Dry eye, also known as keratoconjunctivitis sicca, is a condition caused by inadequate tear production or unstable tear film. It results in ocular irritation, redness, and visual disturbance. The tear film consists of an outer lipid layer, middle aqueous layer, and inner mucin layer. In chronic dry eye, tears have increased salts and decreased proteins and lipocalins. Treatment focuses on lubricating the eyes, managing underlying conditions like blepharitis, and occasionally punctal plugs or anti-inflammatory drugs. Diagnosis involves tests of tear production, stability, and ocular surface staining to determine the best lubricating and anti-inflammatory treatments.

1. Dry eye
By: Manal Al-Romeih

2. definition
A condition that occurs when there
is:
Inadequate tear volume
Unstable tear film
Ocular surface disease
Keratoconjunctivitis sicca (KCS)

3. Tear film consists of:
• Lipid layer  evaporarive dry
eye.
• Aqueous layer
• Mucin layer  aqueous
deficiencies & evaporative states.

4. Tears in Chronic Dry Eye
↓ water, ↑salts, ↓proteins
↑Electrolyets  ↑osomlarity
↓ lipocalins (lipid-binding proteins)
 ↑ surface tension
↓ lysozyme ↑ inflammation
susceptability
Proteases  activated
Cytokines:
Protein protective mechanism
↑ IL-1β (excitatory, initiates the fight,
irritation)
↓ IL-1RA (inhibitory)
↑ TGF  ↑ inflammation

5. Factors affecting resurfacing of tear
film:
• Normal blink reflex
• Contact between external ocular surface &
eyelids
• Normal corneal epithelium

6. Regulation of tear film
component:
Hormonal:
• Androgens  lipid production.
• Oestrogen & progesterone receptors in
conjunctiva & lacrimal glands  normal
tissue function.
Neural:
• Adjacent fibers to lacrimal glands & goblet
cells  aqueous/ mucus secretion.

7. :Lacrimal gland innervation

8. 12 Cranial nerves:
2nd Optic: vision (II)
3rd Oculomotor: eyelid and eyeball movement (III)
4th Trochlear: motor for vision (turns eye downward &
laterally) (IV)
5th Trigeminal: chewing, face and mouth touch and pain
6th Abducens: motor to lateral rectus muscles (VI)
7th Facial: controls most facial expressions , taste,
secretion of tears & saliva (VII)

9. Trigeminal 5th
The ophthalmic
nerve (V1) carries
sensory information
from the scalp and
forehead, the upper
eyelid, the conjunctiva
and cornea of the eye,
the nose, the nasal
mucosa, the frontal
sinuses, and parts of
the meninges.

10. Classification
Aqueous layer
deficiency
Sjogren
syndrome
Non-Sjogren
evaporative
Meibomian
glands disease
exposure
Defective
blinking
Contact lens
associated
Enviromental
factors

12. Causes of Non-Sjogren KCS
1. Primary age-related hyposecretion
2. Lacrimal tissue destruction:
• Tumour
• Inflammation
3. Absence/ reduction of lacrimal gland tissue:
• Surgical removal
• Rarely congenital

13. 4. Conjunctival scarring with obstruction of lacrimal
gland ductules:
• Chemical burns
• Cicatrical pemphigoid
• Stevens- Johnson syndrome
• Old trachomas
5. Neurological lesions with sensory or motor reflex
loss:
• Familial dysautonomia
• Parkinson’s disease
• Reduced sensation after refractive surgery & CL wear
6. Vitamin A deficiency

15. Causes of evaporative KCS:
1- Meibomian gland dysfunction:
• Posterior blepharitis
• Rosacea
• Atopic keratoconjunctivis
• Congenital meibomian gland absence
2- lagophtalmos:
• Severe proptosis
• Facial nerve palsy
• Eyelid scarring
• Following blepahroplasty
3- miscellaneous:
• CL wear
• Enviromental factors

16. Symptoms
• Feeling of dryness
• Grittiness & burning that worsen during the
day
• Stringy discharge
• Transient blurring of vision
• Redness & crusting of the lids

17. Signs
1. Posterior blepharitis & meibomian gland
dysfunction
2. Conjunctiva  mild keratinaization & redness
3. Tear film:
• Particles & debris of accumlated lipid-
contaminated mucin.
• Thin/ absent tear meniscus
• Forth in tear film or along lid margin
//meibomian gland dysfunction.

