Understanding and Clinical Management of

Dry Eye

Fatma AsyariAINI Eye Hospital

Klinik Mata MayestikRSPI

Ocular Surface ( cornea & conjunctiva )

• Very sensitive

• Should be clear and moist

• Tears : support and maintain integrity

• Blinking reflex : 4x / min

• Dry spot pain reflex stimulation

lacrimation

Dry eye

• Extremely common in our daily practice

• Any age , female , male , even children

• Can be mild to severe

• Devastating and frustrating

• “ Long life treatment “ ?

Lacrimal Glands

Tears Support and MaintainOcular Surface

Secreto-motor Nerve Impulses

Ocular SurfaceNeural Stimulation

N.V

Lacrimation

dry spot pain reflex stimulation lacrimation

PONSN.VII

Tear film composition

Lipid : 0.1 um

• esters, glycerol ,

fatty acids

• product of

palpebral meibomian glands

• prevents excessive evaporation

Aqueos / watery : 7 um

• Secreted from lacrimal gland• electrolytes, protein, antibody,

oxygen , CO2, mineral , glucose

Epithelium

Mucin :0,02 - 0,05 um

• Product of conjunctival Goblet cells present inbulbar conjunctiva , caruncula

• Maintain tear film stability• Glycocalyx produced by epithelial cells help

bind mucins onto the epithelial surface

Tear outflow / each blink ( 4 x / min )

Tear film function

Maintain integrity of cornea & conjunctiva

• Smoothes ocular surface , improve vision

• Wash away all the dirty materials coming onto the eye

• Moisturizing, lubricating for comfort , eye movements

• Media transport for O2 , CO2 ( 40% from atmosphere )

• Nutrition ( glucose, electrolytes, enzymes , protein )

• Defense : Anti bacterial, antibodies, lisozyme

Dry eye

Definition

Etiology

Pathology

Classification

Epidemiology

Symptoms and signs

Treatment

Prognosis

Definition

NEI-Industry Workshop 1995

• Dry eye is a disorder of the tear film due to tear deficiency or excessive tear evaporation which causes damage to the interpalpebral ocular surface and is associated with symptoms of ocular discomfort

DEWS Report 2007• Dry eye is a multifactorial disease of the tears and

ocular surface that results in symptoms of discomfort, visual disturbances, and tear instability with potential damage to ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface

Pathology

Vascular

Infection

Trauma

Auto

immune

MetabolicInflammation

Neoplasia

Degenerative

Dystrophy

Dry Eye – Inflammation Model

Sjogrens Non-Sjogrens

Auto-antibodies

Tear Deficient

Evaporative

Lacrimal Deficiency

Lacrimal Obstruction

Reflex

Oil Deficient Lid Related Surface ChangeContact Lens

Dry Eye Etiology

NEI Workshop - Classification of Dry Eye

Dry Eye – Tear Film Deficiencies

Lipid Layer Deficiency

alterations in meibomian gland secretion (e.g. blepharitis, hordeolum, chalazion )

Aqueous Layer Deficiency

aqueous deficient dry eye (e.g. inflammation, neurological defects, trauma, congenital absence, etc )

Mucin Layer Deficiency

mucin deficient dry eye (e.g. Stevens-Johnson syndrome, pemphigoid, vitamin A deficiency, trachoma, radiation, etc.)

Influential Factors of Dry Eye Age Gender Arthritis Osteoporosis Gout Lens Surgery Contact Lens Wear Blink Disorders Disorders of Lid

Aperture Nutritional Problems Rheumatoid Arthritis Thyroid Problems Time of Day

LASIK Surgery Cosmetic Surgery Gender Mechanical

Disturbances Exposure Keratitis Entropion Ectropion Symblepheron

Formation Large Lid Notches Lagophthalmos Incomplete Blinking Dellen Formation Illumination

Temperature Humidity Air movement Allergies Change in

environment Reading Watching Movies Sleep

Prause JU, Norn M. Relation Between Blink Frequency and Break-Up Time. Acta Ophthalmol. 1983 61: 108-116.

Cho P, Cheung P, Leung K, Ma V, Lee V. Effect of Reading on Non-Invasive Tear Break-Up Time and Inter-Blink Interval. Clin. Exp. Optom. 1997 80: 62-8.

Tsubota K, Seiichiro H, Okusawa Y, Egami F, Ohtsuki T, Nakamori K. Quantitative Videographic Analysis of Blinking in Normal Subjects and Patients with Dry Eye. Arch. Ophthalmol. 1996

114(6): 715-720.

Nally L, Ousler GW, Abelson MB. Ocular discomfort and tear film break-up time in dry eye patients: a correlation. IOVS 2000 41(4): 1436.

Collins M, Seeto R, Campbell L, Ross M. Blinking and Corneal Sensitivity. Acta Ophthalmologica 1989 67(5): 525-531.

Abelson MB, Holly FJ. A tentative mechanism for inferior punctate keratopathy. Am. J. Ophthalmol. 1977 83: 866-869.

