Dry Eye The Eye Centers of Racine and Kenosha

1
Dry EyeThe Eye Centers of Racine and
Kenosha
Dr. Kanwar A. Singh MDDr. I. Paul Singh MDDr.
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.
• Sjögrens - 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 eyes
  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
Stern et al, Cornea. 199817584
8
Dry Eye Disease An Immune-Mediated Inflammatory
Disorder
Inflammation disrupts normal neuronal control of
tearing.

• Lacrimal Glands
• Neurogenic Inflammation
• T-cell Activation
• Cytokine Secretion into Tears

Interrupted Secretomotor Nerve Impulses
Tears Inflame Ocular Surface
Cytokines Disrupt Neural Arc
Stern et al, Cornea. 199817584
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. 20042Pflugfelder 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 neuronal control of tearing

• Lacrimal Glands
• Chronic irritation
• T-cell activation
• Cytokine secretion into tears

Interrupted Secretomotor Nerve Impulses
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 proteinsLysozyme, 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 oftear film
• Proteases activated
• Increased electrolytes

Solomon et al. Invest Ophthalmol Vis Sci.
2001. 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
• Wind
• Air Pollution
• Ocular Surgery (LASIK, Corneal Transplant)
• Medications

• Low Humidity Heating/Air Cond.
• Lack of Sleep
• Use of Computer Terminals

17
Medications That May Contributeto Dry Eye Disease

• Systemic
• Antihypertensives
• Antiandrogens
• Anticholinergics
• Antidepressants
• Cardiac Antiarrhythmic Drugs
• Parkinsons Disease Agents
• Antihistamines

• Topical
• Preservatives in Tears

18
Dry Eye DiseaseAutoimmune Triggers

• Systemic Autoimmunity
• Rheumatoid Arthritis
• Lupus
• Sjögrens 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
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 199521221
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

• Do your eyes feel dry, painful, or sore?
• Do you experience episodes or periodsof blurred
  vision?
• How often are your eyes sensitive to light?
• Do you have problems with your eyes when you are
  working on a computer, watching TV, or reading?
• Do you use artificial tears three or more times a
  day?

No
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
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 EyeMay 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.