sabhlok the eye strain book

8/12/2019 Sabhlok the Eye Strain Book

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Eye strain, computer vision syndrome, dry eyes, ocular surface disorders, eye allergy: some explorations. A free book by Sanjeev Sabhlokhttp://eyestrain.sabhlokcity.com/pics/Sabhlok-The-Eye-Strain-Book.oc

Eye strain, computer vision syndrome, dry eyes,

ocular surface disorders, eye allergy

- some explorations

A free book by Sanjeev Sabhlok, patient

his is a patients personal compilation of information from the internet !including academic

papers"# $eferencing is through hyperlinks %here possible#

This !book" has been prepare purelyfor my o#n benefit. $t mi%ht help others. &o' can interact#ith me on my eye blo% eyestrain.sabhlokcity.com

This is #ork in pro%ress. (ersion ).))* ate + ,ovember )

&'(E(S

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Normal Lid Margin Anatomy......................................................................................................................................4

Normal Tear Film omposition..................................................................................................................................4

)E .A/(01+ EE 2 /3E(/0/(4 )E &A1SE############################################################################################# ######5

an !e managed, not cured........................................................................................................................................"

#o not self$diagnose..................................................................................................................................................."

S&0T1S

.......................................................................................................................................................................2TESTS...............................................................................................................................................................................3%smolarity of tears.....................................................................................................................................................&

Tear4ab System......................................................................................................................................................................3Tear 'uantity tests.......................................................................................................................................................&

5l'orescein.............................................................................................................................................................................36ose ben%al stainin% test........................................................................................................................................................34issamine 7reen.....................................................................................................................................................................8

Tear film sta!ility tests................................................................................................................................................(

)iomicroscope....................................................................................................................................................... ...*+eibo%raphy........................................................................................................................................................................)

9$A7,1ST$ET;191417&.........................................................................................................................................)peed of onset...........................................................................................................................................................*+

6api onset...........................................................................................................................................................................)

Slo# onset............................................................................................................................................................................)Eye parts affected............................................................................................................................................... ......*+

A....................................................................................................................................................Auto$immune response..............................................................................................................................................**

)acterial infections.................................................................................................................................................. .**Anterior Blepharitis..............................................................................................................................................................

Anterior !lep-aritis........................................................................................................................................ ..........*

tap-ylococcal !lep-aritis.......................................................................................................................................*

e!orr-eic !lep-aritis..............................................................................................................................................*

e!orr-eic/stap-ylococcal !lep-aritis.....................................................................................................................*

Mei!omian se!orr-eic !lep-aritis............................................................................................................................*0

e!orr-eic !lep-aritis 1it- secondary mei!omianitis.............................................................................................*0

Mei!omian 2eratocon3unctivitis.......................................................................................................................... .....*0

Angular !lep-aritis...................................................................................................................................................*02in disease..............................................................................................................................................................*0

Blepharitis............................................................................................................................................................................?
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Atrop-y of Me!omian glands....................................................................................................................... .......... ..*09ama%e %oblet cells =m'c'o's layer>.................................................................................................................................?7oblet cells %enerally lo# in ry eyes..................................................................................................................................?$ncrease level of solvents in ry eyes can kill %oblet cells..................................................................................................*4ess blinkin% can kill %oblet cells.........................................................................................................................................2

#amaged lac-rymal glands......................................................................................................................................*&

#eficiencies..................................................................................................................................................... .........*&$oine eficiency..................................................................................................................................................................3Testosterone eficiency........................................................................................................................................................3

A mite in t-e eyelas-es demodex folliculorum5.......................................................................................................*&9emoicosis.........................................................................................................................................................................3

$E*E3 0'$ A1'-/**1(E $ES.'(SE############################################################################################################67

S&0T1AT$6E4$E5: ,1,-T;E6A0E hy%iene..............................................................................................................................................................8#o not use !a!y s-ampoo.........................................................................................................................................*8

#o not use !icar!onate of soda................................................................................................................................*(

9se only Lidare or one of t-ese.............................................................................................................................*(

T;E6A0E


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ontact lens 1ear.....................................................................................................................................................(

B. 1


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The normal eye

5or simplicity $ ass'me that everyone reain% this book kno#s abo't the anatomy of the eye. Thatcan be reaily iscovere on the internet. ;o#everD a s'mmary is provie here:

Normal Lid Margin Anatomy

The li mar%in is abo't mm thick an has a thin %ray line separatin% its anterior an posteriorportions. The anterior portion has t#o or three ro#s of eyelashes. The posterior borerD in closeapposition to the %lobeD contains the orifices for the tarsal %lans. The meibomian %lansapproFimately ?) to *) in the 'pper an ) to 2 in the lo#er liare embee in the tarsal platesan secrete lipis that comprise the oily layer of the tear film. D?Altho'%h the maFim'm tearcapacity of the oc'lar s'rface an fornices is abo't 2 G4D the normal vol'me is only abo't 3 G4.Each blink rene#s the tear film an istrib'tes a fresh layer across the eFpose cornea an

conj'nctiva.

Normal Tear Film Composition

The preoc'lar tear film =01T5> has three ientifie b't ynamically interactin% layers @ lipiDaH'eo'sD an m'co's.)The pilosebaceo's meibomian %lans in the lis pro'ce most of theo'termost =lipi> layer. The Ieis an oll %lans of the eyeli mar%insD #hich are associate #iththe lashesD also contrib'te to this layer. 1ily secretions in this layer f'nction to contain the aH'eo's

phase of the 01T5 by re'cin% s'rface tension. $n aitionD the lipi layer stabiliJes an retarsevaporation of the 'nerlyin% aH'eo's layer.D*D2

$n the normal healthy eyeD the lipi layer thickness is less than ). Gm. eibomian lipis =meib'm>

are mainly #aFy an cholesterol esters. ?D+ ;i%h molec'lar #ei%ht an lo# polarity are importantproperties for the formationD stabiliJationD an protection of the 01T5K alteration of polarity inisease states s'ch as blepharitis may have an averse effect on its stability an lea to oc'lars'rface isorers an symptoms of ry eye. $nterference frin%e patterns become istorte in the

presence of a contaminate or thickene lipi layer. ?D3$n aitionD meibomian secretions may beistinctly altere in patients #ith meibomian %lan ysf'nction.8

The aH'eo's layer makes 'p abo't ) percent of the 01T5. The major contrib'tion to this layercomes from the accessory eFocrine lacrimal %lans of Cra'se an olfrin%.D)The aH'eo's layercontains lysoJyme an proteinsD incl'in% lactoferrinD that eFhibit antibacterial activities.4aboratory analysis may prove 'sef'l for ia%nostic eval'ation of the aH'eo's layer.

The innermost layer of the 01T5 is the m'co's layer. 0ro'ce primarily by the %oblet cells of theconj'nctivaD m'c's l'bricates the lis an serves as an asorbin% interface bet#een the aH'eo'slayer an the hyrophobic corneal epitheli'm. $n aitionD it collects cell'lar ebris from the oc'lars'rface .)DThe %lycocalyF on the epithelial microvillae anchors the m'co's layer. )The moel fortear film break'p is base partially on thinnin% of the aH'eo's layer an s'bseH'ent contact

bet#een the lipi an m'cin layers.D1ther mechanismsD s'ch as ne'ral receptorsD may play a rolein tear film break'p.?

ThereforeD oc'lar s'rface isorers can res'lt from compromise to the str'ct're or f'nction of theconj'nctivaD eyelis an their %lansD conj'nctiva an its accessory %lansD or cornea. This7'ieline escribes the most common clinical etiolo%ies of oc'lar s'rface isorers: blepharitis an

ry eye. =See AppeniF 5i%'re for $9-)- lassification.>

*
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The painful eye identifying the cause

The most common oc'lar s'rface isorers stem from tear-film abnormalities an li-%lanysf'nction =!blepharitis">D either of #hich may lea to oc'lar s'rface isorers. The 'se of

terms s'ch as ry eye =9E>D oc'lar s'rface isease =1S9>D or eficient tear synrome =9TS>Drepresents attempts to escribe si%ns of clinical ama%e to the intrapalpebral oc'lar s'rface orsymptoms of s'ch isr'ption from a variety of ca'ses. LSo'rceM

Can be managed, not cured

oc'lar s'rface iseases s'ch as ry eyes an blepharitis are chronic conitions thatD at bestD canbe controlle b't rarely c're. ana%in% patient eFpectations is criticalD %iven the tenency forpatients to eFpect immeiate improvement an %ive 'p too soon on their therapies. henealin% #ith oc'lar s'rface iseasesD one has to be persistent an 'se combination therapies inorer to reach the f'll treatment effect. LSo'rceM

Do not self-diagnoseSymptomatic patients may try to solve their perceive problems #ith self treatment. S'chapproaches may elay acc'rate ia%nosis of oc'lar s'rface isease. LSo'rceM

;o#everD it has been my eFperience that most octors ont really kno# m'ch abo't this an o notpay m'ch attention. So yo' are #ell avise to research the topic on the internet an %et betterinforme abo't #hat yo' mi%ht be eFperiencin%.

