1. Dry eye work up Speaker: RAJKUMAR N R Moderator: Ms. RAJALAKSHMI.G Chairperson: Dr. R R SUDHIR

2. ANATOMY OF TEAR FILM

3. 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)

4. 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

5. 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

6. 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

7. 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

8. RISK FACTORS  Age  Women  Smoking  Using of drugs like Anti muscarinics Anti histamine Anesthetics Phenothiazines Anti Androgens

9. CLASSIFICATION  According to National Eye Institute, dry eye classified as DRY EYE AQUEOUS TEAR DEFICIENCY (ATD) EVAPORATIVE TEAR DEFICIENCY (ETD) Sjogren’s Non – Sjogren’s

10. 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

11. EVAPORATIVE TEAR DEFICIENCY Meibomian gland disease Lid surfacing/blinking anomalies Contact lens related Chronic allergy/toxicity

12. 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

13. EVALUATION OF DRY EYE

14. 1. Detailed history 2. Lid evaluation I. Palpebral fissure height II. Lid margin (Blepharitis, meibomitis and MGD)

15. 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

16. Corneal filaments

17. 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

18.  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

19.  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

20.  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

21.  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

22. Lissamine green B  Dye which stains dead and degenerated cells  Equivalent to Rose Bengal  Produces less irritation

23. 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

24.  The most sensitive and specific test for dry eye is osmolarity measurement of nanoliter tear samples collected from the inferior marginal tear strip

25.  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)

26. MANAGEMENT OF DRY EYES

28. TYPES OF TREATMENT  Medical/pharmacological  Supportive  Therapy for underlying cause  Surgical Temporary occlusion Permanent occlusion  Laser punctoplasty  Punctal cautery

29. 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

30. SUPPORTIVE THERAPY  Reduces tear loss by evaporation Glasses, Eye shields etc., Hydrophobic contact lenses Vaporizer or humidifier

31. CASE DISCUSSION

32. 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

33.  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

34.  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

35.  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

36.  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

37. 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

38.  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

39.  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

40.  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

41.  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

42.  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

43.  Dry eye evaluation OU Punctum-open TMH-Decreased BUT-2 sec Flou-3/3/3 RB-0/0/0  Impression Severe Dry eye secondary to SJ syndrome

44.  Advise OU: Punctal cautery  Symptoms alleviated after Sx  To continue Tears plus