The document discusses the diagnosis and treatment of dry eye syndrome, highlighting its prevalence, symptoms, and underlying causes. Treatment approaches include patient education, environmental modifications, and various therapeutic options like artificial tears, gels, and punctal plugs. Genteal artificial tears are presented as an effective, preservative-free solution that offers significant patient satisfaction and clinical outcomes for dry eye relief.

1. Making Dry Eyes Wet Dr. Zia-Ul-Mazhry FCPS(Pak), FRCS(Edin), FRCS(Glasgow), CIC Ophth- (UK) Consultant Eye Surgeon & Head, Department of Ophthalmology Wapda Hospital Complex Lahore. Making Dry Eyes Wet

2. How to put the audience to sleep? Making Dry Eyes Wet z z z z z z %age of audience dosing off Time (minutes) 0 10 20 30 40 50 60 Boring topic Just after meals Too comfortable Late afternoon 10 20 30 60 0

3. Discussion Plan Definition and classification Simplified diagnostic approach Therapeutic approach Choosing right treatment for right patient Review of the study Discussion and conclusion Making Dry Eyes Wet

4. Historical Perspective E. Wolff first described the multi-layer tear film in 1946. 1 In 1973, Frank J. Holly, Ph.D., explained that mucin had a much greater role than previously thought. 2 In 1997, Scheffer Tseng, M.D., Ph.D., that the layers are inextricably intertwined to produce a healthy ocular surface. 3 Making Dry Eyes Wet 1-Wolff E. The muco-cutaneous junction of the lid margin and distribution of the tear fluid. Trans Ophthalmol Soc UK 1946;66:291-308. 2-Holly FJ. Formation and stability of the tear film. Int Ophthalmol Clin 1973 Spring;13(1)73-96. 3-Tseng SC, Tsubota K. Important concepts for treating ocular surface an tear disorders. Am J Ophthalmol 1997 Dec;124(6):825-35.

5. The Healthy Tear Film A Delicate Balance Lipid, aqueous and mucin components Outer lipid layer prevents evaporation Secreted by meibomian glands Aqueous component – a complex mixture of proteins, mucins, electrolytes Secreted by main & accessory lacrimal glands Mucins provide viscosity and stability during the blink cycle Mucin gel decreases in density toward tear film surface Making Dry Eyes Wet Image from Dry Eye and Ocular Surface Disorders , 2004

6. Definition Making Dry Eyes Wet

7. Prevalance 5% of adult population 4rth decade of life 10-15% Over 65 years of age Making Dry Eyes Wet

8. Etiological Classification Making Dry Eyes Wet

9. Symptomatology Making Dry Eyes Wet Burning, stinging, itching dry or FB sensation redness Fatigue Gritty sensation blur (fluctuations of vision) occasional excess tearing

11. Consequences of Tear Composition Changes in CDE Altered environment for ocular surface tissues Increased osmolarity Imbalanced growth factors and cytokines fail to promote normal epithelial growth Poor viscosity can cause thin spots in tear film and tear break-up – Lubrication compromised Ocular surface damage Loss of corneal epithelial integrity Squamous metaplasia of conjunctival epithelium corneal filamentary keratitis; marked corneal punctate staining; central corneal staining, conjunctival scarring; corneal erosions; severe corneal staining Altered lifestyle Making Dry Eyes Wet

12. Dry Eye affects vision 33 % Report Night Driving Problems 28 % Report Reading Problems 26% Report Computer Problems 17% Report Problems Watching Television DEWS Diagnostic Study Group Making Dry Eyes Wet

13. Dry Eye does affect quality of life Making Dry Eyes Wet

14. Factors that cause “DES” aging hormonal changes contact lens wear laser vision surgery computer use medications systemic diseases Making Dry Eyes Wet

15. Dry Eye Diagnosis thorough slit-lamp examination Uneven or scanty tear meniscus Vital staining Tear film break-up time Schirmer lacrimation test Lack of goblet cells The lid functioning , Mucous shreds and strings Lid parallel folds Making Dry Eyes Wet

16. Dry Eye Diagnosis Making Dry Eyes Wet Test cutoff value for dry eye diagnosis ● Schirmer's I less than or equal to 5 mm wetting over 5 minutes ● Tear Breakup time less than or equal to 10seconds ● Tear Meniscus height less than or equal to 0.2 mm ● Fluorescein staining more than 3 out of 15 ● Rose Bengal staining more than 3 out of 18 ● Tear film osmolarity more than 316 mOsm/L ● Impression cytology more than 1 ● Brush cytology more than 1 ● Tear lactoferrin less than or equal to 0.9 ug/mL

17. Non Invasive Break up time (NIBUT) clinician focuses and views the crisp keratometric mires , and then records the time taken for the mire image to distort (TTT) and/or break up (NIBUT). NIBUT measurements are longer than fluorescein break up time. Making Dry Eyes Wet

