Dry eyes - aqueous tear deficiency, evaporative tear deficiency

1. MANAGEMENT OF DRY EYE
Dr. Sameeksha Agrawal

2. Introduction
• Now “dysfunctional tear syndrome” is used instead of dye
eye
• In 2007, the international dry eye workshop(DEWS): “ Dry
eye is a multifactorial disease of the tears and ocular
surface that results in symptoms of discomfort, visual
disturbance and tear film instability with potential damage
to ocular surface”
• It is accompanied by increased osmolarity of the tear film
and inflammaton of ocular surface

3. Prevalence of dry eye increases significantly with
age
Prevalence of dry eye symptoms by age
0
5
10
15
20
Age 48-59 Age 60-69 Age 70-79 Age 80-91
Prevalence(%)

4. Prevalence of dry eye symptoms by age and sex
0
10
20
30
Age 48-
59
Age 60-
69
Age 70-
79
Age 80-
91
Prevalence(%)
Women
Men
Prevalence of dry eye is higher in women

5. PREVALENCE
Women using postmenopausal hormone replacement
therapy
 Contact Lens Wearers
 Smoker
Alcoholics
 A/C systems at work
Work outside
Computer workers
Coexisting ocular condition – MGD, Pterygium, Blepharitis
and Conjunctival disease
Thyroid dysfunction, Arthritis, Poor general health

6. DRY EYE : Classification
DRY EYE
Aqueous tear deficiency (ATD)
(Tear deficient dry eye)
(Most common)
Evaporative tear
deficiency (ETD)
(Evaporative dry eye)

7. DRY EYE CLASSIFICATION
Aqueous Tear Deficiency
Sjogren’s
syndrome
Primary Secondary
Rheumatoid
arthritis
Systemic lupus
erthematosus
Wegener’s
granulomatosis
Systemic sclerosis
Primary biliary
cirrhosis
Other autoimmune
disorders
Non-sjogren tear deficiency
Lacrimal gland
deficiency
PRIMARY
Congenital
alacrima (Riley
Day
syndrome)
Age related
dry eye
Familail
dysautonomia
SECONDARY
Lyphoma
Hemochromatosis
Sarcoid osis
Amyloidosis
HIV
Xerophthalmia
Graft vs host
reaction
Ablation
Denervation
Lacrimal
obstruction
Trachoma
Cicatrical
phemphigoid
Erythema
multiforme
Chemical and
thermal burns
Postradiation
fibrosis
Reflex
hyposecretion
Neurotrophic keratitis
Chronic contact lens
7th nerve palsy
Diabetes
Multiple neuromatosis
Herpes
PRK,LASIK,RK
Limbal incision
(ECCE)
Topical anesthesia
Atropine like drugs

8. Evaporative dry eye
Meibomian gland
deficient
PRIMARY
Congenital
deficiency
Distichiasis
SECONDARY
Anterior
blephritis
Posterior
blepharitis
Obstructive
mebomian gland
disease
Retinoid therapy
Metaplasia
Turner syndrome
Cicatricial
VKC
Lid related
Low Blink Rate
(Tasks that require
concentration-
working at
computer or
microscope)
Parkinsons
disease
Exposure
( high myopia.,
Proptosis,
Exophthalmos)
Lid palsy
Ectropion
Lid coloboma
intrinsic extrinsic
Vitamin A- deficiency/
xerophthalmia
measles
Ocular surface
disease eg.
allergy
Topical drugs and
preservatives
anesthetics
Contact lens wear

9. Diagnostic Tools
• Symptoms
• Case History
• Slit Lamp Evaluation
• Investigations

10. Symptoms
• Irritation
• Redness
• Burning/ Stinging
• Itchy eyes
• Foreign body sensation
• Blurred vision
• Tearing
• Contact lens intolerance

11. Symptoms
• Mucous discharge
• Photophobia (less frequent
symptom)
• Symptoms gets worsen
 As day progresses
 Windy or air-conditioned
environments.
 After prolonged reading,
working on computers

