The document discusses the diagnosis and management of dry eye, emphasizing various clinical diagnostic tests used to measure tear secretion, stability, and integrity. Key tests outlined include Schirmer tests, tear break-up time, and fluorescein clearance tests, as well as laboratory assessments such as tear osmolarity and mucin measurement. The importance of understanding the underlying causes, including potential autoimmune conditions like Sjogren's syndrome, is highlighted for effective treatment and management strategies.

1. DRY EYE – DIAGNOSIS AND
MANAGEMENT
Dr. Nikhil Gotmare @ eyeamnikhil

2. CLINICAL DIAGNOSTIC TESTS
A. MEASUREMENT OF TEAR SECRETION
B. MEASUREMENT OF TEAR FILM STABILITY
C. MEASUREMENT OF TEAR FILM INTEGRITY
D. LABORATORY AND OTHER TESTS

3. A.MEASUREMENT OF TEAR
SECRETION
Special test strips aregently touched to the surface of the
eyefor several seconds.
The strip absorbstears
and how much tear isabsorbedisrelated to how much
tears is being produced.
This isanindication of how fast tearsare being madeby
the various tearglands.

4. MEASUREMENT OF TEAR
SECRETION
1. Schirmer-1 test
2. Schirmer-2 test
3. Schirmer-3 test
4. Jones basic secretion test
5. Cotton thread test
6. Phenol red impregnated
test
7. Fluorescein clearance test
(FCT)
8. Tear function index

5. Schirmertest
• Most commonly useddiagnostic tests for initial assessmentof
dry eye
Basic secretion Reflex secretion
Is a result of
secretion from
accessory lacrimal
gland, which has
no known
innervation
Is from main
lacrimal gland
possessing
autonomic
innervations.
• Tear secretion maybe divided into basic and reflex secretion

6. Schirmertest procedure
o The Schirmer strip
is placed between inner
2/3rd and outer 1/3rd
of lid
o ‘Whartmann-41’ paper - 35 × 5 mm
o With the patient's eyes closed, wetting of the strip
is measured after 5 minutes

7. Schirmer I (without
anesthesia)
Schirmer II (with anesthesia )
basic and reflex secretion basic secretion
If wetting
>10mm =normaleye
10mm =milddry eye
5-10mm =moderate dryeye
3-5 mm =severe dryeye
<3mm =very severe dryeye
If Wetting <10mm then irritate the
nasal mucosa with cotton bud &
note the wetting after 2 min.
If no Wetting or <1mm -
Sjogren's syndrome
If Wetting increases by 1mm Non-
Sjogren's syndrome

8. 3. Schrimer-3 test : To note the wetting of filter
paper after local anesthesia of conjunctival sac.
Carried out to note the basal tear secretion
4. Jones basic secretion test : its same as
schrimer 1 except that topical anesthesia is used

9. 5. Cotton thread test :
o is a variation of Schirmer test practiced in Japan.
o Fine cotton thread is placed in cul-de-sac for a short
period (3-6 sec) and the removed and measured
o Did not gain popularity because:
amount of fluid present in sac is more then what the
thread can hold
Fluid continues to move even after the thread has been
removed – false high reading

10. 6.Phenol red impregnatedthreadtest
A type of cotton thread Schirmer test
Thread is put in lower fornix and
reading is taken after 15 sec
Wetting of thread is noted
9-18 mm = normal
≤ 6 mm abnormal

11. 7.Fluoresceinclearancetest(FCT)
Standardized amount of
fluorescein (3 micro litre
of 0.5 % fluorescein) is
placed in cojunctival sac
and tear turn over rate is
determined by persistent
of fluorescein in tears at
specific timepoints later

12. Fluorescein clearancetest(FCT)
To detect amount of residual fluorescein we use
A. Schirmer strip to collect fluorescein –stained tears.

