This ppt covers the basics of dry eye and its management according to DEWS 2 report

1. DRY EYE

2. Definition (DEWS2)
• 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 hyper-osmolarity, ocular
surface inflammation and damage, and neuro-sensory abnormalities
play etiological roles

3. Neural pathwayAFFERENT PATHWAY
Ocular surface
Trigeminal Nerve (V1)
Superior Salivary nucleus
(Brain stem)
EFFERENT PATHWAY
Lacrimal Gland
Lacrimal Nerve
Pterygopalatine ganglion via
nerve to pterygoid canal
Nervous intermedius
(Seventh nerve)

4. The definition and classification of dry eye disease: report of the Definition and Classification Subcommittee of
the International Dry Eye WorkShop. Ocul Surf 2007;2007(5):75e92.

5. AQUEOUS DEFICIENCY EVAPORATIVE LOSSLARGE
OVERLAP
Pain without stain
Stain without pain
Neuropathic pain
Neurotrophic pain
EXTERNAL DISEASE

6. Sjogren syndrome
• Definition – It is an autoimmune disorder characterized by
lymphocytic inflammation and destruction of lacrimal and salivary
glands and other exocrine organs

7. • Primary- Occurs in isolation
• Secondary- Associated with Rheumatoid arthritis and SLE
• Diagnosis- Clinically + Criteria by American College of Rheumatology
(ACR):
a. Positivity for anti-SSA or anti-SSB antibodies, or positive rheumatoid factor
together with significantly positive antinuclear antibody
b. Ocular surface staining above a certain grade
c. Focal lymphocytic sialadenitis to a specified extent on salivary gland biopsy
• Other criteria- American-European Consensus Group

8. SIGNS
Visual acuity disturbance, Eyelids –
Anteriorly blepharitis, posteriorly MGD,
Tear film height decreased with mucus
strands, Bulbar conjunctiva punctate
staining, hyperaemia, cornea- punctuate
epithelial erosions
SYMPTOMS
Irritation, redness, burning,
tearing, contact lens
intolerance, increase
frequency of blinking,
itching of eyes, foreign
body sensation, blurred
vision.
DRY
EYES

9. MGD
• Nature of the meibomian gland secretions:
• 0- Clear/normal
• 1- Cloudy
• 2 - Cloudy particulate fluid
• 3 - Inspissated (like toothpaste)
Donnenfeld ED, Solomon R, Roberts CW, et al. Cyclosporine 0.05% to improve visual outcomes after multifocal
intraocular lens implantation. J Cataract Refract Surg 2010; 36:1095 – 1100

11. Diagnosis
• Step 1- Triage questions
• Step 2- Exclude conditions that can mimic DED
• Step 3 - Risk factor analysis
• Step 4 – Diagnostic tests

12. Diagnosis
• Step 1- Triage questions
DEQ 5
 OSDI

13. DEQ >6

14. OSDI>13

15. • Step 2- Exclude conditions that can mimic DED

16. Diagnosis
• Step 3 - Risk factor analysis
Smoking and drugs including preservatives

19. Pathophysiology
ADDE
• Lacrimal gland secretion
reduced
• Normal evaporation
EDE
• Excessive evaporation
• Normal lacrimal gland secretion
Tear hyper-osmolarity
Within epithelial cell, release of
inflammatory mediators with T cells
Goblet cells, epithelial cells loss
Damage to epithelial glycocalyx

20. Diagnosis
• Step 4 – Diagnostic tests
• Tear film volume
• Tear film break up time – Non invasive break up time, fluoresceine break up time
• Osmolarity
• Ocular surface staining
• Fluoresceine staining
• Schirmer test

21. Tear film volume/ meniscometry
• Inferior tear meniscus height is evaluated
• Height< 0.3 mm is abnormal[1]
• Clinically it is a subjective observation
• Other investigations- ASOCT
[1] Savini G, Prabhawasat P, Kojima T, et al. The challenge of dry eye diagnosis.Clin Ophthalmol
2008; 2:31–55.

22. • Other investigations- ASOCT
• Good intra-observer and inter-
observer repeatability
• Instrument dependent and can be
biased by conjunctivochalasis,
disorders of lid margin and apposition
between the lid and ocular surface
Area of inferior
miniscus

23. Osmolarity
• Hyperosolarity is a validated marker of dry eye.[1]
• The normal tear film osmolarity is 270 to 308 mOsm/l
• Threshold of 308 mOsm/l - Early/mild dry eye
• Interocular difference >8 mOsm/L
1.Tomlinson A, Khanal S, Ramaesh K, et al. Tear film osmolarity: determination of a referent for dry eye
diagnosis. Invest Ophthalmol Vis Sci 2006; 47:4309–4315.

