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School of

Optometry:

Dellen-pinguecula

Exposure Keratitis

Exposure Keratitis Chronic Allergy

• Dry eye reported by 36% of allergy suffers

• Destabilizes the tear film

• GPC, vernal KC,

Ocular Surface Toxicity

• Toxic effects of topical agents: preservatives &or the active medication itself: ie. Topicalglaucoma meds. can cause conjunctivalmetaplasia, loss of goblet cells & inflammation

Environmental Influences

• Pollution keratoconjunctivitis, office dry eye,sick building syndrome due to poor indoor air-quality in temperature controlled officeenvironments

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Diagnosing the Dry Eye• History/Symptoms (variable) – “OSDI”

questionnaire (refer to hand out)• Gross evaluation of eyelids structure, apposition,

blink rate, redness, facial features, hands• Biomicroscopy— tear meniscus, tear debris and

viscosity, blepharitis, MGD• Tests of the tear film-TBUT, noninvasive

–(tearscope by Keeler Inst.)• Dye testing-Fl, RB, LG• Schirmer’s testing & phenol-cotton thread test• Tear hyperosmolarity

Medical History

• Identify medications

• Identify related systemic diseases

Ocular Symptoms• Patient’s complaints traditionally have been

considered an unreliable indicatorForeign body sensation PainBurning PhotophobiaRedness ItchingExcess secretion Blurred visionInability to tear BurningSandy, gritty feeling SorenessFilm over vision TearingStinging DrynessTearing

• Hyperemia

• Low tear meniscus

• Tear debris

• Abnormal tear osmolarity

• Fast tear break up time

• Conjunctival staining

• Blepharitis

• Increased cytokines

• Corneal surface damage

• Dryness

• Itchiness or scratchiness

• Photophobia

• Contact lens intolerance

• Burning or stinging

• Foreign body sensation

• Grittiness

• Fluctuating visual acuity

• Tired eyes

• General discomfort

PATIENT SYMPTOMS CLINICAL SIGNS

Ocular Manifestations of Dry Eye Ocular Surface Disease Index (OSDI)

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Diagnostic tests• Schirmer’s tear test 1 shows decreased reflex tearing

in lacrimal gland disease <6mm• Fluorescein tear break up time (FBUT) measures

tear film stabilty< 10 seconds: “The Dry Eye Test”• Fluorescein staining indicates corneal epithelial

integrity• Rose bengal and lissamine green staining indicates

the integrity of conj. surface- grading scale• Tear film osmolarity is increased in dry eye• Impression cytology shows squamous metaplasia• Tear lactoferrin is decreased in aqueous tear def.• Tear turnover rate is 40% lower in dry subjects

Ocular Signs

External & Slit Lamp Examination

• External eye and the adenexa• Blepharitis signs & lid anomalies• Observe the the blink rate, viscous precorneal tear film, tear

debris, tear meniscus, luster of conj., and conj injection• Apply fluorescein dye- height of tear meniscus, corneal

staining, TBUT• Rose bengal or Lissamine green staining• Location of staining can be significant indicator of cause of

dry eye• Mucous plaques, filaments, secondary infections, scarring,

neovascularization, thinning, perforation

Lids

• Positioning

• Blinking pattern

• Punctal positioning

• Patency of puncta

Tear Film Stability

• Result of either tear deficiency or evaporativeDES

• TBUT < 10 secs symptomatic• The Dry Eye Test (DET)• Xeroscope- projects a lighted grid pattern onto

the tear surface 40secs normals & 12 secsabnormal

• New Method for Evaluating TBUT- Hartmann-Shack wave front sensor

• Subjective testing

Non-invasive tear film breakup time

• Use second hand of a watch

• Blink 2 to 3 times and then stare straight aheadat a fixed point

• Note the time from the last blink to firstsensation of ocular awareness.

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Staining

• Fluorescien dye staining indicates where thetight junctions of epithelial cells are disruptedand produce characteristic inferior 1/3 stainingof the cornea

Rose Bengal or LG Staining Scores• Dyes stain dead & devitalized cells, mucous and

areas where the mucous layer is missing over cells• Based on grades 0-3 in each of three areas- nasal

exposed bulbar conj., temporal bulbar exposed conj.and cornea for a total score of 9– If 3 or greater then a positive test– Typically conjunctiva stains more than cornea, nasal

greater• Lissamine green has at least 3 advantages over RB

– Less toxic to the cells– Doesn’t last as long– Doesn’t sting as much– Note: slit lamp exam ASAP- a significant dilutional effect

Tear Production/Schirmer Testing

• Schirmer I test – performed without anesthetic isfelt to be better test to determine how many tearsthe eye can produce without stimulation: < 5 secsconfirms a diagnosis of DES, 6-10 secs. suspicious

• Schirmer with anesthetic-- Basic secretion test –gives less info.