12. Case History
• Dry Eye Is a Symptom Based Disease
• A Good Case History is most Important “Diagnostic
Test”
• It should be thorough & Organized
• Use a Good Questionnaire
 Ocular Surface Disease Index (OSDI)
 McMonnies Dry Eye Index
 Dry Eye Questionnaire (DEQ)

13. Dry Eye Questionnaire (DEQ 5)
I. How Frequently Do Your Eyes water?
II. How Often Do Your Eyes Feel dry?
III. Is the Dryness Worse Late in the day?
IV. How Often Do You Experience Ocular discomfort?
V. Is the Discomfort Worse Late in the day?
Watery Eyes and Late Day Symptoms were highly Correlated with
Evaporative Etiologies
Dryness and Discomfort were highly Correlated with Aqueous
Deficient Etiologies

14. MCMONNIES DRY EYE QUESTIONNAIRE
It is the original specific dry eye diagnostic questionnaire
(Mc.monnies 1986).
1. Have you ever had been prescribed drops or other
treatment for dry eyes?
2. Do you ever experience any of the following symptom
Soreness
Scratchiness
Dryness
Grittiness
Burning
3. How often do your eyes have these symptoms?

15. 4. Do you regard your eyes as being unusually sensitive to
cigarette smoke, smog, air conditioning, central heating?
5. Do your eyes easily become very red and irritated when
swimming in fresh water?
6. Are your eyes dry and irritated the day after drinking
alcohol?
7. Do you suffer from arthritis?
8. Do you experience dryness of the nose, mouth, throat,
chest or vagina?
9. Do you suffer from thyroid abnormality?
MCMONNIES DRY EYE QUESTIONNAIRE

16. 10.Do you have eye irritation as you wake from sleep?
11.Are you known to sleep with your eyes partly open?
12. Do you take?
• Antihistaminic tablets or eye drops
• Diuretics
• Sleeping tablets
• Tranquilizers
• Oral contraceptives
• Medication for duodenal ulcer or digestive problems
• Medication for high blood pressure
• Antidepressants
MCMONNIES DRY EYE QUESTIONNAIRE

17. Slit Lamp Examination
Lid Margins:
 Telangectasia
 Hyperemia
 Scaling or Crusting at
bases of lashes
 Madarosis
Apposition of lids to globe
Anatomical Abnormalities
Tear Film
 Scanty Meniscus
 Foamy (Suponification)
 Tear Debris

18. Slit Lamp Examination
Conjunctiva
 Decreased Luster
 Hyperemia
 Conjunctivochalasis
 Staining
 Symblepharon
 Cicatrix
Cornea
 Punctate Changes
 Erosions
 Filaments
 Ulceration
 Vascularization
 Scarring /
Keratinization

19. Mucous debris Foam on the lid margin

20. Thin marginal tear meniscus
and inferior punctate erosions

21. Fine filaments in
filamentary keratitis
Filaments stained with Rose
Bengal

22. Dry eye consensus guidelines (Delphi model)
2006-07
• Proposed A new terminology for Dry eye- “Dysfunctional tear Syndrome”
(DTS)
• Purpose: To develop a treatment algorithm for DTS along with an
appropriate classification system.
• DTS is classified in to 4 levels based on the severity levels of signs and
symptoms. All diagnostic tests are considered as secondary to the signs
and symptoms, in determining the severity levels of the patient condition

23. Dry Eye Severity
Level
1 2 3 4
Discomfort, severity
and frequency
Mild or
episodic under
stress
Moderate under
stress or no
stress
Severe frequent
even without
stress
Severe or
disabling constant
Visual symptoms None or
episodic
Annoying or
episodic limiting
Annoying/
constant limiting
Constant or
disabling
Conjunctival inj. None to mild None to mild +/- +/++
Conjunctival stain None to mild variable Moderate to
marked
marked
Corneal stain None to mild variable Marked central Severe pnctate
erosion
Corneal tear sign None to mild Mild debris,
meniscus
Filamentary
keratitis,
mucus clumping
+ ulceration
Lid/meibomian gland Variably
present
Variably present frequent Trichiasis,
symblephron
TFBUT (in sec) Variable < 10 <5 immediate
Schirmer’s score
( mm/5min)
Variable < 10 <5 <2

