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Dry eye
- 1. Management of Dry Eye Suhaib Ali Jawad 2nd year trainee Iraqi board of ophthalmology
- 2. Dry eye • Extremely common in our daily practice • Any age , female , male , even children • Can be mild to severe • Devastating and frustrating • “ Long life treatment “ ?
- 3. Lacrimation Lacrimal Glands N.VII Secreto-motor Nerve Impulses Tears Support and Maintain Ocular Surface PONS Ocular Surface Neural Stimulation N.V dry spot > pain > reflex stimulation > lacrimation
- 4. Tear film composition Lipid : 0.1 um • esters, glycerol , fatty acids • product of palpebral meibomian glands • prevents excessive evaporation
- 5. Aqueos / watery : 7 um Epithelium • Secreted from lacrimal gland • electrolytes, protein, antibody, oxygen , CO2, mineral , glucose
- 6. Mucin : 0,02 - 0,05 um May increase up to 30 um • Product of conjunctival Goblet cells present in bulbar conjunctiva , caruncle • Maintain tear film stability • Glycocalyx produced by epithelial cells help bind mucins onto the epithelial surface by by converting cornea hydrophilic.
- 7. Tear dynamics / each blink
- 8. Tear film function Maintain integrity of cornea & conjunctiva • Smoothes ocular surface , improve vision • Wash away all the dirty materials coming onto the eye • Moisturizing, lubricating for comfort , eye movements • Media transport for O2 , CO2 ( 40% from atmosphere ) • Nutrition ( glucose, electrolytes, enzymes , protein ) • Defense : Anti bacterial, antibodies, lysozyme
- 10. Definition DEWS Report 2007 • Dry eye is a multifactorial disease of the tears ( volume or Function ) and ocular surface that results in symptoms of discomfort, visual disturbances, and tear instability with Potential damage to ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface .
- 11. Dry Eye - Inflammation Model
- 13. Dry Eye Etiology Aqueous Evaporative Deficient Oil Deficient Lid Related Contact Lens Surface Change Sjogrens Non-Sjogrens Lacrimal Lacrimal duct Reflex hyposecretionDeficiency Obstruction Auto-antibodies primary VS secondary NEI Workshop - Classification of Dry Eye
- 14. Dry Eye - Tear Film Deficiencies Lipid Layer Deficiency alterations in meibomian gland secretion (e.g. blepharitis, hordeolum, chalazion ) Aqueous Layer Deficiency aqueous deficient dry eye (e.g. inflammation, neurological defects, trauma, congenital absence of lacrimal tissue ) Mucin Layer Deficiency mucin deficient dry eye (e.g. Stevens-Johnson syndrome, pemphigoid, vitamin A deficiency, trachoma, radiation)
- 15. Influential Factors of Dry Eye Age Gender Arthritis Osteoporosis Gout Lens Surgery Contact Lens Wear Blink Disorders Disorders of Lid Aperture Nutritional Problems Rheumatoid Arthritis Thyroid Problems Time of Day LASIK Surgery Cosmetic Surgery Mechanical Disturbances Exposure Keratitis Entropion Ectropion Symblepheron Formation Large Lid Notches Lagophthalmos Incomplete Blinking Dellen Formation Illumination Temperature Humidity Air movement Allergies Change in environment Reading Watching Movies Sleep
- 16. Conditions associated with dry eye • Chronic Systemic inflammation Sjogren’s Syndrome, rheumatroid arthritis, lupus • Ocular surface inflammation Meibomian gland disease, keratitis, infection • Hormonal changes Menopause, oral contraceptives, pregnancy, lactation • Systemic disease Diabetes, thyroid - Stevens Johnson’s syndrome : severe dry eye
- 17. • Environment • Smoke, air pollution, wind, heat, air-conditioning, air travel, light, dry climate staring at TV , computer reading , etc ( Less blinking reflexes ) • Medications Systemic Anti-depressants Antihistamines Antihypertensives diuretics B-blocker Antimuscarinics anesthesia phenothiazines Atropine oral contraceptives anxiolytics antiparkinsonian Anticholinergics antiarrhythmics isotretinoin Topical decongestants preservatives anesthetics
- 18. Diagnosis of dry eye • Obtaining patient history • Physical examination • Staining of the corneal surface • Tests of tear production • Tests of tear film stability (TBUT) • Test of tear osmolarity Confirm and quantify DED
- 19. Complains • irritating • burning / stinging • easily fatigue • itchy • foreign body sensation • photophobia • fluctuating vision / blurry • contact lens intolerance • sticky • dryness / watering • sleepy • discharge • redness
- 20. Patient History • Ocular symptoms Redness, dryness, itching, burning, visual problem, etc. • Current illnesses Sinus or ear trouble, hay fever, skin disorders, asthma, etc. • Medications Antihistamines, beta blockers, oral contraceptives, etc. • Duration of the present problem Recent or ongoing...weeks, months, etc. • Family history of a similar problem Parents, siblings, • Any present refractive condition Glaucoma and contact lenses, etc. • Timing of symptoms on awakening or worse over the day
- 21. Physical examination Five main components of a clinical examination involve: • The lids • The blink mechanism • The tear film • The ocular surface • General physical assessment
- 22. Signs • • • • fast tear break up time • conjunctival keratinization epitheliopathy, filaments, plaques • hyperemia • tear meniscus <0.2-0.4mm • Increase tear debris • posterior blepharitis • conjunctival staining • corneal staining /damage • Complication : epith break Melting,perforation,keratitis
- 23. Signs
- 25. Lid Wiper Epitheliopathy Early sign of DED even in pt w normal TBUT + schirmer and normal staining pattern
- 26. • Complication : - epithelial breakdown - Melting - Perforation - Bacterial Keratitis Signs
- 27. Tear Film Break-Up Time ( TBUT ) • Time required for a random dry spot to appear on the corneal surface after blinking • Dry spots will appear as part of normal evaporation and diffusion of tears • Normal healthy eye : dry spots start occuring between blinks at about 10-12 seconds, and an urge to blink is triggered • abnormal ( < 10 sec ) in aqueous deficiency and MGD.
