dry eyes

1

Dry Eye Disease

DR SARANSH JAIN 24/06/2015

Outline of presentation

INTRODUCTION

LACRIMAL FUNCTION UNIT PATHOPHYSIOLOGY

EPIDEMIOLOGY

CLASSIFICATION/GRADING

CLINICAL FEATURES AND EVALUATION

MANAGEMENT

INTRODUCTION

• Dry eye is a multifactorial disease of the tears and the ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to then ocular surface.

• accompanied by increased osmolarity of the tear film and inflammation of the ocular surface

*2007 Report of the Dry Eye Work Shop (Ocul Surf 2007;5[2]:65-204)

• Ocular surface- entire sheet of epithelium which extends from grey line back over the lid margin onto the back of eyelids, inferior fornix up over the globe and onto cornea

Dry eye is a disturbance of Lacrimal Function Unit (LFU)

•Tearing apparatus

–Production- lacrimal gland

–Clearance- lacrimal passages

•Ocular surface–Conjunctiva –Cornea

•Eyelids•Sensory and motor nerves

Tear and the Tear Film

• Function :Maintain a smooth corneal surface

Moistens cornea and conjunctiva

Lubrication of pre-ocular surface and lids

Transfer of oxygen to cornea from ambient air

Prevents infection

NORMAL TEAR FIM

BIOCHEMISTRY

PHYSICALPROPERTIES

CHEMICAL COMPOSITION

PH- 7.2-7.7

OSMOLARITY -305

REFRACTIVE INDEX – 1.357

TEAR VOLUME- 5-10µl

LIPIDS

PROTEINS

METABOLITES

ELECTROLYTES

ENZYMES

98.2% WATER

Meibomian gland

Lacrimal gland

Ocular Surface Epithelium

Lid Blinking

Lid Closure

Lipid Layer

Aqueous Layer

Mucin Layer

Tear Spread

Evaporation

Tear Clearance

Normal tear film and ocular surface

HEALTHY TEARS TEARS IN CHRONIC INFLAMATION

Solomon et al. Invest Ophthalmol Vis Sci. 2001.Zhao et al. Cornea. 2001.Ogasawara et al. Graefes Arch Clin Exp Ophthalmol. 1996.

Image adapted from: Dry Eye and Ocular Surface Disorders. 2004.

*2007 Report of the Dry Eye Work Shop (Ocul Surf 2007;5[2]:65-204)

PREDISPOSING FACTORS

DRY EYE

Ageing

Allergy

Environmental

Medications

Ocular Surgery

Menopause

HEALTHY EYE FUNCTIONING

Stern et al, Cornea. 1998:17:584

NORMAL TEARINGDEPENDS ON A

NEURONAL FEEDBACK LOOP

Secretomotor Nerve

Impulses

Tears Support and Maintain

Ocular SurfaceLacrimal

GlandsOcular SurfaceNeural

Stimulation

IN DED:IMMUNE MECHANISMINFLAMMATION

DISRUPTSNORMAL NEURONAL

CONTROL OF TEARING.

Lacrimal Glands:

• Neurogenic Inflammation

• T-cell Activation

• Cytokine Secretion into Tears

Interrupted Secretomotor

Nerve Impulses

Tears Inflame Ocular Surface

Cytokines Disrupt Neural

Arc

Stern et al, Cornea. 1998:17:584

Major etiological causes

Dry eye-keratoconjunctivitis sicca

Tear deficiency

Sjögren’s syndrome

Non-Sjögren tear deficiency

Rheumatoid arthritis Systemic lupus erythematosusWegener’somatosis Systemic sclerosis Primary biliary cirrhosis Other autoimmune diseases

Lacrimal disease

Lacrimal obstruction

Reflex

Congenital alacrimaAccquired primary lacrimal gland disease

Trachoma, cicatricial pemphigoidErythema multiformeBurns

Neuro-paralyptic keratitisContact lensVIIth nerve palsySarcoid HIV

Graft vs host Xerophthalmia Other diseasees

Dry eye-keratoconjunctivitis sicca

Evaporative

Oil Deficient

Lid related

Contact Lens

Surface change

Absent glands Distichiasis

Posterior blepharitisObstructive meibomionGland disease

Anterior blepharitis

Blink abnormalities

Lid surface incongruity

Apertureabnormalities

Xerophthalmia

SYMPTOMS

AAO GUIDELINES FOR PATIENTS OCULAR HISTORY

• Contact lens use, lens material, solutions, wearing schedule, lens care.

