/low Lap time reset button Tearscope -the instrument itself…
  • 39. a) normal smooth tear film that is the most representative case, b) post-blink roughness that usually lasts no longer than two seconds, c) bubbles, d) ridges produced by the eyelids, e) unusually rough tear surface, f) tear break-up, g) and h) are typical rough tear surface typical of contact lenses. Tearscope- it depends on the principle of INTERFERENC E
  • 40. Take Home Messages… Ocular surface disorders related to tear film dysfunction is a complex condition It requires careful observation, knowledge about various diseases and their etiologies, and a thorough ocular and systemic history It is crucial to diagnose the correct disease mechanism prior to considering management of any kind  In many situations there may be multiple causes and only careful assessment over multiple visits will lead to the correct diagnosis and proper treatment plan
  • 41. THANK YOU