The document discusses dry eye, defining it as a disorder of the tear film due to reduced tear production or excessive evaporation, causing damage to the ocular surface. It describes the layers of the tear film and their functions in lubricating the eye and protecting it. Symptoms of dry eye are discussed. Diagnostic tests for dry eye including tear break-up time, ocular surface staining, and Schirmer test are summarized. Management strategies are outlined for mild, moderate, and severe dry eye, including artificial tears, anti-inflammatory therapies, punctal plugs, and systemic treatments.

1. DRY EYE
BY:-
DR. SAAMRAGYE SRIVASTAVA

2. DRY EYE DEFINITIONS
NEI DEFINITION :-
Dry eye diseases is a disorder of the tear film due to reduced
tear production or excessive tear evaporation which causes
damage to the inter palpebral ocular surface and is associated
with symptoms of ocular discomfort and or visual symptoms.
DEWS Definition :-
Dry eye disease is a multifactorial disease of tear film and
ocular surface that result in symptoms of discomfort, visual
disturbance, and tear film instability with potential damage to
the ocular surface. It is accompained by increased osmolality
of tear film inflammation ocular surface.

3. Outer lipid layer Middle aqueous layer Inner mucus layer
Oily secretion of MEIBOMIAN,
ZEISS AND MOLL GLAND
Tear fluid secretion from LACRIMAL
GLAND AND THE ACCESSORY
GLAND (Krause and Wolfring)
Mainly secreted by goblet cells,
crypts of Henle and gland of
Manz
0.1- 0.2 mm 8 um 0.02-0.05um
• Prevent overflow of tears
• Prevent migration of skin lipid
onto the ocular surface
• Clears ocular media
• Acts as barrier to prevent
contamination
• Acts as surfactant layer
• Acts as a lubricant to facilitate
smooth movement
• Serves to provide atmospheric
oxygen to epithelium
• Washes away debris and nxious
irritants
• Contains (lysozymes and
betalysin)
• Lubricates ocular and
palpabral surfaces
• Provides slippery coating over
foreign bodies, hence
protecting cornea and
conjunctiva.

5. Symptoms:
Presenting complaints: Irritation, tearing,
burning, stinging, dry or foreign body
sensation, mild itching, photophobia,
blurry vision, contact lens intolerance,
redness, mucous discharge, increased
frequency of blinking, diurnal fluctuation,
and symptoms that worsen later in the
day.
Exacerbating conditions: e.g. wind, air
travel, decreased humidity, prolonged visual efforts
associated with decreased blink rate such as
reading or watching TV.

6. Ocular history details about the following:
• Topical medications used, their frequency and their effect on symptoms: e.g.,
frequent “eyewash”, artificial tears, anti-histaminic, glaucoma medications,
vasoconstrictors, corticosteroids.
• Contact lens wear: type of CL, wearing schedule, and care
• Allergic blepharoconjunctivitis or other type of chronic allergic eye disease.
• Ocular surgical history: e.g., prior keratoplasty, cataract surgery and its type,
keratorefractive surgery.
• Ocular surface disease: e.g., herpes simplex virus, varicella zoster virus, SJS.
• Punctal occlusion: temporary or permanent.
• Eyelid surgery: e.g., prior ptosis repair, blepharoplasty, entropion / ectropion
repair.
• Bell’s palsy

9. Medical history details:
• Menopause
• Systemic inflammatory diseases: e.g., Sjogren syndrome, rheumatoid
arthritis, systemic lupus erythematosis, Scleroderma
• Oral cavity: Dry mouth, dental cavities, oral ulcers
• Dermatological diseases: e.g., rosacea, vesiculo-bullous lesions
• Atopy: e.g., dermatitis, rhinitis, bronchial asthma
• Systemic medications: e.g., antihistamines, diuretics, hormones and
hormonal antagonists, antidepressants, cardiac antiarrhythmic drugs,
isotretinoin, diphenoxylate/atropine, beta-adrenergic antagonists,
chemotherapy agents, any other drug with anticholinergic effects.

