Download DRY EYE

Dry eye work up
Speaker
: RAJKUMAR N R
Moderator
: Ms. RAJALAKSHMI.G
Chairperson
: Dr. R R SUDHIR
ANATOMY OF TEAR FILM
ANATOMY
Three layers of Tear film:
1.
Anterior Lipid layer (Meibomian, Zeiss and Moll
glands)
2.
Middle Aqueous layer (Lacrimal and accessory
glands of Krause & Wolfring)
3.
Posterior Mucin layer (Goblet cells, crypts of
Henle & glands of Manz)
PHYSIOLOGY OF TEAR FILM
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Avg Osmolality – 295 - 309 mosm/l
pH 7.25
Refractive index – 1.336
Surface Tension – 40-42 mN/m
Avg basal tear volume – 5-9 micro liter with flow
rate of 0.5 – 2.2 micro liter / min
Avg thickness of tear film – 8 micrometer
DRY EYE
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Definition

Dry eye is a disease of the ocular surface
attributable to different disturbances of the
natural function and protective mechanisms of
the external eye, leading to an unstable tear
film during the open eye state.
REF: Surv Ophthalmol 2001; 45(2), S199-202
PREVALENCE

In various studies conducted, prevalence of dry
eye varied from 8.4% in younger subjects to
19% in older

Age adjusted prevalence in men was 11.4% compared
with 16.7% in women.
BMC Ophthalmology 2008, 8: 10
Pathophysiology/ Natural History
Loss of water from the tear film with an increase in
tear osmolarity
Decreased conjunctival goblet-cell density and
decreased corneal glycogen
Increased corneal epithelial desquamation
Destabilization of the cornea-tear interface
RISK FACTORS
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Age
Women
Smoking
Using of drugs like
 Anti muscarinics
 Anti histamine
 Anesthetics
 Phenothiazines
 Anti Androgens
CLASSIFICATION

According to National Eye Institute, dry
eye classified as
DRY EYE
AQUEOUS TEAR
DEFICIENCY (ATD)
Sjogren’s
EVAPORATIVE TEAR
DEFICIENCY (ETD)
Non –
Sjogren’s
AQUEOUS TEAR DEFICIENCY
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
Sjogren’s
 Autoimmune disorder with a triad of dry
mouth, dry eye and arthritis
Non-Sjogrens
 Ageing
 Menopause
 Medicamentosa
 Cicatricial disease
 Neurotrophic keratitis
EVAPORATIVE TEAR DEFICIENCY