24. Clinical diagnostic test
• Assessment of tear film stability
• Assessment of tear secretion
• Assessment of ocular surface damage
• Assessment of tear turnover
• Laboratory diagnostic tests

25. Assessment of tear film stability
1.Tear film breakup time –
a) Invasive
• It is abnormal in aqueous tear deficiency and meibomian gland
disorder
• TBUT is the interval between the last blink and the appearance
of the first randomly distributed dry spot in the precorneal tear
film
• 2% Na fluorescein is instilled in lower fornix, and ask patient to
blink. After 10- 30 sec examined in slit lamp
• Examined under cobalt blue light
• TBUT <10 sec is abnormal
• < 2 sec indicate KCS

26. Dry spot

27. b) Non invasive TBUT
• Keratometer
• Keeler Tearscope
• Xeroscope
• Placido based computerized videokeratoscopy
• TMS (BUT –by topographic modelling system)
• More sensitive and specific
• Tear breakup pattern is linear on the inferior and central
cornea- Tear lipid deficiency
• More random circular breakup pattern over areas of
punctate epitheliopathy – Aqueous tear deficiency

28. Assessment of tear secretion
2. Schirmer’s test - For assessing tear secretion( 1903)
Done with a strip of filter paper measuring 5mm by 35 mm
whatman filter paper no. 41.
-Type-I –Done by placing the strip on lower fornix at the
junction of outer 1/3 and inner 2/3 for 5 mins
• < 5 mm at 5 minutes- abnormal
• Jones basal tear secretion – Performed similar to Schirmer’s 1 but
with application of anaesthetic drop prior to placement of the
strips.

29. Scirmer’s Test
• Type-II
- to know reflex secretion of tears
-Done by stimulating unanaesthetised nasal mucosa by cotton tip,
and note the wetting after 5 min.
- Value of < 10 mm at 5 min is abnormal
• Type III-
- Similar to Schirmer’s 1 along with retinal stimulation by looking at
the sun
-no diagnostic value, and is potentially dangerous

30. PHENOL RED THREAD TEST–
by Hamano et al in 1982
• Impregnated with a Phenol sensitive dye
• End of the thread (75 mm in length) is placed under the lateral one fifth of
the inferior palpebral lid margin for 15 seconds
• When thread is wetted with tears, phenol red changes from yellow to
bright orange
• Length of thread wetted measures aqueous tear production.
• Value of 6mm is ABNORMAL
• More repeatable and reliable than Schirmer’s test

31. Assessment of ocular surface damage
FLUORESCEIN STAINING –( by bayer 1871)
 Na salt of resorcinolpthalein is used
 1-2% solution (2μl/strip)
 Large molecule unable to traverse normal corneal epithelium tight
junctions
 Shows area of denuded corneal epithelium and Punctate staining of
cornea
 A highly sensitive test and 96% positive in sjogrens syndrome

32. ROSE BENGAL STAINING
- Affinity for dead and devitalized epithelial cells that have
lost or altered mucous layer
- 1% aqeous sol. or a moistened impregnated strip
- Stains damaged conjunctiva and corneal epithelium,
mucus threads and filaments

33. Corneal & conj. Staining with rose bengal

34. Lissamine green stain- by Norn
• Synthetic organic acid dye
• Less irritating than rose bengal
• 1% solution is used
• Stains degenrated and dead cells and mucus
• Double vital stain —
• 1% fluorescein+ 1% rose bengal
• Preserative free
• No overflow
• Decrease irritation

35. GRADING SCHEME FOR OCULAR SURFACE DYE STAINING
• VAN BIJSTERVELD gave a grading scale, divides the ocular
surface into 3 zones
• Nasal bulbar conj.
• Cornea
• Temporal bulbar conj.
• Each graded 0-3
• 0-none
• 1- just present
• 2- moderate staining
• 3-confluent staining

