BASICS

DESCRIPTION

• Multifactorial disease characterized by an abnormal tear film that is inadequate to support the health of the ocular surface

• Types

– Aqueous tear-deficient

– Evaporative

– Exposure

• Isolated ocular disease

– Primary aqueous tear production deficient

– Secondary aqueous tear production deficient (e.g., surgery, radiation)

– Lacrimal ducts not transporting tears (e.g., chemical injury, mucous membrane pemphigoid, Stevens-Johnson syndrome)

– Seborrheic blepharitis

– Meibomian gland dysfunction

– Primary lagophthalmos

– Secondary abnormal lid closure (e.g., chemosis, conjunctivochalasis, ectropion, post blepharoplasty)

– Eyelid or cheek scar (burn, chemical, thermal, radiation, trauma, surgical)

– Loss of corneal sensation (e.g., herpes simplex virus, varicella zoster virus)

• Associated ocular manifestation of a systemic disease

• Synonym(s). Dry Eyes, Keratoconjunctivitis Sicca, Keratitis Sicca

EPIDEMIOLOGY

Incidence

22% over 10 years

Prevalence

• 17% of females, 12% of males

• 8% in subjects <60 years, 19% >80 years

RISK FACTORS

• Age, female

• Ocular surgery (cataract, corneal transplant, LASIK)

• Diabetes, contact lens use

PATHOPHYSIOLOGY

Desiccation of the ocular surface leads to squamous metaplasia with loss of goblet cells, enlargement and increased cytoplasmic/nuclear ratio of superficial epithelial cells, keratinization and secondary inflammation.

ETIOLOGY

• Aqueous tear-deficient

– insufficient volume of tears to keep conjunctiva and cornea moist, relative to the volume of tears lost by evaporation and via puncta

– Evaporative

– insufficient duration of coating by tears to keep conjunctiva and cornea moist, relative to the speed that tears are lost by evaporation and via the puncta

• Exposure

– insufficient area of the conjunctiva and cornea coated by tears

COMMONLY ASSOCIATED CONDITIONS

• Aqueous tear-deficient

– Gland not producing tears

– Sjögren’s syndrome

– Drugs, (e.g., beta blockers, antihistamine)

– HIV

– Graft—versus–host disease

– Sarcoidosis

– Familial dysautonomia

– Xerophthalmia

– Ducts not transporting tears

– Mucous membrane pemphigoid

– Stevens-Johnson syndrome

– Insufficient hormonal stimulation

– Menopause

– BCP

– Pregnancy

– Androgen deficient?

– Insufficient neural stimulation

Stroke

Neurotrophic keratitis

Radiation

Surgery

• Evaporative

• Androgen deficient

• Drugs, for example, Accutane

• Ectodermal dysplasia

• Meibomian gland dysfunction associated with acne rosacea

• Exposure

– Neurologic

– Unconscious

– Parkinson’s disease (slow blink rate or incomplete)

– Seventh nerve palsy; Bell’s palsy, acoustic neuroma, surgical, traumatic, congenital (Goldenhar syndrome), CVA

– Loss of corneal sensation

– Radiation

– Fifth cranial nerve palsy; CVA, Trauma, surgery, tumor

– Muscular

– Botulinum toxin

– Endocrine

Thyroid (i.e., Grave’s disease)

DIAGNOSIS

HISTORY

• Itching, burning, gritty, foreign body sensation, sharp stabbing pain

• Ache, pressure behind the eye, eyes pulling, tired eyes, eye strain

• Photophobia

• Hard to open eyes upon awakening

• Blurring with prolonged visual effort (e.g., reading, watching TV, computer, driving)

• Inability to tear in response to irritants or emotions

• Intermittent flood of tears, tearing while reading

• Decreased contact lens tolerance

– Chronic, usually worsening over years

– Waxing and waning course

– Seasonal: Often worse in the winter, better in the spring and fall

– Worse toward the end of the day and with blowing air (e.g., fans, A/C), low humidity (e.g., blue sky days, airplanes, malls, offices), fumes, vapors, or smoky areas

– Better with high humidity days (e.g., cool rainy days, foggy days), high humidity environments (e.g., shower, kitchen, basement)

– Bilateral, asymmetrical

PHYSICAL EXAM

• ALL TYPES:

– Conjunctival hyperemia in the exposure zone

– Conjunctivochalasis

– Superficial punctate keratitis in the exposure zone

– Corneal epithelial defect

– Filamentary keratitis

– Lusterless cornea

• Aqueous tear-deficient:

– Poor tear meniscus

– Mucous in tear film

– Enlarged lacrimal gland

• Evaporative:

– Meibomian gland inspissation

– Acne rosacea (i.e., rhinophyma, pustules, telangiectatic vessels of the nose, chin, and cheeks)

– Seborrheic blepharitis

– Seborrheic dermatitis

– Blood vessels crossing the gray line

– Foam in tear lake or lid margin

– Debris in tear film

• Exposure

– Poor blink rate

– Incomplete blink

– Facial weakness

DIAGNOSTIC TESTS & INTERPRETATION

Diagnostic Procedures/Other

• Schirmer Test I (Whatman filter paper #41, 0.5 × 35 mm, lateral or medial third, not center, no topical anesthesia, i.e., a standardized tear stimulus, repeated at least 3 times, 5.5 mm = 85% true positive, 15% false positive)