Meibomian gland disease
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Lid surfacing/blinking anomalies
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Contact lens related
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Chronic allergy/toxicity
SYMPTOMS
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Irritation
Redness
Burning/ Stinging
Itchy eyes
Sandy- gritty feeling (foreign body sensation)
Blurred vision
Tearing
Contact lens intolerance
Increased frequency of blinking
Mucous discharge
Photophobia
EVALUATION OF
DRY EYE
Detailed history
Lid evaluation
1.
2.
I.
II.
Palpebral fissure height
Lid margin (Blepharitis, meibomitis and
MGD)
3.Tear film evaluation
I.
Look for tear film debris
II.
Tear meniscus height
4.Cornea and conjunctiva evaluation
I.
SPK, filaments
II.
Congestion in conj, mucus discharge
5.Fluorescein stain
I.
Tear film stability
II.
Corneal staining
Corneal filaments
SPECIAL EVALUATIONS
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Schirmer’s Test
1. Schirmer I
•
Normal 10 – 30 mm in 5 min
2. Schirmer II
•
Less than 15 mm after 2 min is abnormal
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Schirmer’s is not a specific and sensitive
test for dry eye.
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Values depend on osmolarity
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Shows increased value in MGD and oil in the
lid margin
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Fluorescein Dye staining
Grading of Fluo. Stain
1. Mild
- <1/3 of corneal epi surface
2. Moderate
- <1/2 of corneal epi surface
3. Severe
- >1/2 of corneal epi surface
TBUT – > 15 sec is considered to be normal
< 10 sec – abnormal
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Rose Bengal staining
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It stains devitalized epithelial cells
It also stains the normal epithelial cells which
is not covered by mucus
Helps to evaluate mucus layer
After a wait of 2 min, degree of rose bengal
staining on bulbar conjunctiva and cornea is
seen
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Rose Bengal staining
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Classic location of stain –
inter palpebral conjunctiva
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Stains in the form of
triangle whose base at
limbus
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Usually conjunctiva stains
more than cornea. But its
other way in severe cases
of KCS
VAN BIJSTERVELD SCORE
Lissamine green B
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Dye which stains dead and degenerated cells
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Equivalent to Rose Bengal
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Produces less irritation
NEWER TECHNIQUES
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Non invasive BUT
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Projecting the fine grids on cornea
Double vital staining
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Combination of both Fluorescein and Rose
bengal
2 micro liter in cul-de-sac
No irritation due to preservative free
Even detects subtle changes and can do BUT
also
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The most sensitive and specific test for dry eye is
osmolarity measurement of nanoliter tear
samples collected from the inferior marginal tear
strip
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To differentiate between Sjogren’s and non
Sjogren’s ATD
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Absence of naso lacrimal reflex tearing
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Severity of ocular surface dye testing
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Serum tests (ANA, Rheumatoid factor)
MANAGEMENT OF
DRY EYES
Treatment
Tear replacement
Tear Preservation
Artificial tears
Punctal Plugs
TYPES OF TREATMENT
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Medical/pharmacological
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Supportive
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Therapy for underlying cause
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Surgical
 Temporary occlusion
 Permanent occlusion
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Laser punctoplasty
Punctal cautery
PHARMACOLOGICAL
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Tear substitutes are the mainstay of therapy for
dry eye.
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Improve patients’ quality of life
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Provide adequate relief
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Increase humidity at the ocular surface and
improve lubrication and vision
SUPPORTIVE THERAPY
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Reduces tear loss by evaporation
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Glasses, Eye shields etc.,
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Hydrophobic contact lenses
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Vaporizer or humidifier
CASE DISCUSSION
CASE I
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MRD no – 1305365 (Dec 2008)
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Age/Sex – 43/F
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Main complaints
 OU: C/o difficulty in near Vn x 2 yrs
 OU: C/o difficulty in seeing bright light x 2 yrs
 OU: C/o eye pain asso with burning sensation
x 1 yr. Diagnosed e/w to have Dry eyes
G H : ?CNS demylination
C.Tx: Tx for the same
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Vn (unaided)
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OD: 6/6, N18
OS:6/12, N18 @ 30 cm
BCVA OU: 6/6, N6 with Rx
 SLE
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OD: Meibomitis
OS: Upper lid retraction, Meibomitis
Vertical PFH: OD: 10 mm, OS: 12 mm
Fundus: WNL
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Dry eye work up
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Schirmer’s OD: 3 mm, OS: 1 mm
TBUT OU : 4 mm
TMH OU: decreased
Fluo stain: OU: 0/0/0
Tear debris: OU: +
Adv: Refresh Tears, Lacrigel, Lid hygiene
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Follow up: May 2009
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Feels symptomatically better after using e/d
C.Tx: Refresh tears e/d
BCVA: OU: 6/6, N6 with Rx
SLE:
 OU: MGD
 OS: Nebular scar
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Dry eye work up
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Schirmer’s - OD: 4 mm, OS: 1 mm
TBUT: OU: 4 mm
Fluo : OD: 0/0/1, OS: 0/0/1
TMH: OU: decreased
Tear debris: OU: +
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Diagnosis:
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Dry eye, due to ETD
Adv: to add Restasis e/d
CASE - II
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MRD No: 909653
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Age/sex: 21/M
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I visit Oct 2003
 OU: C/o decrease in Vn x 5 yrs following the
attack of chicken pox
 OU: C/o eye pain and photophobia x 3 yrs
G.H : Good
C.Tx: (OU) Tears plus e/d
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PGP: Nil
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Vn (unaided):
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OD: 3/36; PH 6/36; N12
OS: 6/24; PH 6/18; N6 @ WD
BCVA
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OD: -3.00 (6/36)
OS: plano (6/24) NIF with lenses
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Anterior Segment shows OU
 360 deg limbal vascularisation
 Corneal scar
 Lid margin keratinisation
 Flourescein stain ++
 No RB stain
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Schirmer’s OU: 1 mm in 5 min
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Syringing: OU: NLD patent
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Impression:
 DRY EYE secondary to SJ syndrome
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Advice:
 Tears plus 10/d
 Lacrigel e/o
 Silicone plugs (patn not interested, but
temporary occlusion)
 Rev 4/12
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Next visit – Jan 2009
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Came with same complaints
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C.Tx : OU: Tears plus e/d
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BCVA
 OD: 6/24; N6
 OS: 6/24: N8 with Rx
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SLE
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360 deg limbal vascularisation
Corneal scar
Lid margin keratinisation
Diffuse SPK
Symblepharon
Fluorescein stain ++
No RB stain
Schirmer’s OU: 1 mm in 5 min
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Dry eye evaluation OU
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Punctum
TMH
BUT
Flou
RB
-
open
Decreased
2 sec
3/3/3
0/0/0
Impression
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Severe Dry eye secondary to SJ syndrome
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Advise
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OU: Punctal cautery
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Symptoms alleviated after Sx
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To continue Tears plus