Dry eye recent trends

1. Dry Eye
Recent Trend– a review
Dr. S. K. Rungta
MS (Ophth)
KG Road, Ara,India
S_krungta@rediffmail.com

2. • A manual literature search was
undertaken from authentic reference
books and journals on Ocular Surface
Disease
• No Financial interest in any way
Dr. Rungta

3. DRY EYE
One of the most common
conditions seen by eye
practioners.
Tear substitutes are most often
prescribed (abused) eye drops by
ophthalmologists

4. Most susceptible group to Dry Eye
Post menopausal women & women on HRT
50 yrs + older age group
Patient with blephritis or MGD
Rh arthritis patients.
People exposed to heat & dust.
Patient on diuretics, beta blockers , anti
depressants, chemotherapeutic agents, anti
androgens, antihistaminics.

6. Environmental stresses
Frequent instillation ( > 6 times ) of
preservative containing eye drops for > 6 wks
Environmental factors- such as reduced
humidity and increased wind, air
conditioning or heating
 Air conditioning is as bad as heaters for
increasing the evaporation of your tears.

7. Associated local conditions:
Eye lid malposition, lagophthalmos, any neuro
muscular disorder of eye lids (e.g Bell’s palsy,
Parkinson disease)
Trauma to eye or eye lids, orbital surgery,
radiation, chemical or thermal injuries ,
LASIK.

8. Dry eye is a disturbance of Lacrimal
Functional Unit (LFU)
• Tearing apparatus:
-Production-Lacrimal glands
- Clearance-Lacrimal passage
• Ocular surface( cornea,
conjunctiva , meibomian glands)
• Eye Lids
• Sensory & motor nerve
connections

9. Any dysfunction of this LFU may result in an
unstable , unrefreshed & poorly maintained tear
film - which may induce DED.
 DED caused by inflammation mediated by T-Cell
lymphocytes.
Role of cytokines and matrix metalloproteinase
and androgen is established now.
Patho physiology contd.

10. + MMPs
+
Ocular trauma
Allergy

11. Provoking factors for Dry Eye
Excessive splashing of water on eyes , poor
ocular hygiene.
Extended visual tasking— sitting infront of
monitors for longer duration , watching TV ,
prolonged reading.

12. Tear Film Break-UpTear Film Break-Up
Time (BUT)Time (BUT)
Lissamine GreenLissamine Green
StainingStaining
Fluorescein StainingFluorescein Staining OsmolarityOsmolarityBlink RateBlink Rate Schirmer TestingSchirmer Testing
Diagnostic Tools
Rose BengalRose Bengal
StainingStaining
OsmolarityOsmolarityBlink RateBlink Rate Schirmer TestingSchirmer Testing

13. Basic Tests
1. TBUT (Normal : 15-35 sec )
2. Schirmer –I test (Normal : 15mm)
3. Staining by dyes
• Any 2 of these, if +ve indicate DRY EYE SYND

14. Other Tests to determine the
specific cause of dry eye
Naso-lacrimal reflex
Serum auto antibodies
Meibomian gland evaluation
Impression cytology
Conjunctiva and cornea sensation
Tear protein analysis

15. Pre corneal Tear Film
MucinMucin
LipidLipid
AqueousAqueous
OCULAR SURFACEOCULAR SURFACE
7.0 µm
0.11 µm
Hydrophilic
(MG)
Superficial Thin Lipid Layer
(LG)
Middle Bulk Aqueous Layer
(Goblet Cells)

16. Tear Break-Up Time:
• Special dyes are placed into the eye that mix with the
layer.
• The doctor observes the tear layer with a special
microscope as the eye is held open for several
seconds.
• Eventually the tear film is displaced and dry spots
form.
• The length of time, in seconds, for this to happen is
the Tear Break-Up time.
• A normal tear layer stays intact for about 10 seconds.
In people with dry eye or OSD the time is shortened
to as little as 2 to 4 seconds.

17. Fluroscein and Lissamine dye stain
of the ocular surface:
These dyes will stain only damaged or
devitalized cells of the eye that dry eye
affects. Commonly people with dry eye show
this characteristic staining.
 Areas of damaged tissue result in eye
discomfort such as itching, pain, or foreign
body sensation.

18. Fluorescein clearance test
Standardized amount of fluorescein is placed
in conjuctival sac and tear turnover rate is
determined by persistence of fluorescein in
tears at specific time points later.

19. Tear turnover is important
For removing inflammatory cytokines.
For providing fresh supply of growth factors
Delayed tear clearance will lead to ocular
irritation.