18. Symptomatic Tear Break-Up Time (SBUT) test Obtain a stopwatch or clock. Blink 2 times, then stare straight ahead, taking care to start timing immediately after your second blink. Avoid blinking for as long as possible. Note the time on the clock when you begin to feel eye discomfort (burning, grittiness, dryness, etc.) The SBUT is the amount of time (in seconds) that passes between your last complete blink and the moment you experience eye discomfort. Making Dry Eyes Wet SBUT is 5 seconds or less, you may have dry eye Dry Eye Syndrome test at Systane_com.htm

19. Dry eye questionare Making Dry Eyes Wet

20. Severity Level Level 1: Mild to moderate symptoms; mild to moderate conjunctival signs; no staining Level 2: Moderate to severe symptoms; tear film signs; visual signs; mild corneal punctate staining; conjunctival staining Level 3: Severe symptoms; corneal filamentary keratitis; marked corneal punctate staining; central corneal staining Level 4: Extremely severe symptoms/altered lifestyle; conjunctival scarring; corneal erosions; severe corneal staining Making Dry Eyes Wet

21. comprehensive “dry eye assessment” can include: Making Dry Eyes Wet

22. Principles of treatment Treat the Symptoms Treat the Cause Treat the complications Making Dry Eyes Wet

23. Treatment Goals Establish the diagnosis of dry eye, differentiating it from other causes of irritation and redness Identify the causes of dry eye Establish appropriate therapy Relieve discomfort Prevent complications, such as loss of visual function, infection, and structural damage Educate and involve the patient in the management of this disease Making Dry Eyes Wet

24. Treatment Algorithm (ITF) Level One Patient education Environmental modification Control systemic medications Control allergy Preserved tears Level Two Unpreserved tears Gels and nighttime ointments Nutritional support Cyclosporine Topical steroids Secretagogues Making Dry Eyes Wet

25. Treatment Algorithm (ITF) Level Three Oral tetracyclines Punctal plugs after inflammation controlled Level Four Systemic anti-inflammatory therapy Acetylcysteine Moisture goggles Punctal cautery Making Dry Eyes Wet

26. Therapeutic approach Supplementation of Aqueous Tears (tear substitutes) Preservation of Aqueous Tears (goggles, punctal plugs, etc.) Stimulation of Aqueous Tear Secretion (secretagogues) Making Dry Eyes Wet

27. TEAR REPLACEMENT THERAPY Main stay of Current dry eye management is : Making Dry Eyes Wet

28. Normal healthy tears Making Dry Eyes Wet Normal Healthy Tears

29. Tears in Chronic Dry Eye (CDE) Lesser concentrations of many proteins in CDE e.g. antimicrobial proteins Growth factor concentrations decreased Cytokine balance shifted, promotes inflammation Soluble mucin 5AC greatly decreased Due to loss of goblet cells Impacts viscosity of tear film Activated proteases Degrade extracellular matrix and tight junctions Increased electrolytes Making Dry Eyes Wet

30. Ideal Tear substitute Viscosity Exit time increased Vision decreased Hypoosmolar Ph Value around 7 Thixotropy The property of becoming fluid when shaken and then becoming semisolid again Preservatives/preservative free/disappearing BAK, Polyquad Gen Aqua Sodium Perborate Contact lens Tolerance Patient satisfaction Making Dry Eyes Wet

31. Is Ideal tear substitute currently available? NO Making Dry Eyes Wet

32. A tear drop

33. Artificial Tears Artificial tears contain electrolytes – But they lack the complex mixture of proteins, mucins and other factors found in normal healthy tears Provide temporary, palliative relief Making Dry Eyes Wet Artificial Tears

34. A Tear Drop Composition Making Dry Eyes Wet

35. Drug Components Making Dry Eyes Wet Systane Polyethylene Glycol 400 0.4% (lubricant), Propylene Glycol 0.3% (lubricant), Hydroxypropyl Guar (GEL FORMING MATRIX) Polyquaternium-1 as preservative. Genteal Gel 0.3% Hydroxypropyl Methylcellulose, Carbopol 980 GenAqua (Sodium Perborate) as preservative .

36. Preservatives Chemicals to prevent microbial spoilage of pharmaceutical preparations 1953: FDA adopted the view that a non-sterile ophthalmic solution was unacceptable 1955:A sterility requirement in the official compendium. Mid 60s: Preservatives to be included in the Ophthalmic preparations by regulatory authorities in Europe and USA.

37. Ideal Preservative Broad spectrum antimicrobial activity Chemical and thermal activity Compatibility with container and other compounds present Innocuous towards ocular tissues

38. Preservatives in current use BAK ( Hicel, Naphtears, Optitears) Polyquad ( Tears Naturale11, Systane) Chlorbutanol (Blink fresh,Tears Plus,Lacrilube, Optolube) Sodium Perborate ( GenTeal ) Stabilized Oxychloro Complex (SOC) (Refresh)

39. Preservative a liability Preserved Preservative free Disappearing Making Dry Eyes Wet

40. Choosing the right brand for the right patient Making Dry Eyes Wet

41. Choosing the right brand for the right patient In the treatment of a dry eye, frequent instillation of drops is required We should chose drops which is effective and least toxic. We should chose the one where preservative is either not present or preservative disappear soon after the instillation.

