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

2. Affiliations BMI Droitwich BMI Priory, Edgbaston
Spire Parkway, Solihull

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

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

5. Blepharitis

6. Conjunctivitis

7. Dry eye

8. Watery eye

9. Foreign body

10. Keratitis

11. Uveitis

12. Cataracts

13. Lumps & Bumps

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

15. Overview

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

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

18. 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.

19. Tear Film in relation to Cornea

20. Tear and the Tear Film Function : 1.Cleaning 2.Wetting ocular surface
3.Bacteriostasis
4.Supporting the cornea
(oxygen supply)

21. 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.

22. Dry Eye
Healthy tear film
Dry eye

24. Etiological factor & Classification
Aqueous tear deficiency
Lipid tear deficiency
Mucoprotein deficiency
Kinetic disorders of lacrimal fluid

25. 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.

26. 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.

27. 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

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

29. Schirmer Test
Normal ：≥10mm/5min

30. Tear break-up time, BUT

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

32. Lacrimal river width

33. Tear Osmolarity measurement

34. Meibomian Gland Dysfunction

35. 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.

36. 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.

37. 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.

38. Ocular Surface Disease ★

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

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

42. 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

43. 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.

44. Dry Eye Disease Workshop

45. 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.

46. A Simple Treatment chart

47. 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:   /OPTH.S65263
PMCID: PMC

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

49. Too many choices …..

50. Tear substitutes

51. Treatment pathway

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

53. 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

54. 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

55. Any Questions?