Download TEAR DEFICIENCY (Keratoconjunctivitis Sicca)

CLINICAL MANAGEMENT GUIDELINES
TEAR DEFICIENCY (Keratoconjunctivitis Sicca)
Aetiology
Predisposing Factors
Symptoms
Signs
Differential Diagnosis
Management by Optometrist
Possible Management by Ophthalmologist
Evidence Base
Aetiology
• Most cases are idiopathic (ie have no known cause)
• Sometimes there is an association with inflammatory disease, surgery, infection,
vitamin deficiency or the use of drugs:
- collagen vascular diseases and immune-complex diseases (Sjøgren’s syndrome,
primary or secondary to rheumatoid arthritis, systemic lupus erythematosus, or
scleroderma)
- cicatricial disease of lids or lacrimal ducts (ocular cicatriacial pemphigoid,
Stevens-Johnson Syndrome, trachoma, chemical burn)
- infiltration of lacrimal gland (sarcoidosis, tumour)
- post-radiation fibrosis of lacrimal gland
- lacrimal gland surgery
- herpes simplex keratitis
- vitamin A deficiency
- drugs (e.g. oral contraceptives, antihistamines, beta-blockers, phenothiazine)
• Tear deficiency can also be related to tear film dysfuntion:
- lid abnormality affecting function (blinking) or adequacy of lid closure
(exposure, eg exophthalmos, Bell’s palsy)
- Meibomian gland dysfunction
Predisposing Factors
• Sex: M:F = 2:3
• Older age: prevalence rises from 7.5% in the fifties to 15% in the seventies
• Posterior lid margin disease (posterior marginal blepharitis)
• Factors that aggravate symptoms
- noxious agents (cooking fumes, tobacco smoke)
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CLINICAL MANAGEMENT GUIDELINES
- increased evaporation of tears (air conditioning, central heating)
Symptoms • Ocular irritation
• Foreign body, gritty or burning sensation
• Presence of a stringy mucous discharge
• Blurring of vision from epithelial disruption or (transiently) from mucus strands
• Symptoms exacerbated by smoke, wind or heat
• Symptoms usually bilateral; may not be described as a feeling of dryness
• Associated symptoms of dry mouth, systemic disease (e.g. arthritis)
Signs • Reduced tear meniscus at inferior lid margin (meniscus should be not less than 1
mm in height)
• Pre-corneal tear film break up time <10 sec
• Punctate epithelial erosions in exposed area of cornea and bulbar conjunctiva
(especially in inferior third of palpebral aperture). Stain with fluorescein (cornea)
and lissamine green (conjunctiva)
• Increased mucus strands and other tear film débris
• Filaments (adherent comma-shaped mucus strands)
• Mucus plaques
• Dellen
• Thinning and (very rarely) perforation
• Reduced corneal sensitivity
Differential Diagnosis
• Blepharitis
• Eyelid abnormality leading to exposure (exposure keratopathy)
• Nocturnal lagophthalmos (failure to close eyes at night)
Management by Optometrist
Non-pharmacological
• Tear preservation:
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• Diminish outflow – punctal plugs (refer to College Guidance on the ‘use of punctum
plugs and intracanalicular occlusion’)
• Reduce evaporation – lid hygiene for Meibomian dysfunction (hot compress and
massage, lid cleaning with swabs or cotton buds)
• Advise avoidance of factors that aggravate symptoms
• Epilation for trichiasis
Pharmacological
• Tear supplements for use during the day, unmedicated ointment for use at bedtime
NB Patients on long-term medication may develop sensitivity reactions which may
be to active ingredients or to preservative systems (see Guideline on Conjunctivitis
Medicamentosa). They should be switched to unpreserved preparations
Management category
• B2: alleviation or palliation; normally no referral
(If idiopathic and not associated with systemic disease)
• B1: initial management followed by routine referral if adequate trial of topical
treatment or punctal plugs fails, or for secondary complications (vascularisation,
corneal scaring, melt, or infection). If lid anatomy or function is abnormal, refer.
Also refer (to GP or to Ophthalmologist as appropriate) if not idiopathic, and
underlying disease not identified or treated
Possible Management by Ophthalmologist
• Drug treatment for underlying disease (eg SJS, OCP)
• Electrolysis, cryotherapy
• Protection with therapeutic contact lenses of all types
• Permanent (surgical) occlusion of puncta
• Tarsorrhaphy (surgical or botulinum toxin)
• Transplantation of salivary gland/duct
Evidence Base
• Dry Eye Syndrome. American Academy of Ophthalmology Cornea/External Disease
Panel, Preferred Practice Patterns Committee. Dry eye syndrome. San Francisco
(CA): American Academy of Ophthalmology (AAO); 2003
(Oxford Centre for Evidence-based Medicine Level of Evidence = 2b)
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© The College of Optometrists