Ocular Surface Disease and Dry Eye - Anterior Segment & Ocular Disease Fall 2025

-epithelium

-glycoclayx

-goblet cells

Hyperosmolarity and inflammation due to dry eye cause damage to what parts of the cornea?

Loss of lipid --> loss of tear film aqueous --> higher conc of salt in the tears --> water moves from the cornea to the tear film --> corneal inflammation and pathology over time

How does dry eye lead to hyperosmolarity of the tear film and inflammation of the cornea?

yes -- these are nociceptive symptoms

With dry eye, does the sensory nerve activate?

tissue damage

What may occur d/t sensory nerve activation?

yes (staining & pain will be seen)

Will the symptoms and the signs of nociceptive pain usually match?

dysfunction of the physiological nervous system

What are neuropathic symptoms of dry eye caused by?

not necessarily

D/t the neuropathic symptoms of dry eye, will tissue damage occur?

no -- symptoms are worse than the signs that are presenting

**may not see corneal staining but these patients are in a bunch of pain

Do the symptoms and the signs associated with neuropathic pain match?

-keratoconjunctivitis sicca (KS)

-xerophthalmia

-xerosis

-sjogren syndrome

What are 4 types of dry eye?

keratoconjunctivitis sicca (KS)

an individual with ANY degree of dryness will be diagnosed with what?

xerophthalmia

dryness associated with Vit A deficiency

xerosis

extreme dryness and keratinization in eyes with severe conjunctival cicatrization

sjogren syndrome

autoimmune inflammatory disease with associated dry eye

17.2 million Americans were diagnosed with dry eye in 2019

Why should we care about dry eye?

females (specifically menopausal or postmenopausal women at the highest risk)

Who gets dry eye more: males or females?

yes -- such as with sjogrens syndrome

Do patients with autoimmune diseases have a higher risk of dry eye disease?

yes -- specifically antihistamines, antidepressants, and HRT

Patients who take systemic medications at higher risk of dry eye disease?

yes

Do contact lens wearers have a higher risk of dry eye disease?

yes -- LASIK, cataract sx, botox

Ocular surgery affect the risk of dry eye disease?

cutting nerves when you do ocular sx -- these nerves cannot regenerate

Why do ocular sx result in dry eye symptoms?

true

True or False:

There are both modifiable and non-modifiable factors that contribute to dry eye disease.

-burning

-scratchiness

-irritation

-dryness

-red eyes

-heavy eyelids

-gritty sensation

-light sensitivity

-eye fatigue

-itching

-stinging

-watery eyes

-blurry vision

-FB sensation

What are some dry eye symptoms that can be debilitating?

lid disease such as anterior or posterior blepharitis

What are some common signs of dry eye disease?

collarettes, lid hyperemia, scarring, hypertrophy

What presentations of anterior bleph can be associated with dry eye disease?

meibomian gland capping

What presentations of posterior bleph can be associated with dry eye disease?

lid wiper epitheliopathy

the portion of the marginal conjunctiva of the upper lid that wipes across the globe is affected in this pathology?

increased friction d/t thin or unstable tear production, decreased mucin, incomplete lid closure or CLs wear

What is lid wiper epitheliopathy seen with?

lissamine green

What does the marginal conj stain with in lid wiper epitheliopathy?

epithelial defects

What are punctate epithelial erosions (PEEs)?

fluorescein green

What will PEEs stain with?

inferior or intrapalpebral area of cornea

Where are PEEs typically located?

a mucus core with degenerative cells surrounding

What is filamentary keratitis composed of?

increase in mucin production and epithelial defects d/t decrease in tears. This mucin will sit on top of PEEs.

What does filamentary keratitis result from?

large filaments

Mucus plaques in filamentary keratitis are _______

Tail (which will move with blinking motion) & a stationary plaque with PEE underneath

Shape of filamentary keratitis??

-Plaque removed with jewelers forceps to clear the cornea

-AT to increase aqueous & flush mucin out

What is the common treatment for filamentary keratitis?

