Diagnostic techniques of dry eye

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Diagnostic Techniques of Dry EyeYasmine R. Abdul-Rahman, Optometrist

B.Sc (Hons)

The 1st Palestinian- Jordanian Conference and the 5th ‘EMCO’ Conference on Optometry

Friday, April 17, 2015

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Content

1. Dry eye definition.

2. Dry eye prevalence.

3. Dry eye classification.

4. Dry eye Assessment: ◦ Symptoms Questionnaires.◦ Assessment of tear film stability. ◦ Assessment of tear film volume.


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By the end of this presentation you will a better understanding of

1. What is meant by the Term ‘Dry Eye’

2. The different forms of dry eye encountered

3. The sort of questions you need to ask in order to determine if dry eye is present

4. Methods that used to assess tear stability and volume

5. How to incorporate simple Non-Invasive tests as a part of your clinic.


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Definition

Dry Eye is: ‘A multifactorial 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 osmolality of the tear film and inflammation of the ocular surface’.


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Dry Eye Prevalence

Around the world, between 5% and 34% of people suffer from dry eye.


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Risk Factors


Risk Factors

Gender and Age

Visual Display Terminal

Contact lens wear

Refractive surgery

Low relative humidity

Extreme hot or cold weather

condition

Smoking

Medications

Alcohol Consumption

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Tear Film Component


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Classification of Dry Eye


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Practical Sequence of Dry Eye Tests

1. Patient history, symptoms-oriented questionnaire

2. Tear film instability tests◦ Tear Film Break Up ◦ Non Invasive- Tear Break Up ◦ Examination of lid margin and meibomian gland

3. Tear film volume tests◦ lid-parallel conjunctival folds (LIPCF)◦ Schirmer test ◦ Tear meniscus height


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Patient history & Symptoms-oriented questionnaire


Patient History

• Weather, place, workplace stress.• Systemic diseases• Medication history.

symptoms-oriented questionnaire

• Ocular Surface Disease Index [OSDI]

• McMonnies• Others

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OSDI


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McMonnies


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Tear film instability tests1. Tear Film Break Up AKA = BUT (Break-up Time) and= FBUT (Fluorescein Break-Up Time )

Def: The time required for dry spots to appear on the corneal surface after blinking.

Materials:

1. NaFl ( sodium fluorescein dye)

2. Slit Lamp

3. Timer


Tear Film Break Up Clinical Procedure

Instill sodium fluorescein onto the bulbar conjunctiva.

Instruct patient to blink several times to distribute the fluorescei.

Within 10-30 sec of the fluorescein instillation, the patient is asked to stare straight ahead without blinking, until told otherwise

Set slit-lamp magnification at 10X, use (cobalt blue filter) and use a Wratten yellow filter to enhance observation of the tear film over the entire cornea.

Use timer to record time between last complete blink and first appearance of black spot.

Repeat 3 times and take the average

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Values ≥10 sec Normal

≤10 sec Dry Eye

≤5 sec severe Dry Eye

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Tear film instability testsNon Invasive- Tear Break Up

Materials:

1. Toposcope/keratometer/Tearscope/Xeroscope

2. Timer


Non-Invasive Tear Break-up Procedure

1• The test is conducted in quiet room conditions with low air speed

and low general illumination.

2• The patient sits comfortably at the instrument and is encouraged

to blink freely while fixing on a target, directly ahead.

3• The patient is asked to stop blinking until told to restart.

4• The time between the last complete blink and the first indication

of pattern break-up is recorded with a stop-watch.


Values ≥15.4±2.7 sec Normal

≤15.4±2.7 sec Dry Eye

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Tear film instability tests Examination of lid margin and meibomian gland (MGD )

Using Slit lamp ( diffuse illumination, low magnification, low illumination)

MGD Diagnostic Work-Up

Eyelid Margin Evaluation

MG Expression

Meiboscopy


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Eyelid Margin Evaluation


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MG Expression

Assessed in each of 8 glands of central LL on a 0-3 scale:

Grade 0= Clear meibum

Grade 1= Cloudy meibum

Grade 2= Cloudy with debris (granual)

Grade 3= Thick (toothpaste)


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Meiboscopy

Use of transillumination biomicroscopy to determine

presence of MG loss.


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Tear film volume tests Tear Meniscus Height

The height of the tear film meniscus observed during slit lamp examination.

Set up the slit lamp:

1. 60o

beam angle.

2. Low illumination.

3. 10-16 X magnification.

4. Parallel Piped beam.


Clinical Procedure for Tear Meniscus Height


Focus the parallelepiped on the inferior tear strip near the lateral canthus.

At any point the beam may be narrowed to an optic section to assess the depth of the tear meniscus.

Reduced beam height with beam orientated horizontally.

Values ≥0.2-0.4 mm Normal

≤0.2 sec hypo secretion

≥ Hyper secretion

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Tear film volume tests Temporal lid-parallel conjunctival folds (LIPCOFs)

They can be simply, quickly, and noninvasively identified using the

slit lamp.

Slit Lamp Examination. The participants were

instructed to look straight ahead, and after some

blinking, the LIPCOFs were evaluated with slit

lamp at the temporal lower quadrant of the eye fissure.


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Schirmer test

The Schirmer test measures the secretions of the lacrimal gland.


calibrated filter paper strips (35 × 5 mm) are placed in the conjunctival sac of the temporal third of the lower eyelid

with the patient's eyes closed, wetting of the strip is measured after 5 minutes

Clinical Procedure

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Corneal and Conjunctival Staining Its found either on instability tear film or on inadequate tear film.

Materials: slit lamp( high illumination, Cobalt blue filter, 10-16x), NaFl, Wratten Filter to inhance the view


Wratten Filter

Corneal StainingConjunctival Staining

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How to Grade


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References 1. The definition and classification of dry eye disease: report of the Definition and Classification Sub committee of the

International Dry Eye WorkShop (2007). 2007;5(2):75-92.

2. Gayton, L. (2009). Etiology, prevalence, and treatment of dry eye disease. Clinical Ophthalmology:3 405–412

3. Dtsch Arztebl (2015); The Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease,112: 71–8.

4. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye WorkShop (2007). 2007;5(2):93-107.

5. Methodologies to diagnose and monitor dry eye disease : re p ort of the Diagnostic Methodolog y Subcommittee of the International Dry Eye WorkShop (2007). 2007;5 (2):1 08 -1 5 2.

6. http://www.tearfilm.org/

7. Santosh Khanal. (2008). Dry Eye Diagnosis. Investigative Ophthalmology & Visual Science, Vol. 49, No. 4


http://www.tearfilm.org/

http://www.tearfilm.org/

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Health & Medicine

Diagnostic techniques of dry eye