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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: Anterior Lipid layer (Meibomian, Zeiss and Moll glands) Middle Aqueous layer (Lacrimal and accessory glands of Krause & Wolfring)
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Dry eye work up Speaker : RAJKUMAR N R Moderator : Ms. RAJALAKSHMI.G Chairperson : Dr. R R SUDHIR
ANATOMY Three layers of Tear film: • Anterior Lipid layer (Meibomian, Zeiss and Moll glands) • Middle Aqueous layer (Lacrimal and accessory glands of Krause & Wolfring) • 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 anunstable tear filmduring 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) EVAPORATIVE TEAR DEFICIENCY (ETD) Non – Sjogren’s 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
Detailed history • Lid evaluation • Palpebral fissure height • Lid margin (Blepharitis, meibomitis and MGD)
3.Tear film evaluation • Look for tear film debris • Tear meniscus height 4.Cornea and conjunctiva evaluation • SPK, filaments • Congestion in conj, mucus discharge 5.Fluorescein stain • Tear film stability • Corneal staining
SPECIAL EVALUATIONS • Schirmer’s Test • Schirmer I • Normal 10 – 30 mm in 5 min • 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 • Mild - <1/3 of corneal epi surface • Moderate - <1/2 of corneal epi surface • 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)
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 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 - open • TMH - Decreased • BUT - 2 sec • Flou - 3/3/3 • RB - 0/0/0 • Impression • Severe Dry eye secondary to SJ syndrome
Advise • OU: Punctal cautery • Symptoms alleviated after Sx • To continue Tears plus