Download Presentation: Dry Eyes, Mr Y Ghosh

Common Ophthalmic
Conditions in Primary Care
- Management of Dry Eyes
Mr Yajati K Ghosh FRCSEd
Consultant Ophthalmic Surgeon
Birmingham & Midland Eye Centre
Affiliations
• BMI Droitwich
• BMI Priory, Edgbaston
• Spire Parkway, Solihull
Subspeciality interests
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Lid and lacrimal surgery

Periocular cancer surgery
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Phacoemulsification Cataract surgery
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Management of watery eyes
Common Ophthalmic Conditions
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Blepharitis
Conjunctivitis
Dry eyes
Watery eyes
Foreign body
Keratitis
Uveitis
• Lumps & Bumps
• Cataracts
Red
Eye
Blepharitis
Conjunctivitis
Dry eye
Watery eye
Foreign body
Keratitis
Uveitis
Cataracts
Lumps & Bumps
What to do?
• 50% of ALL red eyes and irritable
eyes are due to Dry Eye related
conditions ………..
Overview
http://www.virtualcancercentre.com
Roles and Characteristics of the eyelids
• Eye protection
• Regular blink: protection and stability of the tear
film
• Rich of glands
• Adequate blood supply
The Anatomy
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Corneal epithelium
Conjunctival epithelium
Tear film
Clinical ocular surface consist of
conjunctiva
cornea
eyelids
lacrimal gland
lacrimal passages
Tear Secretion
• Lacrimal gland
Producing the watery part of the tear film
called the aqueous.
• Meibomian glands
Producing lipids which keep the tear film
from evaporating.
• Goblet cells of the conjunctiva
Producing mucin which allows the wetting
of the ocular surface as well as stabilizes the
tear film.
www.virtualmedicalcentre.com
Tear Film in relation to Cornea
Tear and the Tear Film
• Function :
1.Cleaning
2.Wetting ocular surface
3.Bacteriostasis
4.Supporting the cornea
(oxygen supply)
http://www.drmalcolmmckellar.co.nz
Concept
• The ocular surface is a complex biological
continuum responsible for the maintenance of
corneal clarity, elaboration of a stable tear film for
clear vision, as well as protection of the eye
against microbial and mechanical insults.
• Comprising a variety of disorders on cornea,
eyelid, conjunctiva, lacrimal apparatus and tear
film.
Dry Eye
Healthy tear film
Dry eye
http://www.chronicdryeye.com
Etiological factor & Classification
 Aqueous tear deficiency
 Lipid tear deficiency
 Mucoprotein deficiency
 Kinetic disorders of lacrimal fluid
http://www.drmalcolmmckellar.co.nz
Conception
• Dry eye - is a chronic lack of sufficient
lubrication and moisture in the eye.
• Its consequences range from subtle but
constant irritation to ocular inflammation
of the anterior (front) tissues of the eye.
Clinical Manifestation
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Dry eye symptoms
asthenopia
irritation, grittiness
dryness
burning
light sensitivity
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pink-eye
Do you regularly experience one or several symptoms above?
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Some diseases and conditions (like Rheumatoid arthritis, Lupus
and Sjögren’s Syndrome) also cause chronic Dry Eye in many
patients.
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Activities like Reading, Wearing contact lenses or Working on the
Computer may cause Dry Eye.
Diagnostic Tests for Dry Eye
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Dry Eye questionnaire
• Lacrimal river width
• Schirmer test – uses paper strips under eyelid to measure
the wetness that collects over a specific period of time.
• Break-up time of tear film (BUT)
• Staining – uses special dyes to highlight areas of possible
damage to the eye surface.
• Tear lab – measuring tear osmolarity
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Tear ferning test
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Lactoferrin contents
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Tear penetration pressure test
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Corneal tonographic map
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Impression cytology
Diagnosing
• Schirmer test, BUT, Staining
• Foundation
Symptom
Instability of tear film
Damage to epithelium
Tear penetration pressure increasing
Schirmer Test
• Normal ：≥10mm/5min
Tear break-up time, BUT
Staining
• Using special dyes to highlight areas of
possible damage to the eye surface.