36. Temporal and nasal conjunctiva are divided into 3 parts each
a score of 3.5 out of 9 is considered abnormal

37. THE PATTERN
• INTERPALPEBRAL- Aqueous tear deficiency
• SUPERIOR- superior Limbic keratoconjunctivitis
• INFERIOR- blepharitis or exposure

38. NEI workshop grading system- Uses fluorescein to grade
the cornea and Rose Bengal to stain the conjunctiva.
• >3 out of 15 – abnormal for the cornea
• >3 out of 18 – abnormal for the conjunctiva
OXFORD scheme – Quantify epithelial damage in case of
dry eye – Series of panels labelled A to E in order of
severity (Absent, Minimal, Mild, Moderate, Severe)
GRADING SCHEME FOR OCULAR SURFACE DYE STAINING

39. Assessment of tear turn over
• Florophotometry (fluorimetry)- tear flow
1) Tear turn over- 1 drop of 2% fluorescein is instilled
Scans are taken at 1 min and then every 2 mins for 20 mins
Fluorescein conc are taken
Decay in fluorescence is calculated from the log
2) Tear volume- same technique except scans are taken at 1
min and each min for 4 mins

40. Tear osmolarity
• Gold standard
• By freezing point depression osmometer
• Or by vapor pressure osmometer
• Drawbacks –
expensive equipment
skilled operator
tear microvolumes ( only 0.2μl used)
> 316 mOs/l is cut off value between healthy and dry eyes

41. Laboratory diagnostic tests
1)Conjunctival impression cytology
 It is a substitute for conjunctival biopsy.
 It is simple, easy, reliable, accurate, low cost, non invasive
technique which can be repeated as often as required.
 Abnormal pattern precedes the ocular signs of
xerophthalmia

42. GRADING
• 0- normal cellular structre
• 1- early loss of goblet cells without keratinization
• 2- total loss of goblet cells with enlargment of epithelial
cells
• 3- early and mild keratinization
• 4- moderate keratinization
• 5- advanced keratinization

43. 2) Brush cytology technique
• For a variety of ocular surface disorder
• Collects conjunctival epithelial samples
• Used to detect squamous metaplasia, inflammatory cells
and expression of several surface markers
• Also used to see molecular expression of each cell

44. 3)Tear ferning test(TFT)
• To diagnose quality of tears (electrolyte conc), hyperosmolarity
• Tears when dried on slide shows ferning.
classified in the 4 group:
A. Uniform arborisation and numerous branching are seen. little
or no space between ferns.
B. Branching is less and there is abundent space between ferns.
C. Ferns are thicker and smaller with little branching and very
large spaces between them.
D. No ferning but amorphous patter is seen.
• Pattern A is normal while D suggests severe disease.
• Pattern C and D are associated with lack of lactoferrin and
lysozymes in tears, prone to frequent infections

45. 4)Tear lactoferrin
By radial inmmuno diffusion assay
performed using readily available kits
-it is more sensitive & specific than any other test.
-In milder cases, should be combined with schirmers test
5). Tear lysozyme assay - Most often tear lysozyme
decreases before dry eyes are clinically evident. So it is of
great diagnostic & prognostic value.
Not popular

46. 6) Tear protein analysis
7) Tear evaporation
8) Interleukin levels
9) Conjunctival scraping - stains with giemsa stain -in dry
eyes it shows numerous goblet cells with pink cytoplasm and
nucleus on one side of cell

47. Meibomian gland dysfunction
• Tear film lipid layer interferometry
• Meibometry (by laser meibometer)
• Meibography/ meibooscopy ( by finoff translluminator or
infra red photography)

48. Management of dry eye
• It is generally not curable and, therefore main
aim is to control of symptoms and prevention of
surface damage

49. Dry eye menu of treatments
Artificial tears substitutes
Gels/Ointments
Moisture chamber spectacles
Anti-inflammatory agents (topical CsA and
corticosteroids,omega-3 fatty acids)
Tetracyclines
Plugs
Secretogogues
Serum
Contact lenses
Systemic immunosuppressives
Surgery (AMT, lid surgery. tarsorrhapphy, MM & SG
transplant)
AMT = amniotic membrane transplantation

