Dry Eye

Keratokonjungtivitis sicca
 Lacrimation
N.VII PONS
Secreto-motor
Nerve Impulses
Lacrimal Glands

Tears Support and Maintain

Ocular Surface

Ocular Surface
Neural Stimulation
N.V

dry spot  pain  reflex stimulation  lacrimation

 Tear film composition

Lipid : 0.1 um
• esters, glycerol ,
fatty acids

• product of
palpebral meibomian glands
• prevents excessive evaporation
Aqueos / watery : 7 um

Epithelium
• Secreted from lacrimal gland
• electrolytes, protein, antibody,
oxygen , CO2, mineral , glucose
Mucin :
0,02 - 0,05 um

• Product of conjunctival Goblet cells present in

bulbar conjunctiva , caruncula
• Maintain tear film stability
• Glycocalyx produced by epithelial cells help
bind mucins onto the epithelial surface
Tear outflow / each blink ( 4 x / min )
 Tear film function

Maintain integrity of cornea & conjunctiva

• Smoothes ocular surface , improve vision

• Wash away all the dirty materials coming onto the eye
• Moisturizing, lubricating for comfort , eye movements
• Media transport for O2 , CO2 ( 40% from atmosphere )
• Nutrition ( glucose, electrolytes, enzymes , protein )
• Defense : Anti bacterial, antibodies, lisozyme
 Dry Eye Etiology

Tear Evaporative
Deficient

Oil Deficient Lid Related Contact Lens Surface Change

Sjogrens Non-Sjogrens

Lacrimal Lacrimal Reflex

Deficiency Obstruction

NEI Workshop - Classification of Dry Eye

Auto-
antibodies
 Keratoconjunctivitis Sicca
• Aqueous phase deficiency
• Symptoms
• Redness
• Burning sensation
• Gritty sensation
• “Stiff lids” - difficulty with initial opening
• 2° epiphora in some cases
 Keratoconjunctivitis Sicca
• Signs
• Tear meniscus
• TF debris; TBUT
• Corneal epithelial filaments
• SPE; frank ulceration
• Vital staining with rose Bengal 1%
• Abnormal Schirmer’s test (type I & type 2)
 Keratoconjunctivitis Sicca
• Other investigations
• Reduced lysozyme activity in Sjögren’s syndrome
• Tear osmolarity (normal = ~300mosmol/l; Aqueous
deficiency = ~340mosmol/l)
 Keratoconjunctivitis Sicca
• Causes of aqueous deficiency
• Idiopathic/age related
• 1° & 2° Sjögren’s syndrome
• Inflammatory or infiltrative lesions e.g. Lymphoma, TB, sarcoidosis
• Congenital/iatrogenic absence of lacrimal gland
• CN V defect (sensory arc)
• CN VII defect (motor arc; anticholinergics)
• ADRs (antihistamines; -blockers; phenothiazines; OCP)
 Mucin Deficiency
• Signs
• TBUT
• Bitot’s spots: interpalpebral conjunctival foamy patches
associated with severe vitamin A & xerophthalmia
• Causes
• Vitamin A deficiency
• Cicatrising disease (loss of conjunctival goblet cells):
trachoma, SJS, cicatricial pemphigoid, chemical burns
 Oily Layer Abnormalities
• Meibomianitis, MGD
• Blepharitis, often staphylococcal & compounding
aqueous deficiency
 Management of Dry Eyes
• Artificial tears - if used very frequently, consider
preservative free preparations
• Lid toilet and compresses with occasional use of
topical antibiotics
• Mucolytics for filamentary keratitis
• Vitamin A supplements in xerophthalmia (topically is
experimental)
• Punctal plugs - optometric role?
• Stop exacerbating medication
• Surgery to lid deformities/punctal occlusion