The 1st Palestinian- Jordanian Conference and the 5th ‘EMCO’ Conference on Optometry

Diagnostic Techniques of
Dry Eye

Friday, April 17, 2015 1

 Content
1. Dry eye definition.
2. Dry eye prevalence.
3. Dry eye classification.
4. Dry eye Assessment:
◦ Symptoms Questionnaires.
◦ Assessment of tear film stability.
◦ Assessment of tear film volume.

Friday, April 17, 2015 2

By the end of this presentation you will a better
understanding of

1. What is meant by the Term ‘Dry Eye’

2. The different forms of dry eye encountered
3. The sort of questions you need to ask in order to determine if dry eye is present
4. Methods that used to assess tear stability and volume
5. How to incorporate simple Non-Invasive tests as a part of your clinic.

Friday, April 17, 2015 3

Definition

Dry Eye is: ‘A multifactorial disease of the tears and ocular surface that results in
symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the
ocular surface. It is accompanied by increased osmolality of the tear film and inflammation of the
ocular surface’.

Friday, April 17, 2015 4

Dry Eye Prevalence

Around the world, between 5% and 34% of people suffer from dry eye.

Friday, April 17, 2015 5

 Gender and
Age

Visual

Risk Factors
Alcohol
Display
Consumption
Terminal

Contact lens
Medications wear

Risk
Factors

Refractive
Smoking
surgery

Extreme hot
or cold Low relative
weather humidity
condition

Friday, April 17, 2015 6

Tear Film Component

Friday, April 17, 2015 7

Classification of Dry Eye

Friday, April 17, 2015 8

 Practical Sequence of Dry Eye Tests
1. Patient history, symptoms-oriented questionnaire
2. Tear film instability tests
◦ Tear Film Break Up
◦ Non Invasive- Tear Break Up
◦ Examination of lid margin and meibomian gland

3. Tear film volume tests

◦ lid-parallel conjunctival folds (LIPCF)
◦ Schirmer test
◦ Tear meniscus height

Friday, April 17, 2015 9

Patient history &  Symptoms-oriented
questionnaire

symptoms-oriented
Patient History
questionnaire
• Weather, place, workplace stress. • Ocular Surface Disease Index
• Systemic diseases [OSDI]
• Medication history. • McMonnies
• Others

Friday, April 17, 2015 10

 OSDI

Friday, April 17, 2015 11

 McMonnies

Friday, April 17, 2015 12

 Tear film instability tests
1. Tear Film Break Up
AKA = BUT (Break-up Time) and= FBUT (Fluorescein Break-Up Time )

Def: The time required for dry spots to appear on the corneal surface after blinking.
Materials:
1. NaFl ( sodium fluorescein dye)
2. Slit Lamp
3. Timer

Friday, April 17, 2015 13

 Tear Film Break Up Clinical Procedure

Instill sodium fluorescein onto the bulbar conjunctiva.

1
Values
Clinical Procedure

2 Instruct patient to blink several times to distribute the fluorescei. ≥10 sec Normal

Within 10-30 sec of the fluorescein instillation, the patient is asked to stare straight ahead
3 without blinking, until told otherwise ≤10 sec Dry Eye
Set slit-lamp magnification at 10X, use (cobalt blue filter) and use a Wratten yellow filter
4 to enhance observation of the tear film over the entire cornea.
≤5 sec severe Dry
5 Use timer to record time between last complete blink and first appearance of black spot. Eye

6 Repeat 3 times and take the average

Friday, April 17, 2015 14

 Tear film instability tests
Non Invasive- Tear Break Up

Materials:
1. Toposcope/keratometer/Tearscope/Xeroscope
2. Timer

Friday, April 17, 2015 15

 Non-Invasive Tear Break-up Procedure
• The test is conducted in quiet room conditions with low air speed
1 and low general illumination.
Values
• The patient sits comfortably at the instrument and is encouraged to ≥15.4±2.7
2 blink freely while fixing on a target, directly ahead. sec Normal
• The patient is asked to stop blinking until told to restart. ≤15.4±2.7
3
sec Dry Eye
• The time between the last complete blink and the first indication
4 of pattern break-up is recorded with a stop-watch.

Friday, April 17, 2015 16

 Tear film instability tests
Examination of lid margin and meibomian gland (MGD )

Using Slit lamp ( diffuse illumination, low magnification, low illumination)

MGD Diagnostic Work-Up

Eyelid Margin Evaluation

MG Expression

Meiboscopy

Friday, April 17, 2015 17

Eyelid Margin Evaluation

Friday, April 17, 2015 18

 MG Expression
Assessed in each of 8 glands of central LL on a 0-3 scale:
Grade 0= Clear meibum
Grade 1= Cloudy meibum
Grade 2= Cloudy with debris (granual)
Grade 3= Thick (toothpaste)

Friday, April 17, 2015 19

 Meiboscopy

Use of transillumination biomicroscopy to determine

presence of MG loss.

Friday, April 17, 2015 20

Tear film volume tests
Tear Meniscus Height
The height of the tear film meniscus observed during slit lamp examination.

Set up the slit lamp:

o
1. 60 beam angle.
2. Low illumination.
3. 10-16 X magnification.
4. Parallel Piped beam.