13. Fluorescein clearance test(FCT)
B. Fluorophotometer: quantify amount of fluorescein
persisting in eye
-Minimally stimulated tear samples collected using micro tube
from Inferior tear meniscus
after 20 mins fluorescein is measured and converted into
fluorescein concentration or matched with standard
fluorescein uptake
normal = 22.4 ± 16.9 ng/ml
Grade 1= 96.4 ± 51.2 ng/ml
Grade 2 = 318 ± 146 ng/ml
Grade 3 = 1479 ± 671.9 ng/ml

14. 8. Tear function index
Is a combination of both tear secretion and drainage test
and gives a practical measure to diagnose dry eye
TFI = Schirmer test with anesthesia (basal secretion)
Tear clearance rate (determined by rate at
which colour of dye is faded)
< 96 is suggestive of dry eye
< 34 is diagnostic of dry eye

15. B. MEASUREMENT OF TEAR
FILM STABILITY
TFBUT ( Tear film Break up test )
o Invasive TFBUT introduced by Norn, remains the
most frequently used diagnostic test to determinetear
film instability.
o Non Invasive TFBUT involves observation of an
illuminated grid pattern reflected from the anterior
tearsurface

16. Invasive TFBUT
• Specialdyes are placed into the eye that mix with the
layer.
• Tear layer is observed with SL microscope asthe eye is
held open for several seconds.
• Eventually the tear filmis displaced and dry spots form.
• The length of time, in seconds, for this to happen is the
Tear Break-Uptime.
• Normal tear layer stays intact forabout 10 seconds.
• In people with dry eye or OSDthe time is shortened to
aslittle as2 to 4seconds.

17. Tearbreakup- timetest

18. Tearbreak up- timetest
Indicate of tear film insatiability in all different
causes of dry eye
Normal = > 10 sec
Grade 1 = 10 sec
Grade 2 = 5-10 sec
Grade 3 = 3-5 sec
Grade 4 = < 3 sec

19. Non invasive TFBUT
Doesn’t involve instillation of fluorescein

20. NIBUTcanbe measured by:
a) corneal topography
b) interferometry
c)aberrometry
d) AS-OCT
e) confocal microscopy
o Ocular protection index
o Closed chamber infrared
thermometry
o Closed chamber humidity of eye
o Tearscope

21. A) Topographical analysissystems
TEARFILMTOPOGRAPHER
Uses:
• To evaluate corneal
surfaceregularity
• tear film stability
• evaluation of post-LASIK
dryeye

22. B) Interferometry
LIPIVIEW INTERFEROMETER
• Coloured fringes arise from
interference between light
reflected from the surface of
the lipid layer and from the
interface between the lipid
layer and the aqueous layer of
the tearfilm.
• used to observe the nature,
thickness and rupture of the
lipid layer.

23. b) tear break-upa) normal smooth tear film

24. ss
C)Aberrometry
WAVEFRONTABERROMETER
• non-invasive assessmentof the
visual disturbances causedby
higher order aberrations arising
from tear film instability and
break-up.
• Aberrometry could be utilized
for not only detecting DEbut
also for monitoring the efficacy
of treatments.

25. D.Optical coherence tomography
• Anterior segment OCT can measure the tear film
thickness and tear meniscus parameters which indicate
total tearvolume.
• lower tear meniscus height and radius were the best
indicators of DEwith a cutoff meniscus height of 1.64 mm
and radius of 1.82mm.

26. E)Corneal in vivo confocal microscopy (IVCM)
• non-invasive, high-resolution tool that allows real time imaging of
the cornea at the cellular level and provides images comparable to
histochemical methods and
usedfor non-invasive impression cytology in DEevaluation.
• IVCMenablesthe studyof:-
a) corneal epithelium
b) corneal stroma andkeratocytes
c) endothelial cells,
d) corneal nerves
e) corneal immune and
inflammatory cells
f) conjunctiva
g) meibomian glands

27.  By showing the inflammatory and immunologic cellular changes in the
cornea and conjunctiva (Figure 3), IVCM may be used as a tool to determine
the level of inflammation.
 Though inflammation is not specific to dry eye disease, IVCM would
potentially allow stratification for therapeutic strategies and monitoring of
therapeutic response to anti-inflammatory therapy in the clinic and for
clinical trials for dry eye disease.

28.  Ocular protection index (OPI): It is the TBUT time in seconds divided by
interblink interval in seconds
OPI = TBUT
interblink interval
OPI < 1 = patient at risk
OPI > 1 = No risk
 Closed chamber infrared thermometry:
Temperature is recorded on a fixed point and fixed distance from the eye
with eyes closed and then after opening the eye after 5 seconds
Normal- temp is increased by 0.10 C
Dry eye- No increase in temperature after opening eyes
 Closed chamber humidity of eye: closed chamber is applied to eye
humidity is measured with eyes closed and then 5 seconds after opening of
eye
The difference in humidity in:
Normal = < 1 RH %
Dry eye = > 1 RH % ( 1RH % to 4 RH %)

