Understanding dry feeling eyes. Diagnosis and Treatment · Dry Eye Syndrome (()DES) A team of international experts collectively defined dry eye syndrome as: Dry eye is a multifactor

Understanding dry feeling eyes.eyes. Diagnosis and Treatment

Gunter Wong, BSc(Hons)Optometry, MOptometry, PhD

Training Manager, Asia Pacific

2009.10.02-CN1396

Content – understanding dry feeling eyesContent understanding dry feeling eyes

• Definition and incident

• Physiology of the eye

•Etiology and diagnosis

•Management

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Dry Eye Syndrome (DES)y y y ( )

A team of international experts collectively defined dry eye syndrome as:

Dry eye is a multifactor disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability, with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tearsurface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.1

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Reference 1. Report of the International Dry Eye Workshop. Ocul Surf April. 2007: 5(2):75.

OsmolarityOsmolarity

Tear hyperosmolarity may reasonably be regarded as the signature feature that h t i th diti f “ l f d ”1characterizes the condition of “ocular surface dryness”1

Hyperosmolar levels in the tear film may transiently spike during tear instability, resulting in corneal inflammation and triggering sensory neurons6g gg g y

2009.10.02-CN1396References: 1.Report of the International Dry Eye Workshop. Ocul Surf April. 2007: 5(2):1196. Liu H. et al. A link between tear instability and hyperosmolarity in dry eye. Invest Ophthalmol Vis Sci. 2009 Aug;50(8):3671-9. Epub 2009 Mar 25

Population-based studies of dry eye1

*Different definitions of dry eye were used in each study.

2009.10.02-CN1396Reference 1. Report of the International Dry Eye Workshop. Ocul Surf April. 2007: 5(2):95.

5

The tear film has 2 layersThe tear film has 2 layers

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The Lacrimal ApparatusThe Lacrimal Apparatus

Function: To optimise visual clarity

• Produces tears• Produces tear film components

D i t• Drains away tears

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The Lacrimal ApparatusThe Lacrimal Apparatus

Lacrimal Apparatus

• Principle and accessory (Kraus and Wolfring) lacrimal glands: produce tear fluidp

• Goblet cells: secrete mucins• Meibomian glands: secrete lipids• Glands of Zeiss and Moll: secrete

lipids

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The 7 Functions of Tear FilmThe 7 Functions of Tear Film

1) Maintains hydration of the eye) y y

2) Lubricates the ocular surface

3) Nourishes the cornea)

4) Cleanses the ocular surface

5) Defends against bacterial invasion

6) Buffers the pH of the ocular surface

7) Refracts light for visual clarity

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Overview of Dry Eye DiseaseOverview of Dry Eye Disease

Dry feeling eyes presents in 2 forms that can occur together:

• Evaporative dry eye: caused by increased evaporation of the tear film1

• Tear deficient dry eye: caused by changes in the tears themselves1• Tear-deficient dry eye: caused by changes in the tears themselves1

Tear film instability can be caused bymany thingsmany things

Environmental factors Biological factors

2009.10.02-CN1396 Reference 1. Report of the International Dry Eye Workshop. Ocul Surf April. 2007: 5(2):77

Causes of evaporative dry eyeCauses of evaporative dry eye

Photo courtesy of David W. Hansen, OD, FAAO


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Causes of Tear-Deficient Dry EyeCauses of Tear Deficient Dry Eye


Inflammation and Dry Eye Disease1y y


Slit Lamp ExaminationSlit Lamp Examination

Photo courtesy of Elena Garcia Rubio, DOO

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Test of Tear FunctionTest of Tear Function

1. Tear break up time (TBUT)

• Fluorescein is placed onto the ocular surface

• The time it takes for dark areas to form is measured

• Normal: > 10 sec (Caucasian); > 5 sec (Asian)

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Test of Tear Function

2. Schirmer’s test


• Apply a paper strip to the lower and measure the amount of wetting occuring over a specific time-period (e.g. 5 minutes)

• Schirmer I (without anesthesia); Schirmer II (with anesthesia)

• Dry Eye? < 10 mm in 5 mins (Schirmer II)

Schirmer’s Test

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3. Phenol Red Thread


• A 70-mm thread impregnated with phenon red is inserted into the lowerlid for 15 seconds

• Color changes from red to yellow when the thread absorbs the tears

• Normal > 15 mm; dry eye < 9mm

Phenol Red Thread

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Thread


4. Tears meniscus


• Can be seen resting on the lower lid

• A height of 0.3 mm is considered normalA height of 0.3 mm is considered normal

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Other parameters?Other parameters?

Area of break-up (AB)Maximum blink interval (MBI)

• Transient increases in tear hyperosmolarity during tear instability caused the sensations noted by subjects

Ocular Surface Disease IndexOcular Surface Disease Index

Management ofunderlying disordersunderlying disorders

Eyelid disorders can cause dry eye disease

• Treatment of blepharitis (eyelid inflammation)E lid b Eyelid scrubs

Antibacterial ointments Steroid dropsp

• Treatment of ectropion or entropion


Blepharoplasty

Sjögren's dry eye patients are generally managed theSjögren s dry eye patients are generally managed the same way as non-Sjögren’s


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Natural Therapies for Dry EyeNatural Therapies for Dry Eye

Blinking

• Frequent blinking helps spread the tear film evenly and combats evaporation

Hydration

• Dehydration can make dry eye symptoms worse

Environmental changes

• Use humidifier or air filter1

• Avoid fans1

• Take breaks from the computer1

• Change contact lenses or wear less frequently

Dietary supplements

• Omega 3 fatty acids1


Office Environment & Dry EyeOffice Environment & Dry Eye

Eye irritations in office environment?Eye irritations in office environment?