Friday, April 17, 2015 21

 Clinical Procedure for
Tear Meniscus Height
Focus the parallelepiped on the inferior tear Values ≥0.2-0.4 mm
strip near the lateral canthus.
Normal
≤0.2 sec hypo
At any point the beam may be narrowed to an secretion
optic section to assess the depth of the tear
meniscus. ≥ Hyper secretion

Reduced beam height with beam orientated

horizontally.

Friday, April 17, 2015 22

Tear film volume tests
Temporal lid-parallel conjunctival folds (LIPCOFs)

They can be simply, quickly, and noninvasively identified using the

slit lamp.
Slit Lamp Examination. The participants were
instructed to look straight ahead, and after some
blinking, the LIPCOFs were evaluated with slit
lamp at the temporal lower quadrant of the eye fissure.

Friday, April 17, 2015 23

Friday, April 17, 2015 24
 Schirmer test

The Schirmer test measures the secretions of the lacrimal gland.

Clinical Procedure
calibrated filter paper strips (35 × 5 mm) are
placed in the conjunctival sac of the temporal
third of the lower eyelid

with the patient's eyes closed, wetting of the

strip is measured after 5 minutes

Friday, April 17, 2015 25

 Corneal and Conjunctival Staining
Its found either on instability tear film or on inadequate tear film.
Materials: slit lamp( high illumination, Cobalt blue filter, 10-16x), NaFl, Wratten Filter to
inhance the view

Wratten Filter

Conjunctival Staining Corneal Staining

Friday, April 17, 2015 26

How to Grade

Friday, April 17, 2015 27

 References
1. The definition and classification of dry eye disease: report of the Definition and Classification Sub committee of the
International Dry Eye WorkShop (2007). 2007;5(2):75-92.
2. Gayton, L. (2009). Etiology, prevalence, and treatment of dry eye disease. Clinical Ophthalmology:3 405–412

3. Dtsch Arztebl (2015); The Pathophysiology, Diagnosis, and Treatment of Dry Eye Disease,112: 71–8.
4. The epidemiology of dry eye disease: report of the Epidemiology Subcommittee of the International Dry Eye
WorkShop (2007). 2007;5(2):93-107.
5. Methodologies to diagnose and monitor dry eye disease : re p ort of the Diagnostic Methodolog y Subcommittee of
the International Dry Eye WorkShop (2007). 2007;5 (2):1 08 -1 5 2.
6. http://www.tearfilm.org/
7. Santosh Khanal. (2008). Dry Eye Diagnosis. Investigative Ophthalmology & Visual Science, Vol. 49, No. 4

Friday, April 17, 2015 28

Friday, April 17, 2015 29
DIAGNOSIS &
MANAGEMENT O
DRY
F
EYE
 DIAGNOSTIC TESTS

The tests measure the following parameters:

• Stability of tear film as related to its break-up time (BUT)
• Tear production (schirmer, fluorescein clearance and tear osmolarity)
• Ocular surface disease (corneal stains)

Clinical ophthalmology A systemic approach Jack. J Kanski 8th edition

 Tests For Tear Hyposecretions

 Tear Film Break-up Time (TBUT)

• It is done to assess the stability of the precorneal tear film.
• It is abnormal in aqueous tear deficiency and Meibomian gland disorder.

Procedure:
• Fluorescein strip is moistened with non- preserved saline is instilled into the lower
fornix.
• At the slit lamp with a broad beam using cobalt blue filter tear film is examined
• After interval of time black spots or line indicating dry spots appear in the tear
film.
• BUT is the time between the last blink and the appearance of the first randomly
appearance distributed dry spot.
Short break-up time type dry eye has potential ocular surface abnormalities YoshiyukiIchihashi https://doi.org/10.1016/j.tjo.2015.02.004
 NON- INVASIVE TEAR BREAK-UP TIME

• Non- Invasive Technique

• Can Be Done By Using Placido Disc, Keratometer, Auto-refractometer, tearscope
Or Keratograph 5m.
• Procedure Same As TBUT
• Normal >20sec
• Marginal 10-20sec
• Abnormal <10sec

• https://pdfs.semanticscholar.org/73f1/b17d803c469eba86b0cd9f2b87014d5371d1.pdf
• Tear instability importance, mechanisms, validity and reliability of assessmentImportancia, mecanismos, validez y fiabilidad de la evaluación de la inestabilidad de la
lágrima Charles W.Mcmonnies et al https://doi.org/10.1016/j.optom.2017.11.004
 SCHIRMER TEST

SCHIRMER’S I TEST WITHOUT ANESTHESIA:

• The person is seated comfortably at rest

• The filter paper is folded at 5mm distance from one end and placed over the
lower lid margin taking care not to touch the cornea during the procedure
• Place it at the junction of medial 2/3rd and lateral 1/3rd of the lower lid for a
period of 5 minutes
• The wetting of the strip is recorded at the end of 5 minutes
SCHIRMER’S I TEST WITH ANESTHESIA