20. Tear Volume tests:
Special test strips are gently touched to the
surface of the eye for several seconds.
The strip absorbs tears and how much tear is
absorbed is related to how much tears is
being produced.
This is an indication of how fast tears are
being made by the various tear glands.

21. Biomicroscope Exam of
Tear Glands:
Oil producing glands (Meibomian glands) are
found in the eyelids, with openings on the lid
margins.
The oil component of the tears slows
evaporation of tears.
Dysfunction of these glands is a common
cause of dry eye, and alterations of these
glands can be seen with the biomicroscope.

22. Tear Osmolarity Determination:
• All of the previously discussed methods of dry eye analysis have a high
degree of variability, and have made the exact diagnosis of true dry eye
difficult to determine.
• Finally a revolutionary new diagnostic test is available.
• A special instrument, called the TearLab Osmolarity System, incorporates
a small probe that is gently touched to the white of the eye, and absorbs a
very small sample of tears.
• Special electronic sensors determine the level of salinity (saltiness) of the
tears. The degree of Osmolarity falls within a certain range. The low end
found in normal tears, and the high end found in dry eyes. Not only is the
test highly accurate and specific for true dry eye (not other causes of eye
discomfort), but it rates the severity of dryness as mild, moderate, or
severe and a specific treatment program may be taylored for each
patient and to track improvement over time.

23. Tear film Osmolarity
• Values higher than 312 m osmol / L are
diagnostic of dry eye.
– 90% sensitivity
– 95% specificity
• A commercial Osmometer especially designed
to test nano volume of tear is in use but cost
factor is important.

25. Nasolacrimal reflex
• Can be elicited by stimulating the nasal
mucosa under the middle turbinate with a
cotton – tipped applicator
• Increase tearing dramatically in non-
Sjogren’s syndrome.
• No increase in Sjogren’s syndrome

26. Tear protein analysis
• Lysozyme accounts for 20-40% of total tear
protein
• More sensitive test than Schirmer or Rose
Bengal staining.
• Poor specificity.
• False positive in malnutrition, HSV keratitis,
bacterial conjunctivitis

27. OSDI
A number of questionaires are also available
for evaluation of various aspects of DED
symptomatology , including severity, effect on
daily activities and quality of life.
This permits quantification of common
symptoms.
This Ocular Surface Disease Index is a
valuable tool in clinical treatment trials.

28. Treatment Options
Treat the symptoms
Treat the Cause
Lower the patient’s expectations by HE
Tear replacement alone is not always
successful.
 Causative factors are to be attended
appropriately.

29. Therapeutic Approaches
Stabilize the tear film (subjective)
Increase lubricity –decrease
coefficient of friction.
Increase aqueous production.
Decrease inflammation.
Create a more normal tear film
environment for epithelial healing.
TREATTREAT
SUBJECTIVELSUBJECTIVEL
YY
Manage aManage a
patient’s dry eyepatient’s dry eye
based on the dropbased on the drop
and frequency thatand frequency that
best fits theirbest fits their
particular form ofparticular form of
the condition.the condition.

30. Glycerin Containing Products
Categories of Lubricant Eye Drops
Glycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing ProductsGlycerin Containing Products
Polyethylene Glycol and PropylenePolyethylene Glycol and Propylene
Glycol ProductsGlycol Products
Oil-Based Emulsion ProductsOil-Based Emulsion Products
Glycerin Containing ProductsGlycerin Containing Products
Cellulose Derivative ProductsCellulose Derivative Products
Polyvinyl Alcohol 1.4 % + PovidonePolyvinyl Alcohol 1.4 % + Povidone
IodineIodine

31. Polyvinyl
Alcohol 1.4%
Polyethylene
Glycol
+
Propylene
Glycol
Oil Based
Emulsions
CMC 0.25 –
0.7% - 1%
HPMC 0.3% Gly + CMC Gl + HPMC
Povidone
Iodine
+ Lubrex
Symtears D
Soft visc
Smart Tear
Refresh Tears
Ultra Gel
Aquaray
Soft Drops
Aquaray +
T. Naturale
forte
Systen Ultra
Ocumoist
Ecotears
T Naturale II
Ref Liquigel
Genteal
Visine
Ref Endura
Soothe
Tears Plus
Vel Drop, Moss
Just Tears
Comoist

32. Ideal Product for Dry Eye M/M
 Preservative free
Minimal blurring
Comfort upon instillation*, pH neutral to slightly
alkaline
Ability of product to spread evenly over the cornea
quickly and efficiently
Prolonged retention time for extended efficacy*
Optimal Osmolarity ( between 181 – 354 mOsm/L)
*Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocular Surface*Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007). Ocular Surface
2007;5:165.2007;5:165.