10. • Other systemic conditions: e.g. lymphoma, sarcoidosis
• Chemical injury: e.g. lime burn or any other
• Chronic viral infections: e.g. hepatitis C, HIV
• Non-ocular surgery: e.g. bone marrow transplant, head and
neck surgery, trigeminal neuralgia surgery
• Radiation of the orbit or nearby area
• Neurological conditions: e.g. Parkinson disease, Bell’s palsy,
trigeminal neuralgia
• Smoking or exposure to passive smoking
• Technique and frequency of facial washing including eyelid
hygiene.

12. Examination
Physical examination: visual acuity measurement with
correction, external eye examination, and slit-lamp biomicroscopy.
The purpose is to:
 Assess the presence and severity of deficient aqueous
tear production and/or increased evaporative loss.
 Determine other causes of ocular irritation.

13. External examination:
 Gait: as in rheumatoid arthritis
 Hands: joint deformities characteristic of rheumatoid arthritis
 Skin: e.g., scleroderma, florid acne, facial changes consistent
with rosacea, SLE
 Cranial nerve functions: e.g., trigeminal and facial nerve
 Proptosis
 Eyelids: incomplete closure/malposition, incomplete or infrequent
blink, erythema of the eyelid margins, abnormal deposits or
secretions, trichiasis, entropion, ectropion
 Adnexa: enlargement of the lacrimal glands

14. Slit-lamp examination:
 Eyelashes: trichiasis, districhiasis, deposits
 Anterior and posterior eyelid margins: abnormalities of meibomian glands
(e.g., orifice metaplasia, reduced expressible meibum, atrophy), character of
meibomian gland secretions [e.g., turbid, thickened (tooth-paste sign),
foamy], vascularization crossing the muco-cutaneous junction, keratinization,
scarring
 Puncta: position, patency, position of plugs if present
 Tear film: height of the meniscus, debris, increased viscosity, mucus strands,
and foam

15. Conjunctiva:
Inferior fornix and tarsal conjunctiva: e.g., mucous threads, gross scarring,
stellate scar (in healed trachoma), erythema, papillary reaction, enlarged follicles,
keratinization, fornix shortening, symblepharon.
Bulbar conjunctiva: e.g., punctate staining; follicles, Herbert’s pit (healed
trachoma), hyperemia; localized drying; Bitot’s spot, keratinization
Cornea: localized inter-palpebral drying, punctate epithelial erosions,
superficial punctate staining, filamentary keratopathy, epithelial defects, mucous
plaques, keratinization, pannus formation, thinning, infiltrates, ulceration,
scarring, neovascularization, evidence of cataract, corneal or kerato - refractive
surgery

17. Diagnostic Tests
For patients with mild irritation symptoms: a reduced tear break- up
time (TBUT) may indicate an unstable tear film with normal aqueous
tear production, and there may be minimal or no dye staining of the
ocular surface.
For patients with moderate to severe symptoms: the diagnosis can be
made by using one or more of the following tests:
Tear break-up time (TBUT) test – to evaluate tear-film stability
Ocular surface dye staining test: to evaluate ocular surface
disease (KCS)
Schirmer test: to evaluate aqueous tear production
These tests should be performed in this sequence because the Schirmer test can
disrupt tear film stability and cause false-positive ocular-surface dye staining.

18. Tear break-up time (TBUT) test
• It is performed by moistening a fluorescein strip with sterile non- preserved
saline and applying it to the inferior tarsal conjunctiva.
• After several blinks, the tear film is examined using a broad beam of the slit-
lamp microscope with a cobalt blue filter.
• The time lapse between the last blink and the appearance of the first
randomly distributed dark discontinuity in the fluorescein- stained tear
film is the tear break-up time.
• Recurrent tear break-up may indicate localized anterior basement-
membrane abnormalities. Break-up times less than 10 seconds are
considered abnormal.
• A rapid tear break-up time is observed in both aqueous tear deficiency and
meibomian gland disease.

