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1 Dry Eye The Eye Centers of Racine and Kenosha Dr. Kanwar A. Singh MD Dr. I. Paul Singh MD Dr. Stephen J. Pruett OD 2 Prevalence of Dry Eye Disease • 60 million affected worldwide. • 1 to 2 million suffer from severe, chronic symptoms. • 7 to 10 million Americans have some form of dry eye needing artificial tears. • 33 million adults may be undiagnosed. • Sjögren’s - associated dry effects 1% to 2% of the population. 3 Prevalence of Dry Eye Disease • Average age of a dry eye patient is 54; most are women. • 59 million Americans may be suffering from Dry Eye Syndrome. • Dry Eye Syndrome affects 75% of people over age 65. • Common reason for ophthalmologist visits. 4 What is Dry Eye Disease? Chronic dry eye disease (CDED) is a condition caused by many factors that result in inflammation of the eye and the tear-producing glands. Inflammation can decrease the eye’s ability to produce normal tears that protect the surface of the eye and keep it moist and lubricated. 5 Dry Eye is more than a red eye. 6 Dry Eye Is a Continuum of Disease 7 The Healthy Eye Normal tearing depends on a neuronal feedback loop Secretomotor Nerve Impulses Lacrimal Glands Tears Support and Maintain Ocular Surface Ocular Surface Neural Stimulation Stern et al, Cornea. 1998:17:584 8 Dry Eye Disease: An Immune- Mediated Inflammatory Disorder Inflammation disrupts normal neuronal control of tearing. Lacrimal Glands: • Neurogenic Interrupted Secretomotor Inflammation Nerve Impulses • T-cell Activation • Cytokine Secretion into Tears Tears Inflame Ocular Surface Cytokines Disrupt Neural Arc Stern et al, Cornea. 1998:17:584 9 Dry Eye Disease Continuum • Continuum of severity ranges from mild to severe1 • Chronic dry eye is the result of disease progression 1Pflugfelder. Am J Ophthalmol. 2004. 10 Multiple Factors in Dry Eye • Transient discomfort • May be stimulated by environmental conditions1 • Inflammation and ocular surface damage • Altered tear film composition2 1de Paiva and Pflugfelder. In: Dry Eye and Ocular Surface Disorders. 2004; 2Pflugfelder et al. In: Dry Eye and Ocular Surface Disorders. 2004. 11 Role of Inflammation in Chronic Dry Eye • Inflammation may be present but not clinically apparent • Cycle of inflammation and dysfunction • If untreated, inflammation can damage the lacrimal gland and ocular surface • Consequences: – Lower tear production – Altered corneal barrier function Pflugfelder. Am J Ophthalmol. 2004. 12 Causes of Chronic Dry Eye Disruption of normal Lacrimal Glands: neuronal control of tearing • Chronic irritation • T-cell activation Interrupted Secretomotor • Cytokine secretion into Nerve Impulses tears Lacrimal Damage Tears Damage Ocular Surface Cytokines Disrupt Neural Arc Stern et al. Cornea. 1998. Nelson et al. Adv Ther. 2000. 13 Healthy Tears • A complex mixture of proteins, mucin, and electrolytes – Antimicrobial proteins: Lysozyme, lactoferrin – Growth factors & suppressors of inflammation: EGF, IL-1RA – Soluble mucin 5AC secreted by goblet cells for viscosity – Electrolytes for proper osmolarity Stern et al. In: Dry Eye and Ocular Surface Disorders. 2004. Image adapted from: Dry Eye and Ocular Surface Disorders. 2004. 14 Tears in Chronic Dry Eye • Decrease in many proteins • Decreased growth factor concentrations • Altered cytokine balance promotes inflammation • Soluble mucin 5AC greatly decreased – Due to goblet cell loss – Impacts viscosity of tear film • Proteases activated Solomon et al. Invest Ophthalmol Vis Sci. 2001. • Increased electrolytes Zhao et al. Cornea. 2001. Ogasawara et al. Graefes Arch Clin Exp Ophthalmol. 1996. Image adapted from: Dry Eye and Ocular Surface Disorders. 2004. 