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Lacrimal river width
Tear Osmolarity measurement
Meibomian Gland Dysfunction
http://www.dryeyezone.com
Etiological Factor
• Failure of the glands to produce or secrete lipids.
• Wax ester declining and cholesterol increasing
make the symptoms worse .
• Lack of tears and tear penetration pressure
increasing.
• Lupus, brandy nose etc.
http://www.revophth.com
Clinical Manifestation
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Common in aged people and who lived in cold
region.
• No specific symptoms.
• Lid-margin mostly thickening; abnormal secretion
while pressurizing.
• Disorder in Meibomian
gland, eyelid, conjunctiva.
Figure: Notching of the lid caused
by loss of meibomian glands.
http://www.eyehealthnutrition.com
Diagnosing
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Absence of Meibomian gland.
• The gland orifices are often compromised due to stenosis or
closure.
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A declining quality and quantity of lipid secretion.
Any one of the physical signs can make the
diagnosis of Meibomian gland dysfunction if the patient
has clinical symptoms.
Figure: No visible meibomian gland orifices:
Eversion of the lower lids in both eyes showed
atresic meibomian glands.
http://www.ophmanagement.com
Ocular Surface Disease ★
Treatment
Clearing
• Hot fomentation on eyelids for 5~10mins.
• Massaging the eyelids.
• Swabbing the lid-margin with mild
cleaning solution.
Treatment
• Antibiotics oral administration.
• Local Medication
Antibiotic eye drops
Glucocorticoid eye drops (short term)
Artificial tears
Classification
• Corneal, conjunctival lesion
Squamous epithelization type
Limbal stem cell deficiency type
• Tear film disorders
Aqueous tear deficiency
Lipid tear deficiency
Mucoprotein deficiency
Kinetic disorders of lacrimal fluid
Treatment
• Reconstruction
Epithelium, limbal stem cells
Lacrimal secretion, tear film
Innervation (nerve restore)
Structure and function of eyelid
• Surgical operation
To re-establish conjunctiva, cornea,
tear film and eyelid.
Dry Eye Disease Workshop
Treatment
• According to the clinical category
For tear deficiency: Maintain moisture in the eyes;
reducing the evaporation; increasing the secretion; controlling
inflammation & immunoreaction.
For excess-evaporation: Therapy of Meibomian gland
dysfunction; controlling inflammation; cleaning eyelid; decreasing
the evaporation; lipid replacement.
• According to the eye conditions
For intermittent symptoms: Artificial tears add volume to
the tear film as long as they remain in contact with the surface of
the eye.
For midrange dry eye: Artificial tears and punctal
occlusion.
For Severe dry eye: Appending cyclosporin, surgery.
A Simple Treatment chart
Literature
• Artificial tears potpourri: a literature review
• Majid Moshirfar,1 Kasey Pierson,2,* Kamalani
Hanamaikai,3,* Luis Santiago-Caban,1 Valliammai
Muthappan,1 andSamuel F Passi1
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Clin Ophthalmol. 2014; 8: 1419–1433.
Published online 2014 Jul 31. doi: 10.2147/OPTH.S65263
PMCID: PMC4124072
Artificial Tear Groups
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HPMC
Carboxy Methyl Cellulose
PVA
Liquid Polyols
Hyaluronic acid
Inserts
Miscellaneous
Too many choices …..
Tear substitutes
Treatment pathway
The Future
• Newer eye drops – Lifitegrast,
Tavilermide
• Platelet rich plasma / Albumin
precursor
• Non-invasive intranasal lacrimal
neuro-stimulator
• Salivary gland transplantation
• Stem cell therapy
The DRY EYE PATHWAY
Patient to GP with dry eyes
Suffolk Primary Eyecare
Triage Service
Patient sent to an
optometrist enhanced
service provider(ESP)
Treatment by ESP + drops
and management plan
Review in one month
Hospital if
beyond
capabilities
of ESP
Summary
• Eliminating the etiological factors
• Tears replacement therapy
• Maintain moisture in the eyes
• Increasing the tear secretion
• Immune inhibition therapy
• Re-establish the tear film
• Other supporting treatment
Any Questions?