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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