This document provides information about dry eye disease (DED). It discusses the anatomy and function of the tear film layers. DED is defined as a multifactorial disease caused by tear film instability and inflammation. Risk factors include older age, female sex, menopause, medications, contact lens use and environmental exposures. Signs and symptoms include eye irritation, punctate keratitis, and decreased tear production. Tests to diagnose DED include tear breakup time, Schirmer test, and ocular surface staining. DED can range from mild to severe and cause complications like corneal neovascularization if left untreated.

1. DRY EYE
SAMEER BHAILA
MASTER OF OPTOMETRY
TILGANGA INSTITUTE OF OPHTHALMOLOGY
FACILITATOR
DR. YOGITA RAJBHANDARI

3. Pre-cornealtearfilm
• Superficial thin lipid layer
• Middle bulk aqueous layer
• Innermost mucous layer

4. Lipidlayer
Lipid layer is secreted by the meibomian glands &
gland of Zeiss
Their function is:
 To reduce the evaporation of the aqueous layer.
 To increase the surface tension & assist in vertical
stability of the tear film
 To act as surfactant and help spread the tear
uniformly
 To lubricate the eyelids.

5. Aqueouslayer
The middle layer is secreted by lacrimal gland and
accessory glands of Krause and Wolfring & has
following functions:
 To supply atmospheric oxygen to the avascular
corneal epithelium
 Anti –bacterail function
 To reduce the irregularities by enhancing the
anterior corneal surface optically
 To clean away the debris.

6. Constituents of Aqueous layer
Water
Electrolytes (Na, K, Cl)
Proteins:
1. Epidermal growth factors
2. Immunoglobulins (IgA, IgG, IgM)
Lactoferrin
Lysozyme
Cytokines

7. Mucinlayer
The inner layer is secreted by the conjunctiva goblet
cells, crypts of Henle & glands of Manz.
It converts the corneal
epithelium from
hydrophobic to
hydrophilic state.

8. Normaltearfilm
Volume: 7-10 μl
Thickness : 7microns
Production : 1.2 μl/min (0.5-2.2)
Turn over: 16%
Tear evaporation (0.14 μl/min in 30% humidity)
pH : 6.5-7.6
Surface tension : 40.7 dyne/cm
Refractive index : 1.336
Osmolarity : 300-310 mOsm/l

9. Dry Eye Disease (DED)
 The most frequently encountered ocular
morbidities
 A growing public health problem and
 One of the most common conditions seen by eye
care practitioners
 New concepts illustrates that it is caused by
inflammation mediated by T-cell lymphocytes.

10. DEFINITION
• Dry eye is a disorder of the tear film due to tear deficiency or
excessive evaporation, which causes damage to the
interpalpebral ocular surface and is associated with
symptoms of ocular discomfort.
(National Eye Institute (NEI)/Industry Dry Eye Workshop: 1995)

11. DEFINITION
• Dry eye is 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.
• It is accompanied by increased osmolarity of the tear film
and inflammation of the ocular surface.
(International Dry Eye Workshop, DEWS: 2007)

12. DEFINITION
• Our understanding of dry eye has evolved from
considering:
Tear volume insufficiency
to
Tear film instability with underlying
inflammation due to altered tear composition

13. Vicious cycle of ocular surface inflammation

14. Etiopathogenesis of dry eye disease

15. CurrentTriggersofDryEyeDisease
Environment
Medications
Contact Lens
Surgery
Rheumatoid Arthritis
SLE
Sjögren’s
Graft vs Host
Post menopause
Meibomian
Gland Disease
Symptoms of Ocular Surface Disease
Inflammation
Tear
Deficiency/
Instability
Irritation

16. Risk factors
Older age
Female sex
Postmenopausal status
Previous Refractive Surgeries like LASIK, SMILE, etc

18. Mostsusceptiblegrouptodryeye
 Post menopausal women
 Patient of 50 yrs plus group
 Patient on diuretics , beta blockers, psychotropics &
oral acne medication
 Rheumatoid arthritis patient
 People exposed to heat and dust
 Patient with blepharitis (MGD)

19. Environmental Stresses
Contact Lens Wear
Wind
Air Pollution
Low Humidity: Heating/Air Cond
 Lack of Sleep
 Use of Computer Terminals

20. MedicationsThatMayContributetoDryEye
Disease
Systemic
Antihypertensives
Antiandrogens
Anticholinergics
Antidepressants
Cardiac
Antiarrhythmic Drugs
Parkinson’s
Disease Agents
Antihistamines
Topical
Preservatives in tears

