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Tear film Dr Ferdous
1. TEAR FILM
Dr Md Ferdous Islam
Department of Ophthalmology
CMH, Dhaka
2. THE TEAR FILM
The main role of lacrimal system is to establish &
maintain a continuous tear film over the ocular
surface
Pre-corneal tear film was 1st demonstrated by
Fischer in 1928.
Rollet described it as the most superficial 6th layer
of cornea.
3. STRUCTURE OF THE TEAR FILM
Wolff
Coined the term ‘PRE-CORNEAL FILM’.
Tear film consists of 3 layers.
1)Outer Lipid layer
2)Intermediate Aqueous layer &
3)Inner mucin layer
4.
5.
6. LIPID LAYER
Outer most layer.
0.1um thick
Formed from the secretions of Meibomian, Zeiss &
Moll glands.
Contents 1)low polarity lipids-wax & cholesterol
esters 2)high polarity lipids-TG, FFA ,phospholipids.
Functions 1)prevents the overflow of tears.
2)prevents evaporation.
7. AQUEOUS LAYER
Middle layer.
Formed by secretions from the main & accessory lacrimal
glands of Krause & Wolfring.
Constitutes the main bulk of tear film.
thickness over the cornea 10um.
Film covering the cornea is thinner than over the
conjunctiva.
Contents inorganic salts, glucose, urea, enzymes, proteins
& glycoproteins.
Buffering capacity of the tear film is d/t HCO3 ions & protein
Functions 1)provides O2 to corneal epithelium.
2)washes away debris & irritants.
3)contains antibacterial sub- lysozyme &
betalysin.
8. MUCOUS LAYER
Innermost layer.
Secreted mainly by the conjunctival goblet cells
30um thick.can be demo in living eye by alician blue drops
Functions 1)plays a vital role in the stability of the tear film.
2)converts the hydrophobic corneal epithelium to a hydrophilic
one.
3)lubricates the ocular & palpebral surfaces.
4)provides a slippery coating over the foreign bodies; thereby
protecting the cornea & conjunctiva against the abrasive effects of
such particles as they move about with blinking.
5)absorps various organic compounds in tears
9. NEW TEAR FILM MODEL
Recent observation--
mucins exist as a network
distributed in the aqueous
body of the tear film.
Glycocalyx emanate as
transmembrane molecules
into the aqueous & are
anchored at the cell
membrane.
Membrane associated
proteins-MUC1,4&16 as
well as secretory mucins-
MUC5AC &MUC7 have
been identified at the
ocular surface.
10. PHYSICAL PROPERTIES OF TEAR FILM
Property
Thickness 4-8um
Volume 4-13ul
Rate of secretion 1.2ul per min
Turn over rate* 18% per min
Refractive index 1.357
Ph of tears* 7.3-7.7
Osmotic pressure* 0.90-0.95%
Temperature 30’c at cornea and 35’ at limbus
Oxygen tension 40-160 mm hg
11. TEAR FULID COMPOSITION
Mainly composed of 3 protein factors-albumin,globulin
and lysozyme
IgA is the most prominent Ig.
IgE levels increase in patients with allergic
conjunctivities.
IgM increases in patients with acute infections.
Lysozyme constitutes 20% all tear protiens,highest in
conc among all body fluids
Electrolytes Na,K and Cl higher concetrations in tears
than in blood
12.
13. FUNCTIONS OF TEAR FILM
Makes corea a smooth optical surface
Wets cornea and conjunctiva and prevent from drying
Flushes out debris and organisms
Bactericidal properties (presence of lusozyme,lactoferrin
and betalysin)
Ig’s and specific Ab in tears defend the eye against
infections
Lubricating action
Enables anti inflammatory cells to reach injured cornea
and conjunctiva
Provides epithelial cells with O2 ,Glucose and Growth
Factors
14. NEURAL ASPECTS
The trigeminal v1 (fifth cranial) nerve bears the sensory
pathway(afferent) of the tear reflexes.
The motor pathway is autonomic (involuntary), &, in
general, uses the pathway of the facial (seventh) nerve
in the parasympathetic division via pterygopalatine
palatine ganglion, as efferent pathway.
Applied A newborn infant has insufficient development of
nervous control, so she/he "cries without weeping”.
15.
16.
17. APPLIED ASPECTS
Crocodile tears syndrome/ Bogorad's syndrome"
uncommon consequence of nerve regeneration
subsequent to Bell's palsy or other damage to the facial
nerve in which efferent fibers from the superior salivary
nucleus become improperly connected to nerve axons
projecting to the lacrimal glands (tear ducts), causing one
to shed tears (lacrimate) during salivation while smelling
foods or eating.
Presumed that one would also salivate while crying due to
the inverse improper connection of the lacrimal nucleus to
the salivary glands, but less noticeable.
18. TEAR FILM DYNAMICS
Secretion of tears
Formation of tear film
Retention & redistribution of tear film
Displacement phenomenon
Evaporation from the tear film
Drying & break up of tear film
Dynamic events during blinking
Elimination of tears
20. BASAL SECRETION
In the human eyes the cornea is
continually kept moist & nourished by
basal tears.
