Ocular surface disease and dry eye

What is the vicious circle of Dry eye

hyperosmolarity and inflammation

• leads to dry eye and damage to cells

What are nociceptive symptoms

a mechanism causes the sensory nerve to activate

• tissue damage leading to dry eye symptoms

SYMPTOMS AND SIGNS MATCH

What is neuropathic symptoms

dysfunction of nervous system

SYMPTOMS ARE WORSE THAN SIGNS

What are the types of dry eye

Keratoconjunctivitis sicca

Xerophthalmia - Vit A deficiency

Xerosis - dryness and keratinization with conj. cicatrization

Sjogren syndrome

Who gets dry eye

females (menopause)

Sjogrens

meds (antihistamines, HRT, antidepressants)

Contact lens

Surgery

Signs of dry eye

lid disease

Anterior and posterior bleph

Lid wiper epitheliopathy

increased friction due to poor tear film, incomplete lid closure or contact lens

Stained with lissamine green

PEE’s

• epithelial defect

• stain with fluorescein

• located inferior or interpalpebral

Filamentary keratitis

epithelial defect comprised of mucus and degenerative cells

mucus plaques are large filaments

Treatment: physically remove plaques

Dry eye questionnaires

SPEED

Ocular Surface Disease Index

What is observed during slit lamp for dry eyes

Lid position

Lid debris

Lid hyperemia

Meibomian gland capping and secretions

What is used to evaluate Cornea

fluorescein strips

Do not numb cornea

How is tear meniscus evaluated

measure the height of fear meniscus with slit lamp beam height

What dye stains devitalized cells and mucus

Lissamine green

used to evaluate conj and lid wiper epitheliopathy

Schirmer test

Schirmer 1: measures tear production (gets reflexive tears)

Schirmer: numb eyes first to remove reflexive tears

What technique lets you evaluate the lipid layer of tears

Interferometry

What technique lets you evaluate the meibomian glands

Meibography

Why is tear osmolarity tested

Tested to see how much water the tear film is pulling from the cornea (sign of dry eye)

What device is used to measure MMP-9

Inflammadry

test for inflammation marker

Lifestyle modifications (dry eye treatment)

avoid prolong near task

humid environment

physical protection \

Lid scrubs (dry eye treatment)

clean debris off lids

Eye lid margin debridement (dry eye treatment)

removal of debris and keratinized cells from lid margin

Warm compress (dry eye treatment)

improve meibomian gland expression

Systane ilux (dry eye treatment)

thermal pulsation heating lids

IPL (dry eye treatment)

high intensity light

kills bugs, melts meibum, clots telangictasia

Low level light therapy

used for anti inflammatory benefits

Pharmaceutical (dry eye treatment)

used to clear infection and improve gland secretions

Anterior bleph- topical antibiotic ointment, and steroids

Posterior bleph- systemic antibiotics for anti inflammation (doxycycline melts meibum)

DEWS level 1 symptoms

• mild discomfort

• no visual symptoms

• None to mild conj injection, staining

• none to mild cornea injection, staining

DEWS level 2 symptoms

• moderate discomfort

• annoying or actively limiting visual symptoms

• None to mild conj injection

• variable corneal and conj staining

• mild debris of cornea and tears

• MGD present

• TBUT and schirmer <10 D

DEWS level 3 symptoms

• severe discomfort without stress

• annoying chronic constant active limiting visual symptoms

• Conj injection yes or no

• moderate or marked conj staining

• Corneal staining marked centrally

• increased tear mucus

• Frequent MGD

• TBUT and schirmer <5 D

DEWs level 4 symptoms

• severe discomfort with stress

• constant possibly disabling visual symptoms

• Conj injection yes

• marked conj staining

• Corneal staining severe

• increased tear mucus

• scarring MGD

• TBUT and schirmer <2 D

Treatment for level 1 

• lifestyle modification 

• eliminate systemic medications 

• drops

• eyelid therapy 

Treatment level 2

Level 1 treatment

Treat demodex if present

ADD

• anti inflammatories

• tetracyclilnes macrolides

• Punctal plugs

• topical secretogogues

• moisture chamber spectacles

• MG expression

Treatment Level 3

Level 2 treatment

ADD

• Autologous serum

• sclerals

• Oral secretogogues

Treatment level 4

level 3 treatments

ADD

• Long term topical steroid

• amniotic membrane

• surgery