• Done 15 minutes after doing the test without anesthesia

• Proparacaine hydrochloride 0.5% is instilled into the lower conjunctival cul-de-
sac
• 1 drop, is instilled 1 minute apart for 2 times
• The excess anesthetic solution in the lower conjunctival cul-de-sac is gently
wiped off with a cotton tipped applicator 1 minute after instillation of the last
drop of proparacaine
• Filter paper is placed in the same manner as done for the procedure without
anesthesia for 5 minutes
• The wetting of the strip is recorded at the end of 5 minutes
 • Without anesthesia: the basal tear secretion and the function of the main
lacrimal gland whose secretory activity is stimulated by the irritating nature of
the filter paper.
• After topical anesthesia: the function of the basal lacrimal secretion

• Normal schirmer test i values >10 mm in 2 minutes,

• Abnormal values without anesthesia: <10mm in 5 minutes
• With anesthesia: 10mm in 5min

• Comparison Between Normal Values of 2- and 5-Minute Schirmer Test Without Anesthesia Vasileios Karampatakis, MD, PhD, Athanasios Karamitsos,
MD, Athanasia Skriapa, MD, and Georgios Pastiadis, PhD
• Comparison of the Schirmer I test with and without topical anesthesia for diagnosing dry eye Na Li, Xin-Guo Deng et al doi:
10.3980/j.issn.2222- 3959.2012.04.14
 TEAR MINISCUS HEIGHT

• Measures the tear meniscus formed on the amount of tears resting at

the
junction of the bulbar conjunctiva and the lower eyelid margin.
• Can be done with or without staining
• Thin Optic Section
• Primary Gaze
• Middle Of Lower Lid Margin
• Normal Blinking

• Normal meniscus height is 0.2–0.5 mm

iciency
• A value of <0.2mm suggests a tear insuff

Diagnosis of dry eye disease and emerging technologies Maya Salomon-Ben Zeev doi: 10.2147/OPTH.S45444
 PHENOL RED THREAD TEST

A soft thread is touched to the lid and the results are obtained in 15 seconds per
eye
PROCEDURE:
• Remove the thread by peeling the film
• Bend 3mm end of the thread
• Pull lower eyelid slightly down & place 3mm folded thread on palpebral
conjunctival junction
• Patient is asked to look straight and blink normally
• After 15 second the thread is gently removed with an upward motion
• The entire length of the red portion of the thread is measured in mm from the
very tip regardless of the fold
• True dryness <10 mm wetting, borderline 10 to 20 mm wetting , and >20
 ROSE BENGAL STAINING
• Rose bengal is a fluorescein derivative
• It was thought to stain only devitalized epithelial cells but it also stains healthy
epithelial cells when they are not protected by a healthy layer of mucin
• It has the unique property of evaluating the protective status of the preocular
tear film.
• It also stains dead or degenerating cells, lipid-contaminated mucous strands, and
corneal epithelial filaments
• Rose Bengal causes significant ocular discomfort
• It can be difficult differentiating its red stain in patients with inflamed red eyes
• The interpretation of rose Bengal staining in dry eyes is based on two factors, intensity
and location.
• A grading scale that evaluates the intensity based on a scale of 0 to 3 in three areas:
nasal conjunctiva, temporal conjunctiva and cornea, with a maximum possible score
of 9.
Care, 221–318. doi:10.1016/b978-0-7506-8896-3.50010-9
• the limbus
P R O K O PI CH , C. L., HR Y N C HA K , P. , & E L LI O TT , D. B . (20 0 7 ) .
• May help to differentiate between ATD and lipid tear deficiency (LTD) by
studying the distribution of stain in the non-exposure zone
• Preferential staining has been observed in non exposure zones in the
LTD
• In ATD the staining is seen in the exposed interpalpebral areas.
 LISSAMINE GREEN STAINING

• Lissamine green (LG) is a synthetically produced organic acid dye

with two aminophenyl groups.
• It is less irritating and is better tolerated by patients
• Lissamine green stains ocular surface epithelial cells that are unprotected by
mucin or glycocalyx, as well as cells that have been damaged
• Although rose bengal stains both proliferating corneal epithelial cells and
affects their viability, LG does not
• A volume of 10 μl as the optimally instilled volume of 1% LG for ocular
surface examination in dry eye patients
Optimizing evaluation of Lissamine Green parameters for ocular surface staining P Hamrah doi: 10.1038/eye.2011.184
• VISIBILITY OF STAINING MAY BE ENHANCED USING A WHITE LIGHT SOURCE AND
A RED BARRIER FILTER, TO GIVE A BLACK PATTERN ON A RED GROUND.
Comparisons of dyes, information combined from Alves et al, Efron, Doughty et al, Kim
 KERATOGRAPH 5M

• It is an advanced corneal topographer with a built-in real keratometer and a

color camera optimized for external imaging
• It can examine the meibomian glands, non-invasive tear film break-up time
and
the tear meniscus height measurement and evaluate the lipid layer.
Evaluation of
NIBUT
Meibo-scan according to JENVIS grading scale
 TEARSCOPE
• The tearscope (keeler) developed by guillon in 1986, comprises a
90mm hemispherical cup and handle with a central 15mm
diameter observation hole
• The inner cup surface is illuminated by a cold cathode ring light
source, which was specifically designed to prevent any artificial
drying
• With the patient’s head positioned on the slit-lamp chin rest, the
slit-lamp source should be positioned nasally and switched off.
Alternative illumination is provided by the tearscope itself
• The tearscope should then be held as close to the eye as possible
and positioned to allow observation through the sight hole via one
of the biomicroscope objectives

