‘‘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, Australia

926 16.3%

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

Prevalence of dry eye symptoms by age

0

5

10

15

20

Age 48-59 Age 60-69 Age 70-79 Age 80-91

Prev

alen

ce (%

)Prevalence of dry eye increases significantly with age

Dry eye: Prevalence

Dry eye: Prevalence

Prevalence of dry eye symptoms by age and sex

0102030

Age 48-59

Age 60-69

Age 70-79

Age 80-91

Prev

alen

ce (%

)

Women

Men

Prevalence of dry eye is higher in women

Increasing prevalence of dry eye

Increasing life-span of the population Expansion of consumption of medicationsIncrease in number of people wearing contact lensesIncrease in computer usage.Increase in number of patients undergoing LASIK.Increase in pollution…….

Symptoms Irritation RednessBurning/ StingingItchy eyesSandy- gritty feeling (foreign body sensation)Blurred vision Tearing Contact lens intolerance.Increased frequency of blinkingMucous 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

Reading

Working at computers

Watching television

32.3

27.5

25.7

17.9

Suppl P & T 2003; 28(12) 1-45

Dry eye may be sight-threatening

Bacterial Keratitis Corneal ulcer

Dry EyeAffects Quality of Life

DRY EYE : Classification

DRY EYE

Aqueous tear deficiency (ATD) (Tear deficient dry eye) keratoconjunctivitis sicca(KCS)(Most common)

Evaporative tear deficiency (ETD)(Evaporative dry eye)

According to the National Eye Institute

Clin Exp Optom 2001; 84: 1: 4-18, Surv Oph 2001: 45, S203-S210

Dry Eye: Main CausesTEAR DEFICIENT DRY EYE (KCS) EVAPORATIVE

DRY EYE Sjogrens Non-Sjogrens

–Ageing–Menopause–Medicamentosa–Cicatricial

disease–Neurotrophic

keratitis

Meibomian gland diseaseLid surfacing/blinking anomaliesContact lens relatedChronic allergy/toxicity

Clin Exp Optom 2001; 84: 1: 4-18

Dry Eye: Multifactorial natureElderly woman

Contact lens user

Postmenopausal

Taking glaucoma

medications

Working for long hours in front of

computer

Air-conditioned environment

Tear deficient dry eye Keratoconjunctivitis sicca (KCS)Sjogrens: Autoimmune disorder with a triad of dry mouth, dry eye and arthritisNon-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

syndromeRef: Clin. Exp. Optom 2001: 84: 1:4-18

J. Am. Optom Assoc. 1991; 62: 187-199Suppl P and T Digest 2003; 28(2): 1-45

EVAPORATIVE DRY DISEASE

Meibomian gland disease: Most prevalent (65%). Obstruction of meibomian glandLid surfacing anomalies: Lid closure affected, blinking affectedOcular surface toxicity: Long term use of topical antiglaucoma medications, preservatives like BAKContact lens relatedAllergy

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

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/minWorking on computer: 5 times/min

Clin Exp Optom 2001; 84: 1: 4-18

Abnormal blinking pattern

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?SorenessScratchinessDrynessGrittinessBurning

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 inEarly, 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

A rtific ia l tea rs

Tear rep lacem en t

P u n c ta l P lu g s

Tear P reserva tion

Trea tm en t

•Topical corticosteroids – fluorometholone, loteprednol (short-term)

•Topical androgen

•Cyclosporine ophthalmic emulsion

Late KCS

Tear substitutes:benefits Tear substitutes are the mainstay of therapy fordry 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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