Ocular Surface Diseases

1. Ocular Surface Diseases The Fourth Affiliated Hospital of CMU Eye Centre

2. Overview http://www.virtualcancercentre.com

3. Roles and Characteristics of the eyelids • Eye protection • Regular blink: protection and stability of the tear film • Rich of glands • Adequate blood supply • No venous valve

4. Conception • Corneal epithelium • Conjunctival epithelium • Tear film • Clinical ocular surface consist of conjunctiva cornea eyelids lacrimal gland lacrimal passages

5. Tear and the Tear Film • Function : 1.Cleaning 2.Wetting ocular surface 3.Bacteriostasis 4.Supporting the cornea (oxygen supply) http://www.drmalcolmmckellar.co.nz

6. Origin of Epithelium • Stem cells, SC Corneal epithelium derived from the Limbal stem cells. Conjunctival epithelium derived from forniceal and palpebral regions.

7. Ocular Surface Disease ★

8. Conception • The ocular surface is a complex biological continuum responsible for the maintenance of corneal clarity, elaboration of a stable tear film for clear vision, as well as protection of the eye against microbial and mechanical insults. • Comprising a variety of disorders on cornea, eyelid, conjunctiva, lacrimal apparatus and tear film.

9. Classification • Corneal, conjunctival lesion Squamous epithelization type Limbal stem cell deficiency type • Tear film disorders Aqueous tear deficiency Lipid tear deficiency Mucoprotein deficiency Kinetic disorders of lacrimal fluid

10. Treatment • Reconstruction Epithelium, limbal stem cells Lacrimal secretion, tear film Innervation (nerve restore) Structure and function of eyelid • Surgical operation To re-establish conjunctiva, cornea, tear film and eyelid.

11. Healthy tear film Dry eye Dry Eye http://www.chronicdryeye.com

12. Conception • Dry eye (known by doctors as keratoconjunctivitis sicca) is a chronic lack of sufficient lubrication and moisture in the eye. • Its consequences range from subtle but constant irritation to ocular inflammation of the anterior (front) tissues of the eye.

13. www.virtualmedicalcentre.com Tear Secretion • Lacrimal gland Producing the watery part of the tear film called the aqueous. • Meibomian glands Producing lipids which keep the tear film from evaporating. • Goblet cells of the conjunctiva Producing mucin which allows the wetting of the ocular surface as well as stabilizes the tear film.

14. http://www.drmalcolmmckellar.co.nz Etiological factor & Classification • Aqueous tear deficiency • Lipid tear deficiency • Mucoprotein deficiency • Kinetic disorders of lacrimal fluid

15. Clinical Manifestation • Dry eye symptoms asthenopia irritation, grittiness dryness burning ophthalmalgia light sensitivity pink-eye • Do you regularly experience one or several symptoms above? • Some diseases and conditions (like rheumatoid arthritis, lupus and Sjögren’s Syndrome) also cause chronic Dry Eye in many patients. • On the other hand, activities like reading, Wearing contact lenses or working at the computer may cause Dry Eye.

16. Diagnostic Tests for Dry Eye • Dry Eye questionnaire • Lacrimal river width • Schirmer test – uses paper strips under eyelid to measure the wetness that collects over a specific period of time. • Break-up time of tear film (BUT) • Staining – uses special dyes to highlight areas of possible damage to the eye surface. • Tear ferning test • Lactoferrin contents • Tear penetration pressure test • Corneal tonographic map • Impression cytology

17. Diagnosing • Schirmer test, BUT, Staining • Foundation Symptom Instability of tear film Damage on epithelium Tear penetration pressure increasing

19. Treatment • According to the clinical category For tear deficiency: Maintain moisture in the eyes; reducing the evaporation; increasing the secretion; controlling inflammation & immunoreaction. For over-evaporation: Therapy the Meibomian gland dysfunction; controlling inflammation; cleaning eyelid; decreasing the evaporation; lipid replacement. • According to the eye conditions For intermittent symptoms: Artificial tears add volume to the tear film as long as they remain in contact with the surface of the eye. For midrange dry eye: Artificial tears and punctal occlusion. For Severe dry eye: Appending cyclosporin, surgery.

20. Summary • Eliminating the etiological factors • Tears replacement therapy • Maintain moisture in the eyes • Increasing the tear secretion • Immune inhibition therapy • Re-establish the tear film • Other supporting treatment

21. http://www.dryeyezone.com Meibomian Gland Dysfunction

22. http://www.revophth.com Etiological Factor • Failure of the glands to produce or secrete lipids. • Wax ester declining and cholesterol increasingmake the symptoms worse . • Lack of tears and tear penetration pressure increasing. • Lupus, brandy nose etc.

23. Figure: Notching of the lid caused by loss of meibomian glands. http://www.eyehealthnutrition.com Clinical Manifestation • Common in aged people and who livedin cold region. • No specific symptoms. • Lid-margin mostly thickening; abnormal secretion while pressurizing. • Disorder in Meibomian gland, eyelid, conjunctiva.

24. Figure: No visible meibomian gland orifices: Eversion of the lower lids in both eyes showed atresic meibomian glands. http://www.ophmanagement.com Diagnosing • Absence of Meibomian gland. • The gland orifices are often compromised due to stenosis or closure. • A declining quality and quantity of lipid secretion. Anyone of the physical signs can make the diagnosis of Meibomian gland dysfunction if the patient has clinical symptoms.

25. Treatment Clearing • Hot fomentation on eyelids for 5~10mins. • Massaging the eyelids. • Swabbing the lid-margin with mild cleaning solution.

26. Treatment • Antibiotics oral administration. • Local Medication Antibiotic eye drops Glucocorticoid eye drops (short term) Artificial tears

27. The End

28. Lacrimal river width

29. SchirmerTest • Normal：≥10mm/5min

30. Tear break-up time, BUT

31. 0分 1分 3分 2分 Staining • Using special dyes to highlight areas of possible damage to the eye surface.