- 28. Blink Tear Protected Ocular Surface 0 1 2 3 Time (seconds) Dry Eye - Consequences of an ‘Unprotected Ocular Surface’ TFBUT Unprotected Ocular Surface 4 5 6 Ocular Staining Discomfort Blink Cycle Repeats 7
- 29. Tests of tear production • standard diagnostic tests for aqueous tear production , single test not enough. • Schirmer test I : the filter paper strip is placed in the unanesthetized eye and is left in place for 5 minutes. • no dry eye : enough tears to wet 20 to 25 mm of the paper strip • Wetting of < 10 mm is suggestive of dry eye • Schirmer Tear Test II : with topical anesthesia . • Max tear : basal and reflex , <10mm abnormal . • for basal production only , <6mm abnormal .
- 30. Slit-Lamp Biomicroscopy and Corneal Staining Types of corneal staining include: • Fluorescein - Discloses epithelial breaks and erosions • Rose Bengal - Assesses degenerated tissue; good for Filaments and plaques , S/E discomfort • Lissamine Green - similar to rose bengal but more comfortable to the patient • staining pattern - Interpalpebral , superior , inferior • staining intensity – correlate with the severity
- 31. Corneal Staining
- 32. Tests of tear Osmolarity Use IR wave , high IQ prism tip , results within 1 esc , disposable cap .
- 33. How to treat ... Are artificial tears enough?
- 34. Treatment : supportive Goals : • Alleviate symptoms • Reduce ocular morbidity • Prevent complications • Improve quality of life • Improve productivity • Maximise benefit and relief • Minimise cost
- 35. Treatment Strategy Intervention Tear supplementation Lubricants Tear retention • Punctal occlusion • Moisture chamber spectacles • Contact lenses Tear stimulation Secretagogues Biologic tear substitutes • Serum • Salivary gland transplantation Anti-inflammatory therapy • Cyclosporine • Corticosteroids • Tetracyclines Essential fatty acids Omega-3 fatty acids Environmental strategies • Avoid low humidity • void drafts • VDT lowered below eye level
- 36. Severity level 1 2 3 4 Symptoms Mild/episodic, with Moderate Severe frequent Severe and or stress episodic/chronic, constant no stress disabling no stress + stress Visual symptoms None, or episodic mild Annoying and/or Annoying, chronic, Constant and/or fatigue limiting lid and/orconstant, possibly disabling fatigue limiting activity Conjunctival None to mild None to mild +/- +/++ injection Conjunctival None to mild Variable Moderate to marked Marked staining Corneal staining None to mild Variable Marked, central Severe punctate (severity/location) erosions Corneal/tear signs None to mild Mild debris, Filamentary keratitis, Filamentary keratitis, decreased mucus clumping, mucus clumping, meniscus increased tear debris increased tear debris, ulceration Lid/Meibomian MGD variable MGD variable Frequent Trichiasis, glands keratinization symblepharon TBUT (sec) Variable <10 <5 Immediate Schirmer score Variable <10 <5 <2 (mm/5 min)
- 37. Severity level 1 2 3 4 Treatment If no improvement If no improvement If no improvement options to Level 1, add: to Level 2, add: to Level 3, add: • Patient education environment/dietary modification • Eliminate offending systemic medications • artificial tears/ ointments/gels preservative • Lid therapy • nonpreserved artificial tears •Antiinflammatory Drugs : Topical : - Corticosteroids - cyclosporinA - omega3 fatty acids •Tetracyclines •Cyclosporine •Punctal plugs •Secretagogues •Moisture goggles • Serum : - autologus - Umbilical cord •Contact lenses • Permanent punctal occlusion Systemic antiinflammatory •Oral cyclosporine •Acetylcysteine Moisture goggles Lid Surgery: tarsorrhaphy, AMT graft Mucous m graft Salivary gland transplantation More recent facts : - Start use topical anti inflammatory + plugs for mild cases for better results - Add artificial tears when there is moderate degree of DED
- 38. drop of an artificial tear • The ideal artificial lubricant should be preservative-free, contain potassium, bicarbonate, and other electrolytes, and have a polymeric system to increase its retention time.