-ocular surface discomfort

-visual symptoms

-quality of life

What do the Dry Eye Questionaries that are given to patients measure? (hint - 3 things)

-SPEED

-Ocular Surface Disease Index

What are the 2 most popular dry eye questionaires?

a 4 question test that will assess the FREQUENCY and SEVERITY of a patient's dryness

What is the SPEED test?

current day, 72 hours prior, 3 months prior

The SPEED test assesses dryness over what time frame?

0-4 = mild, 5-7 = moderate, 8+ = severe

A patient's responses to the SPEED test will be scored. Which indicates higher dryness levels: 0 or 8+?

a series of 12 questions that assess ocular symptoms, difficulty with vision related tasks, and discomfort due to environmental factors

What is the Ocular Surface Disease Index 12 test?

13-22 = mild, 23-32 = moderate, 33-100 = severe

A patient's responses to the Ocular Surface Disease Index 12 test will be scored. Which indicates higher dryness levels: 0 or 100?

Same reason as the Ocular Surface Disease Index 12 test, but 6 questions were introduced to reduce the burden to patients of the longer test. It is also more consistently reliable than the 12 question questionaire

What is the Ocular Surface Disease Index 6 test & why was it introduced?

Ocular Surface Disease Index 6

Is scoring easier for the Ocular Surface Disease Index 12 test or for the Ocular Surface Disease Index 6 test?

0-3 = normal, 4-8 = mild to moderate, 8+ = severe

A patient's responses to the Ocular Surface Disease Index 6 test will be scored. Which indicates higher dryness levels: 0 or >8?

-lid position of ectropion or entropion

-lid debris/collarettes

-lid hyperemia

-meibomian gland capping

-meibomian gland secretions

-possible Demodex

What presentations of dry eye can be evaluated with slit lamp?

Thickening of the eyelid margin, eyelash loss, change of lid architecture

What are possible symptoms of Grade 4 collarettes?

large telangectasia and more collarettes present

What are possible presentations of Grade 4 hyperemia?

Grade 1: meibum is not moving but once it is expressed, the meibum may move freely

Grade 2-3: More than 1/2 glands are capped

Grade 4: Entire lid margin is capped, thick meibum like toothpaste is not a good quality Expression does not usually help

What are the differences between a Grade 1, 2-3, and 4 Capping?

Grade 1: olive oil consistency & slightly cloudy meibum

Grade 3: opaque meibum and very thick. Toothpaste like and kinks

Grade 4: Obstructed gland/angry lid margin

What are the differences between a Grade 1, 3, and 4 Meibum Expression?

yes

If the lids are inflammed, will the conj be inflammed too most likely?

Mild: PEEs on inferior 1/3 of cornea

Moderate: PEEs on inferior & superior 2/3 of cornea

Severe: PEEs everywhere on the cornea

What is the difference between mild, moderate, and severe staining on corneal evaluation?

with white light and Flourescene strip

How do we stain the cornea on corneal eval?

no -- Fluress contains an anesthetic. Patient will not feel the need to blink. Fluress is also very thick and will affect the TBUT score.

Should we ever do dry eye testing with Fluress?

measures tear film stability by instilling a fluorescein dye into the eye and observing the cornea to view tear beak up

What is the TBUT test measure?

0.3 mm

What is the normal value for the lacrimal lake in a tear meniscus evaluation?

<0.3mm. Dryness could be the cause of this

What is a reduced value for the lacrimal lake in a tear meniscus evaluation? What could be the cause of this?

>0.3mm. Lacrimal blockage could be the cause of this

What is an excessive value for the lacrimal lake in a tear meniscus evaluation? What could be the cause of this?

Lid Wiper Epitheliopathy

An area of the conj that is in contact with the globe can stain d/t increased friction and mechanical trauma on the lid wiper region due to poor lubrication from inadequate tear film

no

Does the lid wiper region of the lid contain the mucocutaneous junction?

either can

Does aqueous deficient or lipid layer deficient dry eye cause lid wiper epitheliopathy?

0 = none, no staining, 2.25-3 = severe & consistent staining across the lid

**mild and moderate in between these values

Grading Lid Wiper Epitheliopathy

0 = ?

