Dry eye occurs when there is inadequate tear production or function, resulting in an unstable tear film and ocular surface disorder. It can be caused by conditions that reduce tear production such as Sjogren's syndrome, vitamin A deficiency, Stevens-Johnson syndrome, or medications. Other causes affect the tear film layers, like meibomian gland dysfunction reducing the outer lipid layer. Symptoms include dryness, burning, and blurred vision. Treatment focuses on replacing tears, improving ocular surface health, addressing underlying causes, and escalating care based on severity through the DEWS treatment guidelines.

1. DRY EYE:
AN OVERVIEW
Dr.Gayatree Mohanty
Dept. of Ophthalmology, KIMS

2. DRY EYE
Occurs when
 Inadequate tear production
 Inadequate function
Results in Unstable Tear Film and
Ocular Surface Disorder.

3. TEAR PRODUCTION &
TEAR FUNCTION
Healthy tear film Dry eye

4. TEAR PRODUCTION
 Secreted by the
lacrimal glands
 Spreads over the
ocular surface
 Drained the
lacrimal canaliculi
into the
nasolacrimal duct.

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. 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. FACTORS AFFECTING THE
SPREAD OF TEAR FILM
Normal lacrimal
neural arc.
Contact between
the ocular
surface & the
eyelids
Normal corneal
epithelium.

8. OCULAR SURFACE
Conjunctival
epithelium
Limbal Epithelium
Corneal
epithelium
Eyelids
(Mucocutaneous
junction)

9. ETIOPATHOGENESIS
Aqueous tear deficiency
Sjogren’s Dieseases
Non-Sjogren’s Diseases
Lipid tear deficiency
Mucin deficiency
Kinetic disorders of lacrimal fluid

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.

12. 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.

13. VITAMIN A DEFICIENCY
Xerosis of the
conjunctiva
resulting in
goblet cell
destruction &
mucin layer
deficiency.

14. 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.

15. 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.

16. 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.

17. 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.

18. MEDICATIONS CAUSING
DRY EYE
•Diuretics
• Beta-blockers
• Antihistamines
• Sedatives
• Anti-Anxiety medications
• Analgesics

19. 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.

20. 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

21. 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.

22. 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.

23. 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

24. TEAR SUBSTITUTES
Cellulose derivatives: Carboxymethyl
cellulose 1%, Hypromellose 0.5%
Carbomers(Polyacrylic acid)
Polyvinyl alcolhol, Povidone, sodium
Hylauronate
Lipids & Oil:
Acetylcysteine 5% with
Hypromellose.

25. 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

26. 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.

27. 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

28. DEWS CLASSIFICATION

29. DEWS RECOMMENDATION OF
TREATMENT
Level 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
.

30. DEWS RECOMMENDATION OF
TREATMENT
If 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

31. DEWS RECOMMENDATION OF
TREATMENT
If 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.

32. 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.

33. 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.