Symptoms

See this.

itchin%D especially in the inner canthal areaD is almost al#ays a si%n of aller%ic isease. 4ike#iseDit is #ell kno#n that patients #hose symptoms are preominantly 'e to aH'eo's tear eficiency#ill often have forei%n boy sensationD #hich is #orse later in the ay. onverselyD patients #ith

preominantly meibomian %lan isease an concominant evaporative ry eyeD have moreb'rnin% an irritationD #hich is typically #orse in the mornin%.

5l'ct'atin% vision #ith #orsenin% vis'al ac'ity after vis'ally intensive activities is virt'allyia%nostic of an inaeH'ate tear film. LSo'rceM

0atients eFperience:

!'ntil yo've eFperience ry eyeD yo' cant 'nerstan ho# 'nspeakably painf'l it is" LSo'rceM$t is like !livin% in hell" LSo'rceM

!$ #as reay to j'mp o't the #ino#" LSo'rceM

!$ felt like $ ha shars of %lass c'ttin% into my eyes. The only relief $ %ot #as #hen $ #as asleepKmy time a#ake #as tort're." LSo'rceM

$ve trie to classify the levels of pain $ve eFperiencehere.B't a f'rther isc'ssion #o'l be'sef'lD since it is the most abs'rly painf'l eFperienceD #ell beyon any possible escription .

2
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This %reatest problem #ith this pain is that it is locate 9$6ET4& 1, the !#ino#" to ones#orl @ the eyes an forebrain. The entire area insie an aro'n the eyes %ets SE(E6E4&affecte.

A throbbin%D ti%ht pain is eFperience in the eyebro# area. Severe heaache can arise. B't basically

it feels that the !rainis eFperiencin% the pain =altho'%h that is not possible since the brain oesnthave pain receptors>. Basically thereforeD the eFperience is one of continuous sorenessinsie anaro'n the eyes @ almost as if it insie the frontal lobe.This back%ro'n soreness =H'ite ba> can %et a%%ravate baly once the eyes %et ry eno'%h to start

b'rnin% =note that this ryness is ,1T alleviate by eye rops>.itho't s'ch b'rnin% #hat is eFperience is a ti%htpulling sensationinsie the eye an aro'n theeyelis. B't this sensation can %et astonishin%ly ba #hen the eye starts b'rnin%. At that point thereis an acute burning sensationinsie the eye @ as #ell as throbbin% heaache.

Some#here bet#een the b'rnin% an the heaache is an ugly sensation#here the eye is feel as ifthere is some astringent fille insie the eyes. $t is nota %ritty sensationD b't feels as if the entireeyelis are fille #ith somethin% that is p'llin% at the pores an ca'sin% a #eir irritatin%eFperience.Some#here aro'n this level of ryness is associate the inability to move the eyeballs fleFibly#ithin the eyelis. ovin% them aro'n the eyeball =s'ch as rotatin% the eye in a circle> becomesimpossibleD stickyD an painf'l. So essentially one is force to look aheaD an narro# the eye.

The #orst sensation of all is #hen the heaache andb'rnin% reach the ac'te sta%eD andto that isae most 'nbelievable sensation of a !layer" or !film" of pain that fills the entire eye in the front.This !layery" sensation has been #ell escribehere: "menthol sensationD" like a colD mint #inis blo#in% ri%ht in to yo'r eyesD even if yo're j'st stanin% stillD inoorsD in a perfectly calm-aireroom." ",astyD nasty sensation". "as if $ #as !stickin% my hea in a freeJer #ith my eyes #ieopen"$f yo' po'r isopropyl alcohol over the back of yo'r hanD it evaporates veryD very H'ickly. hat yo'feel is a !severe" coolin% sensation that s'rely co'l be escribe as a !menthol moment." Thats're so'ns like severe evaporative ry eye =very short tear break'p time> to me N an mines's'ally less than t#o secons. LSo'rceMThis kin of sensation %enerally arises #hen one is reain% the comp'ter screen after a lon% ay of

#ork. At that point one kno#s that is simply not possible to contin'e. L,ote: this apparently is fiFebest by moist're chamber %lassesMThere is ,1 relief for the entire ay the moment one %ets 'p. The only time one oesnt eFperience

pain is 'rin% sleep.

+
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Tests

smolarity of tears

ear+ab System

(al'es 4$EAE$ )A( >6= m'smolB+are ia%nostic of ry eye isease. LSo'rceM

See etails on this blo% post. $n elbo'rneD ark 6oth of Armaale has access to s'ch a machine.

Tear !uantity tests#

0luorescein

All ophthalmolo%y offices 'se fl'orescein to look for stainin% on the cornea. ;o#everD 6oseBen%al an 4issamine 7reen are act'ally more sensitive than fl'orescein an can be 'se toia%nose ry eye isease at an earlier sta%e by lookin% for stainin% in the conj'nctiva #ith #hiteli%ht. This may be 'sef'lD for instanceD #hen screenin% patients before refractive s'r%ery.

$ prefer 4issamine 7reen since it is tolerate better by the patient. Both can be p'rchase inimpre%nate strips an 'se in a manner similar to fl'orescein strips. LSo'rceM

5l'orescein stainin% that is more prominent in the s'perior cornea =#hich is typically covere bythe 'pper eyeli> is almost never j'st 'e to ry eyes. Stainin% from ry eyes typically affects theinterpalpebral Jone m'ch more si%nificantly. ThereforeD one sho'l have a hi%h ineF of

s'spicion in patients #hose stainin% is more prominent s'periorly.Aitional investi%ations sho'l incl'e evertin% the 'pper eyeli to check for floppiness an/orchan%es on the palpebral conj'nctiva. 4ike#iseD s'perior limbic keratoconj'nctivitis sho'l beconsiere by checkin% for stainin% an re'nancy of the s'perior conj'nctiva.

5inallyD contact lens-in'ce limbal stem cell eficiency #ill typically present #ith stainin% in a#horl pattern startin% in the s'perior cornea an limb's. LSo'rceM

$ose bengal staining test

See this.The p'rpose of this test is to ascertain indirectly the presence of reduced tear volume throughdetection of damaged epithelial cells.The eye is anesthetiJe topically #ith proparacaine ).2O. Tetracaine or cocaine may %ive false-

positive tests beca'se of their softenin% effect on corneal epitheli'm.

1ne rop of O rose ben%al sol'tion or a rop from a saline-#ette rose ben%al strip is instille ineach conj'nctival sac. 6ose ben%al is a vital stain taken 'p by ea an e%eneratin% cells that have

been ama%e by the re'ce tear vol'meD partic'larly in the eFpose interpalpebral area. This test

is partic'larly 'sef'l in early sta%es of conj'nctivitis sicca an keratoconj'nctivitis sicca synrome.

3
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A positive test #ill sho# trian%'lar stipple stainin% of the nasal an temporal b'lbar conj'nctiva inthe interpalpebral area an possible p'nctate stainin% of the corneaD especially in the lo#er t#o-thirs.

5alse-positive stainin% may occ'r in conitions s'ch as chronic conj'nctivitisD ac'te chemical

conj'nctivitis seconary to hair spray 'se an r'%s s'ch as tetracaine an cocaineD eFpos'rekeratitisD s'perficial p'nctate keratitis seconary to toFic or iiopathic phenomenaD an forei%n

boies in the conj'nctiva.

The stain #ill also color m'c's an epithelial ebrisD #hich may mask the res'lts. ertain patients#ho are normal #ill sho# some positive stainin% to rose ben%al on the cornea.

Beca'se of thisD conj'nctival as #ell as corneal stainin% sho'l be present before the ia%nosis ofkeratoconj'nctivitis sicca is mae.See this: http://###.ryeyes'mmit.or%/articles/pros-an-cons-ry-eye-tests

+issamine 4reen

Tear H'antity tests are 'sef'l in confirmin% the ia%nosis of aH'eo's-eficient ry eyes. The mostfreH'ently 'tiliJe proce'res are:

Schirmer tear test#The Schirmer testD either #ith topical anesthesia =basic secretion test> or#itho't =Schirmer $>D can be 'se to eval'ate the H'antity of the aH'eo's layer of the tearfilm.)$n this testD the eFaminer places filter paper in the lo#er forniF to meas're the vol'meof tears pro'ce 'rin% a fiFe time perio. hen performe 'sin% a topical anestheticD it

p'rportely meas'res the tear secretion of the accessory lacrimal %lansK #itho't anestheticDit meas'res the tear pro'ction of the lacrimal %lan by stim'lation of the lacrimal refleF arc.Altho'%h it is controversial beca'se the res'lts are often inconsistentD the Schirmer tear testcan provie 'sef'l clinical information.

0luorescein-enhanced assessment#After ain% fl'oresceinD a #ater-sol'bleD inert ye =notfl'orescein-anesthetic sol'tion> to the oc'lar s'rfaceD the clinician can observe the rate ofil'tion of the aH'eo's component of the 01T5D especially #ith enhancement by cobalt-filtere ill'mination. $n aitionD s'bclinical isr'ption of the oc'lar s'rface #ill be reveale

by stainin% vie#e #ith the cobalt-filtere ill'mination. Acceptance of this metho has beenhampere by lack of a stanar.)D)?

