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Ocular Disease > Ocular Disease: Lecture 7: Dry Eyes > Flashcards

Ocular Disease: Lecture 7: Dry Eyes Flashcards

1
Q
  1. How common is dry eyes?
A
  1. Very. Affects 10-15% of adults
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2
Q
  1. What is Keratoconjuncitivita Sicca (KCS)
  2. What is Xeropthalmia?
    a. What does it cause?
A
  1. Any eye w/some degree of dryness
  2. Dry eye associated with Vit A defect
    a. 20k to 100k new cases of blindness each year
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3
Q

Systemic Related Dry Eye

  1. Xerosis: Define
  2. Sjogren’s Syndrome: Define
    a. What’s it usually associated with?
A
  1. Extreme Dryness and Keratinization w/SEVERE CONJUNCTIVAL SCARRING (Cicatrization)
  2. Auto-immune Inflammatory Disease
    a. Rheumatoid Arthritis
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4
Q

Tear Distribution

  1. Tears are distributed between what 3 things?
A
  1. Pre-ocular film covers exposed bulbar Conj and the Cornea
    b. Tear meniscus
    c. Conjunctival Sac
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5
Q
  1. What is the turnover rate for tears?
  2. pH level?
  3. What happens to tear volume as we get older?
A
  1. 12-16%/min
  2. 6.5-7.6
  3. Volume naturally decreases with age
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6
Q

Basal vs. Reflex Tearing

  1. What is Basal tearing?
  2. What is Reflex tearing?
  3. When is tearing reduced?
  4. How much can tearing increase in RESPONSE to INJURY?
A
  1. Resting Tearing
  2. Response to Conjunctival and Corneal Sensory (V Nerve) stimulation, TBUT, etc.
  3. Under Topical Anesthesia and Sleep
  4. by 500%
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7
Q

Tear Layers

  1. What are the 3 parts?
A
  1. Lipid Layer
  2. Aqueous Layer
  3. Mucin Layer
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8
Q

Outer Lipid Layer

  1. Majority produced by what glands?
    a. Small amt by what glands?
  2. How many glands are in the Upper Lid?
  3. How many are in the Lower Lid?
A
  1. Meibomian Glands
    a. Glands of Zeis
  2. 30-40
  3. 20-30
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9
Q

Lipid Layer Purpose

  1. Purpose of the Lipid Layer?
  2. What does it act as?
  3. What does it Improve?
  4. What does it provide for the tears?
  5. What does it prevent?
A
  1. Prevent Evaporation of the Aqueous Layer
  2. a Surfactant that allows spread of the tear film
  3. The Optics. Gives the Eye a Smooth Surface
  4. Creates a Hydrophobic Barrier that prevents tear overflow
  5. prevents damage to lid margin from tears
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10
Q

Lipid Layer and Meibomian Function

  1. What 2 elements does the Lipid Layer Composition include?
  2. Why is blinking important?
  3. Deficiency of the Lipid Layer results in what?
A
  1. Polar Hydrophilic and Non-Polar Hydrophobic Elements
  2. Releases Lipids from Glands
  3. In Evaporative Dry Eye
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11
Q

Aqueous Layer

  1. Most of it is made by what gland?
  2. What other things help make this layer?
  3. What does it consist of?
A
  1. Primary Lacrimal Gland (95%)
  2. Accessory Lacrimal Glands (It’s structurally the same as the primary lacrimal gland)
  3. Mostly water but many solutes
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12
Q

Properties

  1. % that’s water?
  2. Electrolytes (meaning what)?
  3. What other things?
  4. What Proteins?
A
  1. 98%
  2. Salts (MAJORITY of Solutes)
  3. Glucose (10% of Corneal Supply and Other Serum Components)
  4. IgA (bolded), IgM, IgG, and IgE (Bolded)
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13
Q

Properties

  1. What 2 things are important Tear Antimicrobials?
  2. What Helps to Inhibit Viral Replication?
  3. Purpose of Growth Factors?
  4. Pro-inflammatory Cytokines: Purpose?
A
  1. Lactoferrin and Lysozyme
  2. Interferon
  3. Increase in response to Injury
  4. Increase in Sleep when Tear Production DECREASES
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14
Q

