Dry eye work up

Speaker : RAJKUMAR N R

Moderator : Ms. RAJALAKSHMI.G

Chairperson : Dr. R R SUDHIR

ANATOMY OF TEAR FILM

ANATOMYThree 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

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 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 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)

EVAPORATIVE TEAR DEFICIENCY (ETD)

Sjogren’s Non – Sjogren’s

AQUEOUS TEAR DEFICIENCY

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

Lid surfacing/blinking anomalies

Contact lens related

Chronic allergy/toxicity

SYMPTOMS 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

1. Detailed history2. Lid evaluation

I. Palpebral fissure heightII. Lid margin (Blepharitis, meibomitis and

MGD)

3.Tear film evaluationI. Look for tear film debrisII. Tear meniscus height

4.Cornea and conjunctiva evaluationI. SPK, filamentsII. Congestion in conj, mucus discharge

5.Fluorescein stainI. Tear film stabilityII. Corneal staining

Corneal filaments

SPECIAL EVALUATIONS

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

Schirmer’s is not a specific and sensitive test for dry eye.

Values depend on osmolarity

Shows increased value in MGD and oil in the lid margin

Fluorescein Dye staining

Grading of Fluo. Stain1. Mild - <1/3 of corneal epi surface2. Moderate - <1/2 of corneal epi surface3. Severe - >1/2 of corneal epi surface

TBUT – > 15 sec is considered to be normal

< 10 sec – abnormal

Rose Bengal staining

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

Rose Bengal staining

Classic location of stain – inter palpebral conjunctiva

Stains in the form of triangle whose base at limbus

Usually conjunctiva stains more than cornea. But its other way in severe cases of KCS

VAN BIJSTERVELD SCORE

Lissamine green B

Dye which stains dead and degenerated cells

Equivalent to Rose Bengal

Produces less irritation

NEWER TECHNIQUES

Non invasive BUT Projecting the fine grids on cornea

Double vital staining 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

The most sensitive and specific test for dry eye is osmolarity measurement of nanoliter tear samples collected from the inferior marginal tear strip

To differentiate between Sjogren’s and non Sjogren’s ATD

Absence of naso lacrimal reflex tearing

Severity of ocular surface dye testing

Serum tests (ANA, Rheumatoid factor)

MANAGEMENT OF DRY EYES

A rtific ia l tea rs

Tear rep lacem en t

P u n c ta l P lu g s

Tear P reserva tion

Trea tm en t

TYPES OF TREATMENT Medical/pharmacological

Supportive

Therapy for underlying cause

Surgical Temporary occlusion Permanent occlusion

Laser punctoplasty Punctal cautery

PHARMACOLOGICAL

Tear substitutes are the mainstay of therapy for dry eye.

Improve patients’ quality of life

Provide adequate relief

Increase humidity at the ocular surface and improve lubrication and vision

SUPPORTIVE THERAPY

Reduces tear loss by evaporation

Glasses, Eye shields etc.,

Hydrophobic contact lenses

Vaporizer or humidifier

CASE DISCUSSION

CASE I MRD no – 1305365 (Dec 2008)

Age/Sex – 43/F

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

Vn (unaided) OD: 6/6, N18 OS:6/12, N18 @ 30 cm

BCVA OU: 6/6, N6 with Rx SLE

OD: Meibomitis OS: Upper lid retraction, Meibomitis Vertical PFH: OD: 10 mm, OS: 12 mm

Fundus: WNL

Dry eye work up

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

Follow up: May 2009

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

Dry eye work up 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: +

Diagnosis: Dry eye, due to ETD Adv: to add Restasis e/d

CASE - II MRD No: 909653

Age/sex: 21/M

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

PGP: Nil

Vn (unaided): OD: 3/36; PH 6/36; N12 OS: 6/24; PH 6/18; N6 @ WD

BCVA OD: -3.00 (6/36) OS: plano (6/24) NIF with lenses

Anterior Segment shows OU 360 deg limbal vascularisation Corneal scar Lid margin keratinisation Flourescein stain ++ No RB stain

Schirmer’s OU: 1 mm in 5 min

Syringing: OU: NLD patent

Impression: DRY EYE secondary to SJ syndrome

Advice: Tears plus 10/d Lacrigel e/o Silicone plugs (patn not interested, but

temporary occlusion) Rev 4/12

Next visit – Jan 2009

Came with same complaints

C.Tx : OU: Tears plus e/d

BCVA OD: 6/24; N6 OS: 6/24: N8 with Rx

SLE 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

Dry eye evaluation OU Punctum - open TMH - Decreased BUT - 2 sec Flou - 3/3/3 RB - 0/0/0

Impression Severe Dry eye secondary to SJ syndrome

Advise OU: Punctal cautery

Symptoms alleviated after Sx

To continue Tears plus