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- 1. Dry Eye Disease Presentedby: Dr. Laxmi Dhawal 1st year resident,MD ophthalmology LEIRC
- 2. Layer of tearfilm
- 3. Lipid layer Outermost superficialoily layer, Secreted by meibomian gland, Zeiss and Moll glands. Role : • prevents rapid tear evaporation • smoothes the tear film surface, reducing glare and improving vision • Acts as barrier for preventing contamination of tear film
- 4. Aqueous layer Middle layer,comprises 60% of the tear film Secreted by lacrimal gland and the accessory glands of Krause and wolfring Contains ions of inorganic salts ,glucose , urea and various biopolymers such as enzymes , proteins and glycoproteins Lysozyme , lactoferrin, tear specific prealbumin and secretory IgA are main constituents of protein fraction.
- 5. Functions • Serves toprovide atmospheric oxygen to the epithelium • washes away all the debris and noxious irritants and contains antibacterial substances like lysozymes and betalysin
- 6. Mucin layers • Secretedby conjunctival goblets cells • Role : • Lubricates the ocular and palpebral surfaces • Provides slippery coating over foreign bodies,thereby protecting cornea and conjunctiva .
- 7. Functions of TearFilm • Provides a smooth optical surface for clear vision. • Maintains hydration and protects the corneal epithelium. • Acts as a barrier against infections. • Removes debris and distributes oxygen to the cornea.
- 8. 8 Lacrimal Functional Unit(LFU) • LFU composed of lacrimal gland, ocular surface, lids, and the sensory and motor nerves that connect them" • Responsible for the regulation, production, and health of the tear film • Damage to any component, leads to tear- deficient or evaporative dry eye syndrome.
- 9. Introduction to DryEye Disease • DEWS II Definition: Dry Eye Disease is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film that is accompanied by ocular symptoms ,in which tear film instability and hyperosmolarity ,ocular surface inflammation and damage , and neurosensory abnormalities play etiological roles. • • Prevalence: Affects millions globally, particularly among older adults, women, and those with certain systemic conditions.
- 10. NEI definition • Dryeye disease is a disorder of the tear film due to reduced tear production or excessive tear evaporation which causes damamge to the interpalpebral ocular surface and is associated with symptoms of ocular discomfort and or visual symptoms
- 11. Causes of DryEye Disease Intrinsic Causes: • Age: Decreased tear production with aging. • Hormonal Changes: Particularly in women (e.g., menopause). • Systemic Conditions: Sjogren’s Syndrome, rheumatoid arthritis, lupus, etc. • Medications: Antihistamines, antidepressants, blood pressure medications, etc.
- 12. Extrinsic Causes: • EnvironmentalFactors: Air conditioning, wind, smoke, and dry climates. • Contact Lens Wear: Extended use of contact lenses. • Prolonged Screen Time: Reduced blink rate.
- 13.
- 14.
- 15. Clinical features Symptoms • feelingof dryness, grittiness and burning • Stringy discharge, • transient blurring of vision, • redness and • crusting of the lids
- 16. signs Posterior (seborrhoeic) blepharitiswith meibomian gland dysfunction is often present. Conjunctiva • Redness. • Staining with rose Bengal and lissamine green . • Keratinization. • Conjunctivochalasis is a common response to, and exacerbating factor for, the chronic irritation of dry eye, such that a self-sustaining cycle is maintained.
- 17. Tear film • Inthe dry eye, the lipid-contaminated mucin accumulates in the tear film as particles and debris that move with each blink • In the normal eye the meniscus is 0.2–0.4 mm in height, but in dry eye becomes thin (less than 0.25 mm) or absent
- 18. Cornea • Punctate epithelialerosions that stain well with fluorescein . • Filaments consist of strands of mucus and debris such as shed epithelial cells and are typically attached at one end to the corneal surface . The filaments stain well with rose Bengal but less so with fluorescein
- 19.