33. ViscoelasticViscoelastic
PropertiesProperties
ViscosityViscosity ElasticityElasticity
Lubricant Eye Drops
 viscosity =  blur
 elasticity =  corneal
retention time

34. Recent trend
Pharmaceutical companies are trying to reduce BAK
concn. in their products, e.g. (Intas-in Dortas-T now
62%)
Many products are being made preservative free.
Many products are being prepared in the form of
MINIMS
Replacing BAK with some other safe & newer
preservatives in low concn , e.g. sorbic acid 0.01%,
poly-quarternium 0.001%

35. There is a long list of
prerservatives being used from
very past Benzalkanium chloride (0.01% for eye-drops, 0/02% for C.L.
solutions & 1% as disinfectant)
 Chlorbutanol
 Chlorhexidine (0.002- 0.005%)
 Thimerosal & mercuric oxides (0.002-0.005%)
 EDTA
 Methylparaben
 Propylparaben
 Polyquad (SPK)
 Purite
 Potasium sorbate
 Sodium perborate (air touch changes to H2O2, Then H2O & O2)
 Sorbic acid (less toxic)

36. Ocular complications of preservatives
 Pigmentation: (Mercury deposit in lids, conj.,
cornea & lens)
 Irritation: (redness, photophobia, lacrimation,
burning .
 Allergic: Papillary & follicular conjunctivitis, pseudo
membrane, pemphigoid, symblepharon, SPK,
corneal edema, panus, corneal opacity, CL Intolerance
ocular surface malfunction & inflammation
 Toxic: Epithelial Cell exfoliation, SPK

37. So the trend is to go
preservative free now

38. Topical Steroids or NSAID medication is some
time useful, when there is inflammation
(e.g. Loteprednol 0.5% )- for short term
For more severe diseases, topical
immunomodulating drug such as Cyclosporine
may be rewarding ( 0.05% BID)

39. Cyclosporine
• Approved by FDA for treatment of Dry Eye
• Reduces conjuctival inflammatory markers (IL-6
levels, activated lymphocytes, inflammatory
and apoptotic markers)
• Increases conjunctival goblet cell number

40. • Biological tear substitution options for severe dry eyes:
 Autologous serum drops containing additional
growth factors may help in epithelial healing
 Autologous platelet rich plasma
 Mucous membrane grafting
 Salivary gland auto-transplantation
 Amniotic membrane transplantation

41. Essential fatty acids
Omega 3 & 6 fatty acids
• Reduces inflammation.
• Inhibit the synthesis of pro inflammatory
mediators (PGs and LTs) & inflammatory
markers (IL-1andTNF-G)

42. Recent Trend
• Diabetics are more prone to dry eyes– hence
thorough screening is desired.
• Vit. A def. is imp. Factor for dry eye.
• Thyroid function must be assessed.
• Proper sleep for 5-6 hrs lessens its incidence.
• Water intake should be improved.

43. Newer Drugs for DED
• Tear stimulation secretogogues.
– Diquafosol (P2y2 receptor agonist)approved in Japan
– Lifitegrast 5% (FDA approved)
– Ecabet sodium (mucous membrane stimulant)
– Rebamipide
– Gefarnate
– N-acetyl-cystine eye drops
– Chloroquine phosphate eye drops(0.3mg/ml)
– Lacriserts, collagen shields
– Androgen ointments

44. Prevention
To avoid hot, dry, dusty, smoky
environment and to add moisture to the air
 To avoid excessive use of AC (direction
towards face to be avoided)
To avoid excessive air movement or windy
conditions

46. Preventions cont:
 To wear glasses on windy days.
 Goggles while swimming.
 To take frequent breaks : while watching TV, reading
or prolonged working on computer.
 To position the computer below the eye level
 Frequent blinking .
 To stop smoking (both active or passive)
 To use hot compress & eye massage (in MGD)

47. Take Home Message
Start symptomatic t/t & earliest detection
of the cause and its early m/m
 Just increasing frequency of drop is not
always useful, rather it may aggravate the
dryness.
Customize the treatment
i.e. Selection of drug in individual case is imp.
Preventive measures must be looked for timely.

48. Thank
You