42. Preservative system of GenTeal GenTeal uses a unique perborate buffering system which produces small amounts of H 2 O 2 in solution The H 2 O 2 concentration in the bottle is < 60 ppm When instilled into the eyes, the H 2 O 2 (in GenTeal) is degraded by ocular enzymes to harmless water and oxygen within 30-60 seconds 1 After 1 minute, no preservative is left that could cause irritation or damage to the eyes 1 The H 2 O 2 preservative system used in GenTeal is safe and well-tolerated 1 Chapin MJ, et al. Data on file. Novartis Ophthalmics, 1998

43. Genteal Gel Preservative sodium perborate Making Dry Eyes Wet

44. GenTealGel is non blurring 1 Kessler C. Spektrum Augenheilkd 1991; 5:69-75 Unlike ointments, GenTeal gel is a crystal clear and colorless liquid gel that will not blur patient’s vision 1 The difference is clear GenTeal Gel Ointment

45. Genteal Gel has dual lubricant system Carbomer, a mucomimetic, provides the gel properties and stabilizes the tear film 1 Hypromellose lubricates and soothes 1 Marquardt R, et al. Klin Monatsbl Augenheilkd 1986; 189:254-257 2 Kessler C. Spektrum Augenheilkd 1991; 5:69-75

46. GenTeal gel is thixotropic From gel to liquid in the blink of an eye GenTeal gel is a drop-like gel with thixotropic properties Natural forces applied by blinking liquefies the gel allowing an even, non-smearing distribution over the ocular surface 2

47. GenTeal gel has a long retention time Carbomer (in GenTeal gel) lasts 7 times longer in the eye compared with conventional artificial tears 1 1 Marquardt R, et al. Klin Monatsbl Augenheilkd 1986; 189:254-257 16.5 minutes 2.3 minutes 15.9 minutes 2.03 minutes Carbomer Conventional tear substitute Carbomer Conventional tear substitute LEFT EYE RIGHT EYE

48. GenTeal gel needs fewer applications 1 Bron AJ, et al. Eur J Ophthalmol 1998; 8:81-89 Carbomer (in GenTeal gel) requires significantly fewer applications 1 Mean number of drops per day Day of the study 5 4.5 4 3.5 3 2.5 2 0 4 8 12 16 20 24 28 32 36 40 2 6 10 14 18 22 26 30 34 38 P<0.05 Conventional tear substitute Carbomer gel

49. GenTeal drops and gel are hypotonic Normal tears are isotonic In dry eye, with a smaller aqueous component in tear film, tears become hypertonic (high salt concentration) leading to: irritation, burning, and foreign body sensation due to traumatized epithelial cells GenTeal is hypotonic (low salt) helping to restore the tear layer to its normal isotonic state Patient benefit - soothing relief

50. Do the disappearing preservatives really disappear? Making Dry Eyes Wet

51. Genteal Gel Dual Lubricating Carbomer, a mucomimetic, provides the gel properties and stabilizes the tear film 1 Hypromellose lubricates and soothes Thixotropy GenTeal gel is a drop-like gel with thixotropic properties Natural forces applied by blinking liquefies the gel allowing an even, non-smearing distribution over the ocular surface 2 Making Dry Eyes Wet

52. GenTeal drops and gel – summary Preserved in the bottle - preservative free in the eye 1 Hypotonic formulation to help break the dry eye cycle Convenient and economic multi-dose packaging Available as: Drops for mild to moderate dry eyes Gel for moderate to severe dry eyes clear, colorless and non-smearing 2 lasts 7 times longer than conventional artificial tears 3 requires just 3-4 applications daily even in severe dry eyes 4 1 Chapin MJ, et al. Data on file. Novartis Ophthalmics. 1998 2 Kessler C. Spektrum Augenheilkd 1991; 5:69-75 3 Marquardt R, et al. Klin Monatsbl Augenheilkd 1986; 189:254-257 4 Marquardt R. Klin Monatsbl Augenheilkd 1986; 189:51-53

53. “ a tear drop on cheek of time” Rabinder Nath Tegor Making Dry Eyes Wet

54. To Summarize: Making Dry Eyes Wet

55. Conclusion Genteal artificial tears family is an excellent recent additions to available options to treat dry eyes symptomatically. Both drops and gel showed higher satisfaction and better clinical outcomes as compared to other available wetting agents. Making Dry Eyes Wet

56. Conclusion To reach our collective goal of ocular surface protection, we must heal the damage and reduce inflammation and irritation. This will likely be accomplished by a line of products rather than one “cure-all”. With the many causes of dry eye and nearly as many therapeutic approaches, we will certainly be looking at combination therapy, with different treatments for different ideologies. Making Dry Eyes Wet

57. Keep blinking Making Dry Eyes Wet

58. How to put the audience to sleep? Making Dry Eyes Wet z z z z z z %age of audience dosing off Time (minutes) 0 10 20 30 40 50 60 10 20 30 60 0

59. Thank you