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 INTERFEROMETER

• The lipid layer of the tear film can be analyzed visually using a tear film
interferometer
• This evaluation allows dryness to be measured based on analysis of
the precorneal tear lipid layer and possible correlation of meibomian
gland dysfunction.
• Lipiview is an example of this technology
• Patients with low lipid layer thicknesses were found to have a higher probability
of meibomian gland dysfunction, which can cause and/or exacerbate dry eye
symptoms.
 LIPIVIEW
• LIPIVIEW II OCULAR SURFACE INTERFEROMETER
• DYNAMIC MEIBOMIAN IMAGING (DMI)
• NEAR INFRARED (NIR) SURFACE IMAGING
• VISUALIZATION OF LIPID LAYER THICKNESS
• MEASUREMENT OF LIPID LAYER THICKNESS
• PARTIAL BLINK DETECTION
 Dynamic Illumination
Surface lighting originates from
multiple light sources to minimize
reflection.

Adaptive Transillumination
Changes to the light intensity across the
surface of the illuminator compensate for
the lid thickness variations between
patients.

Dual-Mode DMI
A combination of Dynamic
Illumination and Adaptive
Transillumination offers an enhanced
view of meibomian gland structure.
Analyze Blink Patterns
Computerized analysis of blink patterns objectively quantifies the number of complete and
partial blinks. Results are displayed in a frame-by-frame graphical representation that
shows fluctuations in lipid thickness measurements between each blink. A video capture
allows clinicians and patients to review blinking habits during consultation.
Visualize Blink Response
High-resolution video depicts how well ocular lipids disperse in response to a blink through
variations in light patterns reflected off of the tear film called an interferogram. The system
enhances the interference pattern and displays a profile corresponding to an interferometry color
scale which has been validated to a known standard for lipid layer thickness measurements with
a precision of 1 nm and an accuracy of ±10 nm.
 TEAR OSMOLARITY

• It determines tear osmolarity using nanoliter (nl)

volumes of tear fluid collected directly from the
eyelid margin
• The test card is held by the osmolarity test pen
• The tearlab osmolarity test utilizes a
temperature-corrected impedance measurement
to provide an indirect assessment of osmolarity
• Osmolarity is calculated and displayed as a
quantitative numerical value.
 Abnormal Osmolarity is defined by:
An elevated reading, >300 mOsm/L, indicating loss of homeostasis. †

OR, When the inter-eye difference is >8 mOsm/L, indicating instability of the tear
film
 MANAGEMENT

• Artificial tear: guidelines for selecting lubricants

• A more viscous tear lubricant is selected when there is an increased severity of
dry eye.
• Less viscous eye drops are advisable during the day and a viscous ointment at
night.
• Practitioners need to consider the patient’s needs and this involves
identification of patient activities and suggesting the most suitable dosage
according to their requirements or symptoms on any given day.
• Limitation of artificial tears is it does not contain specific anti-inflammatory
proteins such as lysozyme, lactoferrin, immunoglobulin a, and lipid-binding
proteins
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• The following hydrogels have been used in artificial tear substitutes:
• Hydroxypropyl methylcellulose,
• Carboxy methylcellulose,
• Polyvinyl alcohol,
• Carbopol,
• Polyvinylpyrrolidone,
• Polyethylene glycol,
• Dextran,
• Hyaluronic acid,
• Carbomer 940 (polyacrylic acid).
• Gels (viscotears, gel tears) consist of carbomers. In general, they are
preferable
to drops because they are instilled less frequently
• Ointments containing petrolatum mineral oil (lacri-lube, lubri-tears) can be
used at bedtime
• Lipid-containing artificial tear products such as refresh endura (with castor oil)
and soothe XP (with mineral oil) are intended to decrease tear evaporation by
 DNASE EYE DROPS
• The trial compared eye drops containing a biosynthetic form of an enzyme
called dnase with eye drops without the enzyme. Dnase breaks up nucleic acid-
based material on the surface of the eye
• 47 participants with severe dry eye disease were enrolled. About half the
participants had a diagnosis of sjogren's syndrome and 17% had graft-versus-
host disease -- both of which are associated with significant deficits in tear
production. Forty-one participants completed the trial.
• Participants were given eye drops containing either dnase or a placebo
formulation and instructed to administer one drop of the solution to each eye
four times per day for eight weeks
• The researchers found that participants in the dnase group had a statistically
significant and clinically meaningful reduction in corneal damage at eight
weeks
Anubhav Pradeep, Damiano Rondelli, Sandeep Jain. A Phase I/II Placebo-Controlled Randomized Pilot Clinical Trial of Recombinant Deoxyribonuclease (DNase) Eye
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 PRESERVATION OF EXISTING TEARS

• Reduction of room temperature, by avoiding central heating, to minimize

evaporation of tears.
• A temporary local increase in humidity can be achieved with moist
chamber
goggles
• Taking regular breaks from reading or computer use
• Lowering the computer monitor below eye level so that the gaze is
directed
downward.
• Increasing blink frequency or fast blinking exercises
 PUNCTAL
OCCLUSION
• Punctal plugs are the most commonly used means of
occlusion
• Here are 2 main types of punctal plugs:
o Absorbable
o Nonabsorbable.

