Lids, Lashes, & Dry Eye

Dr. Peterson's Ocular Disease Lecture UMSL School of Optometry

homeostasis

According to the DEWS II report, the main goal of DED treatment is to restore ____________.

1. Advanced age

2. Female sex

3. Asian race

4. Extreme heat or cold weather

5. Low humidity

6. Refractive sx

7. Contact lenses

8. Certain medications

9. Technology use

What are the 9 risk factors of Dry Eye Syndrome?

Keratoconjunctivitis sick (KCS)

Historic term for dry eye referring to any degree of dryness; typically referring to aqueous deficiency dry eye

Xerophthalmia

Severe dry eye due to Vitamin A deficiency

Xerosis

Extreme eye dryness and keratinization secondary to cicatricial disease

Sjogren Syndrome

Autoimmune inflammatory disease; attack on the salivary and lacrimal glands (dry eyes, dry mouth)

1. Meibomian glands

2. Glands of Zeis

3. Glands of Moll

4. Glands of Wolfing & Krause

What 4 glands are present in the eyelid?

Glands of Moll

What glands in the eyelid are apocrine glands and partake in immune defense?

Glands of Wolfing & Krause

What glands in the eyelid undergo merocrine secretion and empty into the fornix of the eye?

Glands of Zeis

What glands in the eyelid undergo holocrine secretion and secrete sebum onto lashes?

1. Gland of Wolfing

2. Gland of Krause

3. Gland of Moll

4. Gland of Zeus

Identify the following glands within the eyelid based on the image (1-4).

1. Lipid layer

2. Aqueous layer

3. Mucin layer

What are the 3 layers of the tear film?

meibomian glands

What gland is responsible for secreting the lipid layer of the tear film?

Lacrimal gland

What gland is responsible for secreting the aqueous layer of the tear film?

goblet cells

What is responsible for the mucin layer of the tear film?

lipid layer

What layer of the tear film prevents evaporation and stabilizes the tear film?

aqueous layer

What layer of the tear film provides essential nutrients and oxygen to avascular cornea, assists in metabolic waste and debris removal, and protects ocular surface with bacteriolytic enzymes?

mucin layer

What layer of the tear film serves as the hydrophilic barrier to the corneal epithelium for wetting of the ocular surface?

1. Aqueous-deficient

2. Evaporative

What are the 2 main types of dry eye?

True

True/False: Dry eye disease is more of a continuum in its classification of being evaporative or aqueous deficient.

Tear Hyperosmolarity; pro-inflammatory mediators

What is the triggering event of all dry eye types in the cascade? What does this event cause the release of?

1. Noninvasive TBUT

2. Tear Osmolarity

3. Ocular surface staining

According to the DEWS II, diagnosing dry eye disease must have a positive result in at least one of what 3 diagnostic tests?

CN V1

In dry eye disease, there is a disruption between the lacrimal gland and neurons of the cornea that are part of what cranial nerve?

ocular sensitivity

Disruption to the lacrimal gland in dry eye disease leads to decreased secretions to the ocular surface followed by decreased _______________________.

Interrupts sensory innervation —> reduced corneal sensitivity —> decreased lacrimal gland feedback —> aqueous deficient dry eye

How does refractive surgery induce dry eye?

Aqueous deficient dry eye

What type of dry eye results from refractive surgery?

MMP-9 levels

What levels are specifically measured in InflammaDry dry eye testing?

inflammation

What is the key mechanism of ocular surface injury in eyes with DED?

1. Tear film disruption

2. Ocular surface cell damage

What 2 triggers stimulate protective immmunoregulatory and pro-inflammatory mechanisms?

Tear hyperosmolarity

What is the key trigger of inflammatory dry eye?

androgens; estrogens

In regards to hormones, ___________ are thought to suppress DED while ____________ are thought to promote DED.

lacrimal & meibomian glands

What is targeted in the influence of dry eye by hormones?

Transdermal 0.5% testosterone eyelid cream

What treatment is often used in post-menopausal women dealing with dry eye?

1. Epstein-Barr virus

2. Hepatitis C virus

3. Human T-cell leukemia virus type I

What 3 viral infections are associated with Sjogren Syndrome?

Other inflammatory diseases (RA, Lupus, Hepatitis, Myasthenia gravis, etc.)

Secondary Sjogren’s Syndrome results from what?

Aqueous-Deficient dry eye

What type of dry eye is associated with Sjogrens syndrome?

1. Anti-SSA (Rho)

2. Anti-SSB (La) antibodies

3. Antinuclear Antibodies (ANA)

4. Rheumatoid Factor (RF)

What 4 levels should be tested in blood work for diagnosing Sjogren’s?

1. Anti-SSA (Rho)

2. Anti-SSB (La)

What 2 levels in the blood are specific for Sjogrens?

The Sjö Test

What test for Sjogrens is 89% sensitive and 78.2% specific?

Refer to rheumatology for work-up

How should you manage a patient in which you suspect sjogrens?

1. Plaquenil

2. Methotrexate

What are 2 common forms of treatment for Sjogrens?

1. Dry mouth

2. Dry eyes

3. Dry nasal passages

4. Joint pain

What are 4 common symptoms of Sjogrens?

1. Topical corticosteroids

2. Restasis

3. Xiidra

What are the 3 main medications given for the ocular treatment of Sjogrens Syndrome?

Pilocarpine

What immunosuppressant medication is used in the ocular treatment of Sjogrens to promote parasympathetic output of the lacrimal gland?

1. Lacrimal deficiencies

2. Obstruction of lacrimal ducts

3. Neurosecretory/reflex block

4. Systemic drugs

What are 4 non-sjogren syndromes that cause aqueous-deficient dry eye?