• They lubricate the eye & help to keep it
clear of dust.
• Secreted by accessory lacrimal glands
21. •
REFLEX SECRETION
•Results from irritation of the
eye by foreign particles,
bright light,hot & peppery
stimuli to the tongue.
•These reflex tears attempt
wash out irritants that may
have come into contact with
the eye.
•Secreted by main lacrimal
gland
22. Applied If lacrimal gland is damaged in
surgery or other failure of lacrimal
function occur, it is not a serious matter,
for the accessory glands are enough for
general secretion
23. 2.FORMATION OF PRE OCULAR TEAR FILM
Conjunctival mucus spreads on to the
cornea by the action of the lids.
On this new surface- aqueous layer is
spread spontaneously.
Over this the superficial lipid layer
spreads; probably contributing to its
stability & retarding evaporation b/w
blinks.
24. 3.RETENTION & REDISTRIBUTION
The outer most layer of corneal
epithelium+mucopolysaccharides leads to
retention.
Precorneal film is stagnant. Redistribution
occurs in the form of bringing of new tear
fluid by way of marginal strip where there
is constant flow of tears
25. 4.DISPLACEMENT PHENOMENON
Demo that cornea is covered by a film which
has stability, compressibility, elasticity &
unaffected by gravity
Demo by upward movement of particles in the
film on displacing lower eyelid upwards over
eyeball
This phenomenon is possible due to presence
of thin monomolecular layer on the surface of
cornea
26. 5.EVAPORATION
All lipid films including wax esters & cholesterol
esters retard evaporation of water
Important in low humidity & turbulent air flow
near cornea, such as exists in a windy & arid
climate
Evaporation from tear film = 10% of production
rate, so, evaporation = 0.12ul/min (as tear
production = 1.2ul/min)
27. 6.STABILITY, DRYING & RUPTURE OF TEAR FILM
Tears has to cover entire preocular surface to function
properly
It is re-established completely after a blink , but has short
lived stability
It takes 15-40 secs for tear film to rupture & dry spots to
appear, when blinking is prevented
Drying of corneal surface cannot be a result of evaporation
of water alone, as it takes at least 10 mins to eliminate
whole tear film by drying alone.
28. 7.ELIMINATION OF TEAR FILM
HOLLY & LEMP’S MECHANISM
Initially all the tear film thins uniformly by evaporation.
When thinned out to critical thickness, some lipid
molecules attracted by the mucin layer & migrate
down to this layer.
When the mucin layer is sufficiently contaminated by
lipid from the top, the mucin becomes hydrophobic &
the tear film ruptures
Blinking repair this and restore aqueous layer
29.
30. 8.DYNAMIC EVENTS DURING BLINKING
As the upper lid moves downwards, the superficial
lipid layer is compressed b/w the lid edges
This will contaminate the mucus & this lipid
contaminated mucus is rolled up in a thread like
shape & dragged into lower fornix
When the eye opens, at 1st the lipid spreads in the
form of a monolayer against the upper eye lid
Then spreading of the excess lipid follows & in
about 1 sec multimolecular lipid layer is formed
The spreading lipid drags some aqueous tears with
it thereby thickening the tear film.
31.
32. 9.ELIMINATION OF TEARS
Lacrimal fluid over the preocular surfacemarginal tear
stripLacus lacrimalisinner canthus lacrimal
passages nasal cavity
Lacrimal pump mechanism:- fibres of the pretarsal &
preseptal portion of the Orbicularis which arise from the
lacrimal fascia & posterior lacrimal crest.
This LPM operates with the blinking movements of the
eyelids as follows:-
33.
34. DRAINAGE OF LACRIMAL FLUID FROM NLD INTO
NASAL CAVITY
Gravity helps downward flow.
Air currents in nose induce negative pressure within
NLD draw the fluid down the potential lumen of the
duct into the nose.
Hasner’s valve present at lower end of NLD,
remains open as long as the pressure within nose
is less than the NLD, allows the tears to flow from
NLD to nose
35.
36. 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
37. HISTORY FOR A DRY EYE(DE) PATIENT
Duration of reading or computer use
Using contact lens
Living in air conditioned environment
Frequent air traveling
Cigarettes smoking
Exposure to allergans or systemic allergies
Hormonal change
Autoimmune diseases
38. 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)
39. 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
40. DISEASES RELATED TO DYSFUNCTION IN
TEAR FILM
•Hyper secretion of tear film
C/O Wet eyes
Lacrimation from
excess tearing
Obstructive
epiphoria as a result
of failure of tear
drainage
( Schirmer’s value)
41.
42. TEAR FILM BREAK-UP TIME(BUT)
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
43. 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
44. 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
Performed in dim light with fans
and ACs switched off
45. SCHIRMER TEST
Without Anesthesia
Measures Reflex Tear
Secretion (dry eye = < 6mm
wetting)
With Anesthesia
Measures Basal Tear
Secretion (dry eye =< 3mm
wetting)
46. 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
47. JONES-II (SECONDARY) TEST
Helps to identify the probable site of partial obstruction
4% xylocaine instilled in the conjunctival sac
residual fuorescein washed out
NLD irrigated with NS
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