Evaluation of the tear prism#The tear menisc's hei%ht can be assesse #ith biomicroscopiceFamination both #ith an #itho't instillin% fl'orescein ye.)3A tear menisc's hei%ht %reaterthan

). millimeters =mm> sho'l be consiere normal.)8A scanty or absent tear menisc's is aninication of an aH'eo's tear eficiency.)5't're irections in tear meniscometry may combine the'se of interference patterns.)

ear-film debris#EFcessive partic'late matter in the tear filmD visible by biomicroscopiceFaminationD may inicate inaeH'ate fl'shin% action 'e to re'ce tear flo#.

$ose bengalB lissamine green staining#A 'sef'l test for ientification of oc'lar s'rfaceisorers has been rose ben%al stainin%. $t hi%hli%hts oc'lar s'rface chan%es associate #ithins'fficient tear flo# an conj'nctival an corneal esiccation. 1ne scorin% system for rose

ben%al stainin% assi%ns val'es of ) to ? for each of the lateral an meial corneal an

8
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conj'nctival re%ions of the eFpose intrapalpebral oc'lar s'rface.A maFim'm score of inicates severe stainin%K ) inicates complete absence of rose ben%al stainin%. A moreetaile techniH'e for H'antitative assessment of rose ben%al stainin% enables escription ofthe intensity an eFtent of involvement an may be more 'sef'l in oc'mentin% s'btlechan%es in response to treatment strate%ies.

The intro'ction of lissamine %reen stain has offere an alternative to rose ben%al that is lessirritatin% to the patient an eH'ally efficacio's in emonstratin% isr'pte oc'lar s'rfacecharacteristics.D?ThereforeD lissamine %reen is preferable to rose ben%al. The 1Ffor scale has

been propose to stanariJe the eFtent an location of lissamine %reen as #ell as fl'oresceinstainin%.*

1ther tests that may be 'se to eval'ate tear H'antity are:

Schirmer $$ =irritation>

otton threa test*

4issamine %reen stainin%2D+ 0henol re threa test 3

Tear vol'me meas'rements

5l'orophotometryK fl'orescein il'tion 8

4acrimal eH'ilibration time

Temporary p'nctal occl'sion.

Tear film stability tests"

Several proce'res are commonly 'se to eval'ate tear film stability:

ear film breakup time !81"#The time reH'ire for the tear film to break 'p follo#in% a

blink is normally 2P) secons )K TB3

4ipi layer interference patterns +D)3D8

Spec'lar reflection of the tear s'rface D?) E4$SA tear protein profile. ?


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After nearly a cent'ry of research attemptin% to characteriJe clinical si%ns amon% patients #ith ryeyeD the consens's is that tear film ysf'nctions are seconary to li an li-%lan isr'ptions. S'chisr'ption leas toD or is a conseH'ence ofD osmolarity chan%es in the aH'eo's layer of the tear filmKit may lea toD or be a conseH'ence ofD inflammatory components in the tear film an on the oc'lars'rface.


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Causes (aetiology)

Each ca'se has a ifferent set of symptoms an ifferent sol'tions. ;ence it is 6


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1ptometrists are oin% more harm than %oo by avisin% patients to employ home-maetreatments s'ch as baby shampoo or bicarb scr'bs for li an lash conitions.

$nepenent est o'ntry 11 Sarah 5arrant sai that some practices #ere oin% more harm than%oo by avisin% patients to 'se baby shampoo or bicarbonate of soa to #ipe lis an lashes.

Baby shampoo is abo't as isr'ptive to the lipi as yo' can %et. She also ca'tione a%ainst the 'seof bicarb escribin% it as: the lesser of t#o evils

8icarbonate of soda

;o# m'chQ D all of#hich have c'lt're #ith pop'lations of normal s'rface or%anisms. $t is present in to ? percent ofimm'nocompetent a'ltsD an is more prevalent in men than in #omen. Altho'%h skininflammation is not necessarily evientD %reasyD foamy scales calle sc'rf s'rro'n the bases of thecilia. Seborrheic ermatitis may be seen in conj'nction #ith other skin iseasesD s'ch as rosaceaD

an acne v'l%aris.Malasse6iayeasts have been associate #ith seborrheic ermatitis. Abnormal orinflammatory imm'ne system reactions to these yeasts may be relate to evelopment of seborrheicermatitis.2

$eborrheic&staphylococcal blepharitis#Another common form of anterior blepharitis iscombine seborrheic/staphylococcalD or miFeD blepharitis.2Associate #ith seborrheic ermatitisDit is characteriJe by seconary keratoconj'nctivitisD papillary an follic'lar hypertrophyDconj'nctival injectionD an miFe cr'stin%. $ts severity #aFes an #anes

over its chronic co'rse. Bacterial c'lt'res are positive in approFimately 8 percent of cases. Theor%anisms fo'n most freH'ently have chan%e from . aureusto . epidermidisD treptococcus=Aan B>D)acillus sp.D oryne!acterium sp.D;ropioni!acteriumDEsc-eric-ia coli, ;seudomonas sp.D

itro!acter sp.Dand andida sp.2?

;istolo%ical eFamination reveals chronicD moerateDnon%ran'lomato's inflammation.
http://sanjeev.sabhlokcity.com/http://eyestrain.sabhlokcity.com/pics/Sabhlok-The-Eye-Strain-Book.dochttp://www.goodhope.org.uk/departments/eyedept/blepharitisweb.pdfhttp://www.goodhope.org.uk/departments/eyedept/blepharitisweb.pdfhttp://www.dryeyezone.com/talk/showthread.php?7115-Video-On-Blepharitis-MGDhttp://www.dryeyezone.com/talk/showthread.php?7115-Video-On-Blepharitis-MGDhttp://www.goodhope.org.uk/departments/eyedept/blepharitisweb.pdfhttp://www.goodhope.org.uk/departments/eyedept/blepharitisweb.pdfhttp://www.dryeyezone.com/talk/showthread.php?7115-Video-On-Blepharitis-MGDhttp://sanjeev.sabhlokcity.com/http://eyestrain.sabhlokcity.com/pics/Sabhlok-The-Eye-Strain-Book.doc


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Meibomian seborrheic blepharitis# eibomian seborrheic blepharitis can be ientifie bythe presence of increase meibomian an seborrheic secretions #itho't inflammation. Tears arefoamy an s'syD res'ltin% in b'rnin% symptomsD especially in the mornin%. $tchin% an tearin% arecommon conc'rrent symptoms. The meibomian %lans are ilateD leain% to copio's secretionsan b'lbar conj'nctival injection. The clinical si%ns are consistent #ith ist'rbe meibomian %lan

f'nction. This form of blepharitis may be more appropriately %ro'pe #ith the posterior variety.$eborrheic blepharitis 'ith secondary meibomianitis# Seborrheic blepharitis #ithseconary meibomianitis =meibomitis> is similar in clinical presentation an symptoms toseborrheic blepharitis. ;o#everD it has episoic inflammation an meibomianitis that res'lt in aspotty presentation of clo%%e meibomian %lans an anterior seborrhea. 4ipi secretions are oftoothpaste consistencyD contrib'tin% to an 'nstable 01T5. 'lt'res reveal the presence of normalflora. This form of blepharitis may also be %ro'pe #ith the posterior variety. The clinical si%ns areconsistent #ith ist'rbe meibomian %lan f'nction.

Meibomian (eratocon)uncti*itis# eibomian keratoconj'nctivitis =primary meibomianitis>is the most severe li mar%in inflammation. Typically occ'rrin% 'rin% the fo'rth ecae of lifeD ithas no preilection for %ener b't is more common in coler climates. $t is freH'ently associate#ith rosacea an is part of a %eneraliJe sebaceo's %lan ysf'nction pattern that clo%s themeibomian %lan openin% #ith esH'amate epithelial cells. This is most likely 'e to altere

polarity of the lipi secretion. Beca'se lipi secretions have a hi%her meltin% point than the oc'lars'rface temperat'reD sta%nation of free fatty acis #ithin the %lans inspissate openin% res'lts in alipi-eficient tear film. $t is very likely that this form of blepharitis sho'l also be %ro'pe#ith the

posterior variety. The clinical si%ns are consistent #ith ist'rbe meibomian %lan f'nction.

