Ocular Surface Diseases

The Fourth Affiliated Hospital of CMU

Eye Centre

Overview

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Roles and Characteristics of the eyelids

• Eye protection

• Regular blink: protection and stability of the tear film

• Rich of glands

• Adequate blood supply

• No venous valve

Conception

• Corneal epithelium • Conjunctival epithelium • Tear film • Clinical ocular surface consist of conjunctiva cornea eyelids lacrimal gland lacrimal passages

Tear and the Tear Film

• Function : 1.Cleaning

2.Wetting ocular surface 3.Bacteriostasis 4.Supporting the cornea (oxygen supply)

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Origin of Epithelium

• Stem cells, SC Corneal epithelium derived from the

Limbal stem cells.Conjunctival epithelium derived from

forniceal and palpebral regions.

Ocular Surface Disease ★

Conception

•The ocular surface is a complex biological

continuum responsible for the maintenance of

corneal clarity, elaboration of a stable tear film for

clear vision, as well as protection of the eye

against microbial and mechanical insults.

•Comprising a variety of disorders on cornea,

eyelid, conjunctiva, lacrimal apparatus and tear

film.

Classification

•Corneal, conjunctival lesion Squamous epithelization type Limbal stem cell deficiency type

•Tear film disorders Aqueous tear deficiency Lipid tear deficiency Mucoprotein deficiency Kinetic disorders of lacrimal fluid

Treatment

• Reconstruction Epithelium, limbal stem cells Lacrimal secretion, tear film Innervation (nerve restore)

Structure and function of eyelid • Surgical operation To re-establish conjunctiva, cornea,

tear film and eyelid.

Dry Eye

Healthy tear film Dry eye

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Conception

• Dry eye (known by doctors as keratoconjunctivitis sicca) is a chronic lack of sufficient lubrication and moisture in the eye.

• Its consequences range from subtle but constant irritation to ocular inflammation of the anterior (front) tissues of the eye.

Tear Secretion

• Lacrimal gland Producing the watery part of the tear film

called the aqueous. • Meibomian glands Producing lipids which keep the tear film

from evaporating.

• Goblet cells of the conjunctiva Producing mucin which allows the wetting

of the ocular surface as well as stabilizes the tear film.

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Etiological factor & Classification

Aqueous tear deficiency

Lipid tear deficiency

Mucoprotein deficiency

Kinetic disorders of lacrimal fluid

Clinical Manifestation

• Dry eye symptoms asthenopia

irritation, grittiness

dryness

burning

ophthalmalgia

light sensitivity

pink-eye

• Do you regularly experience one or several symptoms above?

• Some diseases and conditions (like rheumatoid arthritis, lupus and Sjögren’s Syndrome) also cause chronic Dry Eye in many patients.

• On the other hand, activities like reading, Wearing contact lenses or working at the computer may cause Dry Eye.

Diagnostic Tests for Dry Eye

• Dry Eye questionnaire

• Lacrimal river width

• Schirmer test – uses paper strips under eyelid to measure the wetness that collects over a specific period of time.

• Break-up time of tear film (BUT)

• Staining – uses special dyes to highlight areas of possible damage to the eye surface.

• Tear ferning test

• Lactoferrin contents

• Tear penetration pressure test

• Corneal tonographic map

• Impression cytology

Diagnosing

• Schirmer test, BUT, Staining

• Foundation Symptom

Instability of tear film

Damage on epithelium

Tear penetration pressure increasing

Treatment

• According to the clinical category

For tear deficiency: Maintain moisture in the eyes; reducing the evaporation; increasing the secretion; controlling inflammation & immunoreaction.

For over-evaporation: Therapy the Meibomian gland dysfunction; controlling inflammation; cleaning eyelid; decreasing the evaporation; lipid replacement.

• According to the eye conditions

For intermittent symptoms: Artificial tears add volume to the tear film as long as they remain in contact with the surface of the eye.

For midrange dry eye: Artificial tears and punctal occlusion.

For Severe dry eye: Appending cyclosporin, surgery.

Summary

• Eliminating the etiological factors

• Tears replacement therapy

• Maintain moisture in the eyes

• Increasing the tear secretion

• Immune inhibition therapy

• Re-establish the tear film

• Other supporting treatment

Meibomian Gland Dysfunction

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Etiological Factor

• Failure of the glands to produce or secrete lipids.

• Wax ester declining and cholesterol increasing make the symptoms worse .

• Lack of tears and tear penetration pressure increasing.

• Lupus, brandy nose etc.

Clinical Manifestation

• Common in aged people and who lived in cold region.

• No specific symptoms.

• Lid-margin mostly thickening; abnormal secretion

while pressurizing.

• Disorder in Meibomian

gland, eyelid, conjunctiva.

Figure: Notching of the lid caused by loss of meibomian glands.

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Diagnosing

•Absence of Meibomian gland.

•The gland orifices are often compromised due to stenosis or closure.

•A declining quality and quantity of lipid secretion.

Anyone of the physical signs can make the diagnosis of Meibomian gland dysfunction if the patient has clinical symptoms.

Figure: No visible meibomian gland orifices: Eversion of the lower lids in both eyes showed atresic meibomian glands.

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Treatment

Clearing

• Hot fomentation on eyelids for 5~10mins.

• Massaging the eyelids.

• Swabbing the lid-margin with mild

cleaning solution.

Treatment

• Antibiotics oral administration.

• Local Medication

Antibiotic eye drops

Glucocorticoid eye drops (short term)

Artificial tears

The End

Lacrimal river width

Schirmer Test

• Normal ：≥ 10mm/5min

Tear break-up time, BUT

Staining

• Using special dyes to highlight areas of possible damage to the eye surface.

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