• Allergic conjunctivitis

• Corneal history (prior keratoplasty, LASIK, photorefractive keratectomy, radial keratotomy, or extracapsular cataract extraction)

• Punctal plugs or surgery

• Eyelid surgery (prior ptosis repair, blepharoplasty, entropion / ectropion repair)

• Chronic ocular surface inflammation (acid or alkaline burns, ocular cicatricial pemphigoid, or Stevens-Johnson syndrome)

AAO GUIDELINES FOR PATIENTS MEDICAL HISTORY

• Smoking, menopause, and atopy

• Dermatological diseases (including seborrhea, eczema, rosacea)

• Trauma (including exposure to chemicals, ultravoilet light, dust, sawdust, fumes)

• Systemic inflammatory diseases (Sjögren’s syndrome, rhematoid arthritis, systemic lupus erythematosus, scleroderma, graft-versus-host disease)

• Chronic viral infections, such as chronic hepatitis C or human immuno deficiency virus.

• Surgery (bone marrow transplant, head and neck surgery)

• Radiation of orbit

• Neurological conditions (including Parkinson’s disease, Bell’s palsy, and Riley-Day syndrome)

• Xerostomia (dry mouth) dental cavities, and oral ulcers

AAO GUIDELINES FOR PATIENTS PHYSICAL EXAMINATION

• Skin (scleroderma, facialchanges indicating rosacea)

• Eyelids (incomplete closure / malposition, erythema of eyelid margins, incomplete / infrequent blinking, abnormal deposits / secretions, entropion, ectropion)

• Adnexa (enlargement of lacrimal glands)

• Proptosis

• Cranial nerve function (including cranial nerve V VII)

• Disorders affecting the hand (joint deformities characteristic of rheumatoid arthritis, gout, or psoriasis)

AAO GUIDELINES FOR PATIENTS SLIT LAMP EXAMINATION

• Tear film (height of meniscus, debris, foam)

• Eyelashes (trichiasis, distichiasis, madrosis, deposits)

• Anterior / posterior eyelid margins and character of meibomian gland secretions

• Vascularisation crossing the mucocutaneous junction, ketatini-zation, and scarring

• Puncta (patency and position)

• Conjunctiva (inferior formix and tarsal conjunctiva and bulbar conjunctiva)

• Cornea (localized interpalpebral drying, punctuate epithelial erosions, filaments, microepitrlial defects, punctate staining with rose bengal or fluorescein dyes, mucous plaques, keratinization, pannusformation, thinning, infiltrates, ulceration, neovascularisation, and scarring)

EVALUATION OF DED• Eye lids:

Lid marginEye lashes InfectionsCrusting/keratinisationLid closure

• Conjunctival sac:Decreased tear meniscus Increased debris in the tear filmMucous discharge

• Bulbar conjunctiva: dry lustreless Muddy Bitot’s spotshyperaemia

• Cornea:

– Dry lustreless, hazy look

– Irregular surface

– Superficial punctuate keratitis (Fluorescein staining may be helpful)

– Filaments

– Ulcers/scars in severe cases

DIAGNOSTIC TESTS

• Aims :

– Tear secretion assessment– Tear volume assessment– Tear clearance assessment– Evaluation of tear film stability– Ocular surface damage assessment

Tear secretion assessment

• Schirmer’s test– Schirmer’s I :

Conjunctival stimulation

– Schirmer’s II : Nasal stimulation

– Schirmer’s III: Retinal stimulation

– Jones’ modification : Basal secretion

(2mts. After LA)

Tear clearance assessment

• Fluorescein clearance test• Basal tear secretion• Reflex tear secretion• Tear clearance

• Fluorophotometry

• Tear function index

Tear volume assessment

• Tear meniscus height

Evaluation of tear film stability

• Tear film break-up time (TBUT)• Fluorescein TBUT• Non-invasive TBUT

• Lipid layer assessment

NIBUT

• Corneal Topography

• Interferometry

• Aberrometry

• Functional visual acuity assessment

• Confocal microscopy

LIPIVIEW INTERFEROMETER TEAR FILM TOPOGRAPHER

WAVEFRONT ABERROMETER

LIPID LAYER ASSESSMENT

a) slit lamp b) Meiboscopy c) Meibography d) Meibometry

Ocular surface damage assessment

• Staining

• Corneal sensitivity

• Impression cytology

• Tear osmolarity

• Tear protein assays

• A vital dye which has no intrinsic toxicity.• Detects epithelial defects & irregularities.• Filter paper strips or 0.25% - 2% solution.• Sodium fluorescein emits green light(520nm) when

excited with with blue light (490nm).

Sodium fluorescein

Rose bengal

• Rose bengal is a vital stain taken up by dead and devitalised epithelial cells.

• Also stains mucous threads, filaments & strands .• Does not diffuse into the epithelial defects or penetrate

corneal stroma like fluorescein.• It is toxic resulting in decreased cell vitality, motility & cell

death.• Causes ocular discomfort –prior anaesthesia is needed.