Angular blepharitis#An%'lar blepharitis is localiJe to the li at the o'ter canth's. Thestaphylococcal form is typically ry an scaly #hile the form ca'se byMoraxella Morax$

Axenfeld> iplobacill's is #et an macerateD an has a #hitish frothy ischar%e. There is the

possibility of seconary bacterial conj'nctivitis or keratitis res'ltin% from theMoraxellaor%anism.2*

$(in disease

8lepharitis

Atrophy of Mebomian glands

3amaged goblet cells !mucuous layer"

4oblet cells generally lo% in dry eyes

onj'nctival %oblet cell ensity in normal s'bjects an in ry eye synromes. by 6 A 6alph $nvest.1phthalmol. (is. Sci. April 32 vol. * no. * -?)Serial sections prepare from biopsies of the eep tarsal portion of the inferior nasal conj'nctivalforniF in normal s'bjects an in patients #ith vario's ry eye synromes #ere analyJe #ithrespect to the %oblet cell ensities. hen compare to normal s'bjectsD inivi'als #ith keratitis

siccaD Stevens-Rohnson synromeD oc'lar pemphi%oiD an ac'te alkali b'rn all emonstrate

?
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pro%ressively lo#er %oblet cell ensities per millimeter of epithelial s'rface. These isease entitiescanD thereforeD be consiere %oblet cell-eficient synromes. L5'll TeFtMthere is increasin%ly reco%nition of the importance of %oblet cell ensity in many persistent ry eyecases. The clinical trials 7ary 5o'lks i on 9akrina act'ally sho#e an increase in %oblet cellensity =$ ont have the info hany b't $ believe this #as a st'y on Sjo%rens patients>.

Aitionally $ have hear from a fe# octors #ho sa# presentations by Aller%an statin% that6estasis is believe to increase %oblet cell ensity. LSo'rceM

/ncreased level of solvents in dry eyes can kill goblet cells

$ncrease tear osmolarity can potentially in'ce patholo%ical chan%esD incl'in% loss ofconj'nctival %oblet cells an esH'amation of conj'nctival epitheli'mD to the oc'lar s'rfaceLSo'rceM

From T-eraTears 1e!site:

The tears are a salt sol'tion. As an eye becomes ryD the tears lose #ater an become too salty. Anj'st like #hen yo' thro# salt on a #o'nD it stin%s an b'rns #hen yo'r tears become too saltyDyo'r eyes stin% an b'rnD an later there is a sensation of ryness an sany-%ritty irritation.9ry eye is a conition characteriJe by loss of #ater from the tear film. As a res'lt the tear film

becomes saltier an more concentrate. ost of 's #ill remember !osmosis" from hi%h schoolchemistry. hen the tear film becomes too concentrateD osmosis p'lls #ater o't of the s'rface ofthe eyeD makin% it ry.$n ry eye the hi%h salt concentration in the tear film =the hi%h !tear osmolarity" or hypertonicity>an the chan%es on the s'rface of the eye ca'se the stin%in% an b'rnin%D ryness an sany-%rittyirritation. An beca'se evaporation from the eyes is %reater #hen the eyes are open than #hen theyare closeD the symptoms of ry eye %et #orse as the ay %oes on.

*
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1ne of the most important chan%es that occ'r in ry eye is a re'ction in the n'mber ofconj'nctival %oblet cells on the s'rface of the eye. &o're probably #onerin% #hat a conj'nctival%oblet cell is. 9i yo' ever #oner #hy yo'r eyes ont sH'eak #hen yo' blinkQ $ts beca'se on thes'rface of the eye there are tho'sans of m'c's-containin% cells calle !%oblet cells." 'c's is the

most slippery s'bstance in the h'man boy. Think of these %oblet cells as the !ball bearin%s" of theeye s'rface instea of containin% stainless steel they contain m'c's. An this is #hy normal eyesont sH'eak #hen they blink an one of the reasons #hy ry eyes are so 'ncomfortable.L+isten to 3r 4ilbard of hera earsM

+ess blinking can kill goblet cells

LS'r%eryM keeps the lis seperate> ca'ses tra'ma to the conj'nctiva. The conj'nctiva is #here most%oblet cells are replenishe. LSo'rceM)E$A EA$S &A( )E+.D

TheraTears =Avance (ision 6esearch>. This hypotonic sol'tion is esi%ne to enhance tearvol'me an re'ce the osmolarity of the tear film. Reffrey 7ilbarD .9.D #ho create TheraTearsD

s'%%ests that !sat'ration osin%" #ith this pro'ct can iminish symptoms of ryness an helprestore the normal physiolo%y an health of the oc'lar s'rface. A st'y of post-4AS$C patientsemonstrate that prolon%e therapy #ith TheraTears helpe restore normal conj'nctival %oblet cellensityD #hile treatment #ith a preservative-free control i not.4E0A$(AE< $egenerating goblet cells

7efarnate stim'lates %oblet cell repop'lation follo#in% an eFperimental #o'n to the tarsalconj'nctiva in the ry eye rabbit. Toshia ;D ,akata CD ;amano TD ,akam'ra D ,%'yen 9DBe'erman 6. LSo'rceM7efarnate increases 0AS positive cell ensity in rabbit conj'nctivaD Br R 1phthalmol8K8:?)-??

Anot-er article:

Effect of %efarnate on the oc'lar s'rface in sH'irrel monkeys. Toshia ;D ,akata CD ;amano TD,akam'ra D ,%'yen 9D Be'erman 6. ornea. )) AprK=?>:-.

2
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Topical application of %efarnate #as not associate #ith any averse oc'lar s'rface effects. 7obletcell repop'lation after inj'ry #as si%nificantly %reater in the %efarnate-treate eyes compare #iththe vehicle-treate eyes. $n the %efarnate-treate eyesD tear m'cin content #as si%nificantly %reaterat #eek after inj'ry. 5l'orescein stainin% #as si%nificantly re'ce at ? #eeks after inj'ryD anrose ben%al stainin% #as si%nificantly re'ce in the area of the #o'n at #eeks in the %efarnate-

treate eyes compare #ith the vehicle-treate eyesK at other timesD conj'nctival stainin% in the t#o%ro'ps of eyes #as not si%nificantly ifferent. 1,4

Trefoil factor family peptie ? at the oc'lar s'rface. A promisin% therape'tic caniate for patients#ith ry eye synromeQ by Sch'lJe . Amon% otherfactorsD T55? performs a broa variety of protective f'nctions on s'rface epitheli'm. $ts mainf'nction seems to be in enhancin% #o'n healin% by promotin% a process calle restit'tion.St'ies eval'atin% T55? properties an effects at the oc'lar s'rface 'sin% in vivo as #ell as in vitromoels have reveale a pivotal role of 00> in corneal %ound healing. S'bseH'ent st'ies inosteoarthritic cartila%e seem to ra# a ifferent pict're of T55?D #hich still nees f'rtherel'ciation. This man'script s'mmariJes the finin%s concernin% T55? in %eneral an its role in the

cornea as #ell as artic'lar cartila%e @ t#o tiss'es #hich have some thin%s in common. $t alsoisc'sses the potential of T55? as a caniate therape'tic a%ent for the treatment ofD for eFampleDoc'lar s'rface isorers.Ophthalmic compositions comprising trefoil factor family peptides

See this. "compositions comprisin% trefoil family factor pepties #ill be 'sef'l in preventin% ortreatin% ry eye by topical aministration of the composition to eye of the patient."refoil peptides promote restitution of %ounded corneal epithelial cells#

7ke ,D ook R6D C'nert CSD5ini ED 7ipson $CD 0oolsky 9C.So'rce7astrointestinal


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$s this relevantQ http://###.osns'persite.com/vie#.aspFQriU88??

Damaged lachrymal glands

Deficiencies

/odine deficiency

estosterone deficiency

A mite in the eyelashes +demode folliculorum

See thisfor etails.

9emoeF follic'lor'mD a mite that lives at the base of the lashesD is present in 2O of normals an?2O of patients #ith blepharitis.

3emodicosis# 9emoicosis is the inflammatory reaction to a common mite that inhabits theeyelash follicles in persons over the a%e of 2) years. There are t#o species of miteD #emodex

folliculorum an#emodex !revis.#. folliculorumD #hich is present in hair an eyelash folliclesD

cons'mes epithelial cellsD pro'ces follic'lar istension an hyperplasiaD an increaseskeratiniJationD leain% to c'ffin% at the base of the cilia.#. !revisD #hich is present in sebaceo'san meibomian %lansD may estroy the %lan'lar cellsD pro'ce %ran'lomas in the eyeliD an pl'%the 'cts of the meibomian an other sebaceo's %lans that affect formation of the lipi layer.

#emodexhas been associate #ith rosaceaD b't a ca'sal relationship has yet to be establishe.22D2+

3emodicosis##emodexare present in the lash follicles of most elerly persons. ??This conition is's'ally innoc'o's. hen the mite pop'lation reaches critical proportionsD symptoms res'lt. There isa cr'stin% of the li mar%inD trichiasisD maarosisD loss of lashesD an c'ffin% at the base of thelashes. The ia%nosis can be confirme by epilatin% a lash from the affecte area an eFaminin% the

follicle 'ner a clinical microscope for the presence of mites. 0atients #ith rosacea may be moreprone to#. folliculorumthan those #itho't this ia%nosis.