- 20. Diagnosis of DryEye Disease •Clinical History: Ocular history Systemic history
- 21. Ocular history • Detailedsymptom questions Ocular surface disease index –OSDI Dry eye questionnaire -5 (DEQ -5) Standard patient evaluation of eye dryness questionnaire (SPEED Q) National eye institute vision function questionnaire-25 (NEIVFQ) • Duration and severity of symptoms • Exacerbating conditions (wind , driving, prolong use of gadgets like computers , mobile phone )
- 22. • patients withaqueous tear deficiency worse as the day progresses, or after extensive use of the eyes • Lipid layer deficiency(meibomian gland disease ,blepharitis) worse in the morning---visual blurring upon waking
- 23. – Topical medicationsused, their frequency and their effect on symptoms – Contact lens wear, schedule and care – Allergic conjunctivitis • Ocular surgery history (prior keratoplasty, cataract surgery, keratorefractive surgery, Punctal surgery , Eyelid surgery)
- 24. • Ocular surfacedisease (HSV, varicella zoster virus, ocular mucous membrane pemphigoid, SJS syndrome, ) • Bell’s palsy
- 25. Systemic history – Smoking,alcoholism – Dermatological disease – Menopause and use of Hormone Replacement therapy – History suggestive of Systemic inflammatory disease (Sjogren syndrome, RA, SLE, scleroderma)
- 26. • Other systemicconditions (lymphoma, sarcoidosis) • Chronic viral infections (Hep C, HIV) • Systemic medications • Trauma (mechanical, chemical, thermal) • Non-ocular surgery (bone marrow transplant, head and neck surgery, trigeminal neuralgia surgery) • Radiation of Head and Neck • Neurological conditions
- 27. Medical history • Drugs oralcontraceptives, anticholinergics, antihistamines, antiarrhythmics, Beta blockers antipsychotics, TCA ,SSRIs antispasmodics, diuretics, retinoids, chemotherapy.
- 28. Examination External examination • Skin •Eyelids • Infrequent blink, • Eyelid retraction, eyelid margin erythema, • Abnormal deposits, • Entropion, ectropion Sleeves(demodex) Scurf (seborrhea) Collarette(staph)
- 29.
- 30. • Adnexa – enlargementof lacrimal glands – Proptosis – Cranial nerve function (trigeminal and facial) – Hands/Joints
- 31. Slit lamp examination •Tear film -Height of meniscus , debris,mucous strands • Foam , • Tear break-up time (T-BUT) – Eyelashes: trichiasis, distichiasis, madarosis, deposits
- 32. Eyelid margin: hyperemias,abnormalities of meibomian glands, secretions, keratinization and scarring Puncta: patency and position, presence of plugs
- 33. Examination • Conjunctiva Inferior fornixand tarsal: mucus thread scarring, erythema, papillary reaction, follicle enlargement, keratinization, Conjunctivochalasis Bulbar conjunctiva: punctate staining, hyperemia, localized drying, chemosis, chalasis, follicles
- 34. Cornea – punctate epithelialerosion, epithelial defects, – mucous plaques, – pannus formation, thinning, infiltrates, ulceration, – scarring, neovascularization, – evidence of corneal or refractive surgery
- 35. Diagnosis • Tear filmstability • Ocular surface health • Tear film composition • Tear flow • Impression cytology • Meibomian gland evaluation
- 36. Schirmer test I • Givesvalue for both basic and reflex secretion of tears II • Gives the value for reflex secretion III • Gives the value for reflex secretion
- 37. Schirmer I test Whatmannfilter paper number 41 (5х35 mm)is fold 5mm Placed in junction of outer 1/3rd and inner 2/3rd of lower fornix Eyes are closed for 5 min Paper is removed & moisture is measured
- 38. • Schirmer score(mm/5 min) • Mild –variable • ≤ 10 – moderate • ≤ 5- severe • ≤2 – very severe
- 39. Tear film • Inthe normal eye the meniscus is 0.2–0.4 mm in height, but in dry eye becomes thin (less than 0.25 mm) or absent
- 40. 40 Tear Film Composition •Osmolarity – Normal tear film osmolarity-309-312mOsm/L – Osmolarity >316mOsm/L is seen in dry eye
- 41. 41 • Tear proteinanalysis: – May be quantified by measuring tear lysozymes, tear lactoferrin, epidermal growth factor, immunoglobulin A – Lysozyme accounts for 20-40% of total tear protein – Sensitive but lacks specificity – Done by spectrophotometry – Tear lactoferrin concentrations measured by Lactocard, ELISA technique
- 42. 42 • Phenol redimpregnated thread test
- 43. Ocular surface staining •Fluorescein staining • Rose Bengal staining
- 44.
- 45.
- 46.
- 47.
- 48.
