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 FILMNormal lacrimal neural arc.Contact between the ocular surface & the eyelidsNormal corneal epithelium.
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 DEFICIENCYXerosis 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.
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.
TREATMENTIncrease tear film volume: Artificial tears(Carboxymethyl Cellulose/ Hypromellose) Temporary insertion of punctal plugsImprove Lubrication: Artificial Tear SubstitutesTo break the sticky mucin: Acetylcysteine
TREATMENTImprove 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 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.