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5/9/2019
1
Recent diagnostic modalities of ocular surface disorders
Sihem Lazreg
Algeria
Ocular surface
• Functional unit:
- Lids (Blink)
- Conjunctiva
- Cornea , limbus
- Tear film
- Meibomian glands
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Ocular surface
Glycocalyxcellules
caliciformesGlandes
lacrymalesGlandes de Meibomius
( )
Normal tear film
Normal evaporation rate is 33%
1. Rolando et al. Br J Ophthalmol 2010;94(Suppl. 1):i1–9.Image présentée à des fins d'illustration seulement .
Lipid layer
Acqueouslayer
Epithelial cells
Mucous layer
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Définition
• Dry eye is a multifactorial disease of the ocularsurface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in wich tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological role.
DEWS 2 Definition
What is the purpose of a diagnosis?
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Dry Eye testingWhat tests do I need to do to confirm this?
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NIBUT
Fluorescein
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Lissamin greenColoration of mucous, apoptotic cells and tissues.
Schirmer test I
> 10 mm : normal
6 à 10 mm :moderate dry
eye
< 6 mm :severe dry eye
Quantitative value of the tear film .
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Osmolarity
Electrolyte Concentration(mMol/L)
Sodium 132
Potassium 24
Bicarbonate 32.8
Calcium 0.8
Magnesium 0.61
• Higher of both eye and difference• Variability questioned• Cut-offs (Sullivan et al., 2010, Keech et al., 2013):
• normal (302.2 ± 8.3 mOsm/L)• mild to moderate (315.0 ± 11.4 mOsm/L) • severe (336.4 ± 22.3 mOsm/L)
• How severe is the eye discomfort?• Do you have any mouth dryness or swollen glands?• How long have your symptoms lasted & was there any triggering event?• Is your vision affected and does it clear on blinking? • Are the symptoms or any redness much worse in one eye than the other? • Do the eyes itch, are swollen, crusty or have given off any discharge? • Do you wear contact lenses? • Have you been diagnosed with any general health conditions (including recent
respiratory infections) or are you taking any medications? + detailed anterior eye examination differential diagnosis where indicated by answers
Sub
typ
e C
lass
ific
atio
n T
est
sDiagnostic Tests
Evaporative• Abnormal
lipid• MGD
AqueousDeficiency• Low volume
Ris
k Fa
cto
r A
nal
ysis
Screening Homeostasis Markers
Sym
pto
mo
logy
(D
EQ-5
≥ 6
or
OSD
I ≥1
3)
Non-Invasive [fluorescein]*
tear Breakup Time <10s
Osmolarity≥308mOsm/L in either eye or
interocular difference >8 mOsm/L
Ocular Surface Staining >5
corneal spots, >9 conjunctival spots, or lid margin [≥2mm
length & ≥25% width]
+ 1 of
Tria
gin
g Q
ue
stio
ns
Susp
ect
dry
eye
Aq
ueo
us
/ Ev
apo
rati
ve S
pec
tru
m
e.g. smoking, certain medications, contact lens wear
TMH0.2mm
0.1mm
0.0mm
MGD lid margin drop-out, displacement, secretion ≥13, expressibility 3+ lipid absent / globular / abnormal colored fringes
plugging, vascularity, secretion 8-12, expressibility 2+ lipid meshwork
secretion 4-7, expressibility 1+ lipid wave (flow) / color fringes
Symptoms
* only to be used if NIBUT not available and if so, after osmolarity
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The revenge of ocular surface : imaging
- Diagnosis /etiology- Etiological arguments- Severity- Follow up and treatment
- NIBUT- Meniscometry- Meibography- Interferrometry- Blink analysis
The importance of ocular imaging in the diagnosis of dry eye disease
Tear film stability evaluation
BUT has limits ……
Can be modified by the quantity of fluorescein> Poor reproducibility +++> Hight variability betweendoctors and in the samepatient;
Key element in the pathophysiology of dry eye
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Non invasif break up time (NIBUT) : The solution ?
Tear film stability
- Hight deviation…- Poor reproducibility according to devices …- Automatic versus manual ?
Lee et al. Clin Ophth, 2016Wolffsohn et al. DEWS 2, 2017
Lacrydiag, Quantel medical
Without fluorescein > more reliable ??
NOT DEFINED YET …………
Tear volume
Carracedo et al. Acta, 2018; Li et al. Eye Contact lens; 2012 DEWS 2, Wolffsohn et al. Ocular Surface; 2017 Rousseau et al. JFO, 2018
Ménisc = tear volume + basal secretion
Measures on pictures (Oculus Keratograph 5M, Lacrydiag)
Hight +++ conjonctivochalasis
Variable according to the blinking interval and drops instillation (diagnosis)
Normal = 0,3mm
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Infrared meibography :what can we analyse ?
« Dropout » or meibomian gland
atrophy
Shortening
Tortuosity
Meibomian glands : Structure
Arita et al. Exp Eye Res, 2017
Arita et al. BJO, 2013
Infrared Meibography : automatisation
Atomated detection of MG atrophy
Age modifications +++
No normative data yet …..
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Lipid layer reflect the function of MG
Meibomian glands : Function = interferometry
Lipiview, Tearscience
Automated measure of the lipid layer thickeness :Interférometry(Normal > 75nm) Reproducible
Finis et al. Cornea, 2013Arita et al. Exp Eye Res 2017
MGD diagnosis : Sensitivity / Spécificity : 65%
La couche lipidique forme des franges interférrométriques
Glycocalyx
cellules caliciformes
Glandes lacrymales
Glandes de Meibomius
Épithélium Couche aqueuse - mucinique7-8 μm
Film lipidique0,1 μm
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Interferométrie lacrydiag
Lacrydiag, Quantel medical
Pas toujours facile…Comparaison semi-quantitative
Normale > 30
We need some time to understand …
Interferometry
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Blinking analysis : version 2.0
MGD + incompleteblinking + abnormalBell’s phenomena…
Blinking exercises
https://www.reseau-chu.org/article/oeil-sec-protection-desobstruction-reeducation-le-traitement-en-3-phases-de-bordeaux/
Daily Exercices
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DEMODEX
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Automated diagnosis ???
Lacrydiag
Oculus keratograph 5Meyecarewithfocus.com
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PDF report
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