29. Tearscope : used to see tear film as such or an attachment to slit
lamp

30. Tearscope–plus lipid layerthickness(LLT)
Five main categories of normal lipid appearance are
graded in order of increasing thickness and visibility:
 Open meshwork
 Tight meshwork
 Waves
 Amorphous
 Colors
The abnormal appearances of tle lipid layer are:
 Globular
 Abnormal colors
 Lipid break-up

31. Tearscope–plus lipid layerthickness(LLT)
Waves Colors

32. C. MEASUREMENT OF TEAR
FILM INTEGRITY
1. Fluorescein dye
2. Rose Bengal staining
3. Practical double Vital staining
4. Other dyes – Lissamine green, alcian blue,
tryphan blue, bromothymol blue
 The installation of dyes is a common method to detect ocular
surface epithelial pathology
 Corneal and conjunctival staining is found either on instability tear
film or on inadequate tear film.

33. s
Fluorescein Rose bengal
• Most commonly used stain
• 2 %
• Stains epithelial defects
• Stains only mucous
• Stains the cornea more than
conjunctiva
• Stains tissue by penetrating into
intercellular spaces
• Under blue filter- green colour
• Significantly greater amount of
staining in Sjogren’s aqueous tear
deficiency
• Less irritative
• 1 % solution
• Stains dead and degenerated
epithelial cells
• Stains both mucous and filaments
• Conjunctiva usually stains with
more intensity than the cornea
• Keratinisation and conjunctival
epithelium are more easily
visualised with rose bengal
• Under green filter – red colour
• More irritative

34. when
• Avital dye which hasno intrinsic toxicity.
• Detects epithelial defects & irregularities.
• Filter paper strips or 0.25%- 2%solution.
• Sodium fluorescein emits green light(520nm)
excited with with blue light (490nm).
Sodiumfluorescein

35. Rose bengalstaining
In interpretation of rose bengal staining in dry eye is
based on two factors :(Van Bijsterveld score)
– intensity and location
– scale of 0 – 3 in 3 area
The intensity of rose bengal staining correlates
well with the degree of aqueous tear deficiency

36. Rosebengal
• Rosebengal is avital stain taken up by dead and devitalised
epithelial cells.
• Also stains mucous threads, filaments & strands.
• Does not diffuse into the epithelial defects or penetrate
corneal stroma like fluorescein.
• It is toxic resulting in decreased cell vitality, motility & cell
death.
• Causesocular discomfort –prior anaesthesia isneeded.
Score 0 - absent
Score 1-justpresent
Score 2-moderatestaining
Score 3-grossstaining

37. Diagnosting dyestaining
Rose bengal staining Inferior epitheliopathy

38. • Grading:
– Location
– Intensity
• NEIworkshopgrading:
– Cornea(Fluorescein) >3/15
– Conjunctiva(Rose-bengal)
>3/18

39. Diagnosting dyestaining
Lissamine green B has staining pattern
identical to rose bengal:
-- Degenerated cells, mucus, deadcells
– produces much less irritation
– When score >5 indicated diagnosis of Sjogren’s
syndrome

40. D. LABORATORY TESTS
AND OTHERS
1. Tear osmolarity
2. Tear mucin measurement
3. Qualitative mucous assay
4. Lactoferrin measurement
5. Ocular ferning test
6. Conjunctival biopsy
7. Biopsy of lacrimal gland and
minor salivary glands
8. Impression cytology
9. Nasolacrimal reflex
10. Serum autoantibodies
11. Meibomian gland evaluation
12. Conjunctival and corneal
sensation
13. Tear protein analysis
14. Tear meniscus height

41. 1.Tearfilmosmolarity
In dry eye tear film is in a hyperosmolar state:
Decrease production
Decrease volume
Decrease lipid
Decrease stability
Increase evaporation
Osmolarity

42. Tearfilm osmolarity
Lacrimal gland disease
Decreased corneal
sensation
Increased palpebral
fissure
Meibomian gland
dysfunction
Decreased
secretion
Increased
evaporation
Increased tear
osmolarity

43. Values higher than 312 mOsol / Liter are diagnostic
of dry eye:
– 90% sensitivity
– 95% specificity
A commercial osmometer specifically designed to
test nanometer volume of tear is now in use but is
not widespread due to cost consideration
Condition Expected range of value
Normal < 312 mosm/l
Borderline dry eye 312- 323 mosm/l
Moderate/severe dry eye > 323 mosm/l