Prevalence & symptomsPrevalence & symptoms

•5-40% reported with eye irritation symptoms in office buildings

•symptoms include :•symptoms include :– burning– drydry– gritty– itchy– scratchy– sore– stinging– stinging– strained eyes

Factors associated with eye irritations in office environmentsenvironments

•Humidity

•Room temperature

•Indoor air velocity•Indoor air velocity

•VDU work

•Contact lens wear

•Makeup

Low relative humidityLow relative humidity

•20% decrease of relative humidity will increase the rate of evaporation by 100%of evaporation by 100%

High room temperatureHigh room temperature

1ºC d i t t i t d ith 19% d f•1ºC decrease in room temperature was associated with 19% decrease of reported eye symptoms

Indoor air velocityIndoor air velocity

•High horizontal or downward air velocity along the head region increases evaporation of water from the eye causing dry eyefrom the eye, causing dry eye symptoms

VDU work – TaskVDU work Task

•Blink frequency during an active computer task with demand on vision and hand eye coordination was 69% lower than during avision and hand-eye coordination was 69% lower than during a passive task like watching a film on a VDU

VDU work – Monitor positionVDU work Monitor position

•The effect of lowering the gaze angle by 25º decreased ocular surface area by 7%y

VDU work – Eyelid squintVDU work Eyelid squint

Relaxation

After squint

During squint

S i ti t t d bli k•Squinting at a computer screen may reduce blink frequency by half

MakeupMakeup

•There is a significantThere is a significant association between the use of eye makeup and a thin li id l f th t fillipid layer of the tear film

•Oils in the eye makeup may be able to displace theFemale be able to displace the phospholipids and influence the formation of lipid layer on

Females using makeup p y

the cornea

Franck C. Fatty layer of the precorneal film in the “office eye syndrome”. Acta Ophthalmol (Copenh) 1991;69:737-743.

Ways to reduce dry eye symptoms in office environmentsenvironmentsWORKSTATION

1 R l ti h idit f 40% 60%1. Relative humidity from 40% - 60%

2. Lowering room temperature may reduce tear film evaporation. The optimal room temperature is between 20 and 22ºCoo e pe a u e s be ee 0 a d C

3. Avoid ventilation directed at your eyes

4. Adjust the position of the monitor. Downward gaze may minimize loss of4. Adjust the position of the monitor. Downward gaze may minimize loss of water from the tear film

5. Change font and font size of character displayed on the monitor to avoid i tisquinting

6. Remove glare source to avoid squinting

7 Alt t b t k ith hi h d l d f i l d iti7. Alternate between work with a high and low degree of visual and cognitive demands

8. Microbreaks every 1-2 minute and exercise of complete blinks help restore y p pnormal tear film stability

Basic ingredients of tear supplementsBasic ingredients of tear supplements

• Water: replaces water loss

• Buffer: maintains pH of the solution. Contains electrolytes

• Active ingredient: A lubricant to reduce friction and/or a demulcent to sooth irritated membranes. Increases

l f t ti tiocular surface retention time.

• Preservative: Used to prolong the shelf life. Can be toxic to the eye. Not yused in all formulations.

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Eye drop strategiesEye drop strategies

Increase retention times

The main limitation of eye drops is their relatively short duration of action: they are effective only while they remain on the eye. The most common way to increase ocular retention is to increase viscosity, so many manufacturers add y, ythickening agents. Newer viscoelastics formulations help to increase retention times without blurring.

2009.10.02-CN1396 Reference 1.Report of the International Dry Eye Workshop. Ocul Surf April. 2007: 5(2):87

Eye drop strategiesEye drop strategies

Counteract hypertonicity

The tears of dry eye sufferers have an increased osmolarity (the concentration of solutes in a solution) due to a hypertonic tear film1. The use of a hypotonic eye drop may address this problem. Hypotonic products include blink intensive p y p yp ptears, TheraTears and HypoTears.


Eye drop strategiesEye drop strategiesAvoid older generation toxic preservativesIt i ll i d th t ti d iti it i ll ldIt is generally recognised that preservatives do cause sensitivity, especially older preservatives such as BAK1.

A preservative free solution would be the first choice. However, new generation ‘ t’ ti h P it O P ti h l bi th‘smart’ preservatives such as Purite or OcuPure preservative help combine the best of both worlds.


Thank you for listening

blink and Ocupure are trademarks owned by or licensed to Abbott Laboratories, its subsidiaries or affiliates.

Systane is a trademark of Alcon Laboratories Inc.; Hyabak is a trademark of Thea Laboratories; THERA TEARS is a y ; y ;trademark of Advanced Vision Research Inc.; Hypotears is a trademark of Novartis Inc.; Optrex Actimist is a trademark of Reckitt Benckiser Ltd.; Purite is a trademark of Allergan Inc..

© 2009 Abbott Medical Optics Inc.

2009.10.02 – CN1396

Documents

Understanding dry feeling eyes. Diagnosis and Treatment · Dry Eye Syndrome (()DES) A team of international experts collectively defined dry eye syndrome as: Dry eye is a multifactor