Purpose of the Aqueous Layer

  1. Supplies Oxygen to what structure?
  2. What does it maintain?
  3. Type of defense?
  4. What does it WASH AWAY?
  5. What does it Smooth over?
  6. Aqueous Layer Deficiency is what?
A
  1. to Avascular Cornea
  2. Electrolyte Composition over Ovular Surface
  3. Microbial Defense
  4. Wash away debris and noxious stimuli
  5. Minute Irregularities in Surface
  6. it’s 1 of 2 primary classification of dry eyes
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15
Q

Inner Mucin Layer

  1. Produced by what?
  2. Glycoproteins may be what?
  3. Glycocalyx produced by what?
  4. Staining with Rose Bengal indicates what?
A
  1. Goblet Cells
  2. Transmembrane or Secretory
  3. by Epithelial Cells
  4. that Mucin Layer is Absent
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16
Q

Inner Mucin Layer

  1. Goblet Cell Loss is Associated with what few things?
  2. Mucous Layer deficiency may be present in what 2 things?
A
  1. Chemical Burns, Vit A Deficiency, Toxicity from medications and cicatrizing conjunctivitis
  2. in both Aqueous Layer Deficiency and Evaporative Dry Eye
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17
Q

Purpose of Mucin Layer

  1. What does it do to the Corneal surface?
  2. What does it help lower?
  3. Provides lubrication for what?
A
  1. Allows “wetting” of it due to conversion of Hydrophobic to Hydrophilic Surface
  2. Surface Tension of Tears for even Tear spreading
  3. for Eyelids as they pass over the Globe
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18
Q

Classification of Dry Eye

  1. 2 Major Categories
A
  1. Aqueous Layer Deficiency
  2. Evaporative Dry Eye
    * Most patients have considerable overlap
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19
Q

Aqueous Layer Deficiency

  1. What 2 types of Syndromes are there?
A
  1. Sjogren’s Syndrome

2. Non-Sjogren’s Syndrome

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20
Q

Sjogren’s Syndrome

  1. What causes it?
  2. # of peeps have it in US?
A
  1. AI inflammation w/destruction of Lacrimal and Salivary Glands (get grittiness of eyes and dryness of mouth)
  2. About 4 million peeps have it.
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21
Q

Sjogren’s Syndrome

  1. Primary Sjogren’s
    a. When is it this?
    b. happens in whom more?
  2. Secondary Sjorgren’s
    a. When is it considered this?
A
  1. a. If it happens in Isolation
    b. Women (more than 95%); a little less than 50% are primary versus Secondary Sjogren’s.
  2. a. if a patient also has RA, SLE, MG, Systemic Sclerosis, mixed connective tissue disease, Chronic active hepatitis, primary biliary Cirrhosis
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22
Q

Sjogren’s Syndrome

  1. Typical age of onset?
  2. 30% have what?
  3. It may go undiagnosed for how many years?
  4. This syndrome is a Chronic, progressive condition, however, the progression for most patients is what?
A
  1. 40-60 yrs
  2. 30% of those w/RA and SLE also have Sjogren’s.
  3. for up to 10 years
  4. Progression for most patients is VERY SLOW
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23
Q

Sjogren’s Syndrome

  1. 10-15% have what?
  2. Risk of what disease is 44 times greater than the general pop?
  3. Enlargement of what occurs in 1/3 of SS patients?
  4. Failure of what organ?
  5. What 2 diseases?
  6. What else?
A
  1. Hypothyroid
  2. Lymphoma
  3. Parotid Enlargement
  4. Pancreatic Failure
  5. Pulmonary and Renal Disease
  6. Reflux Esophagitis, and Dental Carries
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24
Q

Diagnostic Tests for Sjorgren’s Syndrome

  1. What tests are there?
  2. Referral to whom?
A
  1. a. Anti-SS-A (Ro) or Anti-SS0B (La)(More specific) (Anti-RNA antibodies). Occur in 60% of Sjogren’s patients
    b. ANA
    c. Rheumatoid Factor
    d. Schirmer’s Test (<5mm in 5 min)
  2. to a Rheumatologist.
25
Q