44. 2.Tear mucin measurement:
 Hexosamine is one of the principal constituent of mucin.
 Pateint with steven johnson syndrome and cicatrical pemphigoid have a
diminished amount of hexosamine in tears
3. Qualitative mucous assay:
Cotton strip 3 x 10 mm is placed in inferior cul-de sac of an un-anesthetised
eye for 5 min -> each strip is then placed on a glass slide and satined with
PAS reagent
If adequate mucus is present strip will show positive PAS reaction turning
dark purple
4. Lactoferrin measurement:
Lactoferrin is normally produced by the lacrimal gland and used as a
relative indicator of lacrimal gland function
Done using radio immune diffusion method.
Normal conc. In tears is 1.4 mg/ml

45. 5.CRYSTALLIZATION:FERNINGTEST
Tear film composition affects the way in which a
coolected sample dries on a glass slide.
Tears are collected with a glass capillary
& placed on a glass slide &
left to dry at room temperature.
The sample is then observed in white light or by
polarized microscopy & classified in to 4 grades
according its appearance following crystallization.
The tears of dry eye patient exibit less ferning than
those of normal patients.
Test may reflect the quality of tear protein profile.

46. Ferning is absent in pemphigus and steven johnson syndrome

47. 6. Conjunctival biopsy :
4 % cocaine on a cotton tipped applicator is applied directly
to lower fornix, an area of max goblet cell.
After 60 sec conjunctival sample is obtained and subjected
to PAS reagent.
Goblet cells are markedly deficient in mucin deficient state.
7. Biopsy of lacrimal and minor salivary glands: presence
of lymphocytes and plasma cells are consistent with
Sjogren’s syndrome

48. 8. Impressioncytology
In advanced dry eye the epithelium undergoes
pathology changes:
– squamous metaplasia
– decreased density of goblet cells
a small piece of nitrocellulose membrane applied
against the conjunctival surface for 2 sec
followed by staining with PAS
to stain mucin in goblet cells
and counter staining with
hematoxyllin
Overall impression cytology is a highly sensitive method

49. Methods to grade the extent and severity of squamous
metaplasia based on :
-Loss of goblet cells
-Enlargement and increase cytoplasmic / nuclear ratio
-Keratinization
(A) Grade 0 = normal impression cytology specimen. (B) Grade 1 = early loss of
goblet cells. (C) Grade 2 = marked decrease of goblet cells. (D) Grade 3 = total loss
of goblet cells, large epithelial cells

50. 9.Nasolacrimalreflex
Can be elicited by stimulating the nasal mucosa
under the middle turbinate with a cotton – tipped
applicator:
– increase tearing dramatically in non-Sjogren’s
syndrome
– no increase in Sjogren’s syndrome

51. 10. Serum autoantibodies
Its criteria used to diagnosis of Sjogren’s syndrome
Presence one or more these auto antibodies:
– ANA (titer≥ 1:160)
– RF (titer≥ 1:160)
– anti – Ro (ss-A) or anti – La (ss-B)
presence of anti – M3 muscarian cholinergic
receptor anti body in a high percentage of Sjogren’s
syndrome

52. 11. Meibomian glandevaluation
• Source of lipids in the lipid layer of the tear film
• MGDis the most common causeof evaporative dryeye
• Meibomian glands canbe assessedby:-
a)slit lamp
b) Meiboscopy
c) Meibography
d) Meibometry

53. Diagnosis is made by following pathologic signs:
– ductal orifice metaplasia (white shafts of keratin in the
orifices)
– increase turbidity and viscosity of the expressed
secretions
– reduced expressibility of secretion
– morphologic abnormality of the gland acini and
ductules

54. MG expression :
Assessed in each of 8 glands of central LL
on a 0-3 scale:
Grade 0= Clear meibum
Grade 1= Cloudy meibum
Grade 2= Cloudy with debris (granular)
Grade 3= Thick (toothpaste)
Meiboscopy: Use of transillumination
biomicroscopy to determine
presence of MG loss
Meiboscopy

55. 12.Conjunctiva and corneasensation
Decreased corneal sensation can be both the cause and
the effect of dry eye
Sensory denervation may lead to dry eye by :
-Decreasing the afferent signal that drive aqueous tear
secretion
-Reducing the blink rate (leading to ocular surface
desiccation)
-Altering growth and differentiation of ocular
surface epithelium through diminished trophic
influence of trigeminal nerve
-Auto immune sensory neuropathy and sensory neural
degeneration due to inflammation or chronic over
stimulation