2.25-3?

the conj and lid wiper epitheliopathy

What is the Lissamine Green Stain used to evaluate?

devitalized cells and mucus

What does the Lissamine Green Stain stain?

filter paper

What does the Shirmer test use to measure test production?

Shirmer 1

Schirmer 1 test vs Shirmer Test

Which measure TOTAL tear secretion?

Shirmer

Schirmer 1 test vs Shirmer Test

Which measures BASAL tear secretion?

10mm in 5min

Schirmer 1 test vs Shirmer Test

What is a normal value for the Shirmer 1 test?

with anesthetic

Schirmer 1 test vs Shirmer Test

How does the Shirmer test eliminate reflex tearing?

10mm in 5 min

Schirmer 1 test vs Shirmer Test

What is a normal value for the Shirmer test?

measuring the thickness of the tear film or the different components of the tear film

What does interferometry measure?

iridescent color

During an interferometry measurement, the lipid layer of the tear film will give a ____ pattern?

in dry eye

During an interferometry measurement, when will you observe a thin tear film?

Meibography

image of the meibomian gland structure

changes in the meibomian gland structure are seen with MGD

What can be observed by meibography?

truncation

shortening or loss of length of the meibomian glands observed on meibography

No -- they will not come back

Will meibomian glands be able to regenerate once they are lost?

to figure out a treatment plan for the patient and monitor for any changes to the glands over time

What is the goal of meibomian gland observation?

measure the amount of water in the tears compared to the number of electrolytes and proteins

How to measure tear osmolarity?

decrease, remains the same

In dry eye disease, the water content will (increase/decrease/remain the same) in the tears while the number of electrolytes and proteins will (increase/decrease/remain the same)?

tear osmolarity teseting

What is the only test that can quantify the severity of dry eye disease?

300 mOsm/L

A tear osmolarity value over _____ is indicative of severe dry eye

inflammadry

this dry eye test will test for inflammatory markers AND IS THE VAIN OF KYLIE'S EXISTANCE

MMP-9 protein which is a cytokine produced by imflammed epithelial cells and only seen with ocular surface disease

What does Inflammadry detect?

-lifestyle modifications

-patient education

-lid disease treatment

-pharmaceuticals

-tear supplements

-oral supplements

-vitamins

-autologous serum and secretagogues

-punctal occlusion

-amniotic membranes

-contact lenses

Are there many different ways to try to treat dry eye disease? What are some of the ways in which we are licensed to treat DED?

-avoid prolonged near work

-take breaks from screens

-avoid dry environments

-use humidifiers

-physical protection with moisture chamber googles

How are we able to reduce DED with lifestyle modifications?

-scrubs (wipes and foams)

-debridement

-WCs

-Systane Ilux

-Intense Pulse Light

-Low Power, High Fluence Monochromatic Light

How are we able to reduce DED with lid hygiene and lid disease treatments?

to clean debris off the lid margin to help with ocular irritation

What is the purpose of a lid scrub?

wipes and foams

Lid scrubs are available in ___ and ____

lid margin debridement

removal of debris and keratinized cells from the surface of the lid margin

meibum to exit glands & go into the tear film

What does lid margin debridement promote?

-Golf club spud

-BlephX brush

What tools do we use for lid margin debridement?

improve MG expression and the quality of the expression

What is the purpose of a warm compress (WC)?

OTC and commercially as Bruder Mask or Lipiflow

How are WC available to patients?

applies heat to the meibomian glands and gently expresses the glands with inflatable air bladders

How does lipiflow thermal pulsation work for patients with DED?

9-12 months but will likely need maintenance sessions after this

Patients may been good results for up to _____ months after Lipiflow treatment

a thermal pulsation that wil lheat the eyelid to 107.6º and melt the meibum while simultaneously compressing and expressing the MGs

**very similar to Lipiflow

What is the Systane Ilux?

-high intensity light

-individuals will receive 4 treatments over 4 months to start

-30 pulses each session

-treatment plan customized based on skin type

How do we use intense pulse light in optometric field?

used in dry eye for anti-inflammatory properties

How do we use low level light therapy:red light in optometric field?