Literatur Review

PATHOGENESIS AND EXAMINATION

ON DRY EYE

MEIRONI WAIMIR

Sub Division of Infection and Immunology

Department of Ophthalmology
Medical Faculty of Andalas University/ DR. M. Djamil Hospital
Padang
2018
 INTRODUCTION

Dry Eye

Disorder of the eye surface characterized by

the production instability and function of the
tear layer
Many of the causes of dry eye affect more than one
component of tear film

 Patients with dry eyes most often complain of

scratchy or sandy sensations
 Other common symptoms are itching, excess mucus
secretion, inability to produce tears, burning
sensation, photosensitivity, redness, pain, and
difficulty moving the palpebra
Examination on dry eye

Tear Meniscus
• assess whether or not meniscus tears

Schirmer Test
• assess tear production

Tear Film Break-Up Time

• for estimating the mucin content in tear fluid

Ferning Test
• assess the quality of the mucin layer

Rose Bengal Coloration

• assess the state of conjunctival cells and corneal pathologies, which are not coated
with mucin
Impression Cytology
• assess the state as well as the density of eye surface cells

Tear Composition Assay

 TEAR FILM

Tear Film

 Liquid layer that covers the front surface

of the eye

 Complex structure whose composition

comes from various sources, namely the
lacrimal gland, meibom glands, goblet
cells, and lacrimal gland accessories from
the surface of the eye
Tear film consists of 3 layers of lipid, aqueous, and mucin
Anatomy and Physiology of the Lipid Layer

The lipid layer  superficial layer of the tear film with

thickness of approximately 100 molecules

Containing polar and non-polar lipids secreted mainly

by the meibom glands

Stages of lipid secretion by the Meibom gland

 lipid synthesis, lipid release from cells, and release
of secretion products from the ducts.
 To slow down evaporation and
smoothing the optical surface

To maintain a hydrophobic barrier

The function of
(lipid strip) that prevents tears from
the lipid layer overflowing

To prevent damage to the skin

edges of the eyelids by tears
Anatomy and Physiology of Aqueous Layer

Secreted by the major lacrimal glands and

accessories, containing electrolytes, water, and
proteins

The largest component of the tear film (± 90%)

 Creating a favorable environment for ocular
surface epithelial cells

Supplying oxygen and essential nutrients to the

avascular corneal epithelium
The function of
the aquoeus layer Maintaining a constant electrolyte composition
over the epithelium of the eye surface
Source of growth factors for the proliferation,
migration of conyungtival and corneal
epithelium, and corneal wound healing
Clears debris and supports corneal function and
conjunctival epithelial cells
Anatomy and Physiology of Mucin Layer

Secreted by conjunctival goblet cells, flattened cells of

the conjunctiva and corneal epithelium, and slightly by
the lacrimal glands of Henle and Manz

Contains mucin (the main component), electrolytes,

water, proteins including immunoglobulins, and lipids
 To change the surface of the corneal
epithelium from the hydrophobic layer
to the hydrophilic layer for distributing
the tear film

The function of Stabilize the tear film

the mucin layer

Capturing the surface of damaged cells,

foreign particles and bacteria, and
palpebral lubrication
PATHOGENESIS DRY EYE

Dry Eye

Multifactorial disease
of tears and ocular surface

Produces symptoms of discomfort, visual

disturbance, and tear film instability with
potential damage to the ocular surface
 Lacrimal Gland

Ocular Surface (cornea,

conjunctiva, and
Dry eye meibomian glands)
 a disorder
of the lacrimal
functional unit Eyelids

The sensory and motor

nerves
Mechanism of dry eye
Dry eye diagnostic classification scheme
Classification Dry eye syndrome Based on International Dry Eye Workshop
 EXAMINATION ON DRY EYE

Tear Meniscus

Normal  tear produces a tear meniscus full, slightly

concave and measuring between 0.5-1.0 mm

Located between the eyeball and the inferior

palpebra

Abnormal (tear film deficiency) 0.3 mm or less

(tear meniscus reduced or none)
 Schirmer Test

• To assess the quantity of

tears
Function • To assess the rate of tear
secretion

• Schirmer I Test (without

Schirmer anesthetic)
Test • Schirmer II Test/ Jones’s
Test (with anesthetic)
 Schirmer I Test

• determine whether tear

production is sufficient to
wet the eyes
Function • measure basal secretion
and lacrimal excretion
reflexes