21. Classification of Dry Eye
The 2007 International Dry Eye Workshop (DEWS),
classified dry eye into:
• Aqueous-deficient
• Evaporative

24. Sjogren Syndrome
Is an autoimmune disorder
Characterized by lymphocytic inflammation and
destruction of lacrimal and salivary gland and other
exocrine glands
Lymphocytic infiltration of the lacrimal gland with
damage to secretory acini

25. Classic triad
Classic triad consists of:
 Dry eye
 Dry mouth
 Parotid gland enlargement

26. Sjogren Syndrome
Classified into:
Primary when it exists in isolation
Secondary when associated with other diseases like
Rheumatoid Arthritis, Systemic Lupus
Erythematosus, Wegener’s granulomatosis and
other autoimmune disorders

27. Clinical Features Dry Eye
Common symptoms
 Ocular discomfort
 Irritation such as scratchiness, grittiness, foreign
body sensation, burning, blurring, and itching

28. Clinical Signs
 Posterior blepharitis and meibomian gland
dysfunction may be present
 Conjunctiva may show mild keratinization and redness
 Tear film
• The lipid-contaminated mucin accumulates in the tear
film as particles and debris that move with each blink
• The marginal tear meniscus becomes thin (< 1 mm) in
height or absent

29. Cornea
• Punctate epithelial erosions that stain with fluorescein
• Filaments consist of mucus strands lined with
epithelium attached at one end to the corneal surface
which stain well with rose bengal
• Mucous plaques consist of semi-transparent, white-to-
grey, slightly elevated lesions of various sizes

30. Complications
Occurs in very severe cases which include:
Peripheral superficial corneal neovascularization
Epithelial breakdown
Melting of corneal
Perforation of cornea and
Bacterial keratitis

31. Severity Grades of DED
 Dry eye is classified according to the clinical
severity into three grades
Grade 1 or mild:
 Patients have symptoms of dryness in normal
environmental conditions
But no signs on slit-lamp examination
Electrophysiological or invasive tests, such as
hyperosmolarity, hypolysozyme or inflammatory
cytokines, may be positive.

32. Grade 2 or moderate:
 In addition to symptoms, patient has reversible
slitlamp signs such as
 Epithelial erosion
 Punctate keratopathy
 Filamentary keratitis
 Short tear breakup time (TBUT), etc.

33. Grade 3 or severe:
The patient has, besides the symptoms of ocular
dryness, signs that have evolved to permanent
sequelae such as
 Corneal ulcer
 Corneal opacity
 Corneal neovascularization or
 Squamous epithelial metaplasia
These signs are commonly seen in untreated
patients.

34. Investigation
The test measure the following parameters:
Tear Film
Stability
• Tear Film Break-up Time (TBUT)
Tear
Production
• Schirmer
• Fluorescein Clearance
• Tear osmolarity
Ocular
Surface Dz
• Corneal Stains
• Impression Cytology

35. Tear Film Break-up Time
 Abnormal in aqueous tear deficiency and MGDs
Fluorescein 2% or an impregnated strip moistened
with saline is instilled in lower fornix
Patient is asked to blink several times
Tear film is examined under cobalt blue filter
BUT is the interval between the last blink and
appearance of first randomly distributed dark dry
spot

36. TBUT
 Values of < 10s are considered abnormal
 Values of < 5s are clearly indicative of severe
dry eye

37. Noninvasive breakup time (NIBUT)
 Is a test of tear stability that does not involve the
instillation of fluorescein dye
 Measurements are performed with a xeroscope

38. Schirmer Test
Useful in assessment of aqueous tear production
The Schirmer strip is placed over the lateral third of
the lower lid
If using an anesthetic , adequate time should be
given after the drop to minimize reflex tearing
from the burning sensation due to drop

39. Schirmer I (without anesthesia ) : basic and
reflex secretion
Schirmer II (with anesthesia ): basic secretion
<5mm wetting in 5 min is sign of clinical dry eye
5-10mm wetting suggests borderline dry eye
>10mm wetting represents normal secretion

41. Ocular Surface Staining
The installation of dyes is a common method to
detect ocular surface epithelial pathology
associated by dry eye
• Fluorescein sodium
• Rose Bengal
• Lissamine green