50. Table 4. Treatment recommendations by severity level
Level 1:
Education and environmental/dietary modications
Elimination of offending systemic medications
Articial tear substitutes, gels/ointments
Eye lid therapy
Level 2:
If Level 1 treatments are inadequate, add:
Anti-inflammatories
Tetracyclines (for meibomianitis, rosacea) Punctal plugs
Secretogogues
Moisture chamber spectacles
Level 3:
If Level 2 treatments are inadequate, add:
Serum
Contact lenses
Permanent punctal occlusion
Level 4:
If Level 3 treatments are inadequate, add:
Systemic anti-inammatory agents
Surgery (lid surgery, tarsorrhaphy; mucus membrane, salivary gland, amniotic
membrane transplantation)

51. 1.Conservative
A. Blink exercises
• five one minute sessions for two weeks
• during which the patient should aim to perform 50 full
blinks
• the patient should aim to close the lids without squeezing
them tightly.

52. B.Lid hygiene and warm compresses :Especially useful in
dry eye due to meibomian gland disease (posterior
blepharitis)
Expression of glands (lid massage)
Scrub with dilute detergents

53. C.Evaporation reduction: Ergonomical changes can reduce
dry eye incidence.
-Avoid excessive use of air conditioner
-Avoid lens wear in aeroplane
-Use room humidifiers
-spectacles with tight fitting side shields

54. D. Patient education
-avoidance of toxic drugs and environmental factor
-review of work environment-who works in air-
conditioned environment and spend a long time with
computer
-caution against laser refractive surgery
-discontinue any unnecessary topical medication that
may be causing TOXIC MEDICAMENTOSA

55. • Tear supplements also c/a lubricants or artificial tears
-almost all are based on replacement of aqueous phase of
tear film.
₋ Frequency of drops 4 times/day to half hrly
a. Drops
b. Gels ( synthetic polymer of acrylic acid)
c. Ointment ( contain petroleum mineral oil)
d. Ocusert ( 5 mm pellet of hydroxy propyl cellulose used)
e. Lipids & oils ( patroleum (soft paraffin, liquid paraffin
& wool fat), lecithin,lanolin ,( lipid replacement)

56. Characteristics should be
• Preservative free or easily dissipated
• Polymeric
• Non toxic
• Sterile
• Electrolytes balanced
• Osmolarity b/w 181 to 354 m osm/ml
• multidoses

57. A. Preservatives-
 Eliminate
1) benzalkonium chloride– epithelotoxic ,
affect cell to cell junction , microvilli
2) EDTA--- increases corneal epithelial permeability
 Add – polyquad( polyquatronium 1)
sodium chlorite ( purite)
sodium perborate
methyl paraben
propyl paraben
potassium sorbate
all these get disintegrated into soluble and evaporative form.

58. B. Electrolytes– add
1. Potassium for corneal thickness, increase goblet cell density,
corneal glycogen content, decrease osmolarity ( mainly in
LASIK patients)
2. Bicarbonate recover epithelial defect
C. Osmolarity– increases in dry eye causes morphological and
biochemical changes and leads to accumulation of pro
inflammatory substances
so its reduction leads to flow across the membrane

59. D. Viscosity agents --- tears contain membrane spanning mucins ( MUC
16 & MUC 4)
Get decreased in dry eye
replacements are -carboxymethyl cellulose ( .25% - 1 %)
polyvinyl alcohol
polyethylene glycol
glycol 400
hydroxypropyl methyl cellulose
Mucomimetic agents- 0.18%
hydroxypropylguarpolysaccharide(HP-guar)
-offers complete protection from desiccation
-provides an environment in which corneal epithelium recovers
damage

60. TEAR RETENTION
A. Punctal occlusion –- it reduces drainage so preserve
natural tear and prolongs the effect of artificial tears.
-for moderate to severe KCS—
symptomatic
schirmer’s < 5mm in 5 mins
ocular surface takes staining
Improvement shown by prolonged TFBUT, increased goblet
cell density, decreased osmolarity