56. Cornealesthesiometry

57. 13.Tearproteinsanalysis
Lysozyme accounts for 20-40% of total tear protein:
–its measurement is based on the enzyme ability to
lyse a suspension of the bacterium , micrococcus
lysodeikticus
–Tear lysozyme level are decreased in ADDE
–more sensitive test than either the Schirmer test
or rose bengal staining
–main disadvantage is lack of specifity
–false positive in HSV keratitis , bacterial
conjunctivitis , smog irritation and malnutrition

58. 14.Tear Meniscus Height
 The height of the tear film meniscus observed during slit lamp
examination.
 Height and breadth of meniscus decreases in dry eye
 Set up the slit lamp:
 o
1. 60beam angle.
2. Low illumination.
3. 10-16 X magnification.
4. Parallel Piped beam.
Focus the parallelepiped on the inferior
tear strip near the lateral canthus.
At any point the beam may be narrowed to an
optic section to assess the depth of the tear
meniscus.
Reduced beam height with beam orientated
horizontally.
Values ≥0.2-0.4 mm
Normal
≤0.2 mm hypo
secretion
≥ Hyper secretion

60. Diagnostic methodology
 Prior to diagnosis, it is important to exclude conditions that can mimic DED
with a number of triaging questions
 Following this, the Dry Eye Questionnaire-5 (DEQ-5) or Ocular Surface
Disease Index (OSDI) should be completed to indicate whether a patient
might have DED,
and a positive symptom score on either of these questionnaires should then
trigger a more detailed examination for clinical signs of DED.
 The presence of any one of three specified signs;
1. reduced non-invasive break-up time;
2. elevated or a large interocular disparity in osmolarity; or
3. ocular surface staining (of the cornea, conjunctiva or lid margin)
in either eye, is considered representative of disrupted homeostasis,
confirming the diagnosis of DED.
 Further subtype classification tests such as meibography, lipid
interferometry and tear volume measurement should be conducted to
determine: 1) where the DED falls on the spectrum between ADDE and EDE,
and 2) the severity of DED, in order to guide treatment.

61. MANAGEMENT

62. Goals of therapy
1. Relief of discomfort
2. Provide a smooth optical surface
3. Prevent structural damage to cornea

63. General measures
 Avoid being in dry atmosphere for long periods of time, If you
have -> use a humidifier
 Avoid direct blasts of heaters and air conditioners at face level
 Sit away from direct heat such as furnace, fires , gas etc.
 Use lubricating eye drops such as artificial tears
 Make a conscious effort to blink regularly with full lid closure and
not ‘half blinks’
 Avoid smoking
 Use wrap around glasses and sunglasses when outdoors
 In order to relieve acute episodes, use periodic cool moist
compresses to decrease burning sensation and itching
 Lid hygiene

64. Systemic therapy Medical management Surgical management
• Indicated in certain
conditions like ocular
pemphigoid
• Drugs that cause dry
eye may be avoided
e.g anti-histaminics
• Artificial tears and
ointments
• Secretogogues
• Vitamin A ointment
• Acetylcystein
• Therapeutic soft
contact lens
• Punctal occlusion
- Temporary
- Permanent
• Tarsorraphy or taping
of lids
• Transplantation of
parotid duct
• Mucosal
transplantation
• Amniotic membrane
transplantation
• Autoconjunctiva

65. A.SUPPLEMENTATION OF
TEARS
Drops
Ointments and
gels
Inserts

66. Artificial tears
 Stabilize & thicken pre-corneal tear film .
 prolongs tear film B.U.T.
 keeps ocular surface wet & lubricated .
 helps to repair ocular surface damage
 keeps ocular surface smooth(improves decreased
vision & aberations)
But cannot completely substitute complex
composition of natural tears

67. Artificial TearEyedrops
Solvent water
Active ingredient Hydrogels (water soluble
polymers)
Viscosity polymers concentration
Preservatives prevention of contamination
balanced tonicity Inorganic electrolytes
NaCl
NaCl&KCL equivalent to 0.9%
P.H buffers
Anti-oxidants Sometimes Vit. A
Lipids phospholipids

68. Hydrogels (water soluble polymers):
- are the viscosity enhancing active ingredients of artificial
tears
- make artificial tears more viscous so that they can stay on
eye for longer
- Property of swelling up in water and retaining moisture
- mucous adhesive properties -> help in prolonging the stay
time