15 Who Is Likely to Have Dry Eye? How Do We Diagnose It? 16 Dry Eye Disease: Predisposing Factors • Aging • Menopause - Decreased Androgens • Allergy Response • Environmental Stresses – Contact Lens Wear – Low Humidity: Heating/Air Cond. – Wind – Lack of Sleep – Air Pollution – Use of Computer Terminals • Ocular Surgery (LASIK, Corneal Transplant) • Medications 17 Medications That May Contribute to Dry Eye Disease • Systemic • Topical – Antihypertensives – Antiandrogens – Preservatives in Tears – Anticholinergics – Antidepressants – Cardiac Antiarrhythmic Drugs – Parkinson’s Disease Agents – Antihistamines 18 Dry Eye Disease: Autoimmune Triggers • Systemic Autoimmunity – Rheumatoid Arthritis – Lupus – Sjögren’s Syndrome – Graft vs. Host Disease • All can result in immune-mediated inflammation in the eye. • Inflammatory mediators secreted into tears. – Promote inflammation of ocular surface. 19 Current Triggers of Dry Eye Disease Environment Rheumatoid Arthritis Medications Lupus Contact Lens Irritation Inflammation Sjögren’s Surgery Graft vs Host Tear Deficiency/ Postmenopause Meibomian Instability Gland Disease Symptoms of Ocular Surface Disease 20 Dry Eye Disease Symptoms • Discomfort • Dryness • Burning, Stinging • Foreign-Body Sensation • Gritty Feeling, Stickiness • Blurry Vision • Photophobia, Itching, Redness Note: Symptoms seldom correlate with clinical signs. Lemp CLAO J 1995;21:221 21 Patient Types with High Incidence of Dry Eye Disease • Women aged 50 or older1 • Women using postmenopausal hormone replacement therapy2 • Those with ocular comorbidities3 • Contact lens wearers3 • Smokers4 • Users of artificial tears ≥ 3 times/day 1Schaumberg et al. Am J Ophthalmol. 2003; 2Schaumberg et al. JAMA. 2001; 3Lemp. CLAO J. 1995; 4Multi-Sponsor Surveys, Inc. The 2005 Gallup Study of Dry Eye Sufferers. 2005. 22 Identifying Potential Dry Eye Patients 1. Do your eyes feel dry, painful, or sore? No 2. Do you experience episodes or periods of blurred vision? 3. How often are your eyes sensitive to light? 4. Do you have problems with your eyes when you are working on a computer, watching TV, or reading? 5. Do you use artificial tears three or more times a day? 23 Diagnosing Dry Eye Disease • Patients who answer “yes” to any one of the previous questions should be evaluated for dry eye disease • Many clinicians use clinical tests plus symptoms and patient history to diagnose1 1Nichols et al. Cornea. 2000. 24 Clinical Presentation Can Vary in Severity Mild Severe Slitlamp Fluorescein Dye Stain Lemp, 1995; Marsh et al, 1999 25 Schirmer Test Without Anesthesia • Measures reflex tear secretion. With Anesthesia • Eliminates stimulated tearing. 26 Potential Severe Consequences of Untreated Dry Eye Disease Sterile Melting Bacterial Keratitis 27 Symptoms of Dry Eye Dry Eye Severity 1 2 3 4 Level Mild Moderate Severe Severe General Symptoms Symptoms Symptoms Symptoms Symptoms Symptoms: Itchy, Sandy, Never to Sometimes Frequent Always Gritty, Dry Seldom Discomfort: Stinging, No Yes Yes Yes Burning, Pain Vision: Blurring, No No Sometimes Usually Interrupted Less than 2X Several times Several times Several times Use of Artificial Tears per day per day per day per day McDonnell et al. ARVO. 2004. 28 What Is Restasis ™? • Ophthalmic emulsion of cyclosporine 0.05%. – Prescription therapy for dry eye disease. – Restasis™ is FDA approved to increase tear production in patients whose tear production may be reduced by inflammation of the eye associated with keratoconjunctivitis sicca. 29 Left Untreated, Chronic Dry Eye May Become a Progressive Disorder • Patients suffering from dry eye disease may move between severity levels and can become worse, if untreated1 – Disease management options can be adjusted for individual patients depending on disease severity 1Nelson et al. Adv Ther. 2000. 30 Summary • Dry eye is a prevalent yet underdiagnosed disease ranging from mild to severe, episodic or chronic • Episodic dry eye can be due to external factors • Chronic dry eye can be a progressive disease with underlying pathophysiology of inflammation and altered tear composition • Certain patient types have a high incidence of dry eye and should be diagnosed with a combination of signs and symptoms • A continuum of care is available to treat both episodic and chronic dry eye across the range of severity levels 31 Do you think you have dry eyes? Make an appointment. • We can examine your eyes to see which treatment is correct for you. 32 Thank You.
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