19. Ocular surface dye staining
Used to assess the extent of ocular surface damage.
Fluorescein dye test: It stains areas of the corneal and conjunctival epithelium
where there is sufficient disruption of intercellular junctions to allow the dye
to permeate into the tissue.
The ocular surface is examined through a Slit lamp microscope using a cobalt
blue filter.
Mild fluorescein staining can be observed in normal eyes and may be more
prominent in the morning.
Exposure-zone punctate or blotchy fluorescein staining is observed in dry eye,
and staining is more easily visualized on the cornea than on the conjunctiva.

20. Rose Bengal staining: It may be performed using a saline- moistened
strip. The saline drop used to moisten the strip should remain in contact
with the strip for at least a minute to achieve an adequate
concentration of rose Bengal to stain the ocular surface. Patients should
be informed that the drop might irritate the eye. Rose Bengal staining is
more intense on the conjunctiva than the cornea. The dye stains ocular
surface cells that lack a mucous coating as well as debris in the tear film,
the staining may be easier to observe with a red-free filter.
Lissamine green dye: has a staining profile similar to that of rose Bengal
and may cause less ocular irritation.

21. Interpretations:
Diffuse corneal and conjunctival staining is commonly seen in viral
keratoconjunctivitis and medicamentosa.
• Staining of the inferior cornea and bulbar conjunctiva is typically observed in
patients with staphylococcal blepharitis, MGD, lagophthalmos, and exposure.
• Staining of the superior bulbar conjunctiva is typically seen in SLK
A pattern of exposure zone (interpalpebral) corneal and bulbar conjunctival
staining is typically seen with aqueous tear deficiency.

22. Schirmer Test :-
Is performed to evaluate aqueous tear production, but it gives variable results
and should not be used as the only criterion for diagnosing dry eye. It is
performed by placing a narrow filter-paper strip (Whatmann Filter paper No:
41) in the lower fornix. Aqueous tear production is measured by the length in
millimeters that the strip wets during the test period, generally 5 minutes.
Used to quantitatively measure the tear secretions by the lacrimal gland
Shirmer I Test Is used to measure tear secretion rate without anesthesia.
Measures reflex + basal secretion
Shirmer II Test is similar to Shirmer I but after instillation of anesthetic drops.
In this the amount of tear secretion is closure to the basal secretion rate as there
is no stimulus from the filter paper strip placed in the inferior conjunctival sac.

24. Classification of Dry Eye Syndrome
• Mild Dry Eye Syndrome : can be defined in patients who have a
Shirmer Test of less than 10 mm in 5 minutes and less than one
quadrant of staining of cornea
• Moderate Dry eye Syndrome:
Can be defined as with Schirmer Test reslts of 5-10 mm in 5 minutes
with punctate staining of more than one quadrant of the corneal
epithelium.
• Severe Dry Eye Syndrome : Can be defined as diffuse punctate or
confluent staining of the corneal epithelium, often ith filaments.
Shirmer Test mostly less than 5 mm in 5 minutes.

25. Management :-
The aims for treating dry eye disease include:
 Reducing or alleviating signs and symptoms of dry eye
 Maintaining and improving visual function
 Reducing or preventing structural damage

26. Mild Dry Eye
Potentially exacerbating exogenous factors are to be eliminated: Long-
term use of antihistamines, diuretics, beta-blockers, anti-depressant, etc.
Cigarette smoking and passive smoking: may be associated because of its
adverse effects on the lipid layer of the tear film and tear proteins.
Environmental factors such as air drafts and low-humidity environments.
Humidifying ambient air and avoiding air drafts by using shields and by
changing the characteristics of airflow at work place, at home, and in the car
may be helpful.

27. Measures such as lowering the computer screen to below eye level to
decrease lid aperture, scheduling regular breaks, and increasing blink
frequency may decrease the discomfort associated with computer and
reading activities.
Artificial tears (eye drops and gels) can be used.
Artificial tears with preservatives may be sufficient for patients with mild dry
eye and an otherwise healthy ocular surface.
When tear substitutes are used frequently (e.g., more than four times a day),
non-preserved tears (or with preservative free on surface) are generally
recommended.
Contributing ocular factors such as blepharitis or meibomianitis should also
be treated .