69. Examples of hydrogels :
• Hyaluronic acid
• Cellulose & methylcellulose & their derivatives:
- hydroxypropyl Cellulose
- hydroxyethyl Cellulose
- hydroxypropyl methylcellulose (HPMC) 0.2% & 0.3% & 0.5%
- Carboxymethylcellulose (CMC) 0.25% & 0.5% & 1% Carmelosa
(low viscosity)
• Polyvinyl alcohol 1.4%
• Povidine 0.6%
• Glycerin 0.3% & 1
• dextran 70
• propylene glycol (PG)
• polyEthyleneGlycol (PEG 400)
• Polycarophil
• hydroxypropyl Agar (Systane R)

70. Preservatives : increase shelf life, facilitate use of multi dose bottles
 BAK (Benzalkanium chloride)
(0.01% for eye-drops , 0/02% for C.L. solutions & 1% as disinfectant )
 Chlorbutanol
 Chlorhexidine (0.002- 0.005%)
 Thimerosal & mercuric oxides (0.002- 0.005% ) EDTA .
 Methylparaben
 Propylparaben
 Polyquad (polyquaterium )
 Sodium chlorite (Purite)
 Potasium sorbate
 Sodium perborate (GenAqua)(air touch changes to H2O2,then H2O &
O2)
 Sorbic acid

71. Ocular complications ofPreservatives
 Pigmentation: (mercury deposits in lids, conj, cornea &
lens )
 Irritation: redness–photophobia–lacrimation–burning)
dermatitis & urticaria & eczema – blepharitis
 Allergy : papillary & follicular conjunctivitis –pseudo
membrane pemphigoid – symblepharon- SPK – corneal
edema – panus –corneal opacity – adherence to CL. & CL.
intolerance – ocular surface mal-function & inflammation
 Toxic: Epith. Cell exfoliation . SPK
Due to side effects of preservatives , now preservative
– free artificial tears are made , but most of them are in
unit dose form (chance of contamination),Also they are
expensive.

72. Mild dry eye Moderate to severe dry
eye
BAK preserved eye drops
are usually well tolerated
when used 4-6 times a day
or less
• Should avoid tear
solutions containing BAK
• If preserved solutions are
used then GenAqua or
Polyquad containing
tears are better tolerated
• Non-preserved solutions
are preferable for
treatment in these
pateints

73. Preservative– freeartificial tears

74. Ointments and Gels
 Second most common method for ocular lubrication
 When instilled into eye dissolve at temperature of
ocular tissue and disperse with tear fluids.
 For moderate to severe dry eye a clear gel is available
that liquefies and spreads rapidly on contact with eye
It contains Carbapol 980 (Polyacrylic acid) a gel with
high water binding power that transforms gel into liquid
upon contact with ocular tissue

75. Lacrisert or SR-AT (slow releasing
artificial tears)
 Small 5 mg pellet of hydroxy propyl cellulose in cylinder form
 Placed in inferior cul-de-sac with plastic inserter
 Absorbs tear and forms soft gelatinous blob
 During next several hours, it slowly dissolves and releases its polymer into
tear film
 Once or twice daily use required
 Problems – inadvertent loss , blurred vision, lid crusting, difficulty for
elderly pateint to place in cul-de-sac, annoyance by feeling the presence
of insert

76. B. PRESERVATION OF EXISTING TEARS
BANDAGE CONTACT
LENSES
Used in patients with:
• Persistent epitheliopathy
• recurrent filamentary keratitis
• Moderate to severe KCS
MOA
• Maintain tear film near cornea
and reduce friction
Contraindication-
• infection(prophylactic
antibiotic indicated and
avoidance of steroids should
be done)
Soft and gas permeable hard
RGP’s can be used
CANALICULAR
OCCLUSION
Used to
• Decrease tear drainage
via occluding
punctum.
• Helps to asses if
patient would get
benefitted by
permanent punctal
occlusion.
(Permanent occlusion C/I
if epiphora results)
Methods
• TAMPONADE
METHODS
• THERMAL METHODS
• SURGICAL METHODS
GOGGLES
• Moist chamber
googles used in
evaporative dry eye
• Maintains
increased humidity
addressing
evaporation
problems