• The secretion reflex is mainly from the lacrimal gland

• Basal secretion is from Wolfring and Krause
 The examination technique

• The examination was performed on both eyes (without

topical anesthesia)
• The filter paper fold was inserted into the inferior
fornix conjunctival sac at the medial encounter and 1/3
of the temporal inferior palpebra
• The patient was advised to close the eye slowly
• After 5 minutes the filter paper is lifted and the wet
paper section measured starting from the indentation
 • If the wet filter is 10-30 mm
lacrimal secretion is normal
Results • If < 5 mm indicates less basal
secretion
Schirmer II Test/ Jones's test

Function • measured basal

secretion
 The examination technique

• The examination was performed on both eyes (with

topical anesthesia)
• The filter paper is placed behind the eyelid to be
examined which has been tested for anesthesia
• The patient was advised to close the eye slowly
• awaited 2-5 minutes, then viewed the wet filter paper
section
 • Normally the filter paper becomes
wet 15 mm after an inspection for
Results 2-5 minutes
 Break Up Time (BUT)

• to see the physiological

function of tear films
Function • to evaluate the stability
of tear film
 The examination technique

The patient sitting in front of the slitlamp

 Fluoresein given to the inferior sac in conjunctiva
 The patient closed his eyes with the aim that
fluoresein spread to the surface of the cornea
 The eyes are irradiated with a blue cobalt filter
 The patient is asked to wink several times
 the patient is asked to open the eyelid and look ahead
and should not blink
 See the occurrence of black dots in the blue green
field area which is a dry area of ​the cornea (dry spot)
 • Normally the tear film has a 15-30
second corneal wetting time
Results • If less than 10 second  there has
been mucin deficiency, this shows an
unstable tear film
 Rose Bengal Coloration

• Assess the state of

conjunctival cells and
corneal pathologies, which
Function are not coated mucin
• This coloring aims to color
the dead cells (a red color)
 The examination technique

 Give local anesthesia to the eye to be examined

 Drop Rose Bengal into the superior bulbi conjunctiva
 Patients were asked to blink, wait for 1 minute
 Rose Bengal spread washed with physiological salt
 Use a red-free (green) filter on the slitlamp to see dye
absorption in the conjunctiva and cornea
 • Score 0: no dye absorption
• Score 1: light dyeing a point
Results • Score 2: staining uneven patches
• Score 3: uniform coloring
 Ferning Test

• assess the quality of the

Function mucin layer

• the phenomenon of Ferning

The principle (leaf fern)
 • Grade 1: a picture of a good and
many ferns
• Grade 2: fern leaf picture starts to
decrease but still good.
Results • Grade 3: fern leaf picture begins to
formless, there is still a small part
which is fern-shaped.
• Grade 4: fern leaf picture is not
formed at all
 Impression Cytology

 Impression cytology using cellulose acetate

filter

 Assess the state and density of eye surface

cells, such as epithelial cells, goblet cells, and
cellular damage features that undergo
keratinization
Tear Composition Assay

Cultures of the palpebra

• Rarely helpful, but may provide useful
information on certain cases

Tear film osmolarity

• Tears have osmolarity of 302 mOsm/l
• In dry eye tear osmolarity increased between 330
and 340 mOsm/l due to decreased flow and
increased tear evaporation

Tear lisozyme
• Normal tear level of lysozyme 2-4 mg/ml
Tear lactoferrin
• Lactoplate test, lactocard test and
colorimetrically.

Tear protein analysis

• Protein tear can be measured by ELISA
• Electroferesis can be used to separate the various
proteins in the tears
 CONCLUSION
Dry Eye is a multifactorial disease of tears and ocular
surface that produces symptoms of discomfort, visual
disturbance, and tear film instability with potential
damage to the ocular surface

Tear film is a complex structure whose composition

comes from various sources namely lacrimal gland,
meibom glands, goblet cells, and lacrimal gland
accessories from the surface of the eyeball. Tear film
consists of 3 layers of lipid, aqueous, and mucin.
The mechanisms of dry eye are associated with
tear film hyperosmolarity, tear film instability and
inflammation

Checking on dry eye in both quantity and quality

is determined by the composition of the
components present in the three tear film layers.
There are 2 categories of checks, namely to
measure tear production and evaluate the
stability of tears
Thank You