Transcript tear deficiency

Dry eyes
Dr R R Sudhir
Dr. G. Sitalakshmi Memorial Clinic for Ocular Surface
Disorders
Prof G Falcinelli MOOKP centre.
Medical Research Foundations,18, College Road, Chennai 600 006,Tamil Nadu, India
Dry eye
• Disorder of tear film due to tear
deficiency or increased evaporation
which damages the inter palpebral
ocular surface and is associated with
symptoms of discomfort.
(NEI1993workshop ).
• Lacrimal keratoconjunctivitis
Dysfunctional lacrimal functional
unit which causes unstable tear film
which promotes ocular surface
inflammation, epithelial disease and
symptoms of discomfort
• DEWS: Multifactorial disease of tears
and ocular surface resulting in
symptoms of discomfort, visual
disturbance and tear film instability with
potential damage to ocular surface with
increased tear film osmolarity and
surface inflammation
Ocular surface
• Conjunctiva
• Limbus
• Cornea
• Close interaction between the ocular surface and
the adnexae (lids, lacrimal glands)
• Ocular surface disease
• Holistic approach essential
 Compositional factors
 Dynamic factors
 Neurotrophic state
 Tear clearance
Dry eye
Compositional
factors
Lipids
Mebomian gland
Aqueou
s
Lacrimal gland
Mucin
Eyelid
blinking
Ocular surface epithelia
Tear spread
Tear clearance
Hydrodynamic
factors
Eye lid
closure
Decreased evaporation
Dry eye: more than an
annoyance…
Can cause functional
and occupational
disability
Dry eye can cause serious corneal
disease !
Irregular corneal surface or altered barrier function
Dry eye can also be
sight-threatening !
Infective keratitis
Sterile Melting
Simulators
• Lid margin disease
• Allergic conjunctivitis
• Infective etiology
• Conjunctivitis Medicamentosa
• Work-related symptoms
Simulators
• Convergence insufficiency
• Thyroid eye disease
• Conjunctivochalasis
• Superior limbic keratoconjunctivitis
• Mucus fishing syndrome
• Floppy eyelid syndrome
EXACERBATORS
• Lid margin disease
• Superior limbic
keratoconjunctivitis
• Conjunctivitis medicamentosa
• Work-related exacerbation
• Nocturnal lagophthalmos
Assessment before Treatment
• Is there tear insufficiency ?
• Exacerbating factors ?
• What is the severity ?
• Is there associated systemic disease ?
• How does the patient perceive his
problem ?
Approach to itchy burny eyes
8. Rx
1. Symptoms
7.Lab. tests
Patients with
dry eye
6. Dye
tests
5. conj./ cornea
2. History
3. Lids
4.Tear
strip
1. Symptoms
Patients
with
dry eye
What are the symptoms ?
… stinging or burning eyes
… scratchiness
… mucus accumulation
… eye irritation from wind / smoke
… difficulty in contact lens wear
… EXCESS TEARING ?
2. History
Patients with
dry eye
History
AgeSexOnset
Duration
Progress
Drug allergy
Systemic medications
Itching –seasonal/perineal
Burning- morning/evening
Tearing
h/o systemic problems
Joint pains
Dry mouth
Any other systemic
disease
itching
Young age
Seasonal/perineal
Perilimbal pigmentation
Papillary reaction
Horner trantas dots.
VKC
Allergic diathesis
Flexural crease
changes
Skin lesions
AKC
Rhinitis
Seasonal
Hay fever
VKC with perilimbal pigmentation
Burning
morning
Decreased tears
ATD
evening
Lid margin disease- MGD
Conjunctivochalasis
Normal tearsfloopy eyelid
Convergence and
accomodation insufficiency
Patients with
dry eye
3. Lids
External examination
Structure and function of lids
Entropion
Ectropion
Lagophthalmo
s
Proptosis
Ptosis
Blink
Rate
Completenes
s
Essential
Blepharospas
m
Skin changes
atopy/eczem
a
Infections
Acne
Rosacea
Floppy eye
lid
Meibomitis- plugged orifice ,telengiectatic vessels, thick secretions
Blepharitis
Scaling and crusting
Lid margin keratinisation
Patients
with
dry eye
4 conj./ cornea
Papillae
Herbets pits
Follicles
OCP
Phlycten
SLKC
Marginal infiltrate
Phlycten
SPK
Melts
Filaments
Conjunctivalisation
Patients
with
dry eye
5.Tear
film
Tear film
Height
 low – dry eyes
 High-tear stasis
Quality:
 Oily tear film- Mebomian gland
dysfunction
Tear film break up
Invasive/non invasive
methods
< 10 seconds – unstable
tear film
Schirmers test
Fluorescein clearance test
Patients
with
dry eye
6 Surface staining
Fluorescein
staining
Rose Bengal staining
Lissamine green staining
7 lab
investigations
Patients
with
dry eye
Local investigations
 Conjunctival swabinfections
 Conjunctival scrapping
Eosinophills/Inclusion
 Impression cytologysquamous metaplasia
goblet cell density
 Conjunctival biopsy- IFOCP
Systemic investigation
CBC
ESR
CRP
RA
ANA
Referral to
Rheumatologist
Referral to
dermatologist
Clinical measures of dry eye
8. Rx
Patients with
dry eye
Management strategies
• Treat symptoms
• Treat the aggravating factors
• Treat the associated ocular problems
• Treat the ocular surface- decrease inflammation, prevent cicatrising
changes
• Treat the systemic factors
• Treat the patient
DRY eye Severity- Delphi
Panel
DEWS Study- Signs and
symptoms
Dry eye- treatment plan