• Absorbable plugs are made of collagen or various

polymers, and may last for days to months.
Some newer absorbable materials may last as
long as 6 months.
• Nonabsorbable plugs, often made of silicone or
hydrophilic acrylic, are intended to be permanent.
• INTRACANALICULAR PLUGS :

AN ALTERNATIVE TO PUNCTAL PLUGS WITH LESS RISK OF EXTRUSION OR

CONJUNCTIVAL IRRITATION. IN CASE OF INFECTION REMOVAL IS MORE
DIFFICULT THAN WITH PUNCTAL PLUGS, REQUIRING MORE INVASIVE
PROCEDURES.

• SURGICAL OCCLUSION (EG, USING ELECTROCAUTERY, LASER, OR GLUE) IS

AN OPTION FOR PATIENTS WHO TOLERATE PLUGS
 MOISTURE
SPECTACLES/GOGGLES

• REDUCE TEAR EVAPORATION BY INCREASING HUMIDITY AROUND THE EYE.

• THE PATIENT’S GLASSES CAN BE MODIFIED USING COMMERCIALLY
AVAILABLE TOP AND SIDE SHIELDS OR SWIMMING GOGGLES CAN BE USED.
• EVIDENCE OF EFFICACY IS LIMITED AND ADHERENCE MAY BE POOR FOR
COSMETIC REASONS.
 CONTACT LENS

• BANDAGE CONTACT LENSES

MAY BE USED IN SEVERE DED, OR WHEN OTHER THERAPY HAS FAILED, TO
HELP RETAIN THE TEAR FILM AND/OR PROMOTE OCULAR SURFACE HEALING.
• SILICONE HYDROGEL LENSES

HIGH OXYGEN PERMEABILITY AND RELATIVELY LOW WATER CONTENTMAKES

THEM LESS LIKELY TO DEHYDRATE IN THE PRESENCE OF A HYPEROSMOLAR TEAR
FILM.
 SCLERAL CONTACT LENS

• Custom-manufactured using a computer assisted design program.

• It is a rigid gas-permeable lens that vaults the cornea and rests entirely on the
sclera, creating a fluid-filled precorneal space.
• It provides a “liquid bandage” for the corneal surface, reducing or eliminating
desiccation, hyperosmolarity, and friction with the eyelids
• It allow tears to flow into the precorneal space, avoiding the development of
negative pressure
 TARSORRHAPHY

• CLOSURE OF THE EYELIDS

• IT IS RESERVED FOR SEVERE OR REFRACTORY DED.
• METHODS INCLUDE:
• SHORT-TERM TARSORRHAPHY USING, FOR EXAMPLE, TAPE, ADHESIVE GLUE (LASTS A FEW
DAYS), OR BOTULINUM TOXIN (LASTS AN AVERAGE OF 16 DAYS).

• TEMPORARY SUTURE TARSORRHAPHY (LASTS AS LONG AS 4-6 WEEKS).

• PERMANENT” TARSORRHAPHY. THE LID MARGINS ARE EXCISED AND SUTURED SO THAT
THEY HEAL TOGETHER. THE PROCEDURE CAN BE REVERSED LATER.
 TEAR STIMULATION

• Cholinergic agents (ie, muscarinic acetylcholine receptor agonists) are

sometimes given orally to treat aqueous-deficient DED.
• Pilocarpine significantly decreased the use of artificial tears and improved
salivary flow
• Cevimeline 20mg doses improved subjective symptoms, tear dynamics, ocular
surface condition, and global assessment
• Topical corticosteroids
• Moderate inflammation shows significant benefits with loteprednol QID 4weeks.
• Prednisolone 0.1% was significantly better than hyaluronic acid in improving
symptom
• Prolonged use may result in ocular infection, glaucoma, and cataracts.

• Topical cyclosporine
• Cyclosporine ophthalmic emulsion 0.05% (restasis)
• Increase tear production in patients whose tear production is presumed to be
suppressed due to ocular inflammation associated with keratoconjunctivitis sicca.
 NUTRITIONAL SUPPLEMENTS

• Essential fatty acids (efas) benefit DED in 2 ways:

• By reducing inflammation
• By altering the composition of meibomian lipids

• There are at least 2 EFA nutritional supplements for DED:

• Omega-3 fatty acids from flaxseed and fish oil,
• A blend of omega-3 and omega-6 fatty acids (docosahexaenoic
acid/eicosapentaenoic acid [DHA/EPA] from cod liver oil and gamma-linolenic acid
[GLA] from black currant seed oil, respectively).
• However, evidence for EFA efficacy is limited and conflicting.