- 49. Tear film breakup time Two types • Invasive • Non invasive Keratometer Video keratoscope Tearscope
- 50. Invasive T BUT •The tear film BUT is abnormal in aqueous tear deficiency and meibomian gland disorders. It is measured as follows: • Fluorescein 2% or an impregnated fluorescein strip moistened with non- preserved saline is instilled into the lower fornix. • The patient is asked to blink several times.
- 51. • The tearfilm is examined at the slit lamp with a broad beam using the cobalt blue filter. After an interval, black spots or lines appear in the fluorescein-stained film, indicating the formation of dry areas. •
- 52. NON INVASIVE TBUT • KERATOGRAPH 5M instrument
- 53.
- 54.
- 55. 55 Meibomian Gland Evaluation •Slit lamp biomicroscopy • Meiboscopy • Meibography • Meibometry
- 56.
- 57.
- 58.
- 59. others • Labial biopsyin case of Sjogren syndrome
- 60. Dry eye severitygrading level (DEWS) Signs and symptoms 1 2 3 4 Discomfort,sev erity, and frequency Mild and/or episodic : occurs under environmental stress Moderate episodic or chronic , stress or no stress Severe frequent or constant without stress Severe and/or disabling and constant Visual symptoms None or episodic mild fatigue Annoying and/or activity limiting episodic Annoying, chronic and /or constant limiting activity Constant and/or poosibly disabling Conjunctival injection None to mild None to mild +/- +/++ Conjunctival staining None to mild variable Moderate to marked marked
- 61. 5 Corneal staining (severity/locati on) None to mildvariable Moderate to marked marked Corneal/tear signs None to mild Mild debris , tear meniscus Filamentary keratitis,mucus clumping ,↑ tear debris Filamentary keratitis,mucus clumping , ↑ tear debris,ulceratio n Eyelid/ meibomian glands MGD variability present MGD variability present MGD frequently present Trichiasis ,kera tinization ,sym blepharon TBUT(seconds ) Variable ≤ 10 ≤ 5 immediate Schirmer score (mm wetting after 5 min) variable ≤ 10 ≤ 5 ≤ 2
- 62. 62 Management Non- pharmacological • Maintainlid hygiene • Warm compression • Lid massage • Dietary supplementation
- 63. 63 Dietary Supplementation Omega-3 fattyacids • Sources: – Salmon fish – Shrimp and crab – Flaxseed oil – Dark leafy greens – Walnuts – Commercial preparation
- 64.
- 65.
- 66.
- 67.
- 68.
- 69. 69 Newer Modalities ForTreatment Of MGD • Mechanical meibomian gland probing Maskin Meibomian Gland Intraductal Probe
- 70.
- 71.
- 72. 72 Contd.. • LipiFlow thermalpulsation system
- 73. Management of dryeye disease Level 1 • Education and environmental/dietary modifications • Establishment of realistic expectations and emphasis on the importance of compliance. • Lifestyle review including the importance of blinking whilst reading, watching television or using a computer screen and the management of contact lens wear. • Environmental review, e.g. increasing humidity may be possible for some environments.
- 74. • Instillation aidsfor eye drops • Caution the patient that laser refractive surgery can exacerbate dry eye. Systemic medication review to exclude contributory effects and eliminate offending agents. Discontinuation of toxic/ preserved topical medication if possible
- 75. Artificial tear substitutesincluding gels and ointments . Eyelid therapy. warm compresses and lid hygiene for blepharitis. Reparative lid surgery (e.g. entropion, ectropion, excessive lid laxity or scleral show). Nocturnal lagophthalmos can be addressed by taping the lids closed at bedtime, wearing swimming goggles during sleep, or in extreme cases by lateral tarsorrhaphy
- 76. Level 2 Non-preservedtear substitutes Anti-inflammatory agents such as topical steroids, oral omega fatty acids and other agents such as topical ciclosporin. Tetracyclines (for meibomianitis, rosacea). Punctal plugs. Secretagogues, e.g. pilocarpine, cevimeline, rebamipide. Moisture chamber spectacles and spectacle side shields.
- 77. Fig : Siliconepunctal plug Punctal Plugs: Block tear drainage to retain tears Reversible punctal plug
- 78. 78 Irreversible Punctal Occlusion •Thermal cautery
- 79. Level 3 Serumeye drops. Autologous or umbilical cord serum. Contact lenses. Permanent punctal occlusion Level 4 Systemic anti-inflammatory agents.