Other Sjogren’s Signs

  1. 2 things that are dry?
  2. What happens to the teeth?
  3. What else?
A
  1. Dry fissured tongue, and Dry nasal passages
  2. Dental Carries
  3. Diminished Vaginal secretions and resultant dyspareunia
26
Q

Non-Sjogren’s KCS

  1. Primary: Most common?
  2. Lacrimal Tissue destruction from what?
A
  1. Age related hyposecretion is most common
  2. from Tumor or Sarcoidosis Granuloma
    * Tear production decreases with age
27
Q

Non-Sjogren’s KCS

  1. Absence or reduction of what?
  2. Deficiency of what?
  3. Conjunctival Scarring with what?
  4. What else?
A
  1. of Lacrimal Gland Tissue (rarely congenital)
  2. of Vit A (rare in USA); Vit A drops may help in SLK
  3. w/Obstruction/destruction of Lacrimal Gland Ductules
  4. Ocular Cicatricial Pemphigoid, Steven-Johnson’s Syndrome, Trachoma, and Chemical burns
28
Q

Non-Sjogren’s KCS

Neurologic Lesions w/Sensory or Motor Reflex Loss:

  1. Parkinson’s Disease
  2. Reduced Corneal Sensation due to what?
  3. Riley-Day Syndrome
    a. affects whom?
    b. What is it?
A
  1. Decreased Blink Rate
  2. Due to Refractive Surgery and Contact Lens Wear
  3. a. Jews of Eastern European Descent
    b. Disability of Nervous System, can’t make tears
29
Q

Evaporative Dry Eye

  1. Meibomian Gland Dysfunction is what?
  2. Affects how many?
  3. Inflammation of Meibomian Glands (Meibomitis) Causes what?
A
  1. Posterior Blepharitis
  2. 40% of routine patients and 50% of Contact Lens patients
  3. Causes the Glands to be obstructed by thick waxy (inspissated) Secretions
    * Frothing is an early sign of Meibomian Gland Dysfunction
30
Q

Evaporative Dry Eye

Meibomian Gland Dysfunction

  1. Reduced Meibomian Secretion or Altered Consistency has Reduced Capability to Perform function of what?
  2. Anterior Blepharitis: what is it?
    a. Contributes to what?
  3. Associated with what?
A
  1. the function of the Lipid Layer
  2. Infectious Blepharitis of Anterior Lid Margin
    a. to Inflammation of Posterior Margin.
    b. Bacteria break down meibum releasing Fatty Acids which irritate the eyes and cause tear film instability
  3. with Acne Rosacea
31
Q

Acne Rosacea

  1. It’s a chronic condition characterized by what?
  2. 4 symptoms?
A
  1. Facial Erythema (redness) and sometimes pimples
  2. a. Burning
    b. Itching
    c. Stinging
    d. Sensitivity to Light
32
Q

Evaporative Dry Eye: Meibomian Gland Dysfunction (Post. Blepharitis)

  1. With Longstanding Disease, Signs include what 5 things?
A
  1. Thickened (tylosis) eyelid margins
  2. Telangiectatic Vessels on Lids
  3. Loss of Lashes (Madarosis)
  4. Poliosis (White Lashes)
  5. Trichiasis and Notching of the Lid Margin
33
Q

Evaporative Dry Eye: Meibomian Gland Dysfunction (Post. Blepharitis)

  1. Chronically inspissated Glands eventually become what?
    a. What does this lead to?
    b. Causes a shift in what?
    c. Results in what?
A
  1. Keratinized and “Drop out”
    a. a Divot in the Lid Margin
    b. in the Meibomian Glands and they can’t secrete oil onto the proper location of the lid
    c. in Permanent changes in the tear film composition and ocular environment, and significant dry eye symptoms
34
Q

Symptoms of Dry Eye (KCS)

  1. What are the 9 symptoms?
  2. When is it worse?
  3. Type of pain?
A
  1. a. intermittent Blurred Vision
    b. Burning
    c. Dryness
    d. Grittiness
    e. Foreign Body Sensation
    f. Itching
    g. Photophobia
    h. Stickiness
    i. Watering
  2. towards the end of the day
  3. Transient, sharp-shooting pains like a rapid needle-stick
35
Q