1. Corneal surgery

2. Diabetes

3. Contact lens wear

What 3 ocular associations cause neurosecretory/reflex block?

1. Anti-depressants

2. Diuretics

3. β blockers

4. Antimuscarinics (Parkinson’s drugs)

What 4 main systemic drug types cause aqueous deficient dry eye?

Decrease lacrimal gland output

What effect do anti-cholinergic medications have on the lacrimal gland?

5 minutes

How long should you test a Schirmer’s test?

At least 15 mm; At least 10 mm

What is the expected Schemer’s result without anesthesia? With anesthesia?

>20 mm; < 6 mm

What is the expected Phenol Red Test results in a normal patient? Abnormal patient?

15 seconds

How long is the Phenol Red Test administered?

SM Tube

What dry eye assessment tests tear volume in 5 seconds?

0.3 mm

What is a normal lacrimal lake height?

a. Increased
b. Decreased
c. Decreased

Identify whether the following would be found in decreased or increased levels in DED.

a. Matrix Metalloproteinase
b. Lactoferrin
c. Lysozyme

Increased

Tear osmolarity is (increased/decreased) in dry eye.

TearLab

What dry eye lab test has the highest predictive value for the diagnosis of dry eye disease among objective tests?

1. Sodium fluorescein

2. Rose bengal

3. Lissamine green

What are 3 ophthalmic dyes used to visualize dry eye observations?

Lid wiper epitheliopathy

What lid staining defect is shown here? What dye was used?

Lagophthalmos

This inferior corneal staining pattern indicates what condition?

Lids/Lashes Toxicity to Cornea (i.e. blepharitis)

This inferior corneal staining pattern indicates what condition?

Aqueous deficiency

This type of staining pattern is common with what dry eye issue?

preservative sensitivity

The diffuse staining pattern shown here indicates what?

Meibomian Gland Dysfunction (MGD)

What is the most under diagnosed, under treated, and under appreciated disease in eye care?

meibomian glands

What gland is responsible for the lipid component of the tear film?

sebaceous glands

What type of glands are meibomian glands?

True

True/False: Meibomian glands are densely innervated.

Meibomian Gland Dysfunction (MGD)

What is most likely the most frequent cause of DED?

Meibomian Gland Dysfunction (MGD)

Chronic, diffuse abnormality of the meibomian glands, commonly characterized by terminal duct obstruction and/or qualitative/quantitative changes in glandular secretion; result in alteration of the tear film, symptoms of eye irritation, clinically apparent inflammation, and ocular surface disease

Meibomian Gland Dysfunction

Leading cause of evaporative dry eye

Rosacea

What is an example of a secondary cause of meibomian gland dysfunction?

60

Up to _____% of rosacea patients show ocular manifestations.

Rosacea

Disease affecting sebaceous glands in the face

Asian populations

What ethnicity has the highest prevalence of MGD?

1. Anterior blepharitis

2. Contact lens wear

3. Demodex

What are 3 ocular associations of MGD?

1. Androgen deficiency

2. Menopause

3. Aging

4. Rosacea

5. Antihistamine use

6. Antidepressant use

What are 6 systemic associations of MGD?

1. Irritation & visual fluctuation

2. Tear film instability

3. Ocular surface compromise

What are 3 clinical features present with both aqueous-deficient & evaporative dry eye?

smoking

What environmental factor causes thickened meibum?

Loss of lipid layer —> evaporation of aqueous layer

What causes tear film instability in MGD?

1. Photophobia

2. Discomfort

3. Burning

4. Itching

5. Grittiness

6. FBS

What are 6 ocular symptoms of MGD?

1. Telangiectasia of the lid margin

2. “Scalloped”, irregular lid appearance

What 2 features of the eyelid appearance indicate inflammation?

1. Inflammation

2. Capped glands

3. Saponification

What are 3 general appearances of the eyelid that aid in the diagnosis of MGD?

Telangiectasia of the lid margin

What is shown in the image?

Saponification; bacterial enzymes react to the tear film

What ocular anomaly is indicated by the arrow in cases of MGD? What causes this to occur?

clear, liquid meibum

What secretion quality of the meibomian glands would you expect in a normal, healthy patient?

Sodium fluorescein

What stain should be used to analyze corneal staining in the diagnosis of MGD?

Lissamine green & Rose Bengal

What stain(s) should be used to analyze conjunctival staining in the diagnosis of MGD?

The ocular surface is protected by the tear film.

An Ocular Protection Index (OPI) > 1 indicates what?

Exposed ocular surface

An Ocular Protection Index (OPI) < 1 indicates what?

Divide TBUT by blink interval in seconds

How do you calculate Ocular Protection Index (OPI)?

Meibography

Allows imaging for direct visualization of meibomian gland morphology

atrophy

Missing meibomian glands seen in meibography indicates __________.

Analyze tear film instability

What is the purpose of TBUT testing in the diagnosis of MGD?

1. Expressibility

2. Quality

What 2 features are you assessing when you express meibomian glands?

1. Warm Compress (Bruder Mask)

2. Mechanical lid massage

3. In-Office expresssion

4. Treatment of accompanying anterior blepharitis

What are the 4 main conservative treatments of MGD?

compliance

What is the biggest problem with conservative treatment of MGD?

Improve tear osmolarity & reduce friction on ocular surface

What is the purpose of using artificial tears in the treatment of MGD?

Refresh Mega-3 drops

What type of artificial tears has a lipid layer supplementation (omega-3s) to aid in the treatment of MGD?

1. Refresh Mega-3

2. Retaine MGD

3. Systane Complete

What 3 drops discussed in glass directly target the lipid layer of the tear film & meibomian gland health?

False—no evidence of bacterial involvement

True/False: Topical antibiotics are a great form of treatment for MGD.