Dry eyes Dr R R Sudhir Dr. G. Sitalakshmi Memorial Clinic for Ocular Surface Disorders Prof G Falcinelli MOOKP centre. Medical Research Foundations, 18, College Road, Chennai ,Tamil Nadu, India

Dry eye Disorder of tear film due to tear deficiency or increased evaporation which damages the inter palpebral ocular surface and is associated with symptoms of discomfort. (NEI1993workshop ). Lacrimal keratoconjunctivitis Dysfunctional lacrimal functional unit which causes unstable tear film which promotes ocular surface inflammation, epithelial disease and symptoms of discomfort DEWS: Multifactorial disease of tears and ocular surface resulting in symptoms of discomfort, visual disturbance and tear film instability with potential damage to ocular surface with increased tear film osmolarity and surface inflammation

Conjunctiva Limbus Cornea Close interaction between the ocular surface and the adnexae (lids, lacrimal glands) Ocular surface disease Dry eye Holistic approach essential  Compositional factors  Dynamic factors  Neurotrophic state  Tear clearance Ocular surface

Compositional factors Hydrodynamic factors Lipids Aqueou s Mucin Eyelid blinking Eye lid closure Mebomian gland Lacrimal gland Ocular surface epithelia Tear spread Tear clearance Decreased evaporation

Dry eye: more than an annoyance… Can cause functional and occupational disability

Dry eye can cause serious corneal disease ! Irregular corneal surface or altered barrier function

Dry eye can also be sight-threatening ! Infective keratitisSterile Melting

Simulators Lid margin disease Allergic conjunctivitis Infective etiology Conjunctivitis Medicamentosa Work-related symptoms

Convergence insufficiency Thyroid eye disease Conjunctivochalasis Superior limbic keratoconjunctivitis Mucus fishing syndrome Floppy eyelid syndrome Simulators

EXACERBATORS Lid margin disease Superior limbic keratoconjunctivitis Conjunctivitis medicamentosa Work-related exacerbation Nocturnal lagophthalmos

Assessment before Treatment Is there tear insufficiency ? Exacerbating factors ? What is the severity ? Is there associated systemic disease ? How does the patient perceive his problem ?

Approach to itchy burny eyes

5. conj./ cornea 7.Lab. tests 3. Lids 2. History 8. Rx

Patients with dry eye 1. Symptoms

What are the symptoms ? … stinging or burning eyes … scratchiness … mucus accumulation … eye irritation from wind / smoke … difficulty in contact lens wear … EXCESS TEARING ?

2. History

History Age- Sex- Onset Duration Progress Drug allergy Systemic medications Itching –seasonal/perineal Burning- morning/evening Tearing h/o systemic problems Joint pains Dry mouth Any other systemic disease

itching Young age Seasonal/perineal Perilimbal pigmentation Papillary reaction Horner trantas dots. VKC Allergic diathesis Flexural crease changes Skin lesions AKC Rhinitis Seasonal Hay fever VKC with perilimbal pigmentation

Burning morning evening Decreased tears ATD Normal tears- floopy eyelid Lid margin disease- MGD Conjunctivochalasis Convergence and accomodation insufficiency

3. Lids

External examination Structure and function of lids Entropion Ectropion Lagophthalmo s Proptosis Ptosis Blink Rate Completenes s Essential Blepharospas m Skin changes atopy/eczem a Infections Acne Rosacea Floppy eye lid

Blepharitis Scaling and crusting Meibomitis- plugged orifice,telengiectatic vessels, thick secretions Lid margin keratinisation

4 conj./ cornea

Papillae Follicles Phlycten Herbets pits OCPSLKC

Marginal infiltrateSPK Filaments PhlyctenMeltsConjunctivalisation

5.Tear film

Tear film Height  low – dry eyes  High-tear stasis Quality:  Oily tear film- Mebomian gland dysfunction Tear film break up Invasive/non invasive methods < 10 seconds – unstable tear film

Schirmers test Fluorescein clearance test

Patients with dry eye 6 Surface staining

Fluorescein staining

Rose Bengal staining

Lissamine green staining

7 lab investigations

Local investigations  Conjunctival swab- infections  Conjunctival scrapping Eosinophills/Inclusion  Impression cytology- squamous metaplasia goblet cell density  Conjunctival biopsy- IF- OCP Systemic investigation CBC ESR CRP RA ANA Referral to Rheumatologist Referral to dermatologist

Clinical measures of dry eye

8. Rx

Management strategies Treat symptoms Treat the aggravating factors Treat the associated ocular problems Treat the ocular surface- decrease inflammation, prevent cicatrising changes Treat the systemic factors Treat the patient

DRY eye Severity- Delphi Panel

DEWS Study- Signs and symptoms

Dry eye- treatment plan