- 80. Surgery • Eyelid surgery,such as tarsorrhaphy , entropion correction, ectropion correction , lagophthalmos correction to decrease tear evaporation. • Salivary gland auto-transplantation. • Mucous membrane or amniotic membrane transplantation for corneal complications
- 81. Other potential approaches •Recombinant human nerve growth factor (RHNGF) : topical e.coli-derived RHNGF for treatment of stage 2 and 3 neurotrophic keratitis. • Bandage soft contact lens : effective in preventing recurrence of filamentary keratopathy. • Secretagogues : pilocarpine , cevimeline approved by FDA to treat symptoms of DRY mouth in patients with SJS syndrome
- 82. Emerging Therapies • InflammationModulators: - Tocilizumab (IL-6 inhibitor). - JAK inhibitors (e.g., Xiidra). • Gene Therapy: Promoting natural tear production. • Biologic Agents: Targeting inflammation and immune responses.
- 83. Conclusion • Dry eyedisease is common, multifactorial, and impactful. • Early diagnosis and treatment can significantly improve symptoms. • Ongoing research shows promise for severe or refractory cases.
- 84. Bibliography • AAO section8 External diease and cornea • Kanski’s Clinical Ophthalmology, 10th Edition • Parson’s disease of the eye 23rd edition • Albert and jokobiec’s principles and practice of ophthalmology 4th edition • Dry Eye Workshop PDF-2007/2017
- 85.
Editor's Notes
- #3 Lipid layers is forms from polar and neutral lipids
- #4 Surface tensions of normal aqueous tears=40 and 42 dyn/cm
- #8 Regulation of tear film components • Hormonal ○ Androgens are the prime hormones responsible for regu lation of lipid production. ○ Oestrogens and progesterone receptors in the conjunctiva and the lacrimal glands are essential for the normal func tion of these tissues. • Neural via fibres adjacent to the lacrimal glands and goblet cells that stimulate aqueous and mucus secretion.
- #13 Primary=occurs in the absence of rheumatic disorder Secondary=associated with underlying rheumatic disease
- #14 Inflammatory mediators in dry eye. ADDE = aqueous deficient dry eye; CL = contact the vicious circle. Hyperosmolarity at the ocular surface initiates an inflammatory sequence leading to damage of epithelial cells, goblet cells, punctate epitheliopathy and tear film instability and breakup. Described by the TFOS DEWS II as a “vicious circle” of inflammation, this process is the common final pathway for all forms of DED. lens; EDE = evaporative dry eye; IFN- γ = interferon gamma; IL-1, 17 = interleukins 1 and 17; KCS = keratoconjunctivitis sicca; MAPK = mitogen- activated protein kinase; MGD = meibomian gland dysfunction; MMPs = matrix metalloproteinases; NFκB = nuclear factor kappa- light- chain enhancer of activated B cells; NSDE = Non- Sjögren dry eye; SSDE = Sjögren syndrome dry eye; TNF-α = tumor necrosis factor alpha; TF = tear film. (Modified with permission from Craig JP, Nelson JD, Azar DT, et al. TFOS DEWS II Report executive summary. Ocul Surf. 2017;15(4):802–812. With permission from Elsevier.)
- #17 In the normal eye, as the tear film breaks down, the mucin layer becomes contaminated with lipid but is washed away
- #19 Severe corneal complications of dry eye. (A) Melting (arrow); (B) perforation with iris plugging; (C) bacterial infection
- #20 he OSDI, which was created by the Outcomes Research Group at Allergan Inc in order to quickly assess the symptoms of ocular irritation in dry eye disease and how they affect functioning related to vision.[5] This 12-item questionnaire assesses dry eye symptoms and the effects it has on vision-related function in the past week of the patient’s life.[6] The questionnaire has 3 subscales: ocular symptoms, vision-related function, and environmental triggers. Patients rate their responses on a 0 to 4 scale with 0 corresponding to “none of the time” and 4 corresponding to “all of the time.” A final score is calculated which ranges from 0 to 100 with scores 0 to 12 representing normal, 13 to 22 representing mild dry eye disease, 23 to 32 representing moderate dry eye disease, and greater than 33 representing severe dry eye disease.
