The talk "Chronic Issues of Dry Eyes" was delivered as a webinar series on 30 Jan 2021. Prof Dr Zia ul Mazhry was the guest speaker. The talk was followed by a lively Q&amp;A session. This webinar was sponsored by Schaigan Pakistan with their leading dry eye treatment brand Eyelub Eye drops. Eyelube composition is as under:<br>Polyethylene Glycol 400 0.4% (lubricant), Propylene Glycol 0.3% (lubricant), Hydroxypropyl Guar (GEL FORMING MATRIX) Sodium Perborate as a disappearing preservative.

1. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Chronic issues of dry eye syndrome
Prof Zia-Ul-Mazhry
FCPS(Pak),
FRCS(Edin),
FRCS(Glasgow),
CIC Ophth- (UK)
Consultant Eye Surgeon &
Head, Department of
Ophthalmology
Wapda Hospital Complex
Lahore.

2. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome

3. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Discussion Plan
Definition and classification
Simplified diagnostic approach
Therapeutic approach
 Choosing right treatment for right patient
Review of the study
Discussion and conclusion
Making Dry Eyes Wet

4. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Historical Perspective
 E. Wolff first described the multi-layer
tear film in 1946.1
 In 1973, Frank J. Holly, Ph.D., explained
that mucin had a much greater role than
previously thought.2
 In 1997, Scheffer Tseng, M.D., Ph.D.,
that the layers are inextricably intertwined
to produce a healthy ocular surface.3
1-Wolff E. The muco-cutaneous junction of the lid margin and distribution of the tear fluid. Trans Ophthalmol Soc UK 1946;66:291-308.
2-Holly FJ. Formation and stability of the tear film. Int Ophthalmol Clin 1973 Spring;13(1)73-96.
3-Tseng SC, Tsubota K. Important concepts for treating ocular surface an tear disorders. Am J Ophthalmol 1997 Dec;124(6):825-35.

5. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Lacrimal Functional Unit
Basic and accessory
lacrimal glands (Wolfring
and Krause)
Corneal and conjunctival
epithelium
Eyelids
Meibomian glands
Sensory and autonomic
nerves

6. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
The Healthy Tear Film
A Delicate Balance
 Lipid, aqueous and mucin
components
 Outer lipid layer prevents
evaporation
 Secreted by meibomian glands
 Aqueous component – a
complex mixture of proteins,
mucins, electrolytes
 Secreted by main & accessory
lacrimal glands
 Mucins provide viscosity and
stability during the blink cycle
 Mucin gel decreases in density
toward tear film surface
Image from Dry Eye and Ocular Surface Disorders, 2004

7. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Definitions
 1995 NEI/Industry working group
on Clinical Trials in Dry Eye
 A disorder of the tear film due to
tear deficiency or excessive tear
evaporation which causes damage
to the interpalpebral ocular surface
and is associated with ocular
discomfort
 2006 Delphi consensus group
Dysfunctional Tear Syndrome
 2007 TFOS DEWS
 A multifactorial disease of the tears
and ocular surface that results in
symptoms of discomfort, visual
disturbance and tear film instability
with potential damage to the ocular
surface. Accompanied by increased
osmolarity of the tear film and
inflammation of the ocular surface.

8. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Dry Eye (Keratoconjunctivitis sicca)
 A multifactorial disease of the ocular surface, characterized by
loss of tear homeostasis and ocular symptoms
 Tear instability
 Hyperosmolarity
 Damage and inflammation of the ocular surface
 Neurosensorial abnormalities
 Affects 5-50% of the population
Craig JP et al. TFOS DEWS II Definition and Classification Report. The Ocular Surface 15 (2017) 276-
Plays an etiological
role

9. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Pathophysiology of Dry Eye
Tear
osmolarity
Inf.
cytokine
secretion
Surface
epithelial
cell
damage
Death of
cells by
apoptosis
Loss of
goblet
cells
Tear
instability

10. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Consequences of Tear
Composition Changes in CDE
• Altered environment for ocular surface tissues
– Increased osmolarity
– Imbalanced growth factors and cytokines fail to promote normal
epithelial growth
– Poor viscosity can cause thin spots in tear film and tear break-up –
Lubrication compromised
• Ocular surface damage
– Loss of corneal epithelial integrity
– Squamous metaplasia of conjunctival epithelium
– corneal filamentary keratitis; marked corneal punctate staining; central
corneal staining, conjunctival scarring; corneal erosions; severe corneal
staining
• Altered lifestyle

11. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Prevalance
5% of adult population
 4rth decade of life
10-15%
 Over 65 years of age
Making Dry Eyes Wet

12. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
 Evaporative type has a greater share (3:1), 30% are
mixed
 Meibomian gland dysfunction is the leading cause of dry
eye

13. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Etiological Classification

14. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome

15. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Symptomatology
Making Dry Eyes Wet
 Burning, stinging, itching
 dry or FB sensation
 redness
 Fatigue
 Gritty sensation
 blur (fluctuations of vision)
 occasional excess tearing

16. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Signs of Dry Eye
Lower tear film strip < 0.5 mm
Tear debris
Conjunctival hyperemia
Appearance of Meibomian glands
Conjunctivochalasis

18. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
‫ویراں‬ ِ‫ت‬‫کش‬ ‫کرے‬ ‫سیراب‬ ‫جو‬ ‫اشک‬ ِ‫ء‬ ‫قطرہ‬
‫آنکھیں‬ ‫سوالی‬ ‫ہیں‬ ‫پھرتی‬ ‫ڈھونڈتی‬ ‫گر‬ ‫چارہ‬

19. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Dry Eye affects vision
 33 % Report Night Driving
Problems
 28 % Report Reading Problems
 26% Report Computer Problems
 17% Report Problems Watching
Television
» DEWS Diagnostic Study Group
Making Dry Eyes Wet

20. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Dry Eye does affect quality
of life
Making Dry Eyes Wet

21. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Factors that cause “DES”
aging
hormonal changes
contact lens wear
laser vision surgery
computer use
medications
systemic diseases

22. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Dry Eye Diagnosis
 thorough slit-lamp examination
 Uneven or scanty tear meniscus
 Vital staining
 Tear film break-up time
 Schirmer lacrimation test
 Lack of goblet cells
 The lid functioning,
 Mucous shreds and strings
 Lid parallel folds
Making Dry Eyes Wet

23. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Dry Eye Diagnosis
Making Dry Eyes Wet
Test cutoff value for dry eye
diagnosis
● Schirmer's I less than or equal to 5 mm
wetting over 5 minutes
● Tear Breakup time less than or equal to 10seconds
● Tear Meniscus height less than or equal to 0.2 mm
● Fluorescein staining more than 3 out of 15
● Rose Bengal staining more than 3 out of 18
● Tear film osmolarity more than 316 mOsm/L
● Impression cytology more than 1
● Brush cytology more than 1
● Tear lactoferrin less than or equal to 0.9 ug/mL

24. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Non Invasive Break up
time (NIBUT)
clinician focuses and views the crisp
keratometric mires, and then records the time
taken for the mire image to distort (TTT) and/or
break up (NIBUT). NIBUT measurements are
longer than fluorescein break up time.
Making Dry Eyes Wet

25. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Symptomatic Tear Break-
Up Time (SBUT) test
 Obtain a stopwatch or clock.
 Blink 2 times, then stare straight ahead, taking care to start timing
immediately after your second blink.
 Avoid blinking for as long as possible.
 Note the time on the clock when you begin to feel eye discomfort
(burning, grittiness, dryness, etc.)
 The SBUT is the amount of time (in seconds) that passes between your
last complete blink and the moment you experience eye discomfort.
Making Dry Eyes Wet
SBUT is 5 seconds or less, you may have dry eye
Dry Eye Syndrome test at Systane_com.htm

26. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Grading of Dry Eye
Patient questionnaires
 Standard Patient Evaluation of Dryness
Questionnaire
 OSDI (Ocular Surface Disease Index)
 DEQ (Dry Eye Questionnaire) DEQ-8, CL DEQ
 NIH Visual Functioning Questionnaire
 Impact of Dry Eye on Everyday Life Questionnaire

27. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Dry eye questionare

28. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Severity Level
 Level 1: Mild to moderate
symptoms; mild to moderate
conjunctival signs; no staining
 Level 2: Moderate to severe
symptoms; tear film signs; visual
signs; mild corneal punctate
staining; conjunctival staining
 Level 3: Severe symptoms;
corneal filamentary keratitis;
marked corneal punctate
staining; central corneal staining
 Level 4: Extremely severe
symptoms/altered lifestyle;
conjunctival scarring; corneal
erosions; severe corneal staining
Making Dry Eyes Wet

29. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Comprehensive “dry eye
assessment” can include:
• To treat a DE the clinician needs to know
according to the Triple Classification of DE
1. Etiology: rareley one; usually, several
2. Affected glands: aqueous, lipid
or/and mucinic
3. Severity: 1, 2 or 3
Making Dry Eyes Wet

30. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Principles of treatment
Treat the Symptoms
Treat the Cause
Treat the complications

31. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Treatment Goals
• Establish the diagnosis of dry eye,
differentiating it from other causes of
irritation and redness
• Identify the causes of dry eye
• Establish appropriate therapy
• Relieve discomfort
• Prevent complications, such as loss of
visual function, infection, and
structural damage
• Educate and involve the patient in
the management of this disease

32. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Treatment Algorithm (ITF)
Level One
 Patient education
 Environmental modification
 Control systemic medications
 Control allergy
 Preserved tears
Level Two
 Unpreserved tears
 Gels and nighttime ointments
 Nutritional support
 Cyclosporine
 Topical steroids
 Secretagogues

33. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Treatment Algorithm (ITF)
Level Three
 Oral tetracyclines
 Punctal plugs after
inflammation controlled
Level Four
 Systemic anti-inflammatory
therapy
 Acetylcysteine
 Moisture goggles
 Punctal cautery

34. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Therapeutic approach
 Supplementation of Aqueous Tears (tear
substitutes)
 Preservation of Aqueous Tears (goggles,
punctal plugs, etc.)
 Stimulation of Aqueous Tear
Secretion (secretagogues)
A
rtificia
l te
a
rs
T
e
a
rre
pla
ce
m
e
nt
P
uncta
l P
lugs
T
e
a
rP
re
se
rv
a
tio
n
T
re
a
tm
e
nt

35. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
TEAR REPLACEMENT THERAPY
Main stay of Current dry eye
management is :

36. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Normal healthy tears
Normal
Healthy
Tears

37. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Tears in Chronic Dry Eye (CDE)
 Lesser concentrations of many
proteins in CDE
 e.g. antimicrobial proteins
 Growth factor concentrations
decreased
 Cytokine balance shifted,
promotes inflammation
 Soluble mucin 5AC greatly
decreased
 Due to loss of goblet cells
 Impacts viscosity of tear film
 Activated proteases
 Degrade extracellular matrix
and tight junctions
 Increased electrolytes
Making Dry Eyes Wet

38. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Ideal Tear substitute
 Viscosity
 Exit time increased
 Vision decreased
 Hypoosmolar
Ph Value around 7
 Thixotropy
• The property of becoming
fluid when shaken and then
becoming semisolid again
 Preservatives/preservative
free/disappearing
 BAK, Polyquad
 Gen Aqua Sodium Perborate
Contact lens Tolerance
Patient
satisfaction

39. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Chronic issues of dry eye syndrome
Is Ideal tear substitute
currently available?
NO

40. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
A tear drop

41. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Artificial Tears
Artificial tears contain
electrolytes –
But they lack the complex
mixture of proteins,
mucins and other factors
found in normal healthy
tears
Provide temporary,
palliative relief
Making Dry Eyes Wet
Artificial
Tears

42. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
A Tear Drop Composition
Making Dry Eyes Wet

43. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Drug Components
Eyelub Polyethylene Glycol 400
0.4% (lubricant),
Propylene Glycol 0.3%
(lubricant), Hydroxypropyl
Guar (GEL FORMING
MATRIX)
Sodium Perborate as a
preservative.
Making Dry Eyes Wet

44. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Preservatives. Historical Perspective
 Chemicals to prevent microbial spoilage of
pharmaceutical preparations
 1953: FDA adopted the view that a non-sterile
ophthalmic solution was unacceptable
 1955:A sterility requirement in the official
compendium.
 Mid 60s: Preservatives to be included in the
Ophthalmic preparations by regulatory authorities
in Europe and USA.

45. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Ideal Preservative
 Broad spectrum antimicrobial activity
 Chemical and thermal activity
 Compatibility with container and other
compounds present
 Innocuous towards ocular tissues

46. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Preservatives in current use
 BAK
 ( Hicel, Naphtears,
Optitears)
 Polyquad
 ( Tears Naturale11,
Systane)
 Chlorbutanol
 (Blink fresh,Tears
Plus,Lacrilube,
Optolube)
 Sodium Perborate
( Eyelub )
 Stabilized
Oxychloro
Complex (SOC)
(Refresh)

47. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Preservative a liability
Making Dry Eyes Wet
Preserved
Preservative free
Disappearing

48. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Choosing the right brand for
the right patient
Making Dry Eyes Wet

49. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Choosing the right brand for the right patient
 In the treatment of a dry eye, frequent
instillation of drops is required
 We should chose drops which is effective
and least toxic.
 We should chose the one where
preservative is either not present or
preservative disappear soon after the
instillation.

50. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Preservative system of
GenTeal
 Eyelub uses a unique perborate buffering system
which produces small amounts of H2O2 in solution
 The H2O2 concentration in the bottle is < 60 ppm
 When instilled into the eyes, the H2O2 (in Eyelub)
is degraded by ocular enzymes to harmless water
and oxygen within 30-60 seconds1
 After 1 minute, no preservative is left that could cause irritation or
damage to the eyes1
The H2O2 preservative system used in
Eyelub
is safe and well-tolerated

51. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Eyelub eye Drops
Preservative sodium
perborate

52. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
GenTeal drops and gel – summary
Preserved in the bottle - preservative free
in the eye1
Hypotonic formulation to help break the dry
eye cycle
Convenient and economic multi-dose
packaging
Available as:
Drops for mild to moderate dry eyes

53. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
“a tear drop on cheek of time”
Rabinder Nath Tegor

54. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
To Summarize:
Dry Eyes
Multi
Factorial
Disorder
Comprehen
sive
assessment
Severity
Level
Tailored
Therapeutic
Approach
Mono
Therapy
Combinatio
n Therapy
Immunomo
dulation
Surgical
Intervention

55. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Conclusion
Disappearing preservative
artificial tears family is an
excellent recent additions to
available options to treat dry eyes
symptomatically.

56. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Conclusion
To reach our collective goal of ocular
surface protection, we must heal the
damage and reduce inflammation and
irritation. This will likely be accomplished
by a line of products rather than one
“cure-all”. With the many causes of dry
eye and nearly as many therapeutic
approaches, we will certainly be looking
at combination therapy, with different
treatments for different ideologies.

57. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
Keep blinking

58. Prof. Mazhry FRCS, FCPS
Chronic issues of dry eye syndrome
‫ویراں‬ ِ‫ت‬‫کش‬ ‫کرے‬ ‫سیراب‬ ‫جو‬ ‫اشک‬ ِ‫ء‬ ‫قطرہ‬
‫آنکھیں‬ ‫سوالی‬ ‫ہیں‬ ‫پھرتی‬ ‫ڈھونڈتی‬ ‫گر‬ ‫چارہ‬