ARTIFICIAL_TEARS presentation dhir .pptx

2. Dry Eye And Artificial Tear
PRESENTER - Dr Nikhil Agrawal ( 1st year resident )
MODERATOR – Dr Parikshit Dhir
DHIR HOSPITAL & POST GRADUATE INSTITUTE OF OPHTHALMOLOGY

3. Tear Film
0.02-0.04microns
6-8microns
0.1-0.2microns

4. Secretion of Tears
Afferent pathway of this secretion is formed by fifth nerve and
efferent by parasympathetic (secretomotor) supply of lacrimal
gland.

5. Dry Eye
• Dry eye disease is a disorder of the tear film due to reduced tear production or
excessive tear evaporation, which causes damage to the interpalpebral ocular
surface.
• Symptoms of discomfort, visual disturbance.
• Tear film instability
• Increased Osmolarity
• Increased cytokines & T-cells ,
IL-17 , MMP-9
• Decreased Viscosity
• Increased Friction between
eyelids and ocular surface

6. Etiology
Aqueous Def.
Sjogren’s KCS
Non-Sjogren’s KCS
• Age related
• Lacrimal gland def.
• Lacrimal duct obstruction
• Neurogenic hyposecretion
Evaporative
Meibomian gland
disfunction
Lagophthalmos
Defective blinking
Vit-A def.

9. Slit Lamp Examination
 Increased debris/mucin strands in tear film
 Inspection of tear meniscus at lid margin.
 Normal thickness – 1mm, convex.
 < 0.5mm – tear deficiency.
 In severe cases – Marginal tear meniscus is concave, small &
absent.

10. Questionnaires
• Ocular Surface Disease Index (OSDI) :
i. Scores 0 to 12 :normal,
ii. 13 to 22 : mild dry eye disease
iii. 23 to 32 : moderate dry eye disease
iv. >33 : severe dry eye disease.
• DEQ5: >6 non-SS DE, >12 suspect SS

11. OSDI

12. DEQ-5

13. NIBUT
• Provides noninvasive and objective evaluation of meibomian glands, tear film,
meniscus height and ocular surface.
• The software asses the different segments and distortion in the reflected mires.
• Any placido based device can be used to see break up of the rings .
Clarion OSA

14. Osmometery
• Collects 50nl of tear fluid .
• Gold plated microchip measures the electrical
impedance , this provides the osmolarity .
• Variability >8mOsmol/L between both eyes
indicative od dry eye.
• >316mOsmol/L - Dry eye
• 290-316mOsmol/L – Borderline
• <290mOsmol/L - Normal

15. Vital stains of the ocular surface
• SICCA Ocular Staining Score
• The National Eye Institute grading system
• The Oxford scale1
• The van Bijsterfeld scale.

18. Meibography
Phoenix Meibography Workstation
It uses a slit-lamp biomicroscope with
IR filter and an IR charge-coupled
device video camera to image a
digitally everted eyelid.

19. Tear Film Breakup Time
• Tear film breakup time of less
than 10 sec represent unstable
tear film .
• Sensitivity -82-84%
• Specificity -76-94%
• Development of dry spot
always in the same location
may indicate a local corneal
surface abnormality.

20. Schirmer test
Whatman Filter Paper no.41
Schirmer 1: Basic + Reflex secretion
Without anaesthesia
<10mm in 5 min
Schirmer 2 : Basic secretion
With anaesthesia
<6mm in 5 min

22. Treatment
 First-line -Over the counter artificial tear drops, gels, ointments,
or lubricants .
 Environmental interventions- Increase air moisture and reduce
particles in the air, and nutritional supplements .
 Anti-inflammatory agents- Corticosteroids, cyclosporine A ,
NSAIDS, and tetracycline derivatives .
 Extreme measures- Application of autologous serum , punctal
plugs.