Management of Dry Eye Michael A. Lemp, MD https://www.ajmc.com/journals/supplement/2008/2008-04-vol14-n3suppl/apr08-

3142ps088-s101?p=5
 LIPIFLOW THERMAL PULSATION SYSTEM

https://www.beye.com/product/lipiflow-thermal-
pulsationsystem? hstc=93015746.eb90123de9f2e8b42ed14828c99ef185.1564234780620.1564234780620.1564234780620.1& hssc=9301
5746.1.1564234780621& hsfp=916090754
• The lipiflow thermal pulsation system is a device for in-office treatment of dry
eye disease (DED) associated with meibomian gland dysfunction (MGD)
• It consists of a console, reusable cable and a single-use sterile device known
as
the activator II.
• The activator cradles the upper and lower eyelid as therapeutic heat and
proximal-to-distal peristaltic pressure is applied to the meibomian glands.
• A maximum therapeutic temperature of 43 degrees celsius is applied directly to
 • Once the activators are placed on the eyes, treatment begins.
• The entire treatment takes 12 minutes and, as normal gland function recovers,
maximum results are usually experienced 6-8 weeks after treatment
• When lipiflow treatment is properly applied, the glands can resume normal oil
production

https://dryeyeandmgd.com/dry-eye-and-mgd-treatments/lipiflow-treatment-leading-cause-dry-eye/
Management of Dry Eye
 Dry
• Extremely eyein our daily
common
practice
• Any age , female , male , even children
• Can be mild to severe
• Devastating and frustrating
• “ Long life treatment “ ?
 Lacrimati
on N.VII PONS
Secreto-motor
Nerve Impulses
Lacrimal Glands

Tears Support and Maintain

Ocular Surface

Ocular Surface
Neural Stimulation
N.V

dry spot > > reflex stimulation > lacrimation

pain
 Tear film
composition
Lipid : 0.1 um
• esters, glycerol ,
fatty acids

• product of
palpebral
meibomian
glands
Aqueos / watery :
7 um

Epithelium
• Secreted from lacrimal gland
•electrolytes, protein, antibody, oxygen , CO2,
mineral , glucose
Mucin :
0,02 - 0,05 um
May increase up
to 30 um

• Product of conjunctival Goblet cells present in

bulbar conjunctiva , caruncle
• Maintain tear film stability
• Glycocalyx produced by epithelial cells help
bind mucins onto the epithelial surface by
by converting cornea hydrophilic.
Tear dynamics /
each blink
 Tear film
function
Maintain integrity of cornea & conjunctiva

• Smoothes ocular surface , improve vision

• Wash away all the dirty materials coming onto the eye
• Moisturizing, lubricating for comfort , eye
movements
• Media transport for O2 , CO2 ( 40% from atmosphere
)
• Nutrition ( glucose, electrolytes, enzymes , protein )
• Defense : Anti bacterial, antibodies, lysozyme
 Definition

Prognosis Etiology

Treatment
Dry Pathology

eye
Symptoms
and signs Classification

Contributing
factors
 Definiti
on
DEWS Report 2007
•Dry eye is a multifactorial disease of the tears ( volume or
Function ) and ocular surface that results in symptoms of
discomfort, visual disturbances, and tear instability with
Potential damage to ocular surface.
It is accompanied by increased osmolarity of the tear film
and inflammation of the ocular surface .
Dry Eye - Inflammation
Model
 Dry Eye
Etiology
Aqueous Evaporative
Deficien
t

Oil Deficient Lid Related Contact Lens Surface Change

Sjogrens Non-Sjogrens

Lacrimal Lacrimal duct Reflex

Deficiency Obstruction hyposecretio
n

NEI Workshop - Classification of Dry Eye

Auto-antibodies
primary VS secondary
 Dry Eye - Tear Film
Deficiencies
Lipid Layer Deficiency
alterations in meibomian gland secretion (e.g. blepharitis,
hordeolum, chalazion )

Aqueous Layer Deficiency

aqueous deficient dry eye (e.g. inflammation, neurological
defects, trauma, congenital absence of lacrimal tissue )

Mucin Layer Deficiency

mucin deficient dry eye (e.g. Stevens-Johnson syndrome,
pemphigoid,
vitamin A deficiency, trachoma, radiation)
 Influential Factors of
Age
Gender
Dry Eye
LASIK Surgery Temperatur
Cosmetic Surgery e Humidity
Arthritis Mechanical Air
Osteop Disturbances movement
orosis Exposure Keratitis Allergies
Gout Entropion Change in
Lens Surgery Ectropion environment
Contact Lens Wear Symblepheron Reading
Blink Disorders Formation Watching
Disorders of Lid Large Lid Notches Movies
Aperture Lagophthalmos Sleep
Nutritional Problems Incomplete Blinking
Rheumatoid Dellen Formation
Arthritis Thyroid Illumination
Problems
Time of Day
 Conditions associated with
dry eye
• Chronic Systemic inflammation
Sjogren’s Syndrome, rheumatroid arthritis, lupus
• Ocular surface inflammation
Meibomian gland disease, keratitis, infection
• Hormonal changes
Menopause, oral contraceptives, pregnancy, lactation
• Systemic disease
Diabetes, thyroid
- Stevens Johnson’s
syndrome : severe
dry eye
• Environment
• Smoke, air pollution, wind, heat, air-conditioning, air
travel, light, dry climate
Systemic Topica
staring at TV , computer Anti-depressants l
decongestants
Antihistami preservatives
reading , etc nes anesthetics
Antihypertensives
( Less blinking reflexes ) diuretics
B-blocker
Antimuscarinics
• Medications anesthesia
phenothiazines
Atropine
oral
contraceptives
anxiolytics
antiparkinsonian
Anticholinergics
antiarrhythmics
isotretinoin
 Diagnosis of
dry eye
• Staining of the corneal surface
• Tests of tear production
• • Tests of tear
Obtaining film stability
patient history(TBUT)
• Test of tear osmolarity
• Physical examination
Confirm and
quantify DED
 Complai
ns