- #21 Tear film n ocular surface society Dry eye workshop II recommends 2 questionnaire
- #22 Combination: Evaporative and aqueous deficiency often occur together. May also include a mucin layer tear deficiency. EYELID REMAINS CLOSED FOR A PROLONGED PERIOD OF TIME DURING SLEEP AND IT ALLOWS EXCESS OIL AND DEBRIS TO ACCUMULATE AROUND EYELASHES---BACTERIAL OVERGROWTH
- #23 Likely secondary to disruption of corneal nerves and interference with normal reflex tearing
- #25 Image :facial rosacea Image 2 :stromal keratitis a/w rosacea of face,neck,shoulders Rosacea is a/w cutaneous sebaceous gland dysfunction Alcohol consumption can contribute to worsening of facial redness because of its effect on vasomotor stability with dilatation of vessels rosacea, psoriasis, atopy) 4. Dry mouth, dental cavities and oral ulcer Smoking irritate eyes.with blinking eyelids coat eye with aprotective layer—keeps dust and debris out—chemicals in smoke can cause this layer to break down. Smoke is a drying agent that promotes tear evaporation rosacea, psoriasis, atopy) 4. Dry mouth, dental cavities and oral ulcer rosacea, psoriasis, atopy) 4. Dry mouth, dental cavities and oral ulcer (rosacea, psoriasis, atopy) 4. Dry mouth, dental cavities and oral ulcer
- #26 Infiltration of the lacrimal glands (e.g., sarcoidosis, tumor) Postradiation fibrosis of the lacrimal glands.
- #28 Fig1 :illustration showing the clinical signs of blepharitis Fig2 : referred as cylindrical dandruff,typical of demodicosis Eyelid scale=scurf Eyelid cylindrical dandruff=sleeves Collaretes=fibrinoius scales and matted,flatte ned crusts surrounding individual cilia Demodex=mites (oral ivermectin,treatment with hypochlorous acid) blepharitis in staph &seborrheic are located in anterior eyelid margin while in MGD is in posterior eyelid margin
- #37 Quantitative test BASAL SECRETION WHEN CONJUNCTIVA IS ANAESTHESIZED When measured withput anasthetic it measures basic + reflex secretion Less than 10 mm of wetting after 5 minutes without anaes thesia or less than 6 mm with anaesthesia is considered abnormal. PERFORMING TEST IN SIMILAR MANNER SCHIRMER 2=rubbing unanesthesized nasal mucosa with a dry cotton and noting the wetting after 2 minutes Schirmer 3 = pt looks directly in the sun ,no diagnostic value and it is potentially dangerous
- #38 Dews system of grading severity of dry eye
- #39 thin marginal tear meniscus In the normal eye, as the tear film breaks down, the mucin layer becomes contaminated with lipid but is washed away. In the dry eye, the lipid-contaminated mucin accumulates in the tear film as particles and debris that move with each blink . The marginal tear meniscus (strip) is a crude measure of the volume of aqueous in the tear film
- #40 Although tear osmolarity is sensitive test for identifying dry eye, it lacks specificity . Before doing test makesure pt has not use topical drugs within 2hrs to avoid false osmlarity reading. Test card is inserted in a pen green light ll appear wid a beep sound. Approach pt from side and tears are collected from side with a tip. Successful collection ll be indicated by beep n green light going off,collectd tear fluid ll be assessed using tear lab osmolarity system
- #41 Proteins and peptides in tears play an important role in ocular surface disease Lysozyme analysis is more sensitive but it lacks specificity as it Tear lactoferrin concentrations measured by Lactocard, commercially available colorimetric solid phase ELISA technique
- #42 Variation of Schirmer test 75mm long Thread impregnated with phenol red is is kept in lower fornix and reading is taken after 15sec and wetting of thread is noted 9-18mm normal <6mm abnormal
- #43 ) Punctate erosions stained with fluorescein; mild (rose Bengal stain) Fluorescein stains corneal and conjunctival epithelium (see Fig. 5.6A) where there is sufficient damage to allow the dye to enter the tissues. • Rose Bengal is a dye that has an affinity for dead or devitalized epithelial cells that have a lost or altered mucous layer (Fig. 5.8C). Corneal filaments and plaques (see Fig. 5.6B and D) are also shown up more clearly by the dye and the use of a red-free filter may help visualization. A 1% solution of rose Bengal or a moistened impregnated strip can be used. The dye may cause intense stinging that can last for up to a day, particularly in patients with severe KCS. To minimize irrita tion a very small drop should be used, immediately preceded by a drop of topical anaesthetic and the excess washed out with saline. ) Rose bengal (RB) stains the conjunctiva more intensely than the cornea. The dye stains ocular surface cells that lack a mucouscoating, as well as debris in the tear film [92]. A red-free f ilter makes examination easier. van Bijsterveld developed a scoring system for RB dye that divides the ocular surface into three zones: nasal bulbar conjunctiva, cornea, and temporal bulbar conjunctiva [95]. Each zone is given a score ranging from zero to 3, with zero indicating of breakupoverthecornea. (b) Inahealthysubject, the first breakup is at 13.64 s, and the cornea does notshowareasof breakup no staining and 3 indicating essentially confluent staining. Scores for each eye are totaled according to this system, and scores of 3.5 or greater indicate dry eye.