Score 0 - absent Score 1-just present Score 2-moderate staining Score 3-gross staining

• Dark green, water soluble

• Degenerated cells, mucus, dead cells

• Less irritating

Lissamine green

Deficient values

Parameters Normal Values

Mild Medium Severe

Lysozyme 1.75 g/l <1.5 <1 <0.5

Lactoferrin 1.75 g/l <1.5 <1 <0.5

IgA 240 mg/l <120 <120 <120

Osmolarity 300-310 mOsm/l

320 330 340

DRY EYE : SEVERITY GRADING SCHEME

The ocular surface April 2007; vol 15 no 2 :

MANAGEMENT

• Goals of management:– Establish the diagnosis.– Differentiate from other causes of

similar symptoms.– Establish presence/absence of limbal

cell deficiency.– Decide appropriate therapy.

• To relieve symptoms• To prevent complications

– Educate patient / relatives about nature of disease and its management.

TREATMENT

Psychological control of surrounding

medical surgical

APPROACH TO TREATMENT

• Elimination/avoidance of exacerbating factors which

• Decrease tear production• Increase tear evaporation

– Humidification of rooms– Avoidance of dusty/smoky rooms– Breaks between prolonged computer use– Lowering the computer monitor below eye level– Low water content contact lenses for Shorter duration at

a time.– Blinking exercises*

• *Wolkoff P et al. Occup Environ Med 2005;62:4-12

Eyelid hygiene

– Hot fomentation– Topical/systemic antibiotics– Topical steroids/CyclosporineA– Artificial tear substitutes

1.Tear supplementation

• Be preservative free

• Contain K+, HCO3- and other electrolytes

• Have a polymeric system to increase its viscosity, hence retention time

• Have neutral to slightly alkaline Ph

• Have osmolarity- 181-354 mOsm/L

• Gels (carbomers) require less frequent application than drops.

• Ointments using petrolatum, lanolin and mineral oil base, dissolve at the temperature of ocular tissue, retained in the cul-de-sac for long - used mainly at night time.

Anti-inflammatory therapy

• Topical cyclosporine(0.05%-0.1% - two to four times a day)• Only pharmacological agent approved by FDA for treatment of dry eye• Reduces conjunctival IL-6 levels, activated lymphocytes, inflammatory

and apoptotic markers• Increases conjunctival goblet cell number

• Corticosteroids• Recommended only for short-term use

• Systemic medications• Oral tetracyclines (used for anti-inflammatory action)

– Decrease matrix metalloproteinase activity and production of cytokines such as IL-1 and TNF-ɑ

A stagnant and unstable tear film who continue to have symptoms that are not relieved by artificial tears AND/OR corneal epithelial disease.

Newer treatment modalities

• Ocular inserts6-

• Cylindrical rod containing 5mg Hydroxypropyl methyl cellulose (HPMC) placed in the lower cul-de-sac.

• Imbibes fluid and swells

• Lasts for 12 -24 hrs

• Secretagogues

• Stimulate endogenous tear production

• Oral pilocarpine (Salagen) 5mg four times a day7 – cholinergic side effects.

• Cevilemine – Fewer side effects

Newer treatment modalities

• Mucolytic agents as acetylcysteine 5% drops used in patients with corneal filaments and mucous plaques.

• Autologous serum drops [diluted 1:3 with saline] have reported to reduce ocular irritation and conjuntival and corneal dye staining in Sjogren’s syndrome associated aqueous tear deficiency.

• Tear retention–Punctal occlusion: Temporary

and Permanent.• Absorbable

– collagen or polymers– Duration- 1 week- 6 months

• Nonabsorbable– Silicone or acrylic

–Moisture chamber spectacles–Contact lenses

• Severe dry eye– Retain tear film– Promote ocular surface healing

–Tarsorrhaphy

Surgical options

• Reserved for severe-very severe dry eyes

• Tarsorrhaphy

• Mucous membrane grafting

• Salivary gland transposition

• Amniotic membrane transplantation

NEWER DRUGS ON THE BLOCK

– Tear stimulation: secretogogues• Diquafosol (P2y2 receptor agonist)• Ecabet sodium (mucous secretion

stimulant)• Rebamipide• Gefarnate

– N-acetyl-cystine eye drops.– Chloroquine Phosphate eye drops

(0.3mg/ml). – Lacriserts, collagen shields.– Androgen ointment.

SUMMARY

• Eliminating the etiological factors

• Tears replacement therapy

• Maintain moisture in the eyes

• Increasing the tear secretion

• Immune inhibition therapy

• Re-establish the tear film

• Other supporting treatment

CARRY HOME MESSAGE…

• Methodical approach to diagnosis.

• Do not miss subtle clinical signs.

• Carefully plan the line of treatment.

• Irrespective of cause of dry eye- immunomodulation + tear replacement.

• Educate the patient and family members about the dilemmas in management.