42. Fluorescein is the most commonly used :
stains the corneal and conjunctival epithelium
where there is sufficient damage to allow dye
to enter tissue
Stains cornea more readily than conjunctiva
significantly greater amount of staining in
Sjogren’s aqueous tear deficiency

43. Fluorescein Stain

44. Rose Bengal unlike fluorescein which stains tissue by
penetrating into intercellular spaces stains:
 Devitalized epithelial cell
 Healthy epithelial cells when they are not
protected by a healthy layer of mucin.
 Corneal filaments and plaques are stained well by
Rose Bengal

45. Rose Bengal Stain
 Van Bijsterveld scoring system applied for Rose
Bengal dye
 Intensity of stain is scored in two exposed
conjunctival zones (nasal and temporal) and
cornea.
 Score of 03 is given for each zone
0 is for no stain
+1 for separate spot
+2 for many separate spots
+3 for confluent spots
With a maximum score of 9

46. Lissamine green B stains in a similar fashion to
Rose Bengal:
Produces much less irritation
Staining pattern to be identical to Rose Bengal

47. Pattern of Staining
The pattern of staining may aid in diagnosis
Pattern
Interpalpebral staining of cornea is common in
aqueous tear deficiency
Superior conjunctival stai may indicate superior
limbic keratoconjuctivitis
Inferior corneal and conjunctival stain is often
present in blepharitis and exposure keratitis

48. Other Investigations
Fluorescein clearance test
 The tear function index is assessed by placing 5 μl
of fluorescein on the ocular surface
 Measures the residual dye in a Schirmer strip
placed on the lower lateral lid margin at intervals
of 1, 10, 20 and 30 minutes.

49. Fluorescein clearance test
 The presence of fluorescein on each strip is
examined under blue light and compared to a
standard scale or measured using
fluorophotometry.
 Normally the value fall to zero after 20 minutes.
 Delayed clearance is observed in all dry eye states.

50. Lactoferrin
The major protein secreted by the lacrimal gland.
Tear lactoferrin is decreased in Sjögren syndrome
and other lacrimal gland diseases.
Immunoassay kits are available to measure
lactoferrin in body fluids

51. Phenol red thread test
 Uses a thread impregnated with a pH sensitive dye.
 The end of the thread is placed over the lower lid and
the length wetted (the dye changes from yellow to red
in tears) is measured after 15 seconds.
 A value of 6 mm is abnormal.
 It is comparable to Schirmer test but takes less time.
Tear meniscometry
Technique to quantify the height and thus the volume of
the lower lid meniscus.

52. Impression cytology
Minimally invasive alternative to ocular surface
biopsy
Superficial layers of the ocular surface epithelium
are collected (e.g. by applying filter paper) and
examined microscopically
Useful for detecting abnormalities such as goblet
cell loss and squamous metaplasia

53. Treatment
DEWS have produced guidelines based on the level of
severity of disease graded from 1 to 4.
LEVEL 1
1. Education and environmental modification
• Lifestyle review: Importance of blinking while reading,
watching television or using computers, learning to take
breaks while reading, rule of 20-20-20, lowering the
computer monitors to decrease lid aperture

54. • Environment review: increasing the humidity of the
room or decreasing the temperature of the room
• Caution the patient that laser refractive surgery and
other ocular surface surgeries exacerbate the dry
eye
2. Systemic medication review:
• To exclude contributory effects and eliminate
offending agents

55. 3. Artificial tear substitutes
• Use of preserved artificial tear drops, gels and
ointments
• Are the mainstay of treatment for mild to moderate
aqueous tear deficiency.
• Aqueous solutions containing polymers such as
cellulose derivatives [e.g. hydroxypropyl methyl
cellulose (HPMC), carboxymethyl cellulose], polyvinyl
derivatives (e.g. polyvinyl alcohol), chondroitin sulfate,
and sodium hyluronate.
• Artificial tears containing preservatives, particularly
benzylkonium chloride, are poorly tolerated and
harmful in moderate to severe cases

56. 4. Eyelid therapy
• Warm compression and lid hygiene for blepharitis
and MGDs
• Reparative lid surgeries for entropion, ectropion, lid
laxity and scleral show

57. LEVEL 2
• Anti-inflammatory agents
Topical steroids like fluometholone
Oral omega fatty acid
Topical cyclosporine A (0.05%) : Is a fungal derived
peptide that prevents Tcell activation and inflammatory
cytokine production
 Oral Tetracyclines (Doxycycline) for mebomianitis,
rosacea
 Punctal plugs
 Secretagogues are cholinergic agonists like pilocarpine
which increases lacrimal secretion
 Moisture chamber spectacles and spectacle side
shields

