Dry Eye Dry eye is a disease of

Dry Eye Dry eye is a disease of the ocular surface attributable to different disturbances of the natural function and protective mechanisms of the external eye, leading to an unstable tear film during the open eye state. Surv Ophthalmol 2001; 45(2), S 199 -202

Dry Eye: Prevalence Study Centre Japan Denmark USA No. of patients 2127 504 2520 Prevalence (%) 17% 11% 15% Melbourne, Australia 926 16. 3% Surv Ophthalmol; 45(2): S 203 -S 210

Dry Eye : Prevalence Beaver Dam study N=3722 3 year study (1993 -1995) Age = 48 -91 years (Mean age 65 + 10 years) Men = 43%, Women = 57% Arch Oph 2000, 118: 1264 -1268

Dry eye: Prevalence of dry eye increases significantly with age

Dry eye: Prevalence of dry eye is higher in women

Increasing prevalence of dry eye Increasing life-span of the population Expansion of consumption of medications Increase in number of people wearing contact lenses Increase in computer usage. Increase in number of patients undergoing LASIK. Increase in pollution…….

Symptoms Irritation Redness Burning/ Stinging Itchy eyes Sandy- gritty feeling (foreign body sensation) Blurred vision Tearing Contact lens intolerance. Increased frequency of blinking Mucous discharge. Photophobia (less frequent symptom) Symptoms worsen in windy or air-conditioned environments. – As day progresses. – After prolonged reading, working on computers Supl P&T Digest 2003, 28(12), 1 -45

Impact of dry eye symptoms on daily life Patients who said dry eye symptoms interfered with activities most or all of the time (%) Vision-related activities Nighttime driving 32. 3 Reading 27. 5 Working at computers 25. 7 Watching television 17. 9 Suppl P & T 2003; 28(12) 1 -45

Dry eye may be sight-threatening Bacterial Keratitis Corneal ulcer

Dry Eye Affects Quality of Life

DRY EYE : Classification According to the National Eye Institute DRY EYE Aqueous tear deficiency (ATD) (Tear deficient dry eye) keratoconjunctivitis sicca (KCS) (Most common) Evaporative tear deficiency (ETD) (Evaporative dry eye) Clin Exp Optom 2001; 84: 1: 4 -18, Surv Oph 2001: 45, S 203 -S 210

Dry Eye: Main Causes TEAR DEFICIENT DRY EYE (KCS) • Sjogrens • Non-Sjogrens EVAPORATIVE DRY EYE • Meibomian gland disease – Ageing – Menopause • Lid surfacing/blinking – Medicamentosa anomalies – Cicatricial disease • Contact lens – Neurotrophic keratitis related • Chronic allergy/toxicity Clin Exp Optom 2001; 84: 1: 4 -18

Dry Eye: Multifactorial nature Elderly woman Post menopausal Taking glaucoma medications Working for long hours in front of computer Contact lens user Air-conditioned environment

Tear deficient dry eye Keratoconjunctivitis sicca (KCS) Sjogrens: Autoimmune disorder with a triad of dry mouth, dry eye and arthritis Non-Sjogrens – Ageing – Gradual deterioration of lacrimal gland tissue occurs with ageing – Menopause – At the time of menopause, levels of androgens drop down – Neurotrophic keratitis – Corneal sensitivity decreases after LASIK, PRK, contact lens wear and diabetes – Medicamentosa – Anti histamines, anti-depressants, – beta blockers – Cicatricial Diseases – Trachoma, chemical burns, Stevens Johnson syndrome Ref: Clin. Exp. Optom 2001: 84: 1: 4 -18 J. Am. Optom Assoc. 1991; 62: 187 -199 Suppl P and T Digest 2003; 28(2): 1 -45

EVAPORATIVE DRY DISEASE Meibomian gland disease: Most prevalent (65%). Obstruction of meibomian gland Lid surfacing anomalies: Lid closure affected, blinking affected Ocular surface toxicity: Long term use of topical antiglaucoma medications, preservatives like BAK Contact lens related Allergy

Chronic Allergy Dry eye is commonly associated with chronic allergic conjunctivitis. An allergic history has been reported by 36% of dry eye patients. Chronic allergy results in loss of goblet cells, destabilization of the tear film & damage to ocular surface. VKC is associated with 38% incidence of dry eye. Surv Oph 2001, 45(2), S 211 -20

Abnormal blinking pattern Extensions of interblink period due to intense concentration due to close work and computer work concentration leads to drying of ocular surface. Normal blink rate : 15 times/min Working on computer: 5 times/min Clin Exp Optom 2001; 84: 1: 4 -18

Environmental Influences Ocular irritation, poor tear film stability and ocular surface desiccation is associated with poor indoor air quality in temperature controlled office environments 35 -48% of individuals working in such environments are affected. Dry climate Growing air pollution.

Mc. Monnies’ Questionnaire Do you experience any of the following eye symptoms? Soreness Scratchiness Dryness Grittiness Burning Symptoms “often” or “constantly” Eyes unusually sensitive to cigarette smoke, smog, air conditioning, central heating? Do you suffer from arthritis? Do you suffer from thyroid abnormality? Eye irritation upon awakening? Cornea 2002, 21(7), 664 -670

Rose Bengal staining Rose Bengal solution 1% placed into the conjunctival sac. After a wait of 2 mins, degree of rose bengal staining on bulbar conjunctiva and cornea is quantitated by microscopic exam. Stains devitalized cells. Also stains mucous strands (very often present in KCS) J Am Optom Assoc 1991, 62: 187 -199

Rose Bengal staining in Early, Moderate and Late KCS EARLY MODERATE LATE

Schirmer test Without Anesthesia – Measures Reflex Tear Secretion (dry eye = < 6 mm wetting) With Anesthesia – Measures Basal Tear Secretion (dry eye =< 3 mm wetting)

Impression cytology Removal of superficial layers of conjunctival epithelium Application of circular discs of cellulose acetate filter paper for a certain period of time. Obtained specimen observed under microscope for signs and symptoms of squamous metaplasia or presence of inflammatory cells. J Am Optom Assoc 1991, 62: 187 -99

Dry Eye: Management

Management of Dry Eye Late KCS • Topical corticosteroids – fluorometholone, loteprednol (short-term) • Topical androgen • Cyclosporine ophthalmic emulsion

Tear substitutes: benefits Tear substitutes are the mainstay of therapy for dry eye. Provide adequate relief Increase humidity at the ocular surface and improve lubrication. Smooth the ocular surface leading to improved vision. Intra/post-operative use has shown to help restore ocular surface after refractive surgery. Improve patients’ quality of life. Highlights ophthalmol Int Ophthalmol Clin 1991, 31: 83 -90

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