3emodicosis. Treatment #ith a *O pilocarpine %el =b.i.. F #k> mayD in some casesD bes'pplemente by the application of antibiotic ointment .)*D)2,i%htly li hy%ieneD follo#e by theapplication of blan ophthalmic ointment tens to inhibit the proliferation of#emodex. Theointment is remove the neFt mornin% #ith li hy%iene. )+D)3

3
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.emedy for auto-immune response

Symptomatic relief: Non-therapeutic reduction in osmolarity

Take thera tears preservative free

A*oid ben/al(onium chloride +#A0

patients #ith oc'lar s'rface isease are m'ch more sensitive to preservativesD partic'larlybenJalkoni'm chlorie =BAC>. $n aition to 'sin% non-preserve topical l'bricantsD #henprescribin% antibioticsD sterois or %la'coma meicationsD $ prefer to 'se non-preserve or non-BAC preserve eye rops #henever possible. LSo'rceM

Non-therapeutic dietary supplements

Apparently Thera tears n'trition is %ooD b't any combination of flaF/fish/primrose oilD an keyvitamins sho'l s'ffice. This 91ES ,1T . $n aition to 'sin% non-preserve topical l'bricantsD #henprescribin% antibioticsD sterois or %la'coma meicationsD $ prefer to 'se non-preserve or non-BAC preserve eye rops #henever possible. LSo'rceM


Apparently Thera tears n'trition is %ooD b't any combination of flaF/fish/primrose oilD an key

vitamins sho'l s'ffice. This 91ES ,1T


19/69


Do not use bicarbonate of soda

1se only LidCare or one of these

Sterli is available in A'stralia.

Eye Scr'b ,ovartis 0re-moistene pas.4i;y%eniF 4i;y%eniF $nc. 5l'i cleanser for 'se #ith cotton balls or sterile pas =pas

not incl'e>.4i Scr'b 5oamin%Eyeli leanser

1c'Soft 5oamin% cleanser.

4i Scr'b 0reoistene 0as

1c'soft 0re-moistene pas.

4i Scr'b Sol'tion 1c'soft 5l'i cleanser for 'se #ith pas.!Effectively removes oilD ebris an esH'amate skin from

the eyelis =ocamiopropyl ;yroFys'ltaine>"Sterili Avance (ision6esearch

5oamin% cleanser =packa%e in spray bottle>. 4on% list ofin%reients =see link> incl'in% tea tree oil.

Sty%iene SterileEyeli leanser

9el 5l'i cleanser #ith pas.0'rifie aterD 0E7 8) Sorbitan 4a'rateD 0olysorbate )DSoi'm hlorieD 0otass'im hlorieD V'aterni'm-2D9isoi'm E9TAD Soi'm itrate.

Therapeutic if caused by bacteria - antibiotics

2oney;oney is an eFcellent antibiotic. Even s'perb'%s can be kille by it. See etaile blo% posthere.

Doycycline

There is eno'%h evience to inicate that meications s'ch as oFycycline can be effective forthe mana%ement of meibomian %lan isease at m'ch lo#er oses than previo'sly tho'%ht.Altho'%h more eFpensive, doxycycline can be prescribed at 9@ mg t%ice a day. /f notaffordable to the patient, then 5@ mg t%ice a day generic version is also an option#


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Another benefit $ve fo'n #ith AJaSite is its seven-ay osin% sche'le for bacterialconj'nctivitis. The re%imen is only nine ropst#o a ay for the first t#o aysD then once a ay forthe remainin% five ays. TypicallyD topical antibacterials reH'ire fo'r-times-a-ay applicationD if notmoreD for a loain% ose. ompliance is a bi% iss'eD especially #ith yo'n%er chilrenD b't AJaSitessimplifie osin% sche'le resolves that in many cases. LSo'rceM

AJasite st'ies sho# promisin% res'lts for treatment of meibomian %lan isease an blepharitisTh'rsayD 2 September ))8 :))6es'lts from t#o sin%le-center st'ies inicate that topical aJithromycin O ophthalmic sol'tion=AJaSite> sho#s potential as a safeD #ell-tolerate an hi%hly effective treatment for meibomian%lan isease =posterior blepharitis> an anterior blepharitis.

1ne st'y of patients sho#e that the compo'nD in combination #ith #arm compressesDprovie a si%nificantly %reater clinical benefit than #arm compresses alone in treatin% the si%nsan symptoms of posterior blepharitisD an that patients rate efficacy #ith aJithromycin incombination #ith #arm compresses as better than #arm compresses alone.Another st'y eval'ate aJithromycin O for 'se in treatin% chronicD miFe =Staphylococcal an

seborrheic> anterior blepharitis 'sin% an off-label aministration techniH'e involvin% irectapplication to the eyelis. The res'lts sho#e that aJithromycin ophthalmic sol'tion #as better thanerythromycin in treatin% si%ns an symptoms of anterior blepharitis.

3 Treatment and !anagement of "nterior #lepharitis

a. Basis for Treatment

Anterior blepharitis 's'ally is the irect res'lt of isr'ption or infection of the lipi-pro'cin%%lans that open to the li mar%in. linical presentation may incl'e internal an eFternal horeola.The treatment is relatively strai%htfor#ar. Tho'%h essentialD li hy%iene alone may not resolve the

problem. 9epenin% 'pon the clinical finin%sD appropriate anti-infective r'%s can be aministeretopicallyD systemicallyD or in combination. A%%ressive therapy sho'l initially incl'e a minim'm of+ #eeks of li hy%iene an appropriate anti-infective meications to %ain control of the conitionDfollo#e by maintenance therapy.

b. Available Treatment Options

Beca'se every cate%ory of anterior blepharitis is act'ally a separate conitionD each nees to bearesse inivi'ally. ;o#everD the 9elphi report ientifie anterior blepharitis as an incl'sivecate%ory in patients #ith ysf'nctional tear synrome an recommene li hy%iene an topicalantibiotic treatment initially. 5or patients #itho't li mar%in iseaseD the initial treatment consists oftopical tear s'pplements an imm'nomo'lators.5ail're to respon sho'l prompt p'rs'it of si%nsof posterior blepharitis.

Staphylococcal blepharitis# Treatment of staphylococcal blepharitis incl'es an antibioticointment to control the infection as #ell as li hy%iene.D4i hy%iene can be performe #ith acommercially available li scr'b form'lation or by 'sin% il'te baby shampoo =:) in #ater>applie #ith a facial cloth. ErythromycinD bacitracinD polymyFin B-bacitracinD %entamicinD antobramycin are all effective antibiotics for treatment of staphylococcal blepharitis. Each of these isavailable in ointment form. Another ointment that may have application to these sit'ations istacrolim'sD #hich the 59A has approve for ecJema.?Antibiotic eye rops can be 'seD b't theyo not #ork as #ell as ointmentsD 'e to re'ce contact time. Tear s'pplements may also bereH'ire to alleviate symptoms. $f peripheral corneal infiltrates are present #itho't epithelial

efectsD topical sterois may be 'se for a limite time.

)
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Seborrheic blepharitis# $n the treatment of seborrheic blepharitisD the application of #armD moistcompresses to soften an loosen the cr'sts is follo#e by #ashin% #ith a commercial li scr'b oril'te baby shampoo =:) in #ater> on a facial cloth or cotton s#abD takin% care not to involve the%lobe. The scalp an eyebro#s sho'l be #ashe #ith a seleni'm anti-anr'ff shampoo.*Theemphasis for treatment of seborrheic blepharitis has shifte to incl'e oral antibioticsD especially

minocycline.2-3The p'rpose of 'sin% minocycline is to alter the polarity of the meibomiansecretion composition.8

SeborrheicBstaphylococcal blepharitis# The 'se of appropriate ophthalmic antibiotic ointments isreH'ire. 4aterD #hen the li is more comfortableD #arm compresses an li scr'bs can be ae.arm compresses an li #ashin% are the same as for seborrheic blepharitis. Tho'%h servin% as anacceptable means of controlD this treatment rarely effects a c're for seborrheic/staphylococcal

blepharitis.

*eibomian seborrheic blepharitis# The treatment incl'es the same #arm compress an lihy%iene re%imen as for seborrheic blepharitis. $n aitionD the meibomian %lans may be massa%eor eFpresse to remove the pl'%s at the openin%s. Antibiotic or antibiotic/steroi ointments may be

ae #hen the infection has been ientifie clinically.?2D

Seborrheic blepharitis %ith secondary meibomianitis# Treatment be%ins #ith li hy%iene.Antibiotic or antibiotic/steroi therapy may be ae #hen a clinical infection has been ientifie.6esistant cases of seborrheic blepharitis #ith seconary meibomianitis may reH'ire systemictetracycline ='p to %/ay> or oFycycline =)) m%/ay> for at least + #eeks.))D)$t is not 'n's'alfor patients #ho have this conition to reH'ire lo#er maintenance oses after taperin%. ,eithertetracycline nor its erivatives sho'l be %iven to chilren 'ner the a%e of 8 years or to pre%nant orn'rsin% #omen. 1ther antibiotic form'lations may be 'se as #ell. These incl'e erythromycinethyls'ccinate =EES> an minocycline. 9osin% sche'les #ill vary epenin% 'pon the patients

presentation.

