1. 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 600 006,Tamil Nadu, India

2. 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

3. 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

4. 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

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

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

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

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

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

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

11. 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 ?

12. Approach to itchy burny eyes

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

14. Patients with dry eye 1. Symptoms

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

16. 2. History

17. 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

18. 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

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

20. 3. Lids

21. 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

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

23. 4 conj./ cornea

24. Papillae Follicles Phlycten Herbets pits OCPSLKC

25. Marginal infiltrateSPK Filaments PhlyctenMeltsConjunctivalisation

26. 5.Tear film

27. 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

28. Schirmers test Fluorescein clearance test

29. Patients with dry eye 6 Surface staining

30. Fluorescein staining

31. Rose Bengal staining

32. Lissamine green staining

33. 7 lab investigations

34. 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

35. Clinical measures of dry eye

36. 8. Rx

37. 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

38. DRY eye Severity- Delphi Panel

39. DEWS Study- Signs and symptoms

40. Dry eye- treatment plan