Dry eyes
Dr R R SudhirDr. G. Sitalakshmi Memorial Clinic for Ocular Surface
Disorders
Prof G Falcinelli MOOKP centre.
Medical Research Foundations,18, College Road, Chennai 600 006,Tamil Nadu, India
Dry eye • Disorder of tear film due to tear
deficiency or increased evaporation which damages the inter palpebral ocular surface and is associated with symptoms of discomfort. (NEI1993workshop ).
• Lacrimal keratoconjunctivitis Dysfunctional lacrimal functional unit which causes unstable tear film which promotes ocular surface inflammation, epithelial disease and symptoms of discomfort
• DEWS: Multifactorial disease of tears and ocular surface resulting in symptoms of discomfort, visual disturbance and tear film instability with potential damage to ocular surface with increased tear film osmolarity and surface inflammation
• Conjunctiva• Limbus • Cornea
• Close interaction between the ocular surface and
the adnexae (lids, lacrimal glands)
• Ocular surface disease Dry eye
• Holistic approach essential Compositional factors Dynamic factors Neurotrophic state Tear clearance
Ocular surface
Compositional factors
Hydrodynamic factors
Lipids
Aqueous
Mucin
Eyelid blinking
Eye lid closure
Mebomian gland
Lacrimal gland
Ocular surface epithelia
Tear spread
Tear clearance
Decreased evaporation
Dry eye: more than an annoyance…
Can cause functional
and occupational
disability
Dry eye can cause serious corneal disease !
Irregular corneal surface or altered barrier function
Dry eye can also besight-threatening !
Infective keratitis Sterile Melting
Simulators• Lid margin disease
• Allergic conjunctivitis
• Infective etiology
• Conjunctivitis Medicamentosa
• Work-related symptoms
• Convergence insufficiency
• Thyroid eye disease
• Conjunctivochalasis
• Superior limbic keratoconjunctivitis
• Mucus fishing syndrome
• Floppy eyelid syndrome
Simulators
EXACERBATORS
• Lid margin disease
• Superior limbic keratoconjunctivitis
• Conjunctivitis medicamentosa
• Work-related exacerbation
• Nocturnal lagophthalmos
Assessment before Treatment
• Is there tear insufficiency ?
• Exacerbating factors ?
• What is the severity ?
• Is there associated systemic disease ?
• How does the patient perceive his problem ?
Approach to itchy burny eyes
6. Dye tests
4.Tearstrip
1. Symptoms
Patients with dry eye
5. conj./ cornea
7.Lab. tests 3. Lids
2. History8. Rx
What are the symptoms ?
… … stinging or burning eyes stinging or burning eyes
… … scratchinessscratchiness
… … mucus accumulationmucus accumulation
… … eye irritation from wind / smokeeye irritation from wind / smoke
… … difficulty in contact lens weardifficulty in contact lens wear
… … EXCESS TEARING EXCESS TEARING ??
Patients with dry eye
2. History
History
Age-
Sex-
Onset
Duration
Progress
Drug allergy
Systemic medications
Itching –seasonal/perinealBurning- morning/eveningTearing
h/o systemic problemsJoint painsDry mouthAny other systemic disease
itching
Young ageSeasonal/perinealPerilimbal pigmentationPapillary reactionHorner trantas dots.
VKC
Allergic diathesisFlexural crease changesSkin lesions
AKC
RhinitisSeasonal
Hay fever
VKC with perilimbal pigmentation
Burning
morning evening
Decreased tears ATD
Normal tears- floopy eyelid
Lid margin disease- MGD
Conjunctivochalasis
Convergence and accomodation insufficiency
Patients with dry eye 3. Lids
External examinationStructure and function of lids
EntropionEctropionLagophthalmosProptosisPtosis
Blink RateCompletenessEssential Blepharospasm
Skin changes atopy/eczemaInfectionsAcne RosaceaFloppy eye lid
BlepharitisScaling and crusting
Meibomitis- plugged orifice ,telengiectatic vessels, thick secretions
Lid margin keratinisation
4 conj./ cornea
Papillae FolliclesPhlycten
Herbets pits OCP SLKC
Marginal infiltrate SPKFilaments
Phlycten Melts Conjunctivalisation
5.Tearfilm
Tear filmHeight low – dry eyes High-tear stasis
Quality: Oily tear film- Mebomian gland
dysfunction
Tear film break up
Invasive/non invasive methods
< 10 seconds – unstable tear film
Schirmers test Fluorescein clearance test
Patients with
dry eye
6 Surface staining
Fluorescein staining
Rose Bengal staining
Lissamine green staining
7 lab investigations
Local investigations
Conjunctival swab- infections
Conjunctival scrapping Eosinophills/Inclusion
Impression cytology-squamous metaplasia
goblet cell density Conjunctival biopsy- IF-OCP
Systemic investigation
CBCESRCRPRAANA
Referral to RheumatologistReferral to dermatologist
Clinical measures of dry eye
Patients with dry eye
8. Rx
Management strategies• Treat symptoms
• Treat the aggravating factors
• Treat the associated ocular problems
• Treat the ocular surface- decrease inflammation, prevent cicatrising changes
• Treat the systemic factors
• Treat the patient
DRY eye Severity- Delphi Panel
DEWS Study- Signs and symptoms
Dry eye- treatment plan