Dry Eye

Dede Achmad Basofi

Introduction
Is NOT a disease entity but a SYMPTOM
complex occuring to defficiency or
abnormalities of the tear film
Inadequate tear volume or function
Unstable tear film
Risk Factor
Classification
Pathogenesis
Tear Film
The three layers of the tear film

Bowling B. Kanski's Clinical Ophtalmology; A Systematic

Approach, Eight Edition. 2016. Elsevier: Sydney, Australia
Dry Eye
Tear film has three layers
Lipid : Meibomian glands
Aqueous : Lacrimal glands
Mucous : Conjunctival goblet cells
The function of tear film
Keeps the cornea and conjunctiva moist
Provide oxygen to the corneal epithelium
Washes away debris and noxious irritants
Prevents infection
Facilitates movement of the lids over the globe
Dry Eye
Lipid Layer
Composition
Outer layer : polar phase containing phospholipids
The polar lipids are bound to lipocalins within the aqueous
layer
Lid movement during blinking is important in releasing lipids
from glands
Function
Prevent evaporation
Act as surfactant
Deficiency results in evaporative dry eye
Dry Eye
Aqueous Layer
Secretion
Lacrimal glands produce about 95% of the aqueous
component
Secretion of tears has basic and much greater reflex
components, secretion can increase 500% in response to
injury
Composition
Water, electrolytes, dissolved mucins and protein
Injury : growth factors
Pro-inflammatory IL cytokines accumulate during sleep
when tear production is reduced
Dry Eye
Aqueous Layer
Function
Provide atmospheric oxygen to corneal epithelium
Antibacterial activity due proteins
Wash away debris
Dry Eye
Mucous layer
Composition
The superficial epithelial cells of the cornea and
conjunctiva produce transmembrane mucins
Functions
Lubrications
Converting corneal epithelium from hydrophobic ti
hidrophyllic surface
Sjoergen Syndrome
Autoimmune disorder
Clinical triad : dry eyes, dry mouth and
parotid gland enlargement
Primary SS affects females > males
Symptoms
Dryness, grittiness and burning, blurring of
vision, redness and crusting of the lids
Sjoergen Syndrome
A. Histology of the
lacrimal gland
lymphocytic
infiltration

B. Dry fissured
tongue
Sjoergen Syndrome
C. Parotid gland
enlargement
Sjoergen Syndrome
Signs conjunctivochalasis

Posterior blepharitis :
dysfunction of
meibomian gland
Conjunctiva
Redness
Staining with
fluorescein and rose
Bengal
Keratinization
Sjoergen Syndrome
Conjunctival staining
in dry eye
A. Fluorescein
B. Rose Bengal
Sjoergen Syndrome
Tear film
Normal eye : tear film
breaks down the
mucin layer
Dry eye :
contaminated mucin,
particles and debris
that move with each
blink
Sjoergen Syndrome
Cornea
Punctate epithelial
erosions that stain
with fluorescein
Filaments : stain well
with rose bengal
Mucous plaque :
severe dry eye, semi
transparent
Sjoergen Syndrome
Complications
Vision threatening,
epithelial breakdown,
melting, perforation,
and bacterial keratitis
Investigation
Tear film break-up time
Aqueous tear deficiency and meibomian gland
disorders
Fluorescein 2% or impregnated fluorescein strip
moistened
The patient is asked to blink several time
Tear film examined at the slit lamp
Break-up time of less than 10 sec. is suspicious
Investigation (1)
Schirmer test
Useful assesment of aqueous tear production
Measuring the amount of wetting a special filter
paper
Performed with or without anaesthetic
Result can be variable, single Schirmer test
should not be used as the sole criterion for
diagnosing dry eye
Investigation (2)
Ocular surface staining
Fluorescein
Allow the dye to enter the tissues
Rose bengal
Shown up clearly corneal filaments and plaques
Lissamine green
Similar to rose bengal, less irritation
Investigation (3)
Ocular surface staining
Investigation (4)
Ocular surface staining
Investigation (5)
Diagnostic tests in
dry eye
A. tear film break-up
time
B. schirmer test
C. conjunctival and
corneal staining with
rose bengal
Treatment
Tear substitutes
Drops and gels : cellulose derivates (hypromellose,
methylcellulose), carbomer gels, polyvinyl alcohol,
diquafosol
Ointments
Paraffin, used at bedtime to supplement daytime
Eyelid sprays
Stabilize the tear film and reduce evaporation
Artificial tear insert
Emplaced once or twice daily
Mucolytic agents
Useful in patients with corneal filaments & mucous
plaque
Treatment (1)
Anti-inflammatory agents
Topical steroids
Supplement for acute exacerbation
Omega fatty acid supplement
Reduction of topical medication
Oral tetracyclines
Control associated belpharitis, meibomianitis, reduce
tear level of infl. mediator
Topical ciclosporin
Reduces T-cell mediated infl. of lacrimal tissue,
increase the number of goblet cell
Treatment (2)
Optimization of environmental humidity
Reduction of room temperature
Minimize evaporation of tears
Room humidifiers
Thank You