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Dry Eye

Dry eye


Tear and the Tear Film

Function :
2.Wetting ocular surface
4.Supporting the cornea
(oxygen supply)

Dry Eye
Healthy tear

Dry eye

Tear film disorders

Aqueous tear deficiency
Lipid tear deficiency
Mucoprotein deficiency
Kinetic disorders of

The dry eye is not a disease entity,

but a symptom complex occurring as
a sequelae to deficiency or
abnormalities of the tear film.

1. Aqueous tear deficiency. It is
also known as keratoconjunctivitis
sicca. It is seen in conditions like
congenital alacrimia, paralytic
hyposecretion, primary and
secondary Sjogrens syndrome, Riley
Day syndrome and idiopathic

2. Mucin deficiency dry eye. It

occurs when goblet cells are
damaged, as in hypovitaminosis A
(xerophthalmia) and conjunctival
scarring diseases such as StevensJohnson syndrome, trachoma,
chemical burns, radiations and ocular

3. Lipid deficiency and

abnormalities. Lipid deficiency is
extremely rare. It has only been
described in some cases of congenital
anhydrotic ectodermal dysplasia along
with absence of meibomian glands.
However, lipid abnormalities are quite
common in patients with chronic
blepharitis andchronic meibomitis.

4. Impaired eyelid function. It is seen

in patients with Bells palsy, exposure
keratitis, dellen, symblepharon,
pterygium, nocturnal lagophthalmos and
5. Epitheliopathies. Owing to the
intimate relationship between the corneal
surface and tear film, alterations in
corneal epithelium affect the stability of
tear film.

Symptoms suggestive of dry eye include

irritation, foreign body (sandy) sensation,
feeling of dryness, itching, non-specific ocular
discomfort and chronically sore eyes not
responding to a variety of drops instilled earlier.
Signs of dry eye include: presence of stringy
mucus and particulate matter in the tear film,
lustureless ocular surface, conjunctival xerosis,
reduced or absent marginal tear strip and
corneal changes in the form of punctate
epithelial erosions and filaments.

Tear film tests

These include tear film break-up time
(BUT), Schirmer-I test, vital staining
with Rose Bengal, tear levels of
conjunctival impression cytology.
Out of these BUT, Schirmer-I test and
Rose Bengal staining are most
important and when any two of these
are positive, diagnosis of dry eye
syndrome is confirmed.

Tear film break-up (BUT)

It is the interval between a complete blink
and appearance of first randomly distributed
dry spot on the cornea. It is noted after
instilling a drop of fluorescein and examining
in a cobalt-blue light of a slit-lamp.
BUT is an indicator of adequacy of mucin
component of tears.
Its normal values range from 15 to 35
seconds. Values less than 10 seconds imply
an unstable tear film.

Tear break-up time, BUT

Schirmer-I test
It measures total tear secretions. It is performed with
the help of a 5 35 mm strip of Whatman-41 filter
paper which is folded 5 mm from one end and kept in
the lower fornix at the junction of lateral one-third
and medial two-thirds. The patient is asked to look
up and not to blink or close the eyes (Fig. 15.4).
After 5 minutes wetting of the filter paper strip from
the bent end is measured.
Normal values of Schirmer-I test are more than 15
mm. Values of 5-10 mm are suggestive of moderate
to mild keratoconjunctivitis sicca (KCS) and less than
5 mm of severe KCS.

Rose Bengal staining

It is a very useful test for detecting even
mild cases of KCS. Depending upon the
severity of KCS three staining patterns A,
B and C have been described: C pattern
represents mild or early cases with fine
punctate stains in the interpalpebral
area; B the moderate cases with
extensive staining; and A the severe
cases with confluent staining of
conjunctiva and cornea.

At present, there is no cure for dry eye. The
following treatment modalities have been tried
with variable results:
1. Supplementation with tear substitutes.
Artificial tears remains the mainstay in the
treatment of dry eye. These are available as
drops, ointments and slowrelease inserts. Mostly
available artificial tear drops contain either
cellulose derivatives (e.g., 0.25 to 0.7% methyl
cellulose and 0.3% hypromellose) or polyvinyl
alcohol (1.4%).

2. Topical cyclosporine (0.05%, 0.1%)

is reported to be very effective drug for
dry eye in many recent studies. It helps
by reducing the cell-mediated
inflammation of the lacrimal tissue.
3. Mucolytics, such as 5 percent
acetylcystine used 4 times a day help
by dispersing the mucus threads and
decreasing tear viscosity.

4. Topical retinoids have recently been reported to be

useful in reversing the cellular changes (squamous
metaplasia) occurring in the conjunctiva of dry eye
5. Preservation of existing tears by reducing
evaporation and decreasing drainage. Evaporation
can be reduced by decreasing room temperature, use of
moist chambers and protective glasses.
6.Punctal occlusion to decrease drainage can be
carried out by collagen implants, cynoacrylate tissue
adhesives, electrocauterisation, argon laser occlusion and
surgical occlusion to decrease the drainage of tears in
patients with very severe dry eye.

Meibomian Gland Dysfunction

Failure of the glands to
produce or secrete lipids.
Common in aged people
and who lived in cold
No specific symptoms.
Lid-margin mostly
thickening; abnormal
secretion while

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.

Hot fomentation on eyelids for 5~10mins.
Massaging the eyelids.
Swabbing the lid-margin with mild cleaning solution.

Antibiotics oral administration.

Local Medication
Antibiotic eye drops
Glucocorticoid eye drops (short term)
Artificial tears