Common Ophthalmic Conditions in Primary Care - Management of Dry Eyes Mr Yajati K Ghosh FRCSEd Consultant Ophthalmic Surgeon Birmingham & Midland Eye Centre

Affiliations BMI Droitwich BMI Priory, Edgbaston Spire Parkway, Solihull

Subspeciality interests Lid and lacrimal surgery Periocular cancer surgery Phacoemulsification Cataract surgery Management of watery eyes

Common Ophthalmic Conditions Blepharitis Conjunctivitis Dry eyes Watery eyes Foreign body Keratitis Uveitis Lumps & Bumps Cataracts Red Eye

Blepharitis

Conjunctivitis

Dry eye

Watery eye

Foreign body

Keratitis

Uveitis

Cataracts

Lumps & Bumps

What to do? 50% of ALL red eyes and irritable eyes are due to Dry Eye related conditions ………..

Overview http://www.virtualcancercentre.com

Roles and Characteristics of the eyelids Eye protection Regular blink: protection and stability of the tear film Rich of glands Adequate blood supply

The Anatomy Corneal epithelium Conjunctival epithelium Tear film Clinical ocular surface consist of conjunctiva cornea eyelids lacrimal gland lacrimal passages

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. www.virtualmedicalcentre.com

Tear Film in relation to Cornea

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

Concept 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.

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

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

Conception Dry eye - 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.

Clinical Manifestation Dry eye symptoms asthenopia irritation, grittiness dryness burning 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. Activities like Reading, Wearing contact lenses or Working on the Computer may cause Dry Eye.

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 lab – measuring tear osmolarity Tear ferning test Lactoferrin contents Tear penetration pressure test Corneal tonographic map Impression cytology

Diagnosing Schirmer test, BUT, Staining Foundation Symptom Instability of tear film Damage to epithelium Tear penetration pressure increasing

Schirmer Test Normal ：≥10mm/5min

Tear break-up time, BUT

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

Lacrimal river width

Tear Osmolarity measurement

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

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

Clinical Manifestation Common in aged people and who lived in cold region. No specific symptoms. Lid-margin mostly thickening; abnormal secretion while pressurizing. Disorder in Meibomian gland, eyelid, conjunctiva. Figure: Notching of the lid caused by loss of meibomian glands. http://www.eyehealthnutrition.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. Any one of the physical signs can make the diagnosis of Meibomian gland dysfunction if the patient has clinical symptoms. Figure: No visible meibomian gland orifices: Eversion of the lower lids in both eyes showed atresic meibomian glands. http://www.ophmanagement.com

Ocular Surface Disease ★

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

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

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

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.

Dry Eye Disease Workshop

Treatment According to the clinical category For tear deficiency: Maintain moisture in the eyes; reducing the evaporation; increasing the secretion; controlling inflammation & immunoreaction. For excess-evaporation: Therapy of 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.

A Simple Treatment chart

Literature Artificial tears potpourri: a literature review Majid Moshirfar,1 Kasey Pierson,2,* Kamalani Hanamaikai,3,* Luis Santiago-Caban,1 Valliammai Muthappan,1 andSamuel F Passi1 Clin Ophthalmol. 2014; 8: 1419–1433. Published online 2014 Jul 31. doi:  10.2147/OPTH.S65263 PMCID: PMC4124072

Artificial Tear Groups HPMC Carboxy Methyl Cellulose PVA Liquid Polyols Hyaluronic acid Inserts Miscellaneous

Too many choices …..

Tear substitutes

Treatment pathway

The Future Newer eye drops – Lifitegrast, Tavilermide Platelet rich plasma / Albumin precursor Non-invasive intranasal lacrimal neuro-stimulator Salivary gland transplantation Stem cell therapy

The DRY EYE PATHWAY Patient to GP with dry eyes Suffolk Primary Eyecare Triage Service Patient sent to an optometrist enhanced service provider(ESP) Hospital if beyond capabilities of ESP Treatment by ESP + drops and management plan Review in one month

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

Any Questions?