- 39. Varieties of Artificial Tears / Lubricants • Hydroxypropyl Methylellulose ( TNII ,Genteal ) • Carboxy Methylcellulose ( Refresh ) • Polyvinyl Alcohol ( Hypotears ) • Dextran • Glycerin • Eye Gels ( vit.A palmitate) • Polyethylene glycol : Systane • Sodium hyaluronates 0.1 - 0.3%
- 41. HYALUB Sodium hyaluronates 0.1% • Lubricating , protecting • Powerful wetting agent • Long lasting • Reduce ocular surface damage • Accelerate wound healing • Safe , well tolerated for long term use • Non preservative • in IRAQ > hyfresh : sodium Hyaluuronate 2 mg
- 42. Lacrisert Slow release lubricants 5mg hydroxypropyl cellulose Start at 1 hr , remain 14-24 hr , So 1 insert at morning is enough
- 43. Anti inflammatory therapy of dry eye • mild-moderate > Xiidra (lifitegrast 5%) 2016 FDA 1-2/d , 3-4 m ,Initial 4wks are crucial ! Bcz of S/E ( irritation , metallic taste , blurring ) • moderate-advance > Lotemax (NSAIDs) 4/d for 2w then 2/d for 2w then can shift to Xiidra > Restasis ( cyclosporin 0.05%) * goblet cell no. * squamous metaplasia
- 44. • Essential fatty acids omega-3 - reducing ocular surface irritation ( 2000mg/day took 4-6 months) - Reduce bulbar hyperemia 1st at day 30 by anti- Inflammatory action - Reduce tear osmolarity and improve tear stability
- 45. -Management of dry eye is shifting from solely using tear replacement strategies to also controlling inflammation. -Also , the most recent approach is to targeting meibomian gland disease (MGD) as primary driver and regarded as a central etiological factor of DED. -Ocular surface cannot rehabilitated in the absence of healthy meibomian gland function. - LipiFlow or - similar device meibomian paddle ( manual ) - Meibomian glands duct probing in all, the aim is to evacuate mebomian gland content and restore normal flow . Future causal therapy of dry eye
- 48. Surgical treatments ( reserved for severe disease poor/non- compliance ) • Punctum Plug • Surgical / thermal / laser occlusion Advantages • Prolongs natural tear retention • Reduces frequency of artificial tears needed for symptomatic relief • no need patient compliance
- 49. Punctal plugs - Absorbable - Made of collagen or polymers - occlusion duration ranges from 7-180 days - plugs dissolve by themselves or may be removed by saline irrigation - Non-absorbable - Made of silicone - punctum plugs and intracanalicular plugs. ( Cylindrical Smartplug ) - Complications of plugs: - Too far , loss , obstruction , scarring , conjactival Papillomtous Overgrowth , infection , discomfort , coasty ONLY after ocular inflammation subside ? WHY
- 50. Surgical treatments • Parotid duct translocation - Frequently secrete more fluid ,increases during eating - Salivary gland may be affected in Sjogren syndrome • Tarsorrhaphy - Narrowing of the palpebral fissure decreasing the rate of evaporation • Submandibular gland transplantation - For extreme dry eye but produce excessive levels of mucus in the tear film .
- 51. Dry Eye Disease and chronic pain syndrom - Patients who complains from symptoms of dry eye which is more sever than ocular sign in 30%. - This subgroup represent a challenge to healthcare providers as those pt are more resistant to standard treatment strategies . - The underlying mechanism is appear to be due to dysfunctional pain perception - Those subgroup complain and possible suggested mechanism support one of the theory of dry eye dz which claims than DED symptoms is dueto dysfunction in corneal pain system. - Chronic pain syndrom is regional pain without obvious pathology , it include : irritable bowel syndrom , chronic pelvic pain and fibromyalgia. - Those pt usually need neuorologist , rheumatologist or pain Mx clinic.
- 52. KIDS-SCREENS dry eye disease It is well-established that visual attentive behaviour of glued child face to some sort of digital screen. One study revealed a strong positive correlartion between duration of smartphone and DED and negative between outdoor play. Smartphone restriction for 4 weeks there will be a dramatic improvement in S/S of DED , no such results in adults as MGD is a main cause.
- 53. Thank you