- #44 Lissamine green stains in a similar fashion to rose Bengal but causes less irritation and may be preferred Lissamine green stains dead and degenerated cells and mucus. The staining qual ity of lissamine green is similar to that of RB but is less irritating on the ocular surface.
- #45 Reduced corneal sensation can be both cause and effect of dry eye Sensory denervation may lead to dry eye by several mechanism:Reducing afferent signal that drives aqueous tear secretion Reducing blink rate There is evidence that corneal sensation decreases secondarily in patient with long standing dry eye. Take cotton swab, extend a few fine strands from tip and gently touch surface of cornea and conjunctiva , patient objective and subjective response can be graded. Apply filament on cornea nd exert slight pressure Cochet bonnet estheiometer shorter the length indicates decreased sensation
- #46 Indication=kcs,atopic keratoconjunctivitis,allergic rhinoconjunctivitis,DES,demonstration of cysts and trophozoites,ocular cicatricical pemphigoid,contact lens wear status,conjunctival squamous metaplasia,ocular surface squamous neoplasia diagnosis and follow up,conjunctival melanosis Conjunctival impression is taken to examine cellular structure using cellulose acetate filter paper to make impression. Filter paper is cut into small strips and after instillation of topical anesthesia it is pressed against nasal, temporal inferior n superior bulbar conjunctiva with help of forcep, pressure is applied for 2-3 sec, filter paper is then fixed for 10 min in mixuture of 70% ethyl alcohol 37% formaldehyde and glacial acetic acid and examined microscopically. For globlet cell count and keratinization
- #47 Useful in screening and evaluating dry eye ,superficial lipid layer is absorbed by tear interferon camera interferon images are then graded on basis of lipid layer stability . Kowa DR-1
- #48 Helps to look quality of tears, 1ul Tear from meniscus is transferred to slide and allowed for evaporation at room temperature and see in a microscope, ferning occurs because of dried mucin Type 1: uniform large arborization Type 2: ferning adequate but lesser size Type 3: partially present, incompletely ferning Type 4: no ferning Type 1 and 2 are normal and 3 and 4 are abnormal
- #49 Non invasive done by : Tear film stability Ocular surface health Tear film composition Tear flow Impression cytology Meibomian gland evaluation
- #50 Fluorescein strip is moistened with saline and applied to inferior cul de sac. After several blinks tear film is examined using boroad-beam of slit lamp with blue filter for appearance of first dry spot on ornea.normal is 15-20 sec. value <10 sec indicates tear film instability Preservative like benzalkonium chloride can artificially speed up tear breakup
- #51 The BUT is the interval between the last blink and the appear ance of the first randomly distributed dry spot. A BUT of less than 10 seconds is suspicious.