77. CANALICULAR OCCLUSION-TAMPONADE METHODS
PUNCTAL
OBSTRUCTION
WITH GLUE
ABSORBABLE
IMPLANTS
NON ABSORBABLE
IMPLANTS
• Temporary
obstruction.
Materials used
• Cyanoacrylate glue.
• Fibrin surgical
glue(tisseel VH).
• Used with 25 to 27
gauge canula.
• Occlusion last for few
days to week
because of natural
cell turnover cycle.
• Temporary
obstruction
Materials used
• Collagen implants
• Absorbable suture
(catgut 2-0,
chromic catgut)
Degrade over 1-2
weeks
Material used
• Polyethylene, silicone,
hydrophobic acrylic(smartplug)
• Permanent but removable
• Visible under slitlamp
biomicroscopy

78. Hydrophobic acrylic implant (smart plug)
• heat responsive
• Dimensions change from 9x0.4 mm to 2x1.00 mm at temperatures
above 32 degree
• No sizing of punctal opening needed

79. COMPLICATIONS (Tamponade method)
 Overdilation and rupture of punctal ring
 Pruritis and discomfort
 Epiphora
 Abrasion of conjunctiva and cornea
 Protrusion, intrusion, total extrusion
 Suppurative canaliculus and pyogenic granuloma
 Fragmentaion of prosthesis
 Canalicular stenosis

80. CANALICULAR OCCLUSION - THERMAL METHODS
 Principal- destruction, scarring and shrinkage of punctal opening and
wall of proximal lumen
 Reversible with punctum dilator
Hot cautery
Aim
• Transmission of heat from
hot probe to achieve
controlled burn injury to
punctal opening
Performed with
• Galvanocautery(electrically
heated nichrome wire tip)
• Alcohol lamp
• Low temperature- better
control
• High temp- deep scarring,
long lasting results
• Late Failiure may occur due
to re-epithelisiation
Diathermy
• Radiofrequency 455kHZ
to 100mHz used
(electrodes placed in close
proximity in bipolar pencil,
forceps style cautery tip )
• Performed under LA
• Commercial diathermy
units include:-
Hyfrecator, mentor
diathermy, surgiton
Argon laser
• Done under topical or
local anaesthesia
• Punctal opening first
encirclaged with laser
spots additional spots
delivered into punctum

81. SURGICAL METHODS
Canalicular ligature Punctum occluded first with hot cautery and then shut with
single nylon stich or vertical canaliculus sutured with 8-0 vicryl
fullthickness eyelid mattress suture tied on skin side
Canalicular offset Surgical laceration of horizontal canaliculus medial to punctum
f/b thermal cautery of exposed surfaces f/b suture closure of
punctum and canaliculus
Canalicular excision Rarely performed, canaliculi identified and extirpated
Risk of eyelid distortion
Punctal tarsoraphy Epithelial tissue debrided from upper and lower puncta and
surfaces sutured with 8-0 vicryl f/b standard medial tarsoraphy(
in severe tear deficiency with neurotrophic and exposure
keratitis )
Punctal patch Bulbar conjunctiva autograft taken and sutured over punctal
orifice
Punctal transfer Punctum opening moved anteriorly through anterior lamellae(
away from tear lake)
Dacryocystectomy
and NLD occlusion

82. C. STIMUALTION OF TEARS:
Oral Bromhexine and pilocarpine- stimulate tears but can cause adverse
effects like flushing sweating nausea
Secretagogues (cholinergic agonists & Muscarinic )
purinergic receptor (p2y2) agonist [Diquafosal (Inspire)]
stimulates mucin &tear secretion of Goblet cells.
Oral Pilocarpine (Salagan) (effective for dry mouth not
dry eye- 5mg tab x 4-6/day)
IBMX (isobutyl-methyl xanthin)
Eledoisin (endekapeptides)

83. D. DISPERSAL OF MUCIN:
10 to 20% acetylcysteine breakup large mucin molecules into
more soluble complex
E. ANTIINFLAMATORY:
Cyclosporin- immunosuppressive 0.05% to 0.1% bd
MOA- suppression of lymphocyte induced apoptosis in lacrimal
gland and ocular surface tissues
Decrease in number of activated lymphocytes in conjunctiva,
increase goblet cells and decrease cytokines
Tetracyclines- decrease bacteria breaking down lipid
- anti-inflammatory activity

84.  Corticosteroid-
Inhibit activity of transcription factors like activator protein 1 and nuclear
factor kB( involved in activation of proinflammatory genes)
Not suitable for long term treatment due to side effects like high iop,
cataract formation
 Lifitegrast (xiidra)
FDA approved drug
Inhibits integrin, lymphocyte function associated antigen 1(LFA-1) from
binding to intercellular adhesion molecule 1, downregulates
inflammation mediated by T lymphocytes
Available in eyedrop for bd application