58. Level 3
• Serum eye drops:
 Autologous or umbilical cord serum
 Serum and plasma contain many anti-inflammatory
factors which include inhibitors of inflammatory
cytokines and inhibitors of MMPs.
 Have potential to inhibit mediators of the ocular
surface inflammatory cascade of dry eye
• Contact lens: Low water content SCL or Silicone
hydrogels use or Scleral lenses
• Permanent punctal occlusion

59. Level 4
• Systemic anti-inflammatory agents
• Surgery:
 Tarsorrhaphy and botulinum toxin induced ptosis
 Salivary gland autotransplantation
 Mucous membrane or amniotic membrane or
limbal stem cell transplantation for corneal
complications

60. Novel therapeutic agents with anti-inflammatory
properties:
 AntiCD4 monoclonal antibody
 Hydroxychloroquine, when given orally for the
treatment of Sjogren syndrome, has a beneficial
effect on dry eye

61. Steven-Johnson Syndrome
 also called as Erythema multiforme major / Toxic
epidermal necrolysis (TEN) / Lyell Syndrome
 Involves a cell-mediated delayed hypersensitivity
reaction

62. Steven-Johnson Syndrome
 Usually related to drug exposure
Antibiotics:
Sulfonamides and trimethoprim
Analgesics:
Paracetamol (acetaminophen), cold remedies and
Anti-convulsants
 Infections due to
Mycoplasma pneumoniae, herpes simplex virus and
some cancers

63. Ocular Features of SJS
Symptoms:
• Redness
• Mild-severe grittiness
• Photophobia
• Watering and
• Blurring
Signs:
• Acute Signs
• Late Signs

64. Acute Sign of SJS
Haemorrhagic crusting of lid margins
Papillary conjunctivitis
Cunjunctival membranes and pseudomembranes
Keratopathy: punctate erosions to large epithelial
defects and in severe case perforation as well
Iritis

65. Late Signs of SJS
Conjunctival cicatrization with forniceal shortening and
symblepharon
Keratinization of conjunctiva and lid margin
Eye lid complications include entropion, ectropion,
triciasis, metaplastic lashes
Keratopathy includes scarring, vascularization and
keratinization
Watering due to fibrosis of lacrimal puncta and severe dry
eye due to fibrosis of lacrimal gland

66. Late Signs of SJS

67. Systemic Features of SJS
Symptoms:
• Flu-like symptoms lasting 14 days before
appearance of lesions
• Nasal pain and discharge
• Pain in micturition
• Diarrhoea
• Cough
• Shortness of breath
• Pain on eating and drinking

68. Systemic Signs of SJS
• Blistering and hemorrhagic crusting of lips, tongue,
oropharynx, nasal mucosa and genitalia
• Small purpuric , vesicular, hemorrhagic or necrotic
skin lesions involving extremities, face and trunk

69. Systemic Treatment
• Removal of the precipitant drugs having toxic effects
like sulphonamides
• Maintenance of adequate hydration, electrolyte
balance and nutrition
• Intravenous steroids treatment may improve
outcomes
• Immunosuppressant like cyclosporine, azathioprine
can be prescribed
• Systemic antibiotics for prophylaxis having no toxicity

70. Ocular Treatment
Acute Disease
• Topical preservative free lubricants like
hypromellose (0.3%)
• Topical steroids for iritis and conjunctival
inflammation
• Topical cycloplegia (1% atropine once or twice daily)

71. Acute Disease
• Lysis of developing symblephara
• Pseudomembrane / membrane peeling
• Prophylactic topical antibiotics for bacterial keratitis
and conjunctivitis
• Conjunctival swab should be considered for
prophylactic culture

72. Chronic Disease
• Adequate lubrication and punctal occlusion if
required
• Topical transretinoic acid 0.01% or 0.025% may
reverse keratinization
• Bandage contact lens (typically gas permeable scleral
lenses and scleral lenses)
• Mucous membrane grafting (e.g. buccal mucosa
autograft) for forniceal reconstruction.

73. • Corneal rehabilitation
Superficial keratectomy for keratinization
Lamellar corneal grafting for superficial scarring
Amniotic membrane grafting
Limbal stem cell transplantation
Keratoprosthesis implantation in end-stage disease

74. Thank you!!!