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Dry Eyes
Classification
1) tear deficiency
a. aqueous deficiency
b. mucin deficiency
c. lipid deficiency
2) Excess loss – evaporative
a. Blepharitis-associated - Obstructive meibomian gland disease
b. Blink disorders
c. Disorders of eyelid aperture and eyelid/globe congruity
Causes
A) Aqueous deficiency
Keratoconjunctivitis sicca (KCS) is a heterogenous term describing patients with
aqueous tear deficiency. Most common cause of dry eyes
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Non-Sjögren syndrome
o Lacrimal disease (primary or secondary)
 Systemic vitamin A deficiency (xerophthalmia)
 Lacrimal ablation
 Congenital alacrima (Riley-Day syndrome)
 Primary lacrimal deficiency
 Graft-versus-host disease
o Infiltrative processes
 Lymphoma
 Amyloidosis
 Hemachromatosis
 Sarcoidosis
o Infectious diseases
 HIV diffuse infiltrative lymphadenopathy syndrome
 Trachoma
o Lacrimal obstructive disease
 Trachoma
 Ocular cicatricial pemphigoid
 Erythema multiforme and Stevens-Johnson syndrome
 Chemical burns
 Endocrine imbalance
o Anticholinergic medications
o Decreased corneal sensation
 Neurotrophic keratitis
 Corneal surgery
 Herpes simplex
 Contact lens wear
 Cranial nerve VII (CN VII) palsy
 Diabetes
 Aging
Sjögren syndrome
o Primary (no associated connective tissue disease [CTD])
o Secondary (associated CTD)
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Rheumatoid arthritis
Systemic lupus erythematosus
Progressive systemic sclerosis (scleredema)
Primary biliary cirrhosis
Interstitial nephritis
Polymyositis and dermatomyositis
B) Lipid deficiency
Leads to increased evaporative loss
o Blepharitis – obstructive meibomian gland disease
o Rosacea
C) Mucin deficiency
Leads to poor wetting of the corneal surface with subsequent desiccation and
epithelial damage
o Mucocutaneous disorders - Stevens Johnsons
o Vitamin A deficiency
o Trachoma
o Diphtheric keratoconjunctivitis
o Topical medications
Management
Nonsurgical
1) preservative-free artificial tears, and a lubricating ointment at night
2) Patch with lubrication at night
3) artificial tear insert (eg, Lacrisert) into the inferior cul-de-sac every morning
4) Insert temporary punctal occlusion with collagen (dissolvable) or silicone
(permanent) plugs, and, if they are effective, perform electric cauterization of
puncti.
Surgical
reserved for very severe cases where ulceration or impending perforation of the sterile
corneal ulcer occurs
1) Corneal or corneoscleral patch for an impending or frank perforation
2) Lateral tarsorrhaphy - Temporary tarsorrhaphy (50%) is indicated in patients
with keratitis sicca secondary to exposure keratitis after facial nerve paralysis
and after trigeminal nerve lesions that give rise to keratitis sicca secondary to
loss of corneal sensation.
3) transposition of the parotid duct into the lateral conjunctival fornix
(sialodochoconjunctival anastomosis)
a. considerable disadvantage of virtually constant epiphora, especially
during food ingestion
b. quality of the purely serous parotic secretion differs basically from the
complex structure of the endogenous tear film.
c. Not done now (except by vets)
4) submandibular salivary gland free flap (PRS 2000; Sieg P, Geerling G)
a. rule out destructive inflammatory processes of the salivary glands (e.g.,
in connection with a systemic disease such as Sjögren syndrome) with
a biopsy of the minor salivary glands of the lower lip.
b. secretory activity of the salivary glands of the head was documented
scintigraphically using Tc 99m pertechnetate
c. In cases such as Stevens-Johnson syndrome or ocular pemphigoid, in
which scarring had obliterated the conjunctival fornix, a cuff of
mucosa from the floor of the mouth is included with the duct opening
d. salivary gland is transposed to the temporal fossa as a free, denervated
flap
e. anastomosed to the superficial temporal artery and vein
f. Denervated so relies on basal secretion and not reflex gustatory
tearing.
g. Wharton's duct was transplanted to the upper lateral conjunctiva
fornix, and the gland was left denervated.
h. The amount of secretion from these glands increases over time,
suggesting that re-innervation occurs.
i. In about 20% of all grafts this can result in excessive secretion.
j. epiphora provoked by physical activity, chewing motions, or
hyperthermia of the temporal region (i.e., head covering)