*eibomian keratoconjunctivitis# This conition respons to #arm compresses an massa%e of theli to eFpress the meibomian contents. hen infection is presentD topical antibiotic orantibiotic/steroi ointments sho'l be 'se. 9iabetes sho'l be a consieration #hen otherconc'rrin% conitions s'ch as rosacea are absent an the conition is 'nresponsive to treatment.1ral tetracycline may be beneficialD by inhibitin% lipolytic enJymesD especially #hen rosacea is

present. The conition sho'l be stable or improve in + #eeks)K ho#everD some patients maynee a lo#er maintenance ose for a lon%er perio. $f keratitis or keratoconj'nctivitis is presentD theclinician sho'l be a#are of the possibility that methicillin-resistant tap-ylococcus aureus

=6SA> is the responsible or%anism.)?

A prospective st'y has inicate the efficacy =improve si%ns an symptoms> of topicalcyclosporine =).)2O> in treatin% posterior blepharitis. *+

Angular blepharitis. Both forms of an%'lar blepharitis are treate #ith antibiotic ointment.

.emedy for mebomian gland dysfunction

Symptomatic relief: Non-therapeutic reduction in osmolarity

Take thera tears preservative free


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A*oid ben/al(onium chloride +#A0

patients #ith oc'lar s'rface isease are m'ch more sensitive to preservativesD partic'larlybenJalkoni'm chlorie =BAC>. $n aition to 'sin% non-preserve topical l'bricantsD #henprescribin% antibioticsD sterois or %la'coma meicationsD $ prefer to 'se non-preserve or non-BAC preserve eye rops #henever possible. LSo'rceM


Apparently Thera tears n'trition is %ooD b't any combination of flaF/fish/primrose oilD an keyvitamins sho'l s'ffice. This 91ES ,1T


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Several st'ies have ientifie s'ccessf'l p'lse li%ht treatment of rosacea associate facialerythema an telan%iectasia.*-+ e have observe similar res'lts in rosacea patients treate #ithintense p'lse li%ht for facial erythema an telan%iectasia. e have also observe improvement ofry-eye symptoms in these laser treate patients.

3iscussion

These preliminary res'lts inicate a potential 'se for intense p'lse li%ht treatment for ry-eye. 1'rinitial 'se of intense p'lse li%ht for ry-eye patients be%an #hen a patient rosacea inicateimprovement of ry-eye symptoms since receivin% $04 treatment.e s'spect $04 treatment improve meibomian %lan pro'ction 'e to either meibomian %lanstim'lation or effectively ecreasin% telan%iectasia. ;o#everD aitional investi%ation is necessaryto etermine the eFact effects of the $04 on s'rro'nin% tiss'e.

Dr !asin*s dry eye treatment6ea this blo% postan #atch the associate vieos.

ipiflo$ Thermal 'ulsation System

&o't'be: http://yo't'.be/l;eT'rB9bc

TearScience %aine


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.emedies for lachrymal gland dysfunction

'unctal plug+ occlusion

.*$n this %ro'p he epilate their lashesD st'ie the baseD an fo'n heavy 9emoeFinfestations. ;e treate these #ith tea tree oil an fo'n a very %oo response #ithin a siF-#eek

*


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perio. These #ere severe patients #ho ha si%nificant corneal finin%sK three #ere tho'%ht to havelimbal stem cell eficiency an they all respone to this therapy.

3hen things get really really bad

Non-therapeutic shutting do$n of ner,e signals

The opthalmalo%ist/ne'rolo%ist that $ see tol me that the cornea is linke to the tri%eminal nervean if the cornea %ets ry an starts b'rnin%D it sens those si%nals to the tri%eminal nerve an that is#hen all that other st'ff kicks in. ;e p't me on TrileptalD #hich is an anti-seiJ're meicine an thathas helpe tremeno'sly. $t is j'st a small oseD b't the res'lts are amaJin%. LSo'rceM

Also:

he trie the Trileptal ?)) m% per ay ho'r before betime an it sh'ts that nerve irritation o#nfor the neFt * ho'rs. 5or me it tr'ly #as a miracle. ;e tol me that there are so many of theser'%s an there is no ri%ht one for everyone. &o' kin of j'st have to try a fe# 'ntil yo' fin theone that #orks. $ ha tho'%ht $ #as %oin% craJy tooD beca'se no one kne# #hat $ #as %oin% thro'%han tho'%h it so'ne a little #eir. y ori%inal octor =#ho $ have 'mpe> basically tol me it#as all in my hea. B't my 7.0. listene to me an referre me to the 1pthalmalo%ist/,e'rolo%ist#ho tol me that my case #as classic @ not as severe as some peopleD b't very efinitely Tri%eminal

,e'ral%ia @ ca'se by the irritation of the ry eye. LSo'rceM

thers

Alternative methos for relievin% symptoms specific to oc'lar isorers incl'e:

2ydrophilic bandage lenses and collagen corneal shields# 3)D3


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Appendi 45 Notes

onitions that alter the pro'ctionD compositionD or istrib'tion of the preoc'lar tear film =01T5>may res'lt in symptoms or si%ns of ama%e to the str'ct'res of the oc'lar s'rface. These sit'ationsmay lea to noticeable irritationD re'ction of vis'al f'nctionD an even chronic tiss'e chan%es.

S'ch conitions are often relate to abnormalities of the str'ct're or f'nction of the eyelisD %lansof the li an their secretionsD conj'nctivaD or cornea. Aitional conseH'ences of chroniccompromise to the oc'lar s'rface incl'e risk of infection an chronic inflammation that may notrespon to treatment. A classification scheme 'ses the term eficient tear synrome =9TS> toencompass these !ry eye" etiolo%ies.

An $nternational 9ry Eye orkShop =9ES> report has separate ry eye systematically intoaH'eo's-eficient an evaporative. S'bclassifications of the former incl'e those associate #iththe Sj%rens synrome =SS> an non- Sj%rens ry eyeD #hich incl'es lacrimal-%lan ysf'nctionof both primary an seconary etiolo%ies. The evaporative isorers are s'bivie into intrinsican eFtrinsic cae%ories.The role of inflammation in ry eye an oc'lar s'rface isorers has been

emphasiJe as a conseH'ence of hyperosmolarity.?D*

The reporte epiemiolo%y of ry-eye conitions varies. 9epenin% on the efinitionD pop'lationst'ieD criteria of incl'sionD an other factorsD the incience an prevalence are often iffic'lt toestimate. 5or eFampleD the prevalence of ry eye amon% the Asian pop'lation may be %reater thanthat of a'casian pop'lations.2$t has been estimate that 2 million Americans over the a%e of 2)years have ry eyeD an 2O of the


27/69


clarify the compleFity of oc'lar s'rface isorers an ry eyes =AppeniF 5i%'res -*>.D*D2Eachhas its 'niH'e aspects an is #orthy of consieration by the practicin% clinician.

The 2 lassification Scheme base on the ,ational Eye $nstit'te =,E$>/$n'stry orkshopseparate ry eye into eficient aH'eo's tear pro'ction an increase evaporative loss .2$ncreaseevaporative tear loss is associate #ith eyeli isorers an meibomian %lan ysf'nction =79>Das #ell as eFpos'reD contact-lens #earD an environmental sit'ations =AppeniF 5i%'re >. Anterior

blepharitisD as classifie by Thy%essonD involves ecJema an lash manifestations b't has beens'persee by an emphasis on posterior blepharitis.+

$n ))+D a 9elphi panel propose a classification scheme for !ysf'nctional tear synrome" =9TS>D#hich comprises a ran%e of isorers. 9TS is s'bivie into %ro'ps #ith an #itho't li mar%inisease as #ell as tear istrib'tion abnormalities. $n aitionD this %ro'p evelope a severity scale

base on symptoms an si%ns =AppeniF 5i%'re ?>. This report also propose treatment %'ielinesthat represent perhaps the most 'sef'l mana%ement al%orithm for practicin% optometrists.

The ))3 9ES report eFpane on the 2 classification scheme of the ,E$ an $n'stry %ro'psto eFpan the ca'ses of oc'lar s'rface isease to incl'e aller%ic conj'nctivitisD chronickeratoconj'nctivitisD conj'nctivitisD an post-refractive s'r%ery =AppeniF 5i%'re *> .*Each ofthese classifications s'%%ests that oc'lar s'rface isorers are compleF manifestations that haven'mero's etiolo%ies #hich may interact #ith each other. These interactions are the res'lt of them'ltiple components of the oc'lar s'rface that protect its physiolo%ical inte%rity.

hat has also emer%e is the importance of 'nerlyin% inflammatory processes in oc'lar s'rfaceisorers. This has been emphasiJe in vario's p'blications an revie#s as a basis foretiopatholo%y an treatment.3-

$ncl'e amon% ry eye-relate oc'lar s'rface isorers are the follo#in%:

AH'eo's-eficient ry eye associate #ith the Sj%rens synrome

,on-Sj%rens aH'eo's eficiency =e.%.D a%e-relate>

Blepharitis

Anterior =lash- an li-associate>

0osterior =li mar%in- an meibomian %lan-associate>

ontact lens-relate evaporative tear isr'ption

Blink an li anatomy abnormalities

Sit'ational an environmental evaporative tear loss

onj'nctivochalasis =re'nant b'lbar conj'nctival tiss'e> Aller%icD chronic infectiveD an non-infective conj'nctivitis an keratoconj'nctivitis

0ost refractive-s'r%ery isr'ptions of the oc'lar s'rface or 01T5.