85. Autologous serum
 It contains factors present in tears including
vit A, epidermal growth factor, TGF-beta, basic fibroblast growth factor
beta, insulin like growth factor, lactoferrin, lysozyme.
 All of them together promote corneal epithelial migration
 proliferation and inhibition of corneal collagenase , upregulation of
goblet cells and mucin
 PREPARATION
 40 ml of blood taken, left for 2 hours, centrifuged at 4000 rpm for 10 min
serum separated (40 ml yields 20 ml of serum)
 3ml of aliquots of serum removed and packed into dropper with sunlight
protection ( bottles contain preloaded chloramphenicol with boric acid or
saline)
 Bottle kept in refrigerator at 5 degree Celsius
 Concentration of 20 to 100% can be used

86. Androgens in dry eye
 Post menopausal women deficient in androgens hence dry eye
more common in them
Mechanism of action
 Increase activity of sebaceous glands and meibomian glands
 Promote retention of water and electrolytes
 Meibomian glands contain androgen receptor MRNA with acinar
epithelial cell nuclear and hype 1,2,5 alpha reductive, promote
production and release of fluid
 Immunomodulatory and anti-inflammatory effects

87. Other methods
 Tarsorrhaphy- decreases evaporation rate of tears
 AMT
Favours epithelial healing via growth factors
Decrease inflammation via inhibitory proteases
 Salivary gland transplantation-
indicated in patients with severe lacrimal gland dysfunction( steven johnson,
post radiation atrophy, surgical removal of gland) with intact salivary gland
function( hence not in Sjogren syndrome)
Parotid duct transposition into inferior fornix, submandibular gland part with
duct transposition into temporal fossa with duct draining sc into
superotemporal fornix have been tried
 Abdominal dacryoreservoir
Implantable pump dacryoreservoir used
Reservoir implanted into pocket under subcutaneous tissue of anterior
abdominal wall and connected to silicone catheter that ascends subcutaneously
along chest, neck and temple to upper fornix
Provides continues source of lubrication

88. Reducing the risk of DES
Reducing intake
of food
increasing risk of
dry eye
Increasing intake of foods
decreasing risk of dry eye
• Sugars
• Artificial
sweeteners
• Processed food
• Toxic fats like
commercial red
meat,
• Fried foods
• Hydrogenated
• Flaxseed oil/n-3 fatty acids
Hydrate essential
(cyanocon/hydrosoft company)
• Combination with primrose
containing linolenic acid)
• Vitamin A- 10,000
• beta carotene-25000 IU
• Vitamin b-6 –aids in producing
pgE7 needed for tear production
• Vitamin c

90. Recommendations for the staged
management and treatment of DED
 Step 1:
Education regarding the condition, its management, treatment and
prognosis
Modification of local environment
Education regarding potential dietary modifications (including oral
essential fatty acid supplementation)
Identification and potential modification/elimination of offending
systemic and topical medications
Ocular lubricants of various types (if MGD is present, then consider
lipid-containing supplements)
Lid hygiene and warm compresses of various types

91.  Step 2: If above options are inadequate consider:
Non-preserved ocular lubricants to minimize preservative-induced
toxicity
Tea tree oil treatment for Demodex (if present)
Tear conservation
- Punctal occlusion
- Moisture chamber spectacles/goggles
Overnight treatments (such as ointment or moisture chamber
devices)
In-office, physical heating and expression of the meibomian
glands (including device-assisted therapies, such as LipiFlow)
In-office intense pulsed light therapy for MGD
Prescription drugs to manage DED
- Topical antibiotic or antibiotic/steroid combination applied to
the lid margins for anterior blepharitis (if present)
- Topical corticosteroid (limited-duration)
- Topical secretagogues
- Topical non-glucocorticoid immunomodulatory drugs (such as
cyclosporine)
- Topical LFA-1 antagonist drugs (such as lifitegrast)
- Oral macrolide or tetracycline antibiotics

92.  Step 3:
If above options are inadequate consider:
Oral secretagogues
Autologous/allogeneic serum eye drops
Therapeutic contact lens options
Soft bandage lenses
Rigid scleral lenses
 Step 4:
If above options are inadequate consider:
Topical corticosteroid for longer duration
Amniotic membrane grafts
Surgical punctal occlusion
Other surgical approaches (eg tarsorrhaphy, salivary gland
transplantation

93. THANK YOU
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