2. Chairman :
Dr. Md. Saifullah
Professor & Head Of Department Of Cornea, NIO&H
Moderator :
Dr. Farhat Jahan
Assistant professor, Department Of Cornea, NIO&H
Presenter :
Dr. Navid Rahman
DO resident, NIO&H
3. Definition
A multifactorial disease of tears
and ocular surface that results in
symptoms of discomfort,visual
disturbence and tear film instability
with potential damage of oculer
surface.
6. Influential Factors of Dry Eye
• Age
• Gender
• Arthritis
• Gout
• Lens Surgery
• Contact Lens wear
• Nutritional problem
• Rheumatoid arthritis
• Thyroid problem
• Time of day
• Blink disorder
• Disorder of lid
aperture
7. • LASIK Surgery
• Cosmetic Surgery
• Mechanical Disturbence
• Exposure keratitis
• Ectropion
• Entropion
• Symblepheron formation
• Large lid notches
• Lagophthalmos
• Incomplete blinkig
• Dellen formation
• Illumination
8. Cont..
• Temperature
• Humidity
• Air movement
• Allergies
• Change in environment
• Reading
• Long time working on computer screen,watching movies
• Sleep
Prause JU, Norn M. Relation Between Blink Frequency and Break-Up Time. Acta Ophthalmol. 1983 61: 108-116.
Cho P, Cheung P, Leung K, Ma V, Lee V. Effect of Reading on Non-Invasive Tear Break-Up Time and Inter-Blink Interval. Clin. Exp. Optom. 1997 80: 62-8.
Tsubota K, Seiichiro H, Okusawa Y, Egami F, Ohtsuki T, Nakamori K. Quantitative Videographic Analysis of Blinking in Normal Subjects and Patients with Dry Eye. Arch. Ophthalmol.
1996 114(6): 715-720.
Nally L, Ousler GW, Abelson MB. Ocular discomfort and tear film break-up time in dry eye patients: a correlation. IOVS 2000 41(4): 1436. Collins M,
Seeto R, Campbell L, Ross M. Blinking and Corneal Sensitivity. Acta Ophthalmologica 1989 67(5): 525-531.
Abelson MB, Holly FJ. A tentative mechanism for inferior punctate keratopathy. Am. J. Ophthalmol. 1977 83: 866-869. Doane MG.
Dynamics of the Human Blink. Ber. Disch. Ophthalmol. Ges. 1980 77: 13-17.
Kaneko K, Sakamoto K. Spontaneous Blinks as a Criterion of Visual Fatigue During Prolonged Work on Visual Display Terminals. Perceptual and Motor Skills 2001 92(1): 234-250.
17. According to Intenational Dry Eye workshop(2007):
Dry Eye Severity Leveled as 1,2,3,4;where Level 4 being most severe
point.
Severity level based upon these 9 conditions-
1.Discomfort,Severity&frequency
2.Visual symptoms
3.Conjunctival injection
4.Conjunctival staining
5.Conjunctival staining(severity/location)
19. 1.Discomfort,Severity &frequency:
1 2 3 4
Mild and/or
episodic,occur
s under
environmental
stress
Moderate
episodic or
chronic,Stress
or no stress
Severe
frequent or
constant
without stress
Severe and/or
disabling
&constant
25. Recomended treatment(AAO):
Mild
• Artificial tear with
preservative upto 4X
daily.
• Lubricating ointment at
bed time
• Hot compresses and eye
lid massage
Moderate
• Artificial tear without
preservatives upto 4x
daily to hourly.
• Lubricating ointment at
bed time.
• Topical anti
inflammatory
treatment(closporin A)
• Reversible lower
punctul occlusion with
plugs.
Severe
• All of the above
• Punctul occlusion(lower
&upper)
• Topical serum drops4-
6x daily.
• Topical corticosteroids
• Moist
environment(Humidifier,
moisture shields)
• Tarsorrhaphy(lateral&m
edial)
26. Qualities of an ideal Dry eye product
• Ability to spread evenly over the cornea quickly
and efficiently.
• Prolonged retention time for extened efficecy
• Objective and subjective improvement in patient
symptoms and signs
*Report of the Definition and Classification Subcommittee of the International Dry Eye Workshop (2007).
Ocular Surface 2007;5:165.