24. Tear film break up time(TBUT)
• Non invasive break up time
• Fluoresceine break up time

25. Fluoresceine break up time
• After osmolarity mesurement
• Before any other drops or anesthetic are applied
• Stability of the tear film
• Dye inserted at the outer canthus to prevent ocular
surface damage
• Positive finding is a value <10 secs, indicates
evaporative tear disease/MGD and/or aqueous tear
deficiency[1,2]
1. Albietz JM, McLennan SG, Lenton LM. Ocular surface management of photorefractive
keratectomy and laser in situ keratomileusis. J Refract Surg 2003; 19:636–644.
2. Pflugfelder SC, Tseng SC, Sanabria O, et al. Evaluation of subjective assessments and
objective diagnostic tests for diagnosing tear-film disorders known to cause ocular
irritation. Cornea 1998; 17:38–56.

26. Ocular surface staining
• Lissamine green staining
• Conjunctival, lid margin damage
• Observation :Between 1 and 4 min post-instillation via red filter
• A positive score is > 9 conjunctival spots

27. Fluorescein staining
• Assessing corneal damage
• Optimal viewing is between 1 and 3 min after instillation
• A positive result is > 5 corneal spots

29. Ocular surface staining scoring system

30. Schirmer test
• Diagnostic method for aqueous tear production
• Results of the test are often variable[1]
• Single result is not be considered sufficient for a diagnosis
• Values between 0 and 35
• Zero signifies dry eye
• Schirmer 1 (5min) - <10 mm
• Schirmer 2 (5min) - <6mm
1.Nichols KK, Mitchell GL, Zadnik K. The repeatability of clinical measurements of dry eye. Cornea 2004; 23:272–
285.

31. Other tests
• Inflammatory markers
• Corneal sensation
• OCT
• Interferometry and meibography
• Serologic markers

32. Staged management and treatment of DED

33. Step 1
Features Mild Dry eye
Discomfort, severity & frequency Mild and/or episodic; occurs
under environmental stress
Visual symptoms None or episodic mild fatigue
Conjuntival staining None to mild
Corneal staining
(severity/location)
None to mild
Corneal/tear signs None to mild
Lid/meibomian glands MGD variably present
TBUT (sec) Variable
Schirmer score (mm/5 min) Variable
Treatment
• Education and counseling
• Environmental management
• Dietary modifications (including oral
essential fatty acid supplementation)
• Elimination of offending systemic and
topical medications
• Ocular lubricants
• Lid hygiene and warm compresses

34. Step 2
Features Moderate Dry eye
Discomfort, severity & frequency Moderate episodic or chronic,
stress or no stress
Visual symptoms Annoying and/or activity-limiting
Conjunctival staining None to mild
Corneal staining
(severity/location)
Variable
Corneal/tear signs Mild debris, ↑↓ meniscus
Lid/meibomian glands MGD variably present
TBUT (sec) ≤10
Schirmer score (mm/5 min) ≤10
Treatment
• Non-preserved ocular lubricants
• Tear conservation- Punctal
occlusion, Moisture chamber
spectacles/goggles
• Device-assisted therapies, such
as LipiFlow)
• Topical corticosteroids and
topical secreatagougues
• Topical LFA-1 antagonist drugs
(lifitegrast)
• Oral macrolide or tetracycline
antibiotics

35. Step 3
Features Severe Dry eye
Discomfort, severity & frequency Severe frequent or constant without
stress
Visual symptoms Annoying, chronic and/or constant,
limiting activity
Conjunctival staining Moderate to marked
Corneal staining (severity/location) Moderate to marked
Corneal/tear signs Filamentary keratitis, mucus
clumping, ↑ tear debris
Lid/meibomian glands Frequent
TBUT (sec) ≤5
Schirmer score (mm/5 min) ≤5
Treatment
• Oral secretagogues
• Environmental management
• Autologous/allogeneic serum
eye drops
• Soft bandage lenses
• Rigid scleral lens

36. Step 4
Features Very Severe Dry eye
Discomfort, severity & frequency Severe and/or disabling and constant
Visual symptoms Constant and/or possibly disabling
Conjunctival staining Moderate to marked
Corneal staining (severity/location) Severe punctate erosions
Corneal/tear signs Filamentary keratitis, mucus clumping,
↑ tear debris, ulceration
Lid/meibomian glands Trichiasis, keratinization,
symblepharon
TBUT (sec) Immediate
Schirmer score (mm/5 min) ≤2
Treatment
• Topical corticosteroid for
longer duration
• Amniotic membrane grafts
• Autologous/allogeneic serum
eye drops
• Surgical punctal occlusion
• Other surgical approaches (eg
tarsorrhaphy, salivary gland
transplantation)