Dry Eyes

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Dry Eyes

• Jason Much, M.D.

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• I have no financial interest in the subject
  matter of this presentation.

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Dry 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.
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International 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.

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• 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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Normal tears
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Tears in Dry Eye Syndrome
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Lacrimal functional unit

• Ocular surface
• Eyelids
• Including Meibomian glands
• Tear secreting glands
• Main lacrimal gland
• Accessory lacrimal glands
• Sensory and autonomic nerves

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Disorders 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
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Dry 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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Medications associated with dry eye

• Antihypertensives
• Antidepressants (e.g. tricyclics)
• Antihistamines
• Anticholinergics
• Marijuana
• Many others

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Dry 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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Meibomian 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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Ocular surface disease

• Tear film
• Eyelids and eyelashes
• Conjunctiva
• Limbal stem cell deficiency

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Eyelid problems

• Malposition
• Ectropion, entropion
• Retraction and scleral show
• Lagophthalmos and exposure
• Floppy eyelid syndrome
• Abnormal blink
• Decreased frequency
• Incomplete blink

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Exposure keratopathy
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Conjunctivochalasis

• Redundant inferior bulbar conjunctiva
• Often overlooked

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Chronic 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

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Dry 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!

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Dry Eye Treatment

• Artificial tears
• Punctal plugs
• Warm compresses
• Oral doxycycline
• Topical steroids
• Restasis

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Sjogrens 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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Artificial Tears

• Alcon
• Systane
• Allergan
• Optive
• Refresh
• Bausch and Lomb
• Soothe
• AMO
• Blink
• Novartis
• Genteal
• Advance Vision Research
• TheraTears

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Restasis (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

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New therapies

• Azasite
• Topical azithromycin drop (suspension)
• Autologous serum eye drops
• Agents to stimulate mucin secretion?
• Hormonal therapy?