• fluctuating vision / • contact lens intolerance

blurry • sticky
• photophobia • dryness / watering
• irritating • sleepy
• burning / stinging • discharge
• easily fatigue • redness
• itchy
• foreign body sensation
 Patient
History
•Ocular symptoms Redness, dryness, itching,
burning, visual problem, etc.
•Current illnesses Sinus or ear trouble, hay fever, skin
disorders, asthma, etc.
•Medications Antihistamines, beta blockers, oral
contraceptives, etc.
•Duration of the present problem Recent or
ongoing...weeks, months, etc.
• Timing of symptoms on
awakening or worse over the
day present refractive condition Glaucoma and
•Any
•contact
Family history
lenses, of
etc.a similar
problem
 Physical
examination
Five main components of a clinical examination
involve:
• The lids
• The blink mechanism
• The tear film
• The ocular surface
• General physical assessment
 Sign
s

• posterior blepharitis
•• hyperemia • conjunctival staining
•• tear meniscus <0.2-0.4mm • corneal staining
/damage epitheliopathy,
••Increase tear debris filaments, plaques
• fast tear break up time •Complication : epith break
•conjunctival Melting,perforation,keratiti
Sign
s
Lid Wiper
Epitheliopathy

Early sign of DED even in pt w normal TBUT + schirmer and normal staining pattern
 Sign
s
• Complication :
- epithelial breakdown
- Melting
- Perforation
- Bacterial Keratitis
 Tear Film Break-Up Time (
TBUT )
•Time required for a random dry spot to appear on the
corneal surface after blinking
•Dry spots will appear as part of normal
evaporation and diffusion of tears
•Normal healthy eye : dry spots start occuring
between blinks at about 10-12 seconds, and an
urge to blink is triggered
• abnormal ( < 10 sec ) in aqueous deficiency
and MGD.
Blink TFBUT Blink
Tear Protected Unprotected Cycle Repeats
Ocular Ocular Surface
Surface

0 1 3 4 5 6 7

2
Time (seconds) Ocular Staining
Dry Eye - Discomfort
Consequences of an
‘Unprotected
Ocular Surface’
 Tests of tear
production
• standard diagnostic tests for
aqueous tear production , single test not enough.
•Schirmer test I : the filter paper strip is placed in the
unanesthetized eye and is left in place for 5 minutes.
•no dry eye : enough tears to wet 20 to 25 mm of the
paper strip
• Wetting of < 10 mm is suggestive of dry eye
• Max tear : basal and reflex , <10mm abnormal .
• Schirmer Tear Test II : with topical anesthesia .
• for basal production only , <6mm abnormal .
Slit-Lamp
Biomicroscopy
and Corneal
Staining
Types of corneal staining include:
• Fluorescein - Discloses epithelial breaks and erosions
•Rose Bengal - Assesses degenerated tissue; good for
Filaments and plaques , S/E discomfort
•Lissamine Green - similar to rose bengal but more
comfortable to the patient
• staining pattern - Interpalpebral , superior ,
inferior
• staining intensity – correlate with the severity
Corneal
Staining
Tests of tear Use IR wave , high IQ prism tip ,
results within 1 esc ,
Osmolarity disposable cap .
How to treat ... Are artificial
tears enough?
 Treatment :
supportive
Goals :
• Alleviate symptoms
• Reduce ocular morbidity
• Prevent complications
• Improve quality of life
• Improve productivity
• Maximise benefit and relief
• Minimise cost
 Treatment Strategy Intervention

Tear supplementation Lubricants

Tear retention • Punctal occlusion
• Moisture chamber spectacles
• Contact lenses

Tear stimulation Secretagogues

Biologic tear substitutes • Serum
• Salivary gland transplantation
Anti-inflammatory • Cyclosporine
therapy • Corticosteroids
• Tetracyclines
Omega-3 fatty acids
Essential fatty acids
• Avoid low humidity
Environmental strategies • void drafts
• VDT lowered below eye level
 Severity level 1 2 3 4
Symptoms Mild/episodic, with Moderate Severe frequent Severe and or
stress episodic/chronic, constant no stress disabling no stress
+ stress
Visual symptoms None, or episodic mild Annoying and/or Annoying, chronic, Constant and/or
fatigue limiting lid and/orconstant, possibly disabling
fatigue limiting activity

Conjunctival None to mild None to mild +/- +/++

injection

Conjunctival None to mild Variable Moderate to marked Marked

staining
Corneal staining None to mild Variable Marked, central Severe punctate
(severity/location) erosions
Corneal/tear signs None to mild Mild debris, Filamentary keratitis, Filamentary keratitis,
decreased mucus clumping, mucus clumping,
meniscus increased tear debris increased tear debris,
ulceration

Lid/Meibomian MGD variable MGD variable Frequent Trichiasis,

glands keratinization
symblepharon
TBUT (sec) Variable <10 <5 Immediate

Schirmer score Variable <10 <5 <2

(mm/5 min)
Severity level 1 2 3 4
Treatmen If no improvement If no improvement If no improvement
t to Level 1, add: to Level 2, add: to Level 3, add:
options