18. 4. cornea:
• Punctuate epithelial erosions (interplabebral &
inferior cornea)
• Filaments of mucus strands
• Mucus plaques
5. complications:
Peripheral superficial corneal neovascularization
Epithelial breakdown
Melting
Perforation
Bacterial keratitis

19. Diagnosis - parameters
• Tear film stability:
break-up time ≥ 10 sec
• Tear production:
- Schirmer 10mm/ 5min c anesthsia,
6mm sc
- fluorescein clearance &tear osmolarity
• Ocular surface disease:
Corneal stains & impression cytology
Break-up time  Schirmer test  ocular surface staining

20. The pattern of staining
1- Aqueous tear deficiency  interpalpebral
staining of the cornea & conjunctiva.
2- Superior limbic keratoconjunctivitis 
superior conjunctival stain.
3- Bleparitis / exposure  inferior corneal &
conjunctival stain.

21. Rose Bengal staining in
Early, Moderate and Late KCS
EARLY MODERATE LATE

22. Treatment
• Not curable
• Control the symptoms & prevent surface
damage.
• Choice of treatment depends on severity of
the case and source of it.

23. Blepharitis/ meibomian gland dysfunction
management:
 Lid hygiene:
Warm compresses.
Lid scrubs.
 Antibiotics:
Topical: sodium fusidic acid, bacitracin,
chloramphenicol.
Oral: azithromycin, tetracycline.
 Weak topical steroids: fluorometholone.
 Tear substitutes, Lubricating drops.
 Omega 3 supplements.

24. Patient education:
• Realistic expectation of outcome.
• Emphasis on importance of compliance.
• Avoidance of toxic drugs or enviromental
factors .
• Discontinuation of toxic topical medication
if possible.
• Review of work enviroment.
• Emphasis on importance of blinking wilst
reading & using VDU.
• Aids should be provided for patients with
a loss of dexterity.
• Caution against laser refractive surgery.
• Discussion of management of CL
intolerance.

25. Tear subtitutes:
1- Drops & gels:
• Mild cases cellulose derevatives.
• Mucin defeciency  polyvinyl alcohol
(↑persistence of tear film).
• Severe cases  autologous serum.
• Carbomers cling to eyelids & are longer lasting.
• Sodium hyaloronate maybe useful in promoting
conjunctival & corneal epithelial healing.
• Povidone & sodium chloride.

26. Tear substitutes:
2- Ointment:
Petrolatum mineral oil.
Used at bed time.
3- Mucolytic agents:
Useful in patients c corneal filaments &
mucus plaques
Acetylcysteine 5% drops q.i.d
It may cause irritation
Malodorous
Limited bottle life 2 wks max

27. Medication
Type of KCSNameFormulation
Evaporative
lubricants
HYDROXYETHYLCELLULOSE, SODIUM CHLORIDE:
MINIMS ARTIFICIAL TEARS
SODIUM CARBOXY METHYLCELLULOSE, GLYCERIN:
OPTIVE LUBRICANT EYE DROPS
CARBOXYMETHYLCELLULOSE
REFRESH LIQUIGEL 1% EYE DROPS
REFRESH PLUS
REFRESH TEARS 0.5% EYE DROPS
Cellulose derevatives
Aqueous deficiencyCARBOMERS (POLYACRYLIC ACID):
LACRYVISC EYE GEL
POLYACRYLIC ACID:
VISCOTEARS OPTH.GEL
Carbomers
Aqueous deficiencyPolyvinyl alcohol, Povidone
Aqueous deficiencySODIUM CHLORIDE:
APISAL 0.9% EYE-NOSE DROPS
SODIUM CHLORIED, HYPROMELLOSE:
OCULAC
Sodium chloride
Aqueous deficiency-SODIUM HYALURONATE, DEXPANTHENOL
-HYLO-COMOD 0.1% EYE DROP
-HYFRESH 2 MG- ML OPHTHALMIC SOLUTION
HYALURONATE:
HYFRESH 2 MG- ML OPHTHALMIC SOLUTION
Sodium hyaluronate
Aqueous deficiencyHYPOTEARS OPHTHALMIC GELVitamin A (retinol), polyacrylic acid,
cetramide
EvaporativeLipids & oils
Mucus deficiencyAcetylcysteine (mucolyctic)

