Dry eye evaluation and mx ppt

History
 Coexisting connective tissue disease, rheumatoid arthritis,
scleroderma, SLE
 Thyroid abnormalities
 History of prolonged medication like anti-Histaminic, Tri-
Cyclic Antidepressants, β-blockers, OC pills & NSAIDs.
• Topical
• Systemic
 History of prolonged dryness of oral cavity, repeated
mucosal ulcers.
 Common dry eye symptoms are grittiness, foreign body
sensation, burning, soreness, stinging, itching, dryness,
blurry vision, a ‘film over the eyes’, paradoxical reflex
tearing and photophobia.

On Examination
 Eye lids:
• Lid margin
• Eye lashes
• Infections
• Crusting/keratinisation
• Lid closure
 Conjunctival sac:
• Decreased tear meniscus
• Increased debris in the tear film
• Mucous discharge

 Bulbar conjunctiva:
• Dry lustreless
• Muddy
• Bitot’s spots
• Hyperaemia
Cornea:
• Dry lustreless, hazy look
• Irregular surface
• Superficial punctuate keratitis
• Filaments
• Ulcers/scars in severe cases

Clinical presentation can vary in severity
Mild Severe
Slit Lamp
Examination
Fluorescein
Dye Stain

Diagnostic Tests
Aims
• Tear secretion assessment
• Tear volume assessment
• Tear clearance assessment
• Evaluation of tear film stability
• Ocular surface damage assessment

Tear secretion assessment
 Schirmer’s Test
• Schirmer’s I Without Anesthesia Basal + Reflex
• Schirmer’s II After Anesthesia Basal only
• Schirmer’s III Nasal stimuli Basal + Reflex
• Jones’ Test Basal secretion (2 minute After LA)
 Phenol Red Thread Test
• pH sensitive test
• More reliable than Schirmer’s test
•24mm in 15 seconds is normal
•<11 mm in 15 seconds indicate Aqueous Tear Deficiency
 Tear osmolarity
 <308 mOsm/L Normal & Inter-eye Difference <8mOsm/L

Schirmer Test
 <30 years : 20 mm/5 min
 31-50 years : 13 mm/5 min
 51 and above : 10mm/5 min
 < 5 mm/5 min- Dry eye (KCS)
 <3 mm/5 min- if topical anaesthesia is used.

Tear volume assessment
 Tear meniscus height
 0.2 to 0.7 mm – Normal
 ≤0.2 – Pathological
• Indicates Aqueous deficiency
• Poor lid-globe apposition
 Increased Height in Naso-
Lacrimal Obstruction

Tear clearance assessment
Fluorescein clearance test*
• Basal tear secretion
• Reflex tear secretion
• Tear clearance
Fluorophotometry
To quantitate tear secretion, tear volume & Tear
turn-over.
Normal Tear Secretion= 1.2 ± 0.5 µL/min
In severe dry eye= 0.2 ± 0.2 µL/min

Evaluation of tear film stability
Tear film break-up time (TBUT)
• Fluorescein TBUT
• Non-invasive TBUT
Lipid layer assessment

Ocular surface damage assessment
Staining
Corneal sensitivity
Impression cytology
Tear protein assays

Staining
 Fluorescein dye
• Where cell to cell junc disrupted
 Rose-bengal dye
• Dead, devitalized cell & Mucin
 Lissamine green*
 Stain blue
Grading
 Location*
 Intensity
NEI workshop grading
 Cornea (Fluorescein) >3/15
 Conjunctiva (Rose-bengal) >3/18
15 3
4
2
1
2
3
4
5
6

Sequence of testing
Clinical tests
• NI-BUTS
• Schirmer’s test
• Staining
• F-BUT
Laboratory tests
• Impression cytology
• Tear osmolarity
• Tear protein assays

Impression Cytology
Used for grading the severity
Has also been used as a prognostic indicator in
evaluating efficacy of therapeutic measures
Features:
• Relatively larger cell size
• Squamous metaplasia
• Inflammatory cells
• Decrease in goblet cell density

MANAGEMENT
Goals
Establish the diagnosis.
Establish presence/absence of limbal cell deficiency.
Decide appropriate therapy.
Educate patient / relatives about nature of disease and its
management.
Caution the patient that Laser refractive surgery can
exacerbate dry eye.
Proper management for contact lens wear.