- #52 NITBUT is the time (in seconds) it takes for distortions to appear in the image of concentric Placido rings that are reflected on the patient’s cornea by the Keratograph. Two types of NITBUT are measured by the Keratograph 5 M: (i) NITBUT-first is the time at which the first distortion of Placido rings occurs, and (ii) NITBUT-average is the average time of first breakup incidents in different locations in a corneal diameter of 8 mm
- #53 Put the pt on video keratoscope ,we can see circular rings on cornea ask pt to blink once n start timer, when circle degrades stop d timer
- #55 Meibomian gland is source of lipid in lipid layer of tear film, MGD is most common cause of evaporative dryeye . Meibomian gland dropout is graded using a 0 to 4 scale based on the area of meibomian gland loss (0, 0%; 1,75%). The score is recorded as “meiboscale” for each eye
- #56 Minimally invasive technique used to assess structure of meibomian glands, meiboscope is transilluminated in upper n lower lid, grand morphology is viewed, no of glands, presence of atrophied gland or dilated gland
- #57 Non invasive method to visualize morphology and density of meibomian glands, using a infrared transilluminator. When infrared coming from transilluinator pass through lipid light becomes scattered, which gives meibomian gland dark apprearane. Normal meiboian gland stripes extend well into depth of eyelid and uniform appearance of gland
- #58 Technique developed to measure basal meibomium level.a sample of meibum at lid margin is transferred to specialized tape whose transparency is altered by exposure to meibum. Degree of change in tape transparency is analyzed photometrically to quantify amt of meibum present in lid margin
- #62 Eyelid hygiene is mainstay of treatment. Warm compression:Liquifies thickened secretions softens adherent crustations. Pt should be warned to avoid excessive or uneven heat .application of heat should be followed by Lid massage-express retained secretions Lipid containing artificial tear products are intended to reduce tear evaporation by restoring lipid layer of tear film
- #63 Omega-3 fatty acids has been shown to increase average tear production and tear volume. This also block proinflammatory eicosanoid and cytokines
- #69 probing using special instruments (Maskin meibomian gland intraductal probe –lyses a fibrovascular membrane growing into duct and may facilitate gland function , permitting normal secretion of meibum
- #70 utilizes thermoelectric heat pump to promote liquefaction of meibum
- #71 During this procedure, gentle pulses of light are delivered to the skin adjacent to the eyes to reduce inflammation and eliminate any bacterial infection. These pulses melt thick secretions on the eyelids, release the buildup of oil, and unclog the meibomian glands Before beginning the IPL treatment, your doctor will place eye shields over your eyelids to protect them from the bright light pulses. A thin layer of cooling gel will also be applied to the skin around your eyes to protect that sensitive area as well. After the IPL has successfully opened your meibomian glands, your doctor may also express a small amount of oil from the glands in your eyelids to stimulate normal oil flow.
- #72 combines gentle pulsatile pressure and thermal energy to increase blood flow to eyelid and open obstructed meiboinian gland ductules, it goes n sits on sclera not touching cornea, post surface sits on inner surface of lower n upper lid . LipiFlow should not be used in the presence of active infection, postoperatively, or in the presence of functional abnormalities of the eyelid
- #76 In addition to its antibacterial properties, tetracycline inhibits collagenase activ ity [115, 116] and decreases leukocyte chemotaxis and phagocytosis [117, 118] Pilocarpine at dose of 5mg orally QID is found to be improving patients low-dose doxycycline (25–50 mg/day) instead of the more common dose of 50–100 mg/day ability to focus their eye during reading and reduced symptoms of blurred vision. cevelimeCevimeline, another oral cholinergic agonist, may have fewer adverse systemic side effects and be better tolerated than oral pilocarpine due to more selective receptor binding. It also has been found to improve ocular irritation symptoms and aqueous tear production at the 30-mg dose but has not been approved by the FDA for dry eye treatment Pilocarpine(salagen),cevimeline (evoxac)
- #77 Other collagen plugs
- #78 Most cost effective manner of performing irreversible punctal occlusion with a disposable cautery or a radiofrequency probe. Fig1-2% lidocaine is placed 2mm post to punctum to anesthetize plug, tip of cautery device is inserted deep into punctum and horizontal canaliculus. Cautrization is done
- #79 Autologous serum tears have been reported to improve ocular irritation symptoms and conjunc tival and corneal dye staining in patients with Sjögren’s syndrome serum also con tains a variety of growth factors, it can also be useful in neurotrophic dry eye. Blood-derived eye drop Contains: Proteins Epidermal growth factors Vitamin A and C Antioxidants and electrolytes Mechanism of action of autologous serum eye drops: mimic biochemical properties of natural basal tears in order to heal ocular surface epithelium
- #80 A smaller palpebral fissure width decreases the evaporative stress on the tear film and ocular surface
- #81 Topical Escherichia coli-derived recombinant human nerve growth factor (RHNGF) has recently been approved by the FDA Oral medications such as cholinergic agonists, pilocarpine (Salagen), and cevimeline (Evoxac Pilocarpine, at a dose of 5 mg orally four times a day, improved patients’ ability to focus their eyes during reading and reduced symptoms of blurred vision compared to placebo-treated patients . Cevimeline, another oral cholinergic agonist, may have fewer adverse systemic side effects and be better tolerated than oral pilocarpine due to more selective receptor binding Tears contain essential fatty acids, both omega-3 and omega-6, which are not manufactured by the body and only obtained through diet