Title: Dry Eyes
1Dry Eyes
2- I have no financial interest in the subject
matter of this presentation.
3Dry Eyes Public Health Impact
- High prevalence especially in women and elderly
- Very common complaint to eye care providers
- Economic implications of missed school/work and
health care utilization - Marked decrease in vision-related quality of life
Prevalence, burden, and pharmacoeconomics of dry
eye disease. Pflugfelder SC. American Journal of
Managed Care. 14(3 Suppl)S102-6, 2008. Impact
of dry eye syndrome on vision-related quality of
life. Miljanovic B. Dana R. Sullivan DA.
Schaumberg DA. American Journal of
Ophthalmology. 143(3)409-15, 2007. Dry eye
prevalence, utilization, and economic
implications. Dalzell MD. Managed Care. 12(12
Suppl)9-13, 2003. Dry eye disease the scale of
the problem. Brewitt H. Sistani F. Survey of
Ophthalmology. 45 Suppl 2S199-202, 2001.
4International Dry Eye Workshop (DEWS)
- Dry eye is a multifactorial disease of the tears
and ocular surface that results in symptoms of
discomfort, visual disturbance, and tear film
instability with potential damage to the ocular
surface. It is accompanied by increased
osmolarity of the tear film and inflammation of
the ocular surface.
5- Tear film
- Refracts light by providing a smooth, clear
optical surface - Lubricates the ocular surface and prevents
friction during blink - Provides oxygen to corneal epithelium as well as
nutrients, growth factors, and anti-microbials
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8Normal tears
9Tears in Dry Eye Syndrome
10Lacrimal functional unit
- Ocular surface
- Eyelids
- Including Meibomian glands
- Tear secreting glands
- Main lacrimal gland
- Accessory lacrimal glands
- Sensory and autonomic nerves
11Disorders of the Lacrimal Functional Unit
Afferent Trigeminal ganglion ablation Herpes
simplex, herpes zoster Familial dysautonomia
(Riley-Day syndrome) Contact lenses Diabetic
neuropathy Lattice corneal dystrophy Surgeriesscl
eral buckling, penetrating keratoplasty, LASIK
Glandular Aginglobular and diffuse fibrosis and
atrophy, periductual fibrosis, lymphocytic
infiltration, decreased EGF and
lactoferrin secretion Cicatricial duct
obstructiontrachoma, Stevens-Johnson
syndrome, ocular cicatricial pemphigoid,
chemical/thermal injury Menopausedecrease in
supportive hormones (androgens) Infection/inflamma
tionHIV, chronic hepatitis C, graft vs
host disease, Sjögren syndrome Nutritionalvitamin
A deficiency Rosacea Isotretinoin (Accutane)
therapy
Efferent Systemic medications with
anticholinergic effectsantihistamines, antispasmo
tics, anti-emetics, and antidepressants M3
acetylcholine receptor autoantibodies (Sjögren
syndrome) Age-related parasympathetic
dysfunction Bells palsy
12Dry Eye Symptoms
- Irritation
- Sandy, gritty, burning, scratchy feeling
- Foreign body sensation
- Sharp or poking pain
- Tired eyes
- Watering
- Redness
- Blurry vision (fluctuating)
- Photophobia
Symptoms worse at night, while reading or
working on computer or driving, and in windy or
low humidity conditions.
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14Medications associated with dry eye
- Antihypertensives
- Antidepressants (e.g. tricyclics)
- Antihistamines
- Anticholinergics
- Marijuana
- Many others
15Dry Eye Signs
- Fast tear break-up-time
- Less than 5-10 seconds
- Low tear lake
- Punctate epithelial erosions or staining
- Especially in interpalpebral zone
- Look for conjunctival staining
- Lissamine green may be helpful
- Tear film debris
- Filamentary keratitis
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17Meibomian gland dysfunction and blepharitis
- Blepharitis
- Anterior vs. posterior Types I-VII
- Staphylococcal - collarettes
- Seborrheic - crusts
- Demodex - sleeves
- Rosacea
- Meibomian gland dysfunction
- Meibomianitis, pouting glands
- Inspissation and toothpasting
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19Ocular surface disease
- Tear film
- Eyelids and eyelashes
- Conjunctiva
- Limbal stem cell deficiency
20Eyelid problems
- Malposition
- Ectropion, entropion
- Retraction and scleral show
- Lagophthalmos and exposure
- Floppy eyelid syndrome
- Abnormal blink
- Decreased frequency
- Incomplete blink
21Exposure keratopathy
22Conjunctivochalasis
- Redundant inferior bulbar conjunctiva
- Often overlooked
23Chronic cicatrizing conjunctivitis
- Stevens-Johnson syndrome (SJS)
- Toxic epidermal necrolysis (TEN)
- Ocular cicatricial pemphigoid (OCP)
- Trachoma
- Epidemic keratoconjunctivitis (EKC)
- Rosacea
- Atopic keratoconjunctivitis
- Sjogrens syndrome
- Progressive systemic sclerosis
- Sarcoidosis
24Dry Eye Tests
- Low Schirmers
- Less than 10mm on 5-minute anesthetized test
- Delayed fluorescein clearance
- Increased tear film osmolarity
- Decreased tear lysozyme and lactoferrin
- Decreased conjunctival goblet cell density on
impression cytology - Kinetic analysis of tear interference images
- And many others!
25Dry Eye Treatment
- Artificial tears
- Punctal plugs
- Warm compresses
- Oral doxycycline
- Topical steroids
- Restasis
26Sjogrens syndrome
- Chronic autoimmune condition of exocrine glands
- Also associated with joint disease, pulmonary
disease, gastrointestinal disease, kidney
dysfunction, hematologic abnormalities,
neuropathy, vasculitis, and lymphoma - Primary vs. secondary
- Systemic immunomodulatory treatment
- Secretagogues
- Oral pilocarpine or cevimeline treats dry eye and
dry mouth
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29Artificial Tears
- Alcon
- Systane
- Allergan
- Optive
- Refresh
- Bausch and Lomb
- Soothe
- AMO
- Blink
- Novartis
- Genteal
- Advance Vision Research
- TheraTears
30Restasis (cyclosporine)
- Approved by FDA for anti-inflammatory therapy of
dry eye - T cell suppression
- May take months before patients notice an effect
- Consider initial pulse of mild topical steroid
- Keep in refrigerator to minimize burning
31New therapies
- Azasite
- Topical azithromycin drop (suspension)
- Autologous serum eye drops
- Agents to stimulate mucin secretion?
- Hormonal therapy?