Symptoms of Dry Eye (KCS)

  1. What 2 things aren’t affected?
  2. Exacerbated by what conditions?
  3. Type of discharge?
A
  1. Reflex and Emotional Tearing
  2. Wind, A/C, Fans, Prolonged computer/reading due to decreased blink rate
  3. Stringy discharge
36
Q

Clinical Signs of Dry Eye (KCS)

  1. Lids?
  2. Conjunctiva?
  3. Tear Film?
  4. Cornea?
A
  1. Redness, Crusting of lids (post bleph/mgd)
  2. Injection/some mild keratinization
  3. Tear Meniscus: Normally 1 mm in dry eye it’s reduced/absent and loss of uniformity across cornea froth in tears (early mgd)
  4. SPK (stain w/Fluorescein)
37
Q

Filamentary Keratitis

  1. What may form in Very Dry Eye Filaments?
    a. What can they do?
    b. Occurs more often in what deficiency?
  2. May also see associated what?
  3. Painful for patient. Why?
A
  1. Mucus lined w/epithelium may form
    a. They’re Very sticky and One End Sticks to the Cornea
    b. In Aqueous Layer Deficiency
  2. Mucous Plaques
  3. Remove them
38
Q

Complications of KCS

  1. Rarely in very severe cases, what may occur?
A
  1. Peripheral Superficial Corneal Neovascularization may occur, Epithelial Breakdown, Corneal Melting and Perforation
39
Q

Testing for KCS

  1. Symptoms are more reliable than testing.
    a. Testing is often not repeatable and it doesn’t always correlate w/symptoms
  2. What 3 tests are there?
A
  1. TBUT: Use
  2. Fluorescein Strip: Measure “Break up” of Fluorescein Strip (Normal is >10 seconds)
  3. Schirmer’s Test (Tear Production)
40
Q

TBUT

  1. What do we use?
  2. How do we put it in?
  3. Normal?
  4. Abnormal?
A
  1. Don’t use Fluress; Use a Fluorescein Strip
  2. Don’t wet the strip by placing saline drop into the eye.
  3. > 10 secs
  4. < 10 Secs
41
Q

Schirmer’s Test

  1. How can you perform the test?
  2. Is it reliable?
A
  1. with (basal) or w/o (reflex + Basal) anesthetic
    a. Patients don’t really enjoy it
  2. No.
  3. No anesthetic: Less than 10mm after 5 min is abnormal.

If Anesthetic: Less than 6 mm after 5 minutes is abnormal

42
Q

Tear Osmolarity Test

  1. What does it test
  2. Cost?
  3. Repeatable?
A
  1. Tear production; Looking at solutes in solution
  2. about $20,000
  3. Yes
43
Q

Fluorescein Staining

  1. What does it stain?
    a. What can be seen?
A
  1. Corneal and Conjunctival Epithelium where there’s sufficient damage to allow the dye to enter the tissues
    a. Epithelial defects are seen
44
Q

Rose Bengal Test

  1. What does it stain? (3-4)
A
  1. Dead or devitalized cells
  2. Epithelial Cells that have lost their Mucin Layer
  3. Also Stains Filaments and Plaques
45
Q

Lissamine Green Test

  1. Equal to what?
  2. What does it stain?
  3. Feels better than what?
A
  1. Rose Bengal in Function
  2. Epithelial Cells that have lost their mucin layer; also stains filaments and plaques; feels better than Rose Bengal
  3. Feels better than Rose bengal and may cost a little more.
46
Q

Other Tests Rarely Performed

  1. Lactoferrin Immunoassay Test: What does it do?
  2. Phenol RED THREAD TEST: what does it do?
  3. Tear Meniscometry
  4. Impression Cytology
A
  1. Lactoferrin is a protein made in Sjogrens. Can measure presence of Lactoferrin
  2. Like Schirmers test but only 15 seconds. Uses a thread impregnated w/a pH sensitive dye. If 6mm or Less it’s abnormal
  3. measures lower meniscus
  4. determines goblet cells
    * Fluorescein Clearance test can also be done.
47
Q