28. Moderate Dry Eye
In addition to the treatments for mild dry eye, the following management options may
be applied:
Artificial tears: Non-preserved tears (or with preservative free on surface) are
important. The frequency may be increased from 6-12 times depending upon the
patient’s need, occupation, and lifestyles.
Anti-inflammatory therapies: 0.05% topical Cyclosporine prevents activation and
translocation of cytoplasmic transcription factors that are required for T-cell activation
and inflammatory cytokine production.
It also inhibits mitochondrial pathways of apoptosis of lacrimal gland and goblet cells.
It typically takes 3 months for the medication to prove to be effective.
With time the dose of topical cyclosporine may be reduced.
Pre-treatment with topical loteprednol reduces cyclosporine-induced stinging in
chronic dry eye disease.

29. • Topical Corticosteroids decrease ocular irritation, decrease corneal
fluorescein staining and improve filamentary keratitis.
Loteprednol etabonate 0.5% patients with KCS with at least a moderate
inflammatory component.
Low-dose topical corticosteroids therapy can be used at infrequent intervals for 2-
week to suppress irritation secondary to inflammation.
Patients prescribed corticosteroids for dry eye should be monitored closely for
adverse effects such as increase in intraocular pressure, corneal melting, and cataract
formation.
• Systemic Omega-3 fatty acid supplements: higher dietary intake of
Omega-3 fatty acids is associated with a decreased risk of dry eye disease
in women.

30. • Punctal occlusion : It can be done surgically with silicone or thermo-labile
polymer plugs that are lodged at the punctal orifice. It is important to
perform a temporary punctual occlusion first with collagen plugs to test its
effect.
Silicone plugs placed in the punctum, and both silicone and collagen plugs placed in
the canaliculus to improve dry eye signs and symptoms. Punctal plugs have the
advantage of being removable if the patient develops symptoms of epiphora.
Intracanalicular thermolabile polymer plugs may offer ease of insertion and a
decreased chance of extrusion, but they have associated with the occurrence of
epiphora, canaliculitis, and dacryocystitis.
• Spectacles with side-shields or moisture chamber goggles are noninvasive
therapies that can be used, but cosmetically may not be accepted.

32. Severe Dry Eye
In addition to the treatments for mild and moderate dry eye, the following
treatments may be considered:
Oral cholinergic agonists: Pilocarpine and cevimeline bind to muscarinic
receptors secretion of the salivary and sweat glands and improve tear
production.
Oral Pilocarpine (5mg) 4 times daily-causes a significant overall improvement.
The most common side effect is excessive sweating,
Oral Cevimeline (30mg) 3 times daily, cholinergic agonist improve ocular
irritation symptoms and aqueous tear production.

33. Systemic immunosuppressants: for patients with systemic disease such
as rheumatoid arthritis, progressive systemic sclerosis or SLE.
Autologous serum drops: to improve ocular irritation symptoms as well
as conjunctival and corneal dye staining in patients with Sjögren
syndrome.
Topical acetylcysteine (10%), a mucolytic agent used four times a day
to treat filamentary keratitis. Filaments can also be debrided with a
cotton-tip applicator, dry cellulose sponge, or with a blunt forceps. Soft
contact lenses are effective in preventing recurrence of filamentary
keratopathy but are poorly tolerated if the patient has severe dry eye.

34. If the patient has associated neurotropic keratopathy, contact lenses
should be avoided.
Correction of eyelid abnormalities: resulting from blepharitis, trichiasis, or
lid malposition (e.g., lagophthalmos, entropion/ ectropion) may be
considered prior to permanent punctal occlusion.
Permanent irreversible punctal occlusion: thermal or laser cautery.
If occlusion with cautery is planned, a trial occlusion with temporary
collagen plugs generally should be performed first to screen for the
potential development of epiphora.
Laser cautery is not as effective as thermal cautery in achieving
permanent, complete occlusion.

35. Tarsorrhaphy: may be required to decrease tear evaporation
in patients with severe dry eye who have not responded to
other therapies.
Botulinum toxins: may be required to induce ptosis to
decrease tear evaporation in patients with severe dry eye
Repeat injection may require in many situations.

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