29. HYALUB
(Sodium Hyaluronate 0.1%)
• Lubricating,protecting
• Powerful wetting agent
• Long lasting
• Reduced Ocular surface
damage
• Accelerate wound healing
• Safe,well tolerated for long
term use
• Non preservative
30. SURGICAL OPTION
Reserved for severe disease poor/non-
complience.
• Punctal plug
• Surgical/Thermal/LASER occlusion.
ADVANTAGES-
• Prolong tear retention.
• Reduces frequency of artificial tears
needed for symptomatic relief.
31. Punctul Plugs
•Absorbable:
-Made of collagen or polymer.
-Occlusion duration ranges from 7-
180 days.
-plugs dissolve by themselves or
may be removed by salaine irrigation.
•Non-absorbable:
-Made of silicon
-punctum plugs & Intracanalicular
plugs(Cylindrecal smartplug)
32. Complications of plug
• Too far insertion,unable to retrieve
• Spontaneous loss into the canaliculus
• Canalicular or NLD obstruction
• Extrusion of plug
• Scarring of punctum
• Ocular surface irritation,epiphora
• Papillomatous overgrowth of exubarent conjunctiva
• Retains inflammatory mediator
• Infection/discomfort
• Costly
33. Surgical tretment
• Parotid duct translocation:
-Salivary gland may be affected in Sjogren syndrome.
-Frequently secrete more fluid,increases during eating.
• Tarsorrhaphy:
-Narrowing of palpebral fissure reduces the rate of evaporation.
36. According to The International Workshop on MGD
-Clinical summery of the MGD staging used to GUIDE treatment:
Stage 1:
MGD Grade Symptoms Corneal
staining
+Minimally
altered
expressibility &
secretion quality
None None
38. Stage 4:
“Plus disease”:
Coexisting or accompanying disorders of the ocular surface and/or
eyelids.
MGD Grading Symptoms Corneal
staining
++++ severely
altered
expressibility &
secretion quality
Marked Marked ;central
in addition
39. Treatment
Stage 1:
-Patient education about
• MGD
• Potential impact of diet & the effect of work/home environment on tear
evaporation
• Possible drying effect of certain systemic medication
-Consider eyelid hygiene including Warming/expression.
Stage 2:
-Advise of improving
• Ambient humidity
• Optimizing Workstations
• Increasing dietary omega-3 fatty acid intake(±)
40. -Institute eyelid hygiene with eylid warming.
-All the above,plus
• Artificial tear
• Topical Azithromycin
• Topical emmolient lubricant or liposomal sprey
• Consider oral tetracycline derivetives.
Stage 3:
-All the above,plus
• Oral tetracyclin derivetives(+)
• Lubricant ointment at bedtime
• Anti inflammatory therapy for dry eye.(±)
41. Stage 4:
-all of the above plus
-anti inflammatory therapy for dry eye(+)
Plus disease:
-Pulsed soft steroid
-Bandage contact lens/scleral contact lens
-Steroid therapy
-Epilation,cryotherapy
-Interlesional seroid or excision.
-Topical antibiotic or antibiotic&steroid combination
-Tea tree oil scrub
42. So,What's the Modern Technology in MGD
LIPIFLOW
A device having an insulated
conformer that heats the inner
surface of the lids.
an inflatable pad applies a pulsatile
pressure to the glands through the
tarsal plate.
45. Future casual therapy
• Cyclosporine A0.05% drops in moderate and severe ocular
surface inflammation
• Essential Fatty acids Omega-3 in ocular surface irritation.
• Secration stimulation,Mucin
stabilizera(Sulglycotide),Mucolytic agents,local androgenic
complexes.
• Systemic immunomodulator/immunosupressive in severe
cases.
• Topical antiCD-4 monoclonal antibody to supress the
activation of CD4+ T cells.
46.
47. Carry Home Messsage
• Symptoms & Signs don't always catch up with other in case of Dry
Eye Disease,so-
Do not miss subtle clinical conditions.
• Methodical approach to Diagnosis.
• Loads of conditions,Lots of options;so,careful plannig for treatment
outline is must.
• Irrespective of cause of dry eye-
Immunomodulation+tear replacement.
• All available options are only Symptom reliever,none of them
curative.
• Educate the patient & family members about the dillemas in
management.