28. Punctal occlusion:
To reduce drainage In moderate to severe cases
Temporary:
Inserting collagen plugs into the canaliculi that dissolve in 1-2
wks.
To ensure non-occurance of epiphoria following permanent
occlusion.
Occlusion of inferior puncta  review after 2 wks No
symptoms  permanent occlusion.
In severe KCS 
plug of both inferior & superior canaliculi.

29. Punctal occlusion:
Reversible:
Prolonged occlusion (plugs that dissolve in 2–6 months.
Can cause extrusion, granuloma formation & distal migration.
Permanent:
Only in severe dry eye with schirmer test of 5mm or less.
Positive response to temporary plugs without epiphora.
Not in pt c reversible pathology.
Performed after punctal dilatation.

30. Lacrimal drainage.
Cannula inserted in lower
punctum after dilation.
Cannula is swung
towards the temporal
side before saline is
released.
On removing the cannula.
The punctum is now
wide and open.

31. Anti-inflammatory agents:
1- Low dose topical steroids:
Supplementary treatment for acute exacerbations.
Balance the risk of long-term ttt against benefit of
increased comfort.
2- Tropical ciclosporin:
↓ T-cell mediated lacrimal tissue inflammation 
↑ no. of goblet cells.
3- Systemic tetracyclines:
Control associated blepharitis & reduce
inflammatory mediators in the tears.

32. Contact lenses:
Reservoir effect of fluid trapped behind the lens.
 Low water (Hema)  moderate cases.
 Silicone (No water)  to protect cornea in extreme cases
 Occlusion gas permable scleral CL  reservoire of saline
over the cornea (extremly dry).

33. Conservative of existing tears
1. Reduction of room temperature:
Avoiding central heating to minimize tear
evaporation.
2. Room humidifiers.
3. Moist chamber goggles.
4. Side shields to glasses.

34. Other options
1. Tarsorrhapy  reducing palbebral aperture.
2. Botulinum toxin injection control
blepharospasm.
3. Oral chlinergic agonists Pilocarbine (5mg
q.i.d), Sjogren.
4. Zidovudine  antiretroviral agent, Sjogren.
5. Submandibular gland transplantation
extreme dry, requires surgery, produce
unacceptable level of mucus in the tear film.

36. Dry eye medication in
the Saudi market:
Cellulose derivatives:
Carboxymethylcellulose Sodium 0.5%
Aqueous insufficiency & lubricant.

37. Systane:
Polyethylene Glycol 400 0.4% (lubricant)
Propylene Glycol 0.3% (lubricant)
Hydroxypropyl Guar (GEL FORMING MATRIX)
Polyquaternium-1 as preservative
Enhance the mucus layer.

38. Tears Naturale Free:
0.3% HPMC (hydroxypropyl methyl cellulose), 0.1%
Dextran 70
Preservative-Free.
Aqueous deficiency

39. HYLO-COMOD lubricant eye drops:
sodium hyaluronate (1mg in 1ml), citric buffer and
sorbitol
Aqueous deficiency
Hyfresh eye drops:
sodium hyaluronate
Aqueous deficiency

40. Optifresh eye drops:
Polyvinyl Alcohol : 14.0 mg, Povidone : 6.0 mg,
Chlorobutanol (as preservative), Sodium Chloride, HCI
and / or Sodium hydroxide and Water for Injection.
Aqueous deficiency

41. Viscotears:
Polyacrylic acid
carbomer
Aqueous deficiency

42. Thank you!