Elimination/avoidance of exacerbating factors which
• Decrease tear production
• Increase tear evaporation
Humidification of rooms
Avoidance of dusty/smoky rooms
Breaks between prolonged computer use (20-20-20)
Lowering the computer monitor below eye level
Blinking exercises & importance of blinking during
reading or any near work.


Eyelid hygiene
Hot fomentation
Topical/systemic antibiotics
Topical steroids
Artificial tear substitutes

Tear supplementation
Ideal tear supplement should
• Be preservative free
• Contain K+, HCO3- * & other electrolytes
• Have a polymeric system to increase its viscosity,
hence retention time
• Have neutral to slightly alkaline pH
• Have osmolarity between 181-354 mOsm/L

Various Tear Supplements
Cellulose Derivative- Hypromellose
Methyl cellulose
 Carbomer gel- Long lasting
but slight blurring of vision
Poly Vinyl Alcohol- useful in Mucin defi.
Propylene glycol,
Sod. Hyaluronate,
Glycerine
Paraffin (Mineral Oil) Ointment to supplement at night
Diquafosol- Secretogogue
Liposome Eyelid spray Reduces evaporation

Tear Retention
Punctal occlusion: Temporary* and Permanent.*
• Absorbable
• Collagen or polymers
• Duration- 1 week- 6 months
• Non-absorbable
• Silicone or acrylic
Moisture chamber spectacles
Contact lenses
• Severe dry eye
• Retain tear film
• Promote ocular surface healing

Various Contact Lenses
Contact lens wear can exacerbate dry eye due to
inflammatory, sensory & evaporative effects.
But that is outweighed by reservoir effect of fluid
trapped between lens & cornea.
Types:
 Low water content HEMA lens
 Silicon rubber lens
 Occlusive Gas permeable scleral contact lens- provides
best reservoir.

Biological tear substitutes
Autologous/ Umbilical cord serum tears
• Production & storage is challenge
Autologous platelet rich plasma (PRP)
• Helpful in healing of longstanding Epi. defect
Salivary gland auto-transplantation
• Complex Surgical procedure

Anti-inflammatory therapy
 Topical cyclosporine
• Only pharmacological agent approved by FDA for
treatment of dry eye
• Reduces conjunctival IL-6 level, activated T-lymphocytes,
inflammatory and apoptotic markers
• Increases conjunctival goblet cell number
 Corticosteroids
• Recommended only for short-term use
 Systemic medications
• Oral tetracyclines (used for anti-inflammatory action)
• Decrease matrix metalloproteinase activity and
production of cytokines such as IL-1 and TNF-α

Essential fatty acids
• Reduce inflammation
• Alter the composition of meibomian lipids
• Omega-3 fatty acids (Good)
• Inhibit the synthesis of proinflammatory mediators
(PGs and LTs)
• Block the production of IL-1 and TNF-ɑ
• Omega-6 fatty acids (Bad)
• Precursors of proinflammatory mediators (PGE2
and LTB4)
• High Ω-6 : Ω-3 ratio is associated with greater risk
for dry eye disease

Surgical options
Reserved for severe-very severe dry eyes
• Tarsorrhaphy
• Mucous membrane grafting
• Salivary gland transposition
• Amniotic membrane transplantation
• Botulinum Toxin Injection*

Newer Drugs On The Block
Tear stimulation: Secretogogues
• Diquafosol P2Y2 receptor agonist
• Ecabet sodium Mucous secretion stimulant
• Rebamipide Natural tear substitute
• Gefarnate Fatty acid
was used for gastric ulcer healing
N-acetyl-cysteine Mucolytic- Useful in Filaments
Chloroquine Phosphate 0.3mg/ml eye drops
Lacriserts HPMC inserts to be placed in
inferior fornix
Androgen ointment useful in MGD to prevent evaporation

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

TAKE HOME MESSAGE…
Methodical approach to diagnosis.
Do not miss subtle clinical signs.
Carefully plan the line of treatment.
Irrespective of cause of dry eye- immunomodulation
+ tear replacement.
Educate the patient and family members about the
dilemmas in management.

Dry eye evaluation and mx ppt

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