Treatment of KCS

  1. Can it be cured?
    a. What can it be?
  2. Choice of therapy depends on what?
  3. Educate patient for what?
A
  1. Not really
    a. It’s palliative and try to mitigate any further damage.
  2. depends on severity of disease and will likely use combination
  3. to maximize the possibility of good compliance. Set realistic expectations.
    * Remember to blink when on Computer/reading/facebook
48
Q

Treatment of KCS

  1. Educate patient on what?
  2. Caution against what?
  3. Contact lens options limited.
A
  1. Use of drops
  2. Laser Refractive Surgery
  3. proclear compatibles, AV Oasys, low water content lenses are best. Scleral RPG lenses if severe dry eye
49
Q

Artificial Tears

  1. Tears are complex
    a. Most artificial tears try to replace what?
    b. Downside?
  2. Upside?
A
  1. a. Aqueous layer only
    b. Only used intermittently and most have preservatives which can irritate the eyes if used often enough. DONT USE MORE than 4 TIMES PER DAY. If so, then switch to non-preserved tears
  2. Non-preserved tears available
50
Q

Artificial Tears

  1. Cellulose Derivatives
  2. Carbomers
  3. Polivynyl Alcohol
  4. Sodium Hyaluronate
  5. Autologous Serum
  6. Povidone
A
  1. Hypromellose (Tears Naturale II)
  2. Last longer, more viscous (gels)
  3. Good in mucin deficiency. Many brand names
  4. (Blink)
  5. Only very severe dry eyes
  6. Often in combo with Polyvinyl
51
Q

Other Treatment Options

  1. Ointments: Work well when?
  2. Mucomyst (Acetylcysteine): Helps with what?
A
  1. at night. Sometimes need to use during the day, but blur vision
  2. Helps with filaments. it Stinks and only keeps about 2 wks. DEBRIDE FILAMENTS
52
Q

Other Treatment Options

  1. Low Dose Topical Steroids: usually used for what?
  2. Topical Cyclosporin: (Restasis): What does it do?
  3. Systemic Tetracycline/Doxycycline: What does it do?
A
  1. short term control of inflammation
  2. reduced inflammation and increases goblet cells. can take a few months to work
  3. can reduce blepharitis and inflammation and can improve symptoms w/rosacea as well. Not for use w/children under 8 year olds and pregnant mothers
53
Q

Other Treatment Options

  1. What things can be done to the room? (3)
A
  1. Reduce room temp. to reduce evaporation
  2. Room Humidifiers
  3. Moisture chamber goggles and side shields
54
Q

Other Treatment Options

  1. Tarsorrhaphy: What does it do?
  2. Oral Cholinergics: Does what?
  3. Zidovudine: Does what?
  4. Azasite: Does what?
  5. What else?
A
  1. Palpebral closure in severe dry eye
  2. Oral pilocarpine but may have unpleasant side effects
  3. an anti-retroviral med may help primary Sjogrens
  4. an antibiotic good against Staph. Aureus which can cause blepharitis
  5. Omega 3 supplementation
55
Q

Punctal Occlusion

  1. What plugs can you try first?
  2. Want to ensure what?
  3. What plugs work well?
  4. May want to treat w/what?
A
  1. Collagen plugs first
  2. No epiphora
  3. Silicone plugs. Use dilator to expand puncta then fit w/tight fitting plug. don’t recommend canalicular plugs as they’re hard to remove. punctal plugs should be easy to remove
  4. may want to treat w/anti-inflammatory and stabilize dry eye first before use so don’t concentrate inflammatory products
56
Q

Punctal Occlusion

  1. Plug what first?
  2. If epiphora, do what?
  3. How well do we fit it?
A
  1. Plug the inferior puncta first as it drains slightly more than superior
  2. you could take out and plug uppers
  3. tightly because 40% can be lost w/in 6 months
57
Q

Punctal Cautery

  1. What is it?
  2. What do you cauterize?
A
  1. Permanent closure could be considered if punctal plugs keep falling out and pt has Schirmer’s still less than 5mm. (Make sure no epiphora with trial)
  2. proximal canaliculus
58
Q

Treatment of MGD

  1. Main thing?
A
  1. Hot compresses and lid massage; Expression of Meibomian Glands

Ocular Disease (11 decks)

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