23. • http://clinicalestablishments.gov.in/WriteReadData/6411.pdf

24. Artificial Tears
• Lubricants are the first-line treatment for many causes of ocular irritation, in
particular for dry eye.
• There are a multitude of artificial tear choices available. Goal of this presentation
is to provide information about
• The components that make up artificial tears
• To discuss the functions of these components

25. How Do These Work
• Decrease dryness.
• Humectants: Compounds which promote hydration and feel good
upon application.
• Lubricant: They decrease friction on the ocular surface .
• Increase tear retention by : Increasing tear viscosity, increasing the
adherence of the tears to the ocular surface, decreasing tear
evaporation, and decreasing tear clearance.
• Osmoprotection : To counteract the effects of hyperosmolarity. Eg:
Erythritol , L – carnitine , Glycerol

26. Components of Artificial Tears
• Active Ingredients:
- Demulcents
- Emollients
• Inactive Ingredients
• Preservatives

27. Active Components of Artificial Tears
• Ophthalmic Demulcent: A water soluble polymer, helps to protect and lubricate
mucous membrane .
1.Cellulose derivatives
1. Carboxymethcellulose sodium (CMC)
2. Hydroxypropyl methylcellulose (HPMC)
2.Dextran 70.
3.Gelatin
4.Polyols, liquid
1. Glycerin 0.2 to 1%
2. Polyethylene glycol
3. Polyvinyl alcohol

28. Types of Artificial Tears
• Ophthalmic emollients: It is usually a fat or oil which is applied locally to eyelids
to protect or soften tissues and to prevent drying and cracking.
1.Lanolin preparations
2.Oleaginous ingredients
1. Light mineral oil up to 50% in combination with other emollient agents
2. Mineral oil up to 50% in combination with other emollient agents
3. Paraffin up to 5% in combination with other emollient agents .
4. Petrolatum up to 100%.
5. White ointment up to 100%.
6. White petrolatum up to 100%.
7. White wax up to 5% in combination with other emollient agents .
8. Yellow wax up to 5% in combination with other emollient agents.

29. Demulcents
Demulsants Properties
Carboxymethylcell
ulose sodium
Increase Viscosity (thickener)
Stabilize emulsions
Hydroxypropyl-
Methylcellulose
Cross links upon contact with tear
film due to pH difference to increase
viscosity.
Too viscous to instill easily alone
Polyethylene
glycol
Increases viscosity
Forms protective layer over mucous
membrane to relieve irritation
Propylene glycol Forms a protective layer over mucous
membranes relieving inflammation.
Increases viscosity
Holds up to 3x own weight in water

30. Demulsants
Demulcents Properties
Dextran 70 Increase mechanical strength of
tear film. Requires thickener due to
low viscosity of compound
Glycerine Blunts the damaging effects of high
osmolarity on the ocular surface.
Lubricant, humectant
Promote epithelial cell growth
Gelatin Gelling agent
Polyvinyl alcohol Lowers tear viscosity
Povidone Lubricating and soothing
Lipid that integrates with existing
oil layer, thickening it and reducing
evaporation

31. Emollients
Emollients Properties
Lanolin Lubrication and soothing
Contributes to oil layer
Light mineral oil
Mineral oil
Replace or thicken lipid layer .
Non-moisturizing, but does seal in existing
moisture.
Paraffin Waxy consistency
Seal in moisture
White Wax
Yellow Wax
Contributes to oil layer

32. Inactive Ingredients-The Difference Makers
Inactive Ingredients Properties
Sorbitol Lowers the viscosity of gelling agents Dissipates
quickly, optimizing viscosity. Main addition to the
solution Systane to produce Systane Ultra
Hyaluronic Acid Binds multiples of its weight in water to lower tear
osmolarity.
Adheres to ocular surface.
Highly viscous until blink thins it out.
Improves cell-cell adhesion.
Sodium Hyaluronate Protects and promotes healing of corneal epithelium
It is a humectant, lubricant, and hypo-osmotic.
Helps control localized inflammation.
Reduces mucous strands.
Highly viscous until blink thins it out.
L-carnitine
Erythritol
Osmoprotectants: blunt the damaging effects of high
osmolarity on the ocular surface by . Gets absorbed
by dehydrated cells where they promote hydration
and prevent cell shrinkage and inflammation.

