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Recent diagnostic modalities of ocular surface disorders

Sihem Lazreg

Algeria

Ocular surface

• Functional unit:

- Lids (Blink)

- Conjunctiva

- Cornea , limbus

- Tear film

- Meibomian glands

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Ocular surface

Glycocalyxcellules

caliciformesGlandes

lacrymalesGlandes de Meibomius

( )

Normal tear film

Normal evaporation rate is 33%

1. Rolando et al. Br J Ophthalmol 2010;94(Suppl. 1):i1–9.Image présentée à des fins d'illustration seulement .

Lipid layer

Acqueouslayer

Epithelial cells

Mucous layer

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Définition

• Dry eye is a multifactorial disease of the ocularsurface characterized by a loss of homeostasis of the tear film and accompanied by ocular symptoms, in wich tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological role.

DEWS 2 Definition

What is the purpose of a diagnosis?

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Dry Eye testingWhat tests do I need to do to confirm this?

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NIBUT

Fluorescein

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Lissamin greenColoration of mucous, apoptotic cells and tissues.

Schirmer test I

> 10 mm : normal

6 à 10 mm :moderate dry

eye

< 6 mm :severe dry eye

Quantitative value of the tear film .

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Osmolarity

Electrolyte Concentration(mMol/L)

Sodium 132

Potassium 24

Bicarbonate 32.8

Calcium 0.8

Magnesium 0.61

• Higher of both eye and difference• Variability questioned• Cut-offs (Sullivan et al., 2010, Keech et al., 2013):

• normal (302.2 ± 8.3 mOsm/L)• mild to moderate (315.0 ± 11.4 mOsm/L) • severe (336.4 ± 22.3 mOsm/L)

• How severe is the eye discomfort?• Do you have any mouth dryness or swollen glands?• How long have your symptoms lasted & was there any triggering event?• Is your vision affected and does it clear on blinking? • Are the symptoms or any redness much worse in one eye than the other? • Do the eyes itch, are swollen, crusty or have given off any discharge? • Do you wear contact lenses? • Have you been diagnosed with any general health conditions (including recent

respiratory infections) or are you taking any medications? + detailed anterior eye examination differential diagnosis where indicated by answers

Sub

typ

e C

lass

ific

atio

n T

est

sDiagnostic Tests

Evaporative• Abnormal

lipid• MGD

AqueousDeficiency• Low volume

Ris

k Fa

cto

r A

nal

ysis

Screening Homeostasis Markers

Sym

pto

mo

logy

(D

EQ-5

≥ 6

or

OSD

I ≥1

3)

Non-Invasive [fluorescein]*

tear Breakup Time <10s

Osmolarity≥308mOsm/L in either eye or

interocular difference >8 mOsm/L

Ocular Surface Staining >5

corneal spots, >9 conjunctival spots, or lid margin [≥2mm

length & ≥25% width]

+ 1 of

Tria

gin

g Q

ue

stio

ns

Susp

ect

dry

eye

Aq

ueo

us

/ Ev

apo

rati

ve S

pec

tru

m

e.g. smoking, certain medications, contact lens wear

TMH0.2mm

0.1mm

0.0mm

MGD lid margin drop-out, displacement, secretion ≥13, expressibility 3+ lipid absent / globular / abnormal colored fringes

plugging, vascularity, secretion 8-12, expressibility 2+ lipid meshwork

secretion 4-7, expressibility 1+ lipid wave (flow) / color fringes

Symptoms

* only to be used if NIBUT not available and if so, after osmolarity

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The revenge of ocular surface : imaging

- Diagnosis /etiology- Etiological arguments- Severity- Follow up and treatment

- NIBUT- Meniscometry- Meibography- Interferrometry- Blink analysis

The importance of ocular imaging in the diagnosis of dry eye disease

Tear film stability evaluation

BUT has limits ……

Can be modified by the quantity of fluorescein> Poor reproducibility +++> Hight variability betweendoctors and in the samepatient;

Key element in the pathophysiology of dry eye

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Non invasif break up time (NIBUT) : The solution ?

Tear film stability

- Hight deviation…- Poor reproducibility according to devices …- Automatic versus manual ?

Lee et al. Clin Ophth, 2016Wolffsohn et al. DEWS 2, 2017

Lacrydiag, Quantel medical

Without fluorescein > more reliable ??

NOT DEFINED YET …………

Tear volume

Carracedo et al. Acta, 2018; Li et al. Eye Contact lens; 2012 DEWS 2, Wolffsohn et al. Ocular Surface; 2017 Rousseau et al. JFO, 2018

Ménisc = tear volume + basal secretion

Measures on pictures (Oculus Keratograph 5M, Lacrydiag)

Hight +++ conjonctivochalasis

Variable according to the blinking interval and drops instillation (diagnosis)

Normal = 0,3mm

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Infrared meibography :what can we analyse ?

« Dropout » or meibomian gland

atrophy

Shortening

Tortuosity

Meibomian glands : Structure

Arita et al. Exp Eye Res, 2017

Arita et al. BJO, 2013

Infrared Meibography : automatisation

Atomated detection of MG atrophy

Age modifications +++

No normative data yet …..

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Lipid layer reflect the function of MG

Meibomian glands : Function = interferometry

Lipiview, Tearscience

Automated measure of the lipid layer thickeness :Interférometry(Normal > 75nm) Reproducible

Finis et al. Cornea, 2013Arita et al. Exp Eye Res 2017

MGD diagnosis : Sensitivity / Spécificity : 65%

La couche lipidique forme des franges interférrométriques

Glycocalyx

cellules caliciformes

Glandes lacrymales

Glandes de Meibomius

Épithélium Couche aqueuse - mucinique7-8 μm

Film lipidique0,1 μm

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Interferométrie lacrydiag

Lacrydiag, Quantel medical

Pas toujours facile…Comparaison semi-quantitative

Normale > 30

We need some time to understand …

Interferometry

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Blinking analysis : version 2.0

MGD + incompleteblinking + abnormalBell’s phenomena…

Blinking exercises

https://www.reseau-chu.org/article/oeil-sec-protection-desobstruction-reeducation-le-traitement-en-3-phases-de-bordeaux/

Daily Exercices

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DEMODEX

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Automated diagnosis ???

Lacrydiag

Oculus keratograph 5Meyecarewithfocus.com

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PDF report

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