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Dry eye: An Overview
 

Dry eye: An Overview

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    Dry eye: An Overview Dry eye: An Overview Presentation Transcript

    • DRY EYE:AN OVERVIEW Dr.Gayatree Mohanty Dept. of Ophthalmology, KIMS
    • DRY EYEOccurs when Inadequate tear production Inadequate functionResults in Unstable Tear Film and Ocular Surface Disorder.
    • TEAR PRODUCTION & TEAR FUNCTION Healthy tear film Dry eye
    • TEAR PRODUCTION Secreted by the lacrimal glands Spreads over the ocular surface Drained the lacrimal canaliculi into the nasolacrimal duct.
    • TEAR FILM• Lipid layer (meibomian glands in the eyelid): Outermost surface of the tear film; 0.1um• Aqueous layer (lacrimal gland): Middle layer; 7um• Mucus layer (goblet cells of conjunctiva): Inner most; 0.2um.
    • FUNCTIONS OF THE TEAR FILM• Lipid layer: Prevents evaporation of tears and acts as an surfactant allowing spread of the tear film.• Aqueous middle layer: Provide atmospheric O2 to the corneal epithelium; Antibacterial activity(Interleukins, lysozymes, IgA & lactoferrin); Cleanses the eye and washes away foreign particles or irritants; Provide a smooth optical surface to cornea by abolishing the irregularities.• Mucus layer: Allows the watery layer to spread evenly over the surface of the eye and helps the eye remain moist.
    • FACTORS AFFECTING THE SPREAD OF TEAR FILMNormal lacrimal neural arc.Contact between the ocular surface & the eyelidsNormal corneal epithelium.
    • OCULAR SURFACEConjunctival epitheliumLimbal EpitheliumCorneal epitheliumEyelids (Mucocutaneous junction)
    • ETIOPATHOGENESISAqueous tear deficiencySjogren’s DieseasesNon-Sjogren’s DiseasesLipid tear deficiencyMucin deficiencyKinetic disorders of lacrimal fluid
    • SJOGREN’S SYNDROME Autoimmune inflammation of the lacrimal glands and the salivary glands. Primary or Secondary (RA,SLE, Systemic sclerosis, primary biliary cirrhosis, chronic active hepatitis, myasthenia gravis etc) Most common symptoms are dry eyes and dry mouth.
    • COMMON NON-SJOGREN’S CAUSES Vitamin A deficiency, Stevens Johnson syndrome and Ocular Cicatricial Pemphigoid (OCP).Affects the inner mucous layer of the tear film and prevents the natural tear film from adhering to the eye. Prolonged computer hours: Evaporative dry eye Allergic conjunctivitis: Altered tear function due to conjunctival & limbal inflammation.
    • VITAMIN A DEFICIENCYXerosis of the conjunctiva resulting in goblet cell destruction & mucin layer deficiency.
    • STEVEN JOHNSON SYNDROME Mucocutaneous vesicullobullous disease. MC Drugs: Sulfa drugs(Acetazolamide), Penicillin, Barb iturates, Salicylates Acute vasculitis affecting conjunctiva & other mucous membranes. Membranous muco-purulent conjunctivitis leading to scarring of conjunctiva & lid margin. Destruction of meibomian glands, conjunctival goblet cells & limbal stem cells.
    • OCULAR CICATRICIAL PEMPHIGOID Autoimmune muco- cutaneous blistering disease. Cicatrization of the conjunctiva & lacrimal ductules result in both mucin layer & aqueous layer deficiency of tear film.
    • COMPUTER VISION SYNDROME Variety of vision related symptoms that may be aggravated by regular use of a computer for two or more hours a day. Reduced blinking leading reduced spreading of fresh tear film results in dry eye, blurring of vision, red eye, watering & asthenopia.
    • ALLERGIC CONJUNCTIVITIS & VERNAL KERATOCONJUNCTIVITIS Recurrent inflammation of conjunctiva & limbus leading to cicatrization and mucin deficiency dry eye. Rubbing of the eye causes meibomian gland disease causing lipid deficiency dry eye.
    • MEDICATIONS CAUSING DRY EYE•Diuretics• Beta-blockers• Antihistamines• Sedatives• Anti-Anxiety medications• Analgesics