These isorers may overlap as #ell as co-eFist. ana%ement reH'ires precise ia%nostic criteriaan specific interventional strate%ies.

1ne paraoF is that patients #ho have increase refleF tearin% may s'ffer from oc'lar s'rfaceisorers for #hich the irritation serves as the stim'l's. oreoverD patients #hose p'ncta havecollapse =stenosis> may have re'ce tear clearanceD #hich may compensate for re'ce aH'eo's

pro'ction.?)

a. A!ueous -Deficient Dry %ye

3


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The symptoms of aH'eo's eficient ry eye are 's'ally bilateral an may pro'ce forei%n-boysensation an lacrimation. AH'eo's-eficient ry eye res'lts from re'ce aH'eo's pro'ction anmay be seconary to lacrimal-%lan o'tp't eficiency as seen in Sj%rens synrome. Appearin%clinically #ith re'ce tear menisc'sD an ebris an strans of m'co's in the tear filmD it can leato the formation of corneal filaments =filamentary keratitis> in avance cases. Aitional clinical

si%ns incl'e re'ce tear break'p time an ecrease #ettin% on Schirmer testin%D as #ell asoc'lar s'rface stainin%D altho'%h these latter si%ns are not specific to aH'eo's eficient ry eye.

Sj%rens synrome =SS> is a chronic systemic inflammatory isorer characteriJe by lymphocyticinfiltrates in eFocrine or%ans. ost s'fferers present #ith symptoms s'ch as Ferophthalmia =ryeyes>D Ferostomia =ry mo'th>D an paroti %lan enlar%ement. EFtra%lan'lar feat'res mayevelopD incl'in% arthropathies s'ch as arthral%iaD arthritisD an myal%ia. $n aitionD 6ayna's

phenomenonD p'lmonary iseaseD %astrointestinal iseaseD le'kopeniaD anemiaD lymphaenopathyDne'ropathyD vasc'litisD renal t'b'lar aciosisD an lymphoma may be accompanyin% manifestations.

;rimarySS occ'rs in the absence of other 'nerlyin% rhe'matic isorers. $n contrastDsecondarySS is associate #ith at least one other 'nerlyin% rhe'matic iseaseD s'ch as systemic l'p's

erythematos's =S4E>D rhe'matoi arthritis =6A>D or scleroerma. 7iven the overlap of SS #ith otherrhe'matic isorersD it may be challen%in% to etermine #hether a partic'lar clinical si%n iseFcl'sively a conseH'ence of Sj%rens synrome or accompanies an isorer.

AH'eo's eficiency seconary to SS res'lts from lacrimal %lan inflammationD infiltrationD anatrophy.?Tho'%ht to be a'toimm'ne in ori%inD primary SS is associate #ith colla%en-vasc'lar orconnective tiss'e iseaseD most freH'ently rhe'matoi arthritis. BrieflyD primary SS involves the%lans of the lis an mo'th. Seconary SS involves a

Y http://emeicine.mescape.com/article/??2-overvie# accesse 2/?/)).

systemic a'toimm'ne isease s'ch as rhe'matoi arthritisD #hich then res'lts in the symptoms of

ry eye or ry mo'th.?D?

A etaile revie# of the istinction bet#een primary an seconary formsof SS is beyon the scope of this 7'ieline b't can be fo'n in literat're revie#s. ?D? 9ry eyesymptoms may be the first manifestation of SS.

4acrimal ins'fficiency occ'rs most often in menopa'sal #omenK its onset is typically 'rin% thefifth ecae of life. linical si%ns an severe symptoms have been associate #ith estro%enD takenalone or in combination #ith pro%esterone or pro%estin as hormone replacement therapy =;6T>.??$talso may occ'r in #omen #ho are pre%nant or takin% birth control pillsD in #hom estro%en an

prolactin levels are

elevate.?*D?2

1ther localD systemicD an eFo%eno's conitions that can aversely affect tear pro'ction incl'e:

Z 9acryoaenitis

5acial nerve paralysis

hemical b'rns

on%enital alacrima

7amma raiation

To varyin% e%reesD systemic meications: antihypertensives =i'reticsD arener%icanta%onistsD an beta-blockers>K antihistamines =especially first-%eneration ;- inhibitors>Kmeications that have anticholiner%ic effects =tricyclic antiepressantsD phenothiaJinesD etc.>K an

hormone replacement therapy =estro%enD pro%esterone>

8
http://sanjeev.sabhlokcity.com/http://eyestrain.sabhlokcity.com/pics/Sabhlok-The-Eye-Strain-Book.dochttp://emedicine.medscape.com/article/332125-overview%20accessed%205/13/2010http://emedicine.medscape.com/article/332125-overview%20accessed%205/13/2010http://sanjeev.sabhlokcity.com/http://eyestrain.sabhlokcity.com/pics/Sabhlok-The-Eye-Strain-Book.doc


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on%enital ysa'tonomia =6iley-9ay synrome>

Mucin -Deficient Dry %ye

6e'ction in the n'mber of conj'nctival %oblet cellsD res'ltin% in a ecrease in m'cin pro'ctionDcan be ca'se by conitions that ama%e the conj'nctiva. 'cin-eficient ry eye conitionsincl'e aller%ic conj'nctivitisD?+oc'lar cicatricial pemphi%oi =10>D erythema m'ltiformae=Stevens-Rohnson synromeK SRS>D severe trachomaD or chemical =especially alkali> b'rns. $mpaire%oblet cell f'nction can also res'lt from marke vitamin A eficiencyD altho'%h it is rare inevelope co'ntries. ost recently m'cin-eficient ry eye has been reporte as a conseH'ence offacial nerve paralysis.?3

$n 10 an SRSD %oblet cell loss is 'e to an a'toimm'ne response that eposits imm'no%lob'linsat the basement membrane Jone of the conj'nctiva.?8This then leas to the clinical pict're of b'llaeat the s'bepithelial level. 0ro%ressive infiltration res'lts in contraction of the conj'nctiva #ithsymblepharon formation.?

0araoFicallyD 7oblet cell ensity may increase seconary to thermal or chemical inj'ry .*)Theres'ltin% oc'lar s'rface isorers iffer from 10 or SRS at the cell'lar level tho'%h appearin%clinically similar. A %rain% system is available for the ophthalmic manifestations in patients #ithchronic SRS.*This incl'es conj'nctival ama%e s'ch as the evelopment of symblepharon ananklyoblepharon as #ell as corneal vasc'lariJation an conj'nctivaliJation. The scale is H'antitativean contin'o's =ran%eD )-?>.

$urface Abnormalities

Any str'ct'ral efect of the li can interfere #ith tear film istrib'tion. $mpairment of normal blinkaction 's'ally res'lts in an irre%'lar m'cin layer. A term that may represent these sit'ationsincl'sively is !li-#iper epitheliopathy."*-*2$ncomplete or infreH'ent blinkin%D #hich res'lts in

eFcessive tear evaporation an eFpos're keratopathyD can be ca'se by Bells palsyD la%ophthalmosDthyroi-relate eye iseaseD forei%n boyD or li tra'ma. 1ther li abnormalities that preventefficient res'rfacin% of the tear layer incl'e ptosisD trichiasisD an maarosis.

%pitheliopathies

orneal epitheliopathies are characteriJe by an irre%'lar epithelial s'rface #here microvilli areprevente from allo#in% m'cin to ahere to the cornea. The ca'ses incl'e corneal scarsD chemicalb'rnsD rec'rrent corneal erosionsD contact lens complicationsD tra'ma from entropion or refractives'r%eryD incomplete blinkin%D or lash abnormalities s'ch as trichiasis an istichiasis. 4i-#iperepitheliopathy is an all-incl'sive term for s'ch isorers that are relate to contact lens #ear or

occ'r follo#in% refractive s'r%ery.2+-2

Contact lens 'ear

ontact lens #ear can in'ce ry eye symptoms in patients #ho have a pre-eFistin%D asymptomaticDmar%inally ry eye conition.+),ot only o contact lens materials reH'ire %reater s'rface #ettin%than the corneal epitheli'mD b't #earin% contact lenses thins the 01T5 an interferes #ith thespreain% of m'cin onto the cornea. 6efittin% a ry eye patient #ith silicon-hyro%el lenses has

been fo'n to provie symptomatic relief of ryness for 'p to three years follo#in% refittin%.+


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b cular Surface Disorders "rising from id-!argin Disorders('osterior #lepharitis)

0osterior blepharitis is reco%niJe as a si%nificant ca'se of isr'ption of the tear film. 23eibomian%lan secretions represent a compleF f'nctionin% 'nit that interacts #ith the lis as #ell as the

aH'eo's layer of the tear film. Some moels s'%%est that the appropriately f'nctionin% lipi layercomprises both non-polar an polar components. Abnormal f'nctionin% of the meibomian %lansres'lts in the clinical si%ns an symptoms of meibomian %lan ysf'nction =79>D incl'in%istinct chan%es in viscosity an clarity of eFpresse contentsD increase tear film osmolarityD #hichmay be reflecte by complaints of b'rnin% an stin%in%D an premat're evaporationD leain% toecrease tear-film stability.28D2linical si%ns of oc'lar s'rface ama%e incl'eD for eFampleDepithelial stainin%. linicians sho'l observe the lis for apposition to the %lobeD telean%iectasis atthe li mar%inD an obstr'cte meibomian %lan orifices.

