Transcript DRY EYE
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:
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)
Sjogren’s
EVAPORATIVE TEAR
DEFICIENCY (ETD)
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
Detailed history
Lid evaluation
1.
2.
I.
II.
Palpebral fissure height
Lid margin (Blepharitis, meibomitis and
MGD)
3.Tear film evaluation
I.
Look for tear film debris
II.
Tear meniscus height
4.Cornea and conjunctiva evaluation
I.
SPK, filaments
II.
Congestion in conj, mucus discharge
5.Fluorescein stain
I.
Tear film stability
II.
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. Stain
1. Mild
- <1/3 of corneal epi surface
2. Moderate
- <1/2 of corneal epi surface
3. 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
Treatment
Tear replacement
Tear Preservation
Artificial tears
Punctal Plugs
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
TMH
BUT
Flou
RB
-
open
Decreased
2 sec
3/3/3
0/0/0
Impression
Severe Dry eye secondary to SJ syndrome
Advise
OU: Punctal cautery
Symptoms alleviated after Sx
To continue Tears plus