•Patient education •nonpreserved • Serum : Systemic

environment/dietary artificial tears - autologus antiinflammatory
modification •Antiinflammatory - Umbilical cord • Oral
•Eliminate offending Drugs : •Contact lenses cyclosporine
systemic medications Topical : • Permanent •Acetylcysteine
•artificial tears/ - Corticosteroids punctal occlusion Moisture goggles
ointments/gels - cyclosporinA Lid Surgery:
preservative -omega3 fatty tarsorrhaphy, AMT
• Lid therapy acids graft
• Tetracyclines Mucous m graft
• Cyclosporine Salivary gland
•Punctal plugs transplantation
• Secretagogue
s
• Moisture
goggles

More recent facts :

- Start use topical anti inflammatory + plugs for mild cases for better results
- Add artificial tears when there is moderate degree of DED
 drop of an artificial
tear

• The ideal artificial lubricant should be

preservative-free, contain potassium,
bicarbonate, and other electrolytes, and have a
polymeric system to increase its retention time.
Varieties of Artificial Tears /
Lubricants
• Hydroxypropyl Methylellulose ( TNII ,Genteal )
• Carboxy Methylcellulose ( Refresh )
• Polyvinyl Alcohol ( Hypotears )
• Dextran
• Glycerin
• Eye Gels ( vit.A palmitate)
• Polyethylene glycol : Systane
• Sodium hyaluronates 0.1 - 0.3%
 HYALUB
Sodium hyaluronates 0.1%

• Lubricating , protecting
• Powerful wetting agent
• Long lasting
• Reduce ocular surface damage
• Accelerate wound healing
• Safe , well tolerated for long term use
• Non preservative
•in IRAQ > hyfresh : sodium
Hyaluuronate 2 mg
Lacrise
rt
Slow release lubricants
5mg hydroxypropyl cellulose
Start at 1 hr , remain 14-24 hr , So 1 insert at morning is enough
 Anti inflammatory therapy of
dry eye > Xiidra (lifitegrast 5%) 2016 FDA
•mild-moderate
1-2/d , 3-4 m ,Initial 4wks are crucial !
Bcz of S/E ( irritation , metallic taste , blurring )
•moderate-advance > Lotemax (NSAIDs) 4/d for 2w
then 2/d for 2w then can shift to Xiidra
> Restasis ( cyclosporin 0.05%)
* goblet cell no.
* squamous metaplasia
 • Essential fatty acids omega-3
- reducing ocular surface
irritation ( 2000mg/day
took 4-6 months)
- Reduce bulbar hyperemia
1st at day 30 by anti-
Inflammatory action
-Reduce tear osmolarity
and improve tear stability
 Future causal therapy of
dry eye
-Management of dry eye is shifting from solely using
tear replacement strategies to also controlling
inflammation.
-Also , the most recent approach is to targeting
meibomian gland disease (MGD) as primary driver
and regarded as a central etiological factor of DED.
-Ocular surface cannot rehabilitated in the absence
of healthy meibomian gland function.
- LipiFlow or
- similar device meibomian paddle ( manual )
- Meibomian glands duct probing
in all, the aim is to evacuate mebomian gland
content and restore normal flow .
TrueTear by Neurostimulation
 Surgical
treatments
( reserved for severe disease
poor/non- compliance )

• Punctum Plug
• Surgical / thermal / laser occlusion

Advantages
• Prolongs natural tear retention
•Reduces frequency of artificial tears
needed for symptomatic relief
• no need patient compliance
 Punctal
plugs
ONLY after ocular inflammation
subside ? WHY
- Absorbable
- Made of collagen or polymers
- occlusion duration ranges from
7-180 days
-plugs dissolve by themselves or may be removed
by saline irrigation
- Non-absorbable
- Made of silicone
- punctum plugs and intracanalicular plugs.
( Cylindrical Smartplug )
- Complications of plugs:
- Too far , loss , obstruction , scarring , conjactival
 Surgical
treatments
• Parotid duct translocation
- Frequently secrete more fluid ,increases during eating
- Salivary gland may be affected in Sjogren syndrome
• Submandibular gland transplantation
- For extreme dry eye but produce excessive levels of
mucus in the tear film .
• Tarsorrhaphy
- Narrowing of the palpebral fissure decreasing the rate
of evaporation
 Dry Eye Disease and chronic pain syndrom
- Patients who complains from symptoms of dry eye which is more
sever than ocular sign in 30%.
- This subgroup represent a challenge to healthcare providers as
those pt are more resistant to standard treatment strategies .
- The underlying mechanism is appear to be due to
dysfunctional
pain perception
- Those subgroup complain and possible suggested mechanism
support one of the theory of dry eye dz which claims than DED
symptoms is dueto dysfunction in corneal pain system.
- Chronic pain syndrom is regional pain without obvious pathology ,
it include : irritable bowel syndrom , chronic pelvic pain and
fibromyalgia.
- Those pt usually need neuorologist , rheumatologist or pain Mx
clinic.
KIDS-SCREENS dry eye disease

It is well-established that visual attentive behaviour of

glued child face to some sort of digital screen.

One study revealed a strong positive correlartion

between duration of smartphone and DED and
negative between outdoor play.

Smartphone restriction for 4 weeks there will be a

dramatic improvement in S/S of DED , no such results
in adults as MGD is a main cause.
Thank
you