Doane MG. Dynamics of the Human Blink. Ber. Disch. Ophthalmol. Ges. 1980 77: 13-17.

Kaneko K, Sakamoto K. Spontaneous Blinks as a Criterion of Visual Fatigue During Prolonged Work on Visual Display Terminals. Perceptual and Motor Skills 2001 92(1): 234-250.

Conditions associated with dry eye

• Chronic Systemic inflammation

Sjogren’s Syndrome, rheumatroid arthritis, lupus

• Ocular surface inflammation

Meibomian gland disease, keratitis, infection

• Hormonal changes

Menopause, oral contraceptives, pregnancy, lactation

• Systemic disease

Diabetes, thyroid

– Stevens Johnson’s syndrome : severe dry eye

• Environment

• Smoke, air pollution, wind, heat, air-conditioning, air travel, light, dry climate

• staring at TV , computer

reading , SMS etc

( Less blinking reflexes )

• Medications

• Blink disorder

Anatomical

surgical (LASIK)

Systemic Topical

Anti-depressantsAntihistaminesAntihypertensivesdiureticsB-blockerAntimuscarinicsanesthesia phenothiazinesAtropineoral contraceptives anxiolyticsantiparkinsonianAnticholinergicsantiarrhythmicsisotretinoin

decongestantspreservatives anesthetics

Dry eye is not just a disease,It is a complex,

multi-factorial disorder

Diagnosis of dry eye

• Obtaining patient history

• Physical examination

• Staining of the corneal surface

• Tests of tear production

• Tests of tear film stability (TBUT)

Commonest symptoms : “ eye discomfort “

• irritating

• burning / stinging

• easily fatigue

• itchy

• foreign body sensation

• photophobia

• fluctuating vision

• contact lens intolerance

• sticky

• dryness / watering

• sleepy

• discharge

• redness

• blurred vision

Patient History

• Ocular symptoms Redness, dryness, itching, burning, constant tearing, etc.

• Current illnesses Sinus or ear trouble, hay fever, skin disorders, asthma, etc.

• Medications Antihistamines, beta blockers, oral contraceptives, etc.

• Duration of the present problem Recent or ongoing...weeks, months, etc.

• Family history of a similar problem Parents, siblings,

• Any present refractive condition Glaucoma, cataracts, contact lenses, etc.

Physical examination

Five main components of a clinical examination involve:

• The lids

• The blink mechanism

• The tear film

• The ocular surface

• General physical assessment

Signs

• hyperemia

• low tear meniscus

• Increase tear debris

• fast tear break up time

• conjunctival pleating

• conjunctival staining

• blepharitis

• increased cytokines

• corneal staining /damage : epitheliopathy, filaments, ulcers

Lid Wiper Epitheliopathy

Slit-Lamp BiomicroscopyCorneal Staining

Types of corneal staining include:

• Fluorescein – Discloses epithelial breaks, erosions and filaments

• Rose Bengal – Assesses degenerated tissue; indirectly measures tear volume deficiencies

• Lissamine Green – similar to rose bengal but more comfortable to the patient

• Carboxyfluorescein – shows the extent of any damage to the corneal epithelium

Tear Film Break-Up Time ( TBUT )

• Time required for a dry spot to appear on the corneal surface after blinking

• Dry spots will appear as part of normal evaporation and diffusion of tears

• Normal healthy eye : dry spots start occuringbetween blinks at about 10-12 seconds, and an urge to blink is triggered

0 1 2 3 4 5 6 7

Time (seconds)

Blink TFBUT

StainingOcularDiscomfort

Blink

Tear ProtectedOcular Surface

UnprotectedOcular Surface

Cycle Repeats

Dry Eye -Consequences of an‘Unprotected Ocular

Surface’

Tests of tear production

• standard diagnostic tests for

aqueous tear production

• Schirmer test I : the filter paper strip is placed in the unanesthetized eye and is left in place for 5 minutes.

• no dry eye : enough tears to wet 20 to 25 mm of the paper strip

• Wetting of < 10 mm is suggestive of dry eye

• Schirmer Tear Test II : with topical anesthesia .

Ferning test : quality and stability of tear film

I

III IV

II

How to treat ... Are artificial tears enough?

Treatment : supportiveGoals :

• Alleviate symptoms• Reduce ocular morbidity• Prevent complications• Improve quality of life• Improve productivity

• Maximise benefit and relief• Minimise cost

Consultations• rheumatologist , internal medicine, dermatologis

Treatment Strategy Intervention

Tear supplementation Lubricants

Tear retention • Punctal occlusion• Moisture chamber spectacles• Contact lenses

Tear stimulation Secretagogues

Biologic tear substitutes • Serum• Salivary gland transplantation

Anti-inflammatory therapy • Cyclosporine• Corticosteroids• Tetracyclines

Essential fatty acids Omega-3 fatty acids

Environmental strategies • Avoid low humidity

• Avoid drafts• VDT lowered below eye level

Anatomy of an artificial tear

Qualities of an ideal Dry Eye Product

• Ability to spread evenly over the cornea quickly and efficiently (Long Lasting)

• Prolonged retention time for extended efficacy(Long Lasting)

• Objective and subjective improvement in patient signs and symptoms (Efficacy)

*Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocular Surface 2007;5:165.

