Dry eyes

Dr R R SudhirDr. G. Sitalakshmi Memorial Clinic for Ocular Surface

DisordersProf 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.Tear

strip

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

HistoryAge-Sex-Onset DurationProgressDrug allergySystemic 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