• Schirmer II test– stimulating the nasal mucosawith a cotton tip application is rarely indicated

• Phenol red tear test (PRT): normal-24mm in 15secs, abnormal-11mm in 15 secs

Schirmer Tear Tests

• Severe: 5mm or less

• Moderate: 5-10 mm

• Mild: 10-15 mm

New Diagnostic Clinical Tests

• DET fluorescein strips from Akorn– Small thin strip

– Much less fluorescein instilled

– Several studies report this makes TBUT testing more repeatable

Other Tests

• Abnormal tear lysozymes- tear lactoferrin- TheTouch Tear Lactoferrin Micro assay by TouchScientific

• Conjunctival scrapings—numerous goblet cells,divitalized and keratinized cells are seen

• Osmometers to measure tear film osmolarity

• Fluorescein clearance test

• Corneal sensation- cotton wisp

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Oral Symptoms

• Saliva production– Key question to ask is“Can you eat a biscut or a cracker withoutdrinking water and do you sleep with a glassof water by your bed at night”

• Poor oral hygiene and frequent dental caries

• Decreased parotid flow

• Labial salivary gland biopsy

Systemic Evaluation

• Serological tests— LE, ANA, CBC, ESR,Anti DNA antibody levels, RH factor,Autoantibodies ( Ro/SS-A and SS-B)

• Presence of antinuclear antibody>1:160,rheumatoid factor1:160, & positive SS-A(Ro), and /or SS-B (La)

Normal Tear Prism Tear prism- Dry eye

Desiccation of the corneal

epithelial cells due to

varied causes

Mucins cannot attach and

the water repellant corneal

surface is exposed

Tear film destabilizes,

increasing evaporation and

diffusion, exposing the cornea

Damaged corneal cells show up as dry

spots during corneal staining.

How Tear Film Instability Occurs Tear film break up viewed with fluorescein stain on a patient with dry eye

0 seconds 1 second 2 seconds 3 seconds

6 seconds4 seconds 5 seconds 16 seconds

Tear film break up is indicated by

the dark areas that appear on the

cornea.

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Tear Film Break-up Negative Staining -EBMD

Schirmer Tear Test NaFl Staining-severe dry eye

NaFl- severe dry eye

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Mild RB staining

Moderate RB staining Moderate RB staining

Moderate RB staining Severe RB staining /Conj

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Mucin ball-Rose Bengal Severe RB staining/mucin strand

Complications

• Filaments• Persistent epithelial defects• Secondary infections• Scarring

Filamentary Keratitis

Filmentary keratitisCorneal scarring – severe dry eye

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Lid margin RB stainingWhat is the Lid Wiper?

• The epithelial health of the lid wiper can bedetermined with a simple graded staining test similarto those used in analyzing the ocular conjunctiva

Korb, DR, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens. 2005 Jan; 31(1):2-8.

The lid wiper is that portion of the

marginal conjunctiva of the upper

eyelid that wipes the ocular surface

during blinking.

Dry Eye Symptoms and LidWiper Epitheliopathy

• Presence of lid wiper staining accompanies dry eyesymptoms (DES) even in patients who do not merit aDES diagnosis based on other clinical signs

• Lid-wiper staining may be a more accurate measureof DES than current clinical tests

• An artificial tear capable of reducing lid wiperstaining could alleviate dry eye symptoms

44%

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Symptomatic Patients Asymptomatic Patients

Grade 1 Grade 2 Grade 3 Total

Prevalence of Lid-Wiper StainingPrevalence of Lid-Wiper Staining

(by Grade and Total) in Symptomatic and(by Grade and Total) in Symptomatic and

Asymptomatic SubjectsAsymptomatic Subjects

Korb, DR, et al. Lid wiper epitheliopathy and dry eye symptoms. Eye Contact Lens. 2005 Jan; 31(1):2-8.

Lid Wiper EpitheliopathyLid Wiper Epitheliopathy

1. Korb DR, Herman JP, Greiner JV, et. al: Lid Wiper epitheliopathy and dry eye symptoms. Eye & Contact Lens 31(1): 2-8, 2005.

2. Korb DR, Herman JP, Greiner JV, et. al: Lid Wiper epitheliopathy and dry eye symptoms in contact lens wearers. CLAO J 28: 211-216, 2002.

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Characterized by presence of damaged epithelial cellsCharacterized by presence of damaged epithelial cells

on lid wiper portion of marginal conjunctivaon lid wiper portion of marginal conjunctiva

Fluorescein or rose bengal can be used to dye the lidFluorescein or rose bengal can be used to dye the lid

wiperwiper

Staining graded on scale of 0 to 3, where 0 = noStaining graded on scale of 0 to 3, where 0 = no

staining, 3 = heavy stainingstaining, 3 = heavy staining