2. DRY EYE
“Dry eye is a multifactorial disease of the ocular surface
characterized by a loss of homeostasis of the tear film, and
accompanied by ocular symptoms, in which tear film
instability and hyperosmolarity, ocular surface inflammation
and damage, and neurosensory abnormalities play
etiological roles.”
(TFOS DEWS II 2017)
10. Investigations
▪Stability of the tear film:
- Tear break-up time
▪Tear production
- Schirmer’s test
- Fluorescein clearance test (Tear turn over)
- Phenol red thread test
▪Ocular epithelial health
- Staining (Fluorescein , rose Bengal , Lissamine green)
11. Tear break-up time
• BUT is abnormal in aqueous tear deficiency and meibomian gland disorders
• It is the difference between the last blink and the appearance of the first
randomly distributed dry spot
• Assessed with fluorescein and cobalt blue filter in broad beam
• <10 seconds is abnormal
12. Schirmer’s Test
Assessment of aqueous tear production
Schirmer’s I - without anesthesia
Basal + Reflex
Interpretation- Normal wetting > 15 mm
Dry Eye
Mild : 9 – 14 mm
Moderate: 4-8 mm
Severe : < 4mm
19. Life Style Modification
• Elimination/avoidance of exacerbating factors
• Humidification of rooms
• Breaks between prolonged computer use (20-20-20)
• Lowering the computer monitor below eye level
• Increase blinking tendency during reading or any near work
• Dietary supplementation with omega 3 fatty acid
21. Preservation of Existing Tear
• Environmental modification
Reduction of room temperature
Humidifiers
Avoidance of wind/dust
• Life style / work place modification
Taking regular breaks from reading or computer use
Increasing blink or fast blink exercise
Lowering the computer below eye level
Discontinue medication that exacerbate dry eyes
22. Tear Substitutes
• Drops
• Gels – consists of carbomers
• Ointments – consists of petroleum mineral oil
• Inserts – Hydroxypropyl cellulose
24. Tear Substitutes
Ointments & Gel :
• Second most common method for ocular lubrication
• Petrolatum (Paraffin) ointment can be used at bed time
• Carbapol 940 (polyacrylic acid) a gel with high water binding power
that transform gel into liquid upon contact with ocular tissue
25. Tear Substitutes
• Inserts : Lacrisert / SR-AT
Ingradient - Hydroxypropyl cellulose – small 5 mg pellet
Placed in inferior cul-de-sac with plastic inserter
Dose – once or twice daily
• Eyelid sprays
Applied to the closed eyes and typically contain liposome based agent that
may stabilize the tear film and reduce evaporation
27. Anti-inflammatory Agents
Steroids:
Dry eye is related to the inflammation of ocular surface & also immune
mediated inflammation plays an important role
Preferably weak steroid – Fluorometholone , loteprednol
Rapidly & effectively relieve the sign symptoms of moderate to severe
dry eyes
Pulse therapy for 1-3 weeks
28. Anti-inflammatory Agents
Ciclosporin (0.05%)
Reduces T-cell mediated inflammation of lacrimal tissue
Increase the number of goblet cells
Reversal of squamous metaplasia of conjunctiva
Decrease artificial tear use
29. Anti-inflammatory Agents
Tetracycline
• Mechanism
Antibacterial by decreasing the bacteria producing lipase
Anti-inflammatory
Antiangiogenesis
• Indication – Acne rosacea and blepharitis
• Oral doxycycline usually preferred often extended course in low dose
30. Anti-inflammatory Agents
Omega fatty acid
Mechanism : Inhibit lipid mediators synthesis & block IL-1 and TNF α
Source – Fish oil , walnuts , flax seeds , soyabean etc
Dramatic effect on symptom & may facilitate the reduction of topical
medication
31. Autologous Serum Eye Drop
Autologous or umbilical cord serum ( 20%)
Healing of persistent epithelial defects
Subjective & objective improvements in severe dry eye
Production & storage is challenge
32. Secratagogues
• Mechanism : Increase aqueous secretion , mucin or both
• Agents : pilocarpine, cevimeline, rebamipide
• Indication : May reduce the symptoms of dry eye and dry mouth in
patients with sjogren syndrome
• Dose - pilocarpine 5 mg four times daily
33. Androgen
• Post menopausal women deficit in androgen, so DED is more
common in women
• Mechanism – Increase the activity of sebaceous & meibomian glands
Promotes retention of water & electrolytes
Immunomodulatory & anti-inflammatory effects
Indication - useful in MGD to prevent evaporation
34. Mucolytic Agents
• Acetylcysteine 5% drops
• Indication - patients with corneal filaments and mucous plaques
• Side effects - may cause stinging on instillation.
Acetylcysteine is malodorous and has a limited shelf-life.
36. Contact Lenses
• Function : Retain tear film
Promote ocular surface healing
Used in Severe dry eye
• Types:
Low water content HEMA lens
Silicon rubber lens
Occlusive gas permeable scleral contact lens- provides best reservoir
38. Punctal Occlusion
•Reduces tear drainage and thereby preserves natural tears and
prolongs the effect of artificial tears
•It is of greatest value in patients with moderate–severe KCS who have
not responded to frequent instillation of topical agents
Temporary
Revesible
Permanent
39. Temporary Punctal Occlusion
• Collagen plugs are used
• Dissolve in 1-2 weeks
• Initially the inferior puncta are occluded and the patient is reviewed
after 1 or 2 weeks
• If the patient is asymptomatic and without epiphora, the plugs can be
removed and the inferior canaliculi permanently occluded
• In severe KCS both the inferior and superior canaliculi can be plugged
40. Reversible Punctal Occlusion
• Prolonged occlusion can be achieved with silicone or long-acting
collagen plugs (2–6 months)
• Problems
Extrusion
Granuloma formation
Distal migration
41. Permanent Punctal Occlusion
• Done in severe dry eye
• Avoided in young patients
• All four puncta should not be occluded at the same time
• Permanent occlusion is performed following punctal dilatation by
coagulating the proximal canaliculus with cautery
• Laser cautery is another option
42. Modern Technology in MGD
• LIPIFLOW
A device having an insulated conformer that heats the inner surface of
the lids
An inflatable pad applies a pulsatile pressure to the glands through the
tarsal plate
43. Step wise DED Treatment
TOFS DEWS II produced guidelines for Dry Eye, in which suggested
treatment options depend on the level of severity of disease graded
from 1 to 4
TFOS DEWS II 2017
49. Follow up & Counselling
• To provide reassurance and constant counselling is very important
part of dry eye management
• To asses the therapeutic response
• To monitor for structural ocular damage
• Frequency & extent of follow up depends on
Disease severity
Therapeutic approach
Therapeutic response
50. Take Home Message
• Dry eye is a challenging problem now a days
• Methodical approach to diagnosis
• Carefully plan the line of treatment
• Educate the patient and family members about the dilemmas in
management