Varieties of Artificial Tears / Lubricants

• Hydroxypropyl Methylellulose ( TNII ,Genteal )

• Carboxy Methylcellulose ( Refresh )

• Polyvinyl Alcohol ( Hypotears )

• Dextran

• Glycerin

• Eye Gels ( vit.A palmitate)

• Polyethylene glycol : Systane

• Sodium hyaluronates 0.1 – 0.3%

HYALUBSodium hyaluronates 0.1%

• Lubricating , protecting

• Powerful wetting agent

• Long lasting

• Reduce ocular surface damage

• Accelerate wound healing

• Safe , well tolerated for long term use

• Non preservative

Treatment should be based on disease severity

• The ideal artificial lubricant should be preservative-free, contain potassium,

bicarbonate, and other electrolytes, and have a polymeric system to increase its retention time.

• The goals of pharmacotherapy To reduce morbidity andto prevent complications

Severity level 1 2 3 4

Symptoms Mild/episodic, with stress

Moderate episodic/chronic,+ stress

Severe frequent constant no stress

Severe and or disabling no stress

Visual symptoms None, or episodic mildfatigue

Annoying and/or limiting lidfatigue

Annoying, chronic, and/orconstant, limiting activity

Constant and/or possibly disabling

Conjunctivalinjection

None to mild None to mild +/- +/++

Conjunctivalstaining

None to mild Variable Moderate to marked Marked

Corneal staining(severity/location)

None to mild Variable Marked, central Severe punctateerosions

Corneal/tear signs None to mild Mild debris, decreasedmeniscus

Filamentary keratitis,mucus clumping,increased tear debris

Filamentary keratitis,mucus clumping,increased tear debris,ulceration

Lid/Meibomianglands

MGD variable MGD variable Frequent Trichiasis, keratinizationsymblepharon

TBUT (sec) Variable <10 <5 Immediate

Schirmer score

(mm/5 min)

Variable <10 <5 <2

Severity level 1 2 3 4

Treatment options

If no improvement to Level 1, add:

If no improvement to Level 2, add:

If no improvement to Level 3, add:

• Patient educationenvironment/dietarymodification• Eliminate offendingsystemic medications• Artificial tears/ointments/gels• Lid therapy

• nonpreservedartificial tears •AntiinflammatoryDrugs : Topical :- Corticosteroids- cyclosporinA- omega3 fatty acids•Tetracyclines•Cyclosporine A•Punctal plugs•Secretagogues•Moisture goggles

• Serum :- autologus- Umbilical cord •Contact lenses• Permanent punctal occlusion

Systemic antiinflammatory•Oral cyclosporine•AcetylcysteineMoisture gogglesLid Surgery:tarsorrhaphy, AMT graftMucous m graft Salivary gland transplantation

Report of the Definition and Classification Subcommittee of the International Dry Eye WorkShop (2007). Ocul Surf 2007 Apr;5(2):75-92

Surgical treatments

( reserved for severe disease poor/non-

compliance )

• Punctum Plug

• Surgical / thermal / laser occlusion

Advantages

• Prolongs tear retention • Reduces frequency of artificial tears

needed for symtomatic relief

Punctal plugs

– Absorbable

- Made of collagen or polymers

- occlusion duration ranges from 7-180 days

- plugs dissolve by themselves or may be removed by saline irrigation

– Non-absorbable

- Made of silicone

- punctum plugs and intracanalicular plugs.

( Cylindrical Smartplug )

Complications of plugs:

• insertion too far, unable to retrieve• spontaneous loss into the canaliculus• canalicular or NLD obstruction• extrusion of plug• scarring of punctum• ocular surface irritation, epiphora• papillomatous overgrowth

of exuberant conjunctiva

• Retains inflammatory mediators• Infection / discomfort (Plugs)• Costly

Surgical treatments

• Parotid duct translocation

– Frequently secrete more fluid ,increases during eating

– Salivary gland may be affected in Sjogren syndrome

• Tarsorrhaphy

– Narrowing of the palpebral fissure decreasing the rate of evaporation

Future causal therapy of dry eye

• Cyclosporine A 0.05% drops in moderate and severe ocular surface inflammation

• essential fatty acids omega-3 in reducing ocular surface irritation

• Secretion stimulation, mucin stabilizing ,mucolytic agents ,local androgenic complexes

• systemic immunomodulation / immunosuppressive in severe cases

• topical anti-CD4 monoclonal antibody to suppress the activation of CD4+ T cells

• Dry eye is not just a disease,

It is a complex,

multi-factorial disorder

• Regardless of the cause,

all dry eye patients have in common

an abnormal tear film or abnormal tear function

• individuals who experience signs and symptoms of dry eye at one time or another

due to environmental factors

= 100%

Thank you