2: Dry Eye

Question 1

dry eye: dry eye disease (DED), dry eye syndrome (DES)

Answer 1

a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by variable ocular symptoms

Question 2

DED etiology

Answer 2

tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities

Question 3

DED demographics

Answer 3

• more common with age

- women > men

Question 4

DED laterality

Answer 4

bilateral > unilateral, can be asymmetric

Question 5

DED: aqeuous deficient dry eye

Answer 5

• Sjogren’s syndrome (can also cause MGD)
• age-related changes of the lacrimal gland
• cicatricial obstruction of the lacrimal gland (e.g., trachoma, SJS, OCP, chemical injury)
• inflammation and infiltration of the lacrimal gland (e.g., sarcoidosis, lymphoma, viral infection, radiation injury)
• hyposecretory states: CN V damage, parasympathetic pathway damage, medications, familial dysautonomia
• lacrimal gland ablation
• congenital alacrima (aplasia or hypoplasia of lacrimal glnads)

Question 6

DED: evaporative dry eye

Answer 6

• primary MGD
• secondary MGD (e.g., blepharitis, rosacea, atopic dermatitis, antiandrogens)
• distichiasis (congenital condition in which a row of aberrant lashes grows from meibomian gland orifices)
• disorders of lid aperture, congruity, and dynamics (e.g., lagophthalmos, ectropion, blink-related, blepharospasm)
• ocular-surface related (e.g., allergic eye diesease, vitamin A deficiency, CL-related)

Question 7

DED symptoms

Answer 7

• red eye
• ocular irritation: burning, FBS, pain; “sandy, gritty, trash in eye”
• ocular itching
• tearing
• intermittent blurred vision
• discomfort with CL wear

Question 8

DED signs

Answer 8

• conjunctival injection (bulbar and palpebral)
• conjunctival staining with lissamine green and rose bengal (typically in the inferior 1/3 or in the interpalpebral region)
• superficial punctate keratitis (SPK) (typically in the inferior 1/3 or as a horizontal band in the interpalpebral region; inferior 1/3 may symbolize MGD, lagophthalmos)
• lid wiper epitheliopathy (damage of lid wiper region)- stains with fluorescein, lissamine green, and rose bengal
• decreased TBUT
• decreased tear prism (normal is 0.2-0.4 mm)
• increased tear osmolarity (can use TearLab)
• positive InflammaDry

Question 9

diffuse SPK causes

Answer 9

• viral conjunctivitis
• trauma
• toxicity

Question 10

inferior SPK causes

Answer 10

• blepharoconjunctivitis
• lagophthalmos
• trichiasis

Question 11

interpalpebral SPK causes

Answer 11

• dry eye disease
• exposure
• neurotrophic keratopathy

Question 12

superior SPK causes

Answer 12

• superior limbic keratoconjunctivitis
• foreign body under eyelid
• trichiasis

Question 13

3 and 9 o’clock SPK causes

Answer 13

contact lens

Question 14

lower conjunctivitis SPK causes

Answer 14

• mechanical

- meibomian gland dysfunction

Question 15

dry eye screening tests (surveys)

Answer 15

• SPEED
• OSDI
• DEQ-5

Question 16

severe dry eye signs

Answer 16

• pannus
• corneal epithelial breakdown
• corneal ulceration
• corneal scarring
• bitot spot (keratinization of the conjunctiva; typically seen with vitamin A deficiency)
• filamentary keratitis (filaments attached to the corneal epithelium; move with each blink, stain well with dye)
• signs of lacrimal gland, meibomian gland, and/or goblet cell/ocular surface damage
• signs of CN V and parasympathetic (CN VIII) pathway damage
• signs of increased eyelid aperture, poor eyelid congruity and dynamics

Question 17

DED complications

Answer 17

• microbial keratitis
• corneal ulcer
• corneal perforation

Question 18

DED treatment and management

Answer 18

• determine and treat the underlying cause
• modification of local environment
• blinking exercises
• warm compress to liquify the meibum
• eyelid cleanser qday-bid
• hypochlorous acid eyelid spray (neutralizes bacteria, toxins, and inflammatory mediators)
• topical lubrication
• omega-3 fatty acid supplement (fish oil)- improves meibum production
• punctal occlusion/plugs
• moisture chamber goggles qhs
• topical steroid or antibiotic/steroid combo bid-qid for 2-4 weeks
• Restasis or Xiidra bid
• acetylcysteine for dissolving mucous filaments
• oral doxycycline
• BlephEx with eyelid cleanser in office (scrubs lids/lashes clean; Rx antibiotic/steroid ung following Tx)
• meibomian gland expression in office
• meibomian gland probing in office
• LipiFlow in office
• iLux in office
• intense pulse light (IPL) therapy in office
• autologous serum eye drops
• BCL or scleral lens
• amniotic membrane
• if significant stromal thinning occurs, limit the risk of corneal perforation by treating with ascorbic acid and citric acid or a tetracycline
• if medical therapy fails, refer for surgery (surgical punctal occlusion, tarsorrhaphy)

Question 19

DED clinical pearls:

• low degree of (+) staining is _____ on the normal conj and cornea
• 85% of dry eye cases have _____ as primary cause or contributory

Answer 19

a regular finding;

MGD