    • LIPID LAYER DEFICIENCY Blepharitis, Meibomitis and Rosacea.Affect the outer lipid layer of the tear film, causing excessive evaporation of the natural tears from the eye.
    • CLINICAL FEATURE: SYMPTOMS Burning sensation Foreign body sensation (exaggerates over the day) Stringy mucus discharge Transient blurring of vision Redness Difficulty wearing contact lenses Crusting of the lids
    • CLINICAL MANIFESTATION: SIGNS Tear meniscus at the inferior eye lid margin <1mm. Tear Breakup Time <10sec Punctate corneal & conjunctival fluorescein. Rose bengal staining esp. inferiorly & interpalpabral area. Excess mucus & debris in the tear film & filaments on the cornea.
    • WORK-UP History with external examination Slit lamp examination with Fluorescein stain to examine TBUT, Conjunctive & Cornea. Schirmer’s test:Schirmer filter paper placed at the angle of middle & lateral 1/3rd of the lower lid in each eye for 5 min.Schirmer I: Unasthetized; Basal+reflex; N:15mm/5min.Schirmer II: Anaesthetized: Basal; Abnormal: 5mm/5min.
    • TREATMENTIncrease tear film volume: Artificial tears(Carboxymethyl Cellulose/ Hypromellose) Temporary insertion of punctal plugsImprove Lubrication: Artificial Tear SubstitutesTo break the sticky mucin: Acetylcysteine
    • TEAR SUBSTITUTESCellulose derivatives: Carboxymethyl cellulose 1%, Hypromellose 0.5%Carbomers(Polyacrylic acid)Polyvinyl alcolhol, Povidone, sodium HylauronateLipids & Oil:Acetylcysteine 5% with Hypromellose.
    • TREATMENTImprove Corneal epithelium (In severe dry): Artificial Tear Substitutes in gel form with pad & bandage Bandage contact lens Amniotic membrane grafting Limbal stem cell transplant
    • TREATMENT Reduce Evaporation: Protective glasses Reduce room temperature with humidifier. Lipidic artificial tear substitutes Lid massage for mechanical expression of the meibomian gland expression Lateral tarsorrhaphy For Computer vision syndrome: Computer screen should be 15 to 20 degrees below eye level. Use of anti-glare screen.
    • TREATMENT Treatment of Lids: T/t of Blepharitis: Lid hygiene, Lid massage, Doxycycline 100mg BD Control of Inflammation: Topical steroids Topical cyclosporine A 0.5% BD Supplement Growth Factors: To increase goblet cell expression & improvement of ocular surface. Autoserum Eye Drops
    • DEWS CLASSIFICATION
    • DEWS RECOMMENDATION OF TREATMENTLevel 1 treatment consists of the following: Education and environmental or dietary modifications Elimination of offending systemic medications Preserved artificial tear substitutes, gels, and ointments Eyelid therapy.
    • DEWS RECOMMENDATION OF TREATMENTIf level 1 treatment is inadequate, level 2 measures are added, including the following: Nonpreserved artificial tear substitutes Anti-inflammatory agents Tetracyclines (for meibomitis or rosacea) Punctal plugs (after inflammation has been controlled) Secretagogues Moisture chamber spectacles
    • DEWS RECOMMENDATION OF TREATMENTIf level 2 treatment is inadequate, level 3 measures are added, including the following: Autologous serum or umbilical cord serum Contact lenses Permanent punctal occlusion If level 3 treatment is inadequate, level 4 treatment, consisting of the administration of systemic anti-inflammatory agents, is added.
    • CONCLUSION Dry eye complaints are a frequent presentation at Ophthalmic OPD due our current environment, pollution & life style. Prevalence(DEWS):35% The management of Dry Eye is simple if diagnosed early but tedious and difficult as the severity of the dry eye increases. Any patient with C/o red eye, grittiness, FB sensation & photophobia along with predisposing factors should be referred to the Eye clinic for further management.
    • REFERENCE; 2007 Report of the International Dry Eye Workshop (DEWS). The OcularSurface. 2007;5:65-204. Systemic Approach to Clinical Ophthalmology. Kanski. 6th edition,2008.