• Tear breakup test (TBUT) (instill a small volume of highly concentrated fluorescein-made by wetting a fluorescein strip with saline and shaking the strip to remove any excess moisture, after several blinks to distribute fluorescein throughout the tear film, the patient stares and the length of time until the first dry spot develops is determined, normal is >10 seconds)

• Rose Bengal 1% (stains desiccated epithelium, traumatized cells, and mucous. Van Bijsterveld score: 1+ sparsely scattered, 2+ densely scattered, 3+ confluent; determined at nasal, temporal conjunctiva & cornea, then sum scores; a total ≥4 is abnormal)

Pathological Findings

• Schirmer Test I <5.5 mm on repeated testing is consistent with Aqueous tear-deficient dry eye

• Tear breakup test <10 seconds on repeated testing is consistent with evaporative dry eye

• Aqueous tear-deficient dry eye (i.e., Schirmer Test I <5.5 mm) and dry mouth needs a further work-up for Sjögren’s Syndrome

• Van Bijsterveld score of ≥4 is consistent with dry eyes of any type

DIFFERENTIAL DIAGNOSIS

• Allergic conjunctivitis

• Corneal foreign body

• Conjunctival foreign body

• Trichiasis

TREATMENT

MEDICATION

First Line

• Supplemental moisture

– Artificial tear drops (usually more viscous formulations for evaporative dry eye, usually less viscous formulations for Aqueous tear-deficient), gels, sprays

• Preserving moisture

– Artificial tear ointment, h.s ± during day

– Humidifier

Second Line

• Seborrheic blepharitis

– Eyelid margin scrubs

– Culture eyelid margin then antibiotic

• Meibomian gland dysfunction

– Warm compresses (gel filled)

– Eyelash scrubs contraindicated

– Doxycycline

– Omega-3 supplements

• Exposure

• Moisture chamber h.s

• Lid taping h.s

• All types of dry eye

– Cyclosporin A eye drops

– Autologous serum eye drops

– Secretagogue

– Pilocarpine or cevimeline tablets

– Consider changing to non-drying systemic medications

Pediatric Considerations

Doxycycline, tetracycline, and derivatives should not be used in children <8 years of age.

Pregnancy Considerations

Doxycycline, tetracycline, and derivatives should not be used in pregnant or nursing mothers.

ADDITIONAL TREATMENT

General Measures

• Stay hydrated

• Blink often while reading, watching TV, on the computer or driving

• Avoid drying or irritating environments

Issues for Referral

Patients with signs and symptoms of Sjögren’s syndrome should be evaluated by a rheumatologist.

SURGERY/OTHER PROCEDURES

• First line

– Preserving moisture

Punctal plugs

Punctal occlusion

• Second line

– Exposure

Eye lid spring

Eye lid gold weight

Tarsorrhaphy

Lid lengthening

Conjunctival flap

Hypoglossal transposition

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

• It can take 2 weeks to know if a new artificial tear, warm compresses or plugs are helping

• It can take 4 weeks to know that doxycycline or cyclosporin A drops are helping

DIET

• Stay hydrated

• A diet high in Omega 3 fatty acids

PROGNOSIS

Excellent, for most patients dry eyes are easily controlled

COMPLICATIONS

• Secondary bacterial conjunctivitis

• Filamentary keratitis

• Secondary bacterial keratitis – rare

• Persistent corneal epithelial defects – very rare

• Calcific band keratopathy– very rare

• Keratinization – very rare

• Corneal perforation—very, very rare

– Spontaneous

– After cataract

• Psychological-social-economic

• Multiple serious systemic complications are with Sjögren’s Syndrome (see …)

ADDITIONAL READING

• Moss SE, Klein R, Klein BE. Incidence of dry eye in an older population. Arch Ophthalmol 2004;122:369–373.

• Graham JE, Moore JE, Goodall EA, et al. Concordance between common dry eye diagnostic tests. Br J Ophthalmol 2009;93(1):66–72.

• Perry HD, Solomon R, Donnenfeld ED, et al. Evaluation of topical cyclosporine for the treatment of dry eye disease. Arch Ophthalmol 2008;126:1046–1050[A].

• Vogel R, Crockett RS, Oden N, et al. Demonstration of efficacy in the treatment of dry eye disease with 0.18% sodium hyaluronate ophthalmic solution (Vismed, Rejena). Am J Ophthalmol 2010;149:594–601.

• Jackson WB. Management of dysfunctional tear syndrome: A Canadian consensus. Can J Ophthalmol 2009;44:385–394.

CODES

ICD9

• 373.02 Squamous blepharitis

• 373.12 Hordeolum internum

• 375.15 Tear film insufficiency, unspecified

CLINICAL PEARLS

• All artificial tears are formulated differently, patients will need direction.

• There are different types of dry eye that have different mechanisms and treatments.

• It is important to check for Sjögren’s Syndrome, ask about a dry mouth.

Stay updated, free articles. Join our Telegram channel

Join