Post on 30-Jan-2016
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DRY EYE SYNDROMEWhy is so Prevalent ?
Rukiah SyawalDepartment Ophthalmology
Faculty of Medicine Hasanuddin University
MAKASSAR
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DEFINITION OF DRY EYE
• N.E.I. (1993)
Dry Eye : Disorder of the tear film due to tear deficiency or excessive
evaporation which cause damage to the interpalpebral ocular surface and is
associated with symptoms of discomfort.
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• Foulks (2003)
Dry eye : A disturbance of the normal homeostatic interaction of the tear film and the ocular
surface.
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• Pflugfelder (2004)Dry eye : A disorder where by dysfunction
of the lacrimal function unit causes an unstable tear film which in turn promotion ocular surface inflammation,
epithelial disease and symptom of discomfort.
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• Dry Eye Workshop (DEWS) : 2007Dry eye : is a multifactorial disease of the
tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.
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• Lacrimal Function Unit (LFU)
→ an integrated system of :
♦ Lacrimal gland
♦ Ocular surface (cornea, conjunctiva)
♦ Palpebra and mebomian gland
♦ Sensory and motoric nerves
(nerv V1, nerv VII)
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Neural pathways linking components of the lacrimal functional unit
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CLASSIFICATION OF DRY EYE
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MECHANISM OF DRY EYE
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RISK FACTOR/CAUSES• Murube :
▪ Aging
▪ Hormonal
▪ Immunologi : autoimmun reaction
▪ Pharmacologic : topical, systemic
▪ Hyponutrition : vit.A deficiency, alcoholism
▪ Infection : HSK, trachoma
▪ Trauma : surgery
▪ Neurogenic : contact lens, post LASIK
▪ Defective gland
▪ Inability to utilize tears
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• DEWS
● Aging
● Low androgen
● Drugs : systemic, topical
● Inflammatory lacrimal damage
● Refractive surgery
● Contact lens wear
● Environment
● Xerophthalmia
● Ocular allergy
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PREVALENCE OF DRY EYE
Study N Age (year) Prevalence (%)
Salisbury Eye Study 2420 ≥ 65 14,6
Beaver Dam 3722 ≥ 48 14,4
Women Health 36995 ≥ 40 7,8
Physician’s health I and II 26655 ≥ 50
Blue Montains 1075 ≥ 50 15,3
Melbourne 926 ≥ 40 5,5
Shihpai 2038 ≥ 65 33,7
Sumatra 1058 ≥ 21 27,5
Over all → 5 – 30%
Population – based epidemiologic studied of dry eye
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• Variability in Prevalence
1. Definition of dry eye syndrome.
2. Lack of understanding of the etiology of dry eye.
3. The lack of a standardized clinical testing protocol to diagnose dry eye, mostly based on subject reporting system.
4. Recognition of dry eye as a multifactorial inflammatory condition.
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Prevalence by age and sex
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Rates of diagnoses and procedures, by age and sex
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Test use to detect clinical signs
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• Other factors increase of prevalence
1. Diabetic2. Cigarette / smoke3. Computer vision syndrome4. Post LASIK
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Dry eye and Diabetic
- Microvascular complication
- Neuropathy, retinopathy, nephropathy
- Schirmer test <, tear protein composition <
- Damage (microvasculature) lacrimal
gland, neuropathy of cornea → tear
secretion↓↓
- KEISERMAN et al (2004)
22382 DM patients → 20,6 % dry eye
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Dry eye and Smoke
- 25%-40% employees smoke → 25 % of them dry eye related.
- ALTINOS et al : 60 smoker vs 34 healthy.
- Schirmer, BUT, goblet cell density not significant differ.
- Higher grade changes on lipid precorneal tear film → smoke cause damage on lipid layer.
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Dry Eye and Smoke
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Dry Eye and Computer ( Computer Vision Syndrom)
♦ > 50% work force uses computer.
♦ > 75% all job (2000) use computer.
♦ > 100 million working suffer computer eye strain in USA.
♦ ± 54 million children connect internet each day at home or school.
♦ > 2 hours each day in front of computer screen → CVS
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• Pathogenesis CVS
1. Ocular surface mechanism2. Accomodative mechanism3. Extraocular
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Clinical Features CVS
- Asthenophia : tired eyes, sore eyes
- Ocular surface related : dryness, watery, irritated eyes
- Visual : ♦ blurred vision
♦ slowness of focus change
♦ double vision
- Extraocular : neck pain, back pain, shoulder pain
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Dry Eye and LASIK
• USA : 800.000 – 900.000 LASIK/Year• DE post LASIK : yu (60%), Hovanesian (50%),
Goto (66,7%)• Etiology
1. Corneal denervation
2. Pressure induced by the suction ring → damage conjunctival goblet cell
3. Medicament : antybiotic, anti inflammation→ toxic epithel
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Dry Eye and LASIK
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Dry Eye and Gender
• Majority dry eye syndrome are women
• Sjogren’s syndrome > women
• MGD > Men
• Hypothesis :
Androgen deficiency is a critical etiological factor in aquous deficient dry eye in Sjogren’s
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CASE PRESENTATION
CASE 1. Female 38 years ● 3 months : redness, itching, some times
gritty, mucous secretion.
She had been treated ED, EO, Gel, and oral without improvement.
● Ophthalmology exam : pleated conj, hyperemia, small mucous secretion medial canth.
VA, OD : 20/20 OS : 20/20
● DD : Chronic allergic conjunctivitis ?
DES ?
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• BUT : 8 sec, schirmer 4 mm, staining : punctate epitheliopathy interpalpebral.
• Expression meibom gland : grade 2
DES ? or Allergic ?
● Therapy : - topical → Polynel ED, repithel ED
- oral → loratadine, retivit plus.
itching <, pleated conj and hyperemia persist. Epitheliopathy (-)
after 2 months Th/.
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CASE 2. Male, 60 years
♦ RE : central corneal ulcer, Th/ LFX ED, dibekacin ED, a week prior
admitted Hialid 0,1% ED, ciprofloxacin 2x500mg, Becom C.
♦ DM > 10 years, uncontrolled
♦ 2 years before : timolol 0,5%
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♦ REVA : 0 LEVA : 0,1
♦ On the RE :
- Corneal edema.
- Pupil 4 mm, shallow anterior chamber.
- Tn + 1, senile cataract.
- Central corneal epithelial erosion with punctat epitheliopathy.
- Corneal sensitivity decrease.
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♦ D/ : DES ocular surface disorder
Causes ?? Multifactorial
1. Aging
2. Neuropathy
3. Medicament : antibiotic, antiglaucoma
♦ Th/ : - AMT + Bandage C.L → fail
- Repithel ED + SA 20% ED
→ very slow resolution
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SUMMARY
1. High prevalence of dry eye (5-30%) increasing with age.
2. Cost of dry eye increse, reduced productivity, increased for doctor visit → economical implication.
3. Quality of life reduced → substancial cost to society.
4. Need better understanding of dry eye and developing more effective therapies.
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