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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: Anterior Lipid layer (Meibomian, Zeiss and Moll glands) Middle Aqueous layer (Lacrimal and accessory glands of Krause & Wolfring) - PowerPoint PPT Presentation
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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