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					„„DRY EYE‟‟
                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), S199-202
          Dry Eye: Prevalence
Study Centre   No. of patients   Prevalence (%)
Japan          2127              17%
Denmark        504               11%
USA            2520              15%
Melbourne,     926               16.3%
Australia




                             Surv Ophthalmol; 45(2): S203-S210
       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



Prevalence of dry eye increases
     significantly with age
       Dry eye: Prevalence



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)             Evaporative tear
(Tear deficient dry eye)                  deficiency (ETD)
keratoconjunctivitis sicca                (Evaporative dry eye)
(KCS)
(Most common)
 Clin Exp Optom 2001; 84: 1: 4-18, Surv Oph 2001: 45, S203-S210
           Dry Eye: Main Causes
 TEAR DEFICIENT DRY EYE (KCS)      EVAPORATIVE DRY
                                        EYE
Sjogrens         Non-Sjogrens          Meibomian gland
                 – Ageing             disease
                 – Menopause          Lid
                 – Medicamentosa      surfacing/blinking
                 – Cicatricial        anomalies
                 disease              Contact lens
                 – Neurotrophic       related
                 keratitis
                                      Chronic
                                      allergy/toxicity




                             Clin Exp Optom 2001; 84: 1: 4-18
              Dry Eye: Multifactorial nature
             Elderly woman




                                   Taking
   Post                          glaucoma
menopausal                      medications
                                                 Contact lens
                                                    user




                             Working for long                   Air-conditioned
                             hours in front of                   environment
                                computer
     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), S211-20
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.
                      McMonnies‟ 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 = <
        6mm wetting)
      With Anesthesia
      – Measures Basal Tear
        Secretion (dry eye =<
        3mm 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
Thank you

				
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