34. Inactive Ingredients
Inactive Ingredients Properties
Hydroxypropyl Guar (HP
Guar)
Increasing viscosity.
Mimics the mucin layer of the eye .
Binds to cornea and aqueous layer .
Actively cross links/gels at pH above pH 7/.
Boric acid
Borate Buffer
Sodium-citrate
Phosphate
Phosphate-citrate
Phosphate-citrate-
bicarbonate
Sodium hydroxide
Buffer systems used to obtain a pH for the
artificial tear that is healthy and comfortable
for the eye.
Calcium chloride
Magnesium chloride
Potassium chloride
Zinc chloride
Sodium chloride
Sodium citrate
Sodium bicarbonate
Electrolytes are added to maintain or lower
tear osmolarity as high osmolarity products
pull water from epithelial cells, interfering
with metabolism.
Some of the added electrolytes are also
important for corneal epithelial metabolism.
Some electrolytes are part of buffer system
• These ingredients function
as buffers, electrolytes,
emulsifiers,
osmoprotectants or
viscosity-enhancers. These
ingredients set individual
drops apart from one
another.
• Trehalose, an
osmoprotectant found in
Refresh Optive Mega-3
stabilizes cell membrane
lipids and proteins and can
protect corneal epithelial
cells from death .

37. Preservatives
• They prevent bacterial growth and subsequent infection.
Detergent type
• Bacterial cell
death by
interrupting the
lipids in their cell
membranes
• Fairly toxic to
human cells
• BKC ,polyquad ,
Oxidative type
• Damages bacterial
DNA, proteins,
and lipids
• Effective at very
low
concentrations
• Sodium perborate
, stabilized OCC ,
Ionic buffering
systems
• Similar to
oxidative
preservatives
• Have both
antibacterial and
antifungal
properties
EDTA-Chelating
Agent

38. References
• https://www.reviewofcontactlenses.com/article/artificial-tears-looking-beneath-
the-surface
• http://webeye.ophth.uiowa.edu/eyeforum/tutorials/artificial-tears.htm
• https://www.researchgate.net/publication/323579529_Combination_of_hyaluro
nic_acid_carmellose_and_osmoprotectants_for_the_treatment_of_dry_eye_dise
ase/fulltext/5a9e960b0f7e9b80dfb4e452/Combination-of-hyaluronic-acid-
carmellose-and-osmoprotectants-for-the-treatment-of-dry-eye-
disease.pdf?origin=publication_detail
• https://www.reviewofoptometry.com/article/master-the-maze-of-artificial-tears
• Google Images

40. TYPES
DRY EYE
Aqueous
deficiency
Mucin
deficiency
Lipid
abnormality
Impaired lid
function
 Keratoconjunctivitis
sicca
 Riley-Day syndrome
 Congenital Alacrima
 Paralytic hyposecretion
 Idiopathic
 Hypo-vitaminosis A,
 Ocular pemphigoid,
Stevens-Johnson
syndrome
 Drug induced
 Chemical burns.
 Chronic
blepharitis.
 Exposure keratitis
 Symblepharon
 Pterygium
 Eyelid trauma
Others :
 Alteration in microvillous morphology of corneal epithelium.
 Anaesthetic cornea after damage to the trigeminal nerve .

41. Dry Eye and Inflammation
• White Inflammation
• Due to
-neurogenic inflammation
-Hyperosmolarity
-Chronic irritation ( contact lens )
-Auto immune disease
• Mediated by T-cells , IL-17 , MMP-9
• Cyclosporine and tacrolimus might help in mild cases .