DRY EYE SYNDROMEDRY EYE SYNDROME
TEAR FILMTEAR FILM
Total thickness(7-10 µm)
• Mucus layer(0.02- 0.04
µm)• Aqueous layer
(6.5 µm)• Lipid layer
(0.1 µm)
ELEMENTS OF OCULAR ELEMENTS OF OCULAR DEFENCEDEFENCE
Stable precorneal tear film
Compositional factors
Hydrodynamicfactor
• Lipid
• Aqueous
• Mucin
• Lid blinking
• Lid closure
• Meibomian gland
• Lacrimal gland
• Ocular surface epithelium
• Tear spread• Tear clearance
• Prevents evaporation
DEFINITIONDEFINITION
Dry eye is a disorder of the tear film due to tear deficiency or excessive tear evaporation which causes damage to the interpalpebral ocular surface and is associated with symptoms of ocular discomfort
Loss of goblet Loss of goblet cellscells
Loss of goblet Loss of goblet cellscells
Absence of mucin
Absence of mucin
Tear film destabilizes
Tear film destabilizes
KCSKCS
VICIOUS CYCLE
VICIOUS CYCLE OF VICIOUS CYCLE OF DRY EYEDRY EYE
CLASSIFICATIONCLASSIFICATION
• Tear-deficient dry eye:– There is a disorder of lacrimal function
or a failure of transfer of lacrimal fluid into the conjunctival sac
• Tear-sufficient dry eye: – Lacrimal function is normal, the tear
abnormality is due to increased tear evaporation
TEAR - DEFICIENTTEAR - DEFICIENT
Sjogren syndrome Non- Sjogren tear deficient
Primary Lacrimal Disease
Lacrimalobstruction
Reflex Secondary
Rh arthritisSLE
Wegener’s Granulomatosis
Systemic sclerosis
PrimaryCong
alacrimiaPrimarylacrimaldisease
SecondarySarcoid
HIVVit A def
TrachomaPemphigoid
Burns
ContactlensVII n Palsy
Neurop-keratitis
EVAPORATIVEEVAPORATIVE
Oil deficient
Lid related Contact lens Ocular surface
disorder
Primary
Absent glands
Distichiasis
Secondary
BlepharitisMeibomian
gland disease
Blink,Aperture abnormal
Lid surface incongruity
Xerophthalmia
EVAPORATIVEEVAPORATIVE
Blephritis
Meibomian gland dysfunction
Allergic conjunctivitisAllergic conjunctivitis
LID RELATEDLID RELATED
Lid surface incongruity
Lid surface incongruityLagophthalmosLagophthalmos
CLINICAL CLINICAL MANIFESTATIONMANIFESTATION
• Burning or itching • Fluctuating vision • Foreign body
sensation • Grittiness or
irritation
• Sore or tired eyes • History of Styes • Ocular discharge • Light sensitivity • Contact lens
discomfort • Watering or
excessive tearing
DIAGNOSISDIAGNOSIS
• Slit lamp examination• Demonstration of tear instability
(Tear film break up time, TBUT )• Demonstration of ocular surface
damage • Demonstration of tear
hyperosmolarity
DIGNOSTIC METHODSDIGNOSTIC METHODS
Slit lamp examination
Tear film meniscus area (look for a decrease <0.1 mm in thickness)
Tear film itself (look for debris) Conjunctival surface (look for increased
mucous strands)
DIGNOSTIC METHODSDIGNOSTIC METHODS
Slit lamp examination
Corneal surface (look for punctate erosions, course mucous plaques, or filamentary keratitis)
Look for coexisting eyelid disease such as seen in meibomian gland dysfunction
TEAR FILM MENISCUSTEAR FILM MENISCUS
• Evaluate the height of the prism at the lower lid margin
• The normal tear meniscus height is between 0.2 and 0.5 mm
• A generalized decrease in tear volume will be represented as an absent or very thin line of fluorescein
DECREASED TEAR FILM DECREASED TEAR FILM MENISCUSMENISCUS
TEAR FILM INSTBILTYTEAR FILM INSTBILTY
Fluorescein Tear Breakup time (FBUT)
Non-invasive Tearscope/ Xeroscope
TEAR FILM INSTBILTYTEAR FILM INSTBILTY
Fluorescein Tear Breakup time (FBUT)
– Index of precorneal tear film stability– Interval between the last blink and the
appearance of the first randomly distributed dry spot– BUT of <10sec is abnormal
TEAR FILM INSTBILTYTEAR FILM INSTBILTY
Abnormal (FBUT)• Mucin-deficient
states especially cause a rapid BUT
TEAR FILM INSTBILTYTEAR FILM INSTBILTY
TearscopeTearscope Bad tearsBad tears
OCULAR SURFACE OCULAR SURFACE DAMAGEDAMAGE
• Schirmer’s test• Fluorescein Staining • Rose bengal stain• Lissamine Green Staining
SHIRMER’S TESTSHIRMER’S TEST
• Measurement of the aqueous layer quantity only
• 5x30 strips of Whatman filter paper • The amount of moistening is of the exposed
paper is recorded at the end of 5minutes
SCHIRMER’S TEST - ISCHIRMER’S TEST - I
• Measures total reflex and basic tear secretion
Results: Normals will wet approximately 10 to
30mm at the end of 5minutes. If wetting > 30 mm, reflex tearing is
intact but not controlled or tear drainage is insufficient
A value of <5mm indicates hyposecretion
FLUORESCEIN STAINING FLUORESCEIN STAINING
Punctate staining is recorded
ROSE BENGAL STAINROSE BENGAL STAINHighlights areas of desiccation and
keratinization
3 and 9’o clock staining
Inferior stainingFilaments
LISSAMINE GREEN LISSAMINE GREEN STAININGSTAINING
Aqueous/lipid layer Aqueous/lipid layer
Tear hyperosmolarityTear hyperosmolarity
Squamous metaplasiaLoss of Goblet cells
Squamous metaplasiaLoss of Goblet cells
Ocular surface damageOcular surface damage
TEAR HYPEROSMALRITYTEAR HYPEROSMALRITY
TEAR HYPEROSMALRITYTEAR HYPEROSMALRITY
• Tear film osmolarity > 312 mOsm/ L is considered abnormal
HISTOLOGICAL TESTSHISTOLOGICAL TESTS
• Cellulose acetate filter discs are pressed onto the conjunctival surface and then removed
• Examined for morphological abnormalities such as a determination of goblet cell densities, squamous metaplasia, and keratinization
Impression cytology Normal Decreased goblet cells
TREATMENTTREATMENT
• Artificial tear solutions
• Artificial tear inserts • Ointments • Mucolytic agents • Punctal occlusion• Bandage contact lens • Moisture chambers
TREATMENTTREATMENTArtificial tear solutions • Main stay of treatment for dry eyes • Have a polymeric agent such as polyvinyl
alcohol, methylcellulose, or dextran to increase viscosity
Ointments • Petrolatum based ointments relieve the
symptoms, primarily through lubrication Mucolytic agents • N-acetylcysteine 5% --- corneal filaments
and mucus plaques
PUNCTAL OCCLUSIONPUNCTAL OCCLUSION
• Sandy-gritty irritation • A rose bengal
staining pattern characteristic of aqueous tear deficiency
• Elevated tear film osmolarity
OTHERSOTHERS
• Topical cyclosporine (0.05%, 0.1%) • Oral cholinergic agents • Lateral tarsorraphy
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