# .pidemiology of cular Surface Disorders

4" Dry %yea. Prevalence

$n terms of prevalence an characteriJationD ry eye may be the most ill efine of all oc'larisorers. ontrib'tin% factors incl'e the lack of a efine ia%nostic test or protocol an the lackof con%r'ity bet#een patient symptoms an clinical tests.

Severe forms of aH'eo's-eficient ry eye can be associate #ith systemic iseasesD especiallycolla%en-vasc'lar iseases.

.*+D+0atients #ith Sj%rens synrome have the classic tria of ryeyeD ry mo'thD an arthritis. 1ther systemic conitions that may res'lt in aH'eo's-eficient ry eyeincl'e l'p's erythemato's an oc'lar rosacea. $n aition to systemic conitionsD other ca'ses mayincl'e r'%s s'ch as antiepressantsD beta blockersD i'reticsD oral contraceptivesD an topical beta-

blockers 'se to treat %la'coma. $nivi'als likely to be affecte incl'e: postmenopa'sal #omenDpatients #ithelico!acter pyloriD oler peopleD comp'ter 'sersD an lon%-term contact lens#earers.+?-+2

Tr'e m'cin eficiency is rareK one report estimates the prevalence of 10 to be in )D)))persons.++icatricial pemphi%oi is the most common of the imm'nob'llo's isorers ca'sin%conj'nctival cicatriJation seconary to estr'ction of %oblet cells. The isease is 's'ally bilateralan more common in femalesD #ith most cases occ'rrin% bet#een ?) an ) years of a%eD b't mostfreH'ently in the seventh ecae of life.+34oss of %oblet cells occ'rs as a complication ofinflammatory inj'ries to the conj'nctiva or 10. $t is also a possible sie effect of prolon%e topical

choliner%ic an anticholinesterase aministration 'se in the treatment of %la'coma.+8-3Thismeically

in'ce complication is rarely seen since the intro'ction of contemporary %la'coma treatmentoptions.

ost problems involvin% lipi layer instability are relate to %lan'lar ysf'nctions that pro'cethickene meib'mD leain% to accelerate s'rface evaporation. This complication leas to an'nstable or ysf'nctional tear film. ThereforeD there is a close association of vario's forms ofmeibomianitis especially #ith posterior blepharitis. 4ipi layer abnormalities res'ltin% fromcomplete absence of meibomian %lan secretion are rare.*eibomian %lan eficiencies have beeneval'ate by eyeli transill'mination an classifie as atrophic or ysf'nctional =rosacea> amon%

patients #ith symptoms consistent #ith oc'lar irritation. This form of %lan'lar ysf'nction hasno# been reco%niJe as posterior

?)


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blepharitis.*D3?

b. Risk Factors

Amon% the common risk factors for ry eye are avancin% a%eD the presence of rhe'matoi arthritisD7raves iseaseD the 'se of r'%s that ecrease aH'eo's or m'co's membrane secretionsD eyeli or

blinkin% abnormalitiesD an a history of tra'ma to the lis.3)-3

Environmental an post-refractives'r%ery can also be ca'ses of ry eye.3*-38

6" #lepharitis

a. Prevalence

Epiemiolo%ic characteristics of blepharitis varyD epenin% on the type. Types of blepharitis ran%efrom ac'te to chronic isorersD #ith inflammation affectin% the anterior or posterior li mar%insDalon% #ith involvement of both skin an m'co's membranes.

The prevalence of ry eye an blepharitis is 'nkno#n. The 9ES %ro'p has compile a reportevote to the prevalence of ry eye. The %ro'p concl'e that bet#een 2 an ?2 percent of

patientsD epenin% on a%eD %eo%raphic locationD efinition 'se in the st'yD an episoiccontrib'tin% factors may eFhibit ry eye =incl'in% blepharitis> si%ns or symptoms.

ost staphylococcal blepharitis occ'rs in yo'n%er #omen =mean a%eD * years>D3D8)#hereas theseborrheic variations ten to occ'r in oler inivi'als. 6osaceaD a isease of 'nkno#n prevalenceDis more common in fair-skinne persons bet#een the a%es of ?) an 2)D especially #omen.87rossoc'lar lesions occ'r in many cases of rosaceaD an almost all affecte persons event'ally eveloprec'rrent or chronic blepharitis an meibomianitis. There is a stron% association bet#een CS anstaphylococcal blepharitis.8

b. Risk Factors


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limite toD lo# h'miityD smoky environmentD recirc'late air environmentD an prolon%ecomp'ter 'se.8D3*D33D8*-83As the conition pro%ressesD the eye cannot maintain the vol'me of moist'rereH'ire an the symptoms become more common an more bothersome. !0araoFical epiphora"=hypersecretion> from irritation-in'ce refleF tearin% may be the presentin% symptom.

$n severe 9E conitionsD symptoms of b'rnin% an vis'al interference can be ebilitatin%.88Thecornea appears 'llD the conj'nctiva an li mar%ins may be hyperemic an eemato'sD ans'perficial p'nctate stainin% may be present. 5ilamentary keratitisD a painf'l corneal responsecharacteriJe by strans of partially esH'amate epithelial cellsD can res'lt from cornealesiccation an acc'm'lation of sta%nant m'cin an she epithelial cells. $n aition to the liinfections commonly associate #ith ry eyeD the patient #ith 9E has a hi%her likelihoo of havin%conj'nctivitis an keratitis. ThereforeD moerate or severe ry eye may aversely affect the H'alityof life.

b. !igns" !ymptoms" and #omplications

$n mil cases of 9ED symptoms of scratchinessD b'rnin%D or stin%in% may be accompanie by milan/or transient sit'ational bl'rrin% of vision #hen the tear film is isr'pte. $n moerate casesDoc'lar iscomfort becomes marke an vis'al ac'ity may be re'ce. As the ry eye becomes moresevereD observable si%ns may incl'e rapi tear film break'pD ebris in the tear filmD a minimallo#er li tear menisc'sD increase m'co's threas in the tear filmD corneal an conj'nctivalstainin%D filamentary keratitisD an loss of corneal l'ster.

$nstability of the tear film can initiate oc'lar s'rface complications. 89ecrease aH'eo's vol'me isassociate #ith re'ce oc'lar s'rface efense an increase s'sceptibility to irritationD aller%yD aninfection 'e to tear sta%nation an epithelial compromise.)-?A major conseH'ence of re'ceaH'eo's vol'me is re'ce antibacterial f'nction beca'se of ecrease lactoferrin an lysoJymelevels. *-+$n aitionD staphylococcal or%anisms can pro'ce toFins that can ca'se s'perficial

p'nctate keratopathy.3

Seborrheic blepharitis can ca'se an inferior stainin% pattern from an alteration of the li-tearinterfaceD perhaps beca'se of lost tear retentionD ecrease tear vol'meD an intrapalpebralesiccation.8D0ersistent ry spotsD a more si%nificant conseH'ence of an 'nstable tear filmD may beassociate #ith either abnormalities of the tear istrib'tion system or re'ce tear flo#.

SH'amo's metaplasia of the conj'nctiva occ'rs seconary to chan%es in the oc'lar s'rfaceD perhapsas a res'lt of environmental eFpos're.))$mpression cytolo%y st'ies s'%%est abnormal conj'nctivalepitheli'm as #ell as chan%es in the %oblet cells.)D)T#o possible etiolo%ies have been propose:=> loss or re'ction of conj'nctival vasc'lariJationD #hich prevents normal epithelial

ifferentiationD an => inflammatory chan%es that in'ce epithelial alteration. SH'amo's chan%eshave also been reporte in m'cin- an aH'eo's-eficient conitions.2

c. $arly %etection and Prevention

5actors beyon the patients control ca'se some forms of 9E. ;o#everD appropriate action can helpto elay the onset or minimiJe the e%ree of symptoms for a lar%e portion of the affecte

pop'lation. The 'se of tear s'pplements may make symptoms tolerable in miler sit'ations.

SpecificallyD nonpreserve tear s'pplements also play a role in the relief of moerate an avancecases. 4i hy%ieneD an #hen appropriate antibiotic intervention for anti-inflammatory effectsDminimiJes the effects of altere lipi secretion an re'ces the possibility of seconary infection.

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