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Dry eye work up

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

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  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: • 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)

  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 anunstable tear filmduring 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) Non – Sjogren’s 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. Detailed history • Lid evaluation • Palpebral fissure height • Lid margin (Blepharitis, meibomitis and MGD)

  15. 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

  16. Corneal filaments

  17. 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

  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 • 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

  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

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

  28. 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

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

  30. CASE DISCUSSION

  31. 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

  32. 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

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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

  40. 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

  41. 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

  42. 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

  43. Advise • OU: Punctal cautery • Symptoms alleviated after Sx • To continue Tears plus

  44. THANK YOU

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