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 Disord...
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  int...
TEAR FILM• Lipid layer (meibomian  glands in the eyelid):  Outermost surface of the  tear film; 0.1um• Aqueous layer (lacr...
FUNCTIONS OF THE TEAR           FILM• Lipid layer: Prevents evaporation of tears and acts as an  surfactant allowing sprea...
FACTORS AFFECTING THE   SPREAD OF TEAR FILMNormal   lacrimal neural arc.Contact between the ocular surface & the eyelids...
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 deficien...
SJOGREN’S SYNDROME Autoimmune     inflammation of the  lacrimal glands and the salivary  glands. Primary or Secondary  (...
COMMON NON-SJOGREN’S CAUSES Vitamin A deficiency, Stevens Johnson syndrome and Ocular Cicatricial Pemphigoid (OCP).Affe...
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...
OCULAR CICATRICIAL PEMPHIGOID Autoimmune muco-  cutaneous blistering  disease. Cicatrization of the  conjunctiva & lacri...
COMPUTER VISION SYNDROME Variety of vision related  symptoms that may be  aggravated by regular  use of a computer for  t...
ALLERGIC CONJUNCTIVITIS &    VERNAL KERATOCONJUNCTIVITIS Recurrent inflammation  of conjunctiva & limbus  leading to cica...
MEDICATIONS CAUSING         DRY EYE•Diuretics• Beta-blockers• Antihistamines• Sedatives• Anti-Anxiety medications• Analges...
LIPID LAYER DEFICIENCY Blepharitis, Meibomitis     and Rosacea.Affect the outer lipid layer of the tear film, causing e...
CLINICAL FEATURE:          SYMPTOMS Burning  sensation Foreign body sensation (exaggerates  over the day) Stringy mucus...
CLINICAL MANIFESTATION:             SIGNS   Tear meniscus at the    inferior eye lid margin    <1mm.   Tear Breakup Time...
WORK-UP History with external examination Slit lamp examination with Fluorescein stain to  examine TBUT, Conjunctive & C...
TREATMENTIncrease    tear film volume: Artificial tears(Carboxymethyl  Cellulose/ Hypromellose) Temporary insertion of ...
TEAR SUBSTITUTESCellulose derivatives: Carboxymethyl cellulose 1%, Hypromellose 0.5%Carbomers(Polyacrylic acid)Polyviny...
TREATMENTImprove     Corneal epithelium (In  severe dry): Artificial Tear Substitutes in gel form  with pad & bandage B...
TREATMENT Reduce   Evaporation: Protective glasses Reduce room temperature with humidifier. Lipidic artificial tear su...
TREATMENT Treatment    of Lids: T/t of Blepharitis: Lid hygiene, Lid massage,  Doxycycline 100mg BD Control of Inflamma...
DEWS CLASSIFICATION
DEWS RECOMMENDATION OF            TREATMENTLevel 1 treatment consists of the following: Education and environmental or di...
DEWS RECOMMENDATION OF         TREATMENTIf level 1 treatment is inadequate, level 2  measures are added, including the fol...
DEWS RECOMMENDATION OF         TREATMENTIf level 2 treatment is inadequate, level 3  measures are added, including the fol...
CONCLUSION Dry  eye complaints are a frequent  presentation at Ophthalmic OPD due our  current environment, pollution & l...
REFERENCE; 2007 Report of the International Dry Eye Workshop  (DEWS). The OcularSurface. 2007;5:65-204. Systemic Approac...
Dry eye: An Overview
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Dry eye: An Overview

  1. 1. DRY EYE:AN OVERVIEW Dr.Gayatree Mohanty Dept. of Ophthalmology, KIMS
  2. 2. DRY EYEOccurs when Inadequate tear production Inadequate functionResults in Unstable Tear Film and Ocular Surface Disorder.
  3. 3. TEAR PRODUCTION & TEAR FUNCTION Healthy tear film Dry eye
  4. 4. TEAR PRODUCTION Secreted by the lacrimal glands Spreads over the ocular surface Drained the lacrimal canaliculi into the nasolacrimal duct.
  5. 5. 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.
  6. 6. 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.
  7. 7. FACTORS AFFECTING THE SPREAD OF TEAR FILMNormal lacrimal neural arc.Contact between the ocular surface & the eyelidsNormal corneal epithelium.
  8. 8. OCULAR SURFACEConjunctival epitheliumLimbal EpitheliumCorneal epitheliumEyelids (Mucocutaneous junction)
  9. 9. ETIOPATHOGENESISAqueous tear deficiencySjogren’s DieseasesNon-Sjogren’s DiseasesLipid tear deficiencyMucin deficiencyKinetic disorders of lacrimal fluid
  10. 10. 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.
  11. 11. 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.
  12. 12. VITAMIN A DEFICIENCYXerosis of the conjunctiva resulting in goblet cell destruction & mucin layer deficiency.
  13. 13. 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.
  14. 14. 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.
  15. 15. 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.
  16. 16. 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.
  17. 17. MEDICATIONS CAUSING DRY EYE•Diuretics• Beta-blockers• Antihistamines• Sedatives• Anti-Anxiety medications• Analgesics
  18. 18. 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.
  19. 19. 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
  20. 20. 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.
  21. 21. 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.
  22. 22. 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
  23. 23. TEAR SUBSTITUTESCellulose derivatives: Carboxymethyl cellulose 1%, Hypromellose 0.5%Carbomers(Polyacrylic acid)Polyvinyl alcolhol, Povidone, sodium HylauronateLipids & Oil:Acetylcysteine 5% with Hypromellose.
  24. 24. 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
  25. 25. 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.
  26. 26. 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
  27. 27. DEWS CLASSIFICATION
  28. 28. 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.
  29. 29. 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
  30. 30. 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.
  31. 31. 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.
  32. 32. 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.

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