61. Contraindications-
1.Allergy to bovine collagen
2.Allergy to silicon
3.Infective conjunctivitis
4.Dacryocystitis
5.Inflammation of eyelid
6.Epiphora
7. Punctal ectropion
8. Naso lacrimal duct block

62. TYPES
• PROTOTYPE PLUG– dumb bell shaped silicone plug ( by
Freeman 1975)
• ABSORBABLE/ TEMPORARY– collagen / polymer based ( stay
for 3 days to 6 mnths)
• NON ABSORBABLE /PERMANENT–
 eg. Freeman
 Herricks plug ( golf tee shaped, intracanalicular)
 cylindrical smart plug ( hydrophillic acrylic
component , expands inside)
 FCI umbrella plug
 Oasis soft plug

63. Latest
Freeman tapered shaft plugs , these are preloaded on
applicator tools
available in 4 sizes (0.5,0.6,0.7,0.8mm)

64. Complications
• Extrusion
• Internal migration
• Biofilm formation
• Pyogenic granuloma
• Permanent occlusion can also be achieved by laser ablation at
punctum or intracanalicular
• Surgical ablation by canaliculotomy and intracanalicular cautery

65. B . Moist chamber spectacles
• Increases periocular humidity
• Increases lipid layer thickess

66. c. Contact lens
• Low water containing HEMA lens
• Silicon rubber lens
• Gas permeable scleral bearing hard contact lens with or
without fenestrations
• Highly oxygen permeable ( for overnight use) but limited
due to corneal toxicity

67. 3 . Tear stimulation- Secretogogues
• Diquafosol tetrasodium (1% or 2%)
• -is a novel dinucleotide P2Y2 receptor agonist
• -promotes nonglandular secretion of fluid, mucin and possibly
lipid production in the meibomian glands
-stimulate the ocular surface directly
• -able to rehydrate the surface without stimulating the lacrimal
gland
• Others – rebamipide, gefamate, ecabet sodium
15(s)-HETE ( MUC 1 stimulant)

68. • Orally administered cholinergic agonists
• Leads to stimulation of exocrine glands
pilocarpine– mainly in KCS -5mg qid
side effect is eccessive sweating
cevilemine- 15- 30 mg tds
• Evaluated in clinical trials

69. 4 . Biological tear substitute
1. Serum (Autologous Serum (20%-100%):-
by tsubotas
mainly in autoimmune diseases
-Prepared from patients own venous blood (centrifugation),
refrigerated and stored for 2wks.
- contains growth factors (EGF,TGF b),anti inflammatory
components, fibronectin ,Ig G and retinol
- Downregulates inflammation in dry eye and promote epithelial
healing.
- for treating patients with severe dry eye, surface disease, recurrent
infection and slow-healing epithelial defects

70. 2. Salivary gland autotransplantation—
 often no effect on vision but for patient comfort
 in absolute aqueous def.– sub mandibular gland grafts
 Mainly used in
a) In end stage dry disease
b) conjunctivalization surface epithelium
c) Persistant pain despite punctal occlusion

71. 5. Anti inflammatory therapy
• Increased inlammation due to increased osmolarity, prolonged
stress, autoimmune disease
A. IMMUNOPHILIN—
Cyclosporin A (CsA)– 0.5%- 1%
• Is a fungal derived peptide may be used instead of steroids
- For moderate to severe dry eye due to primary or secondary KCS
-inhibit T cell activation,
- significant decrease in the levels of inflammatory cells and markers
in the conjunctival epithelium
- augmentation in the number of conjunctival goblet cell
-Given twice daily for at least 6 months
OTHERS – primerolimus, tacrolimus.

72. B. Corticosteroids (Marsh ,1999)
Amongst topical steroids main are
• Loteprednol 0.5%to 0.2%
• Fluoromethalone (FML) 1%
• Rimexolone1% bid to qid
have low propensity to raise IOP with excellent therapeutic efficacy
-stronger steroids (1% prednisolone) may be used to start if
necessary, and then changed to the former types or to
cyclosporine A
EFFECT IS SEEN AFTER 2 TO 4 WEEKS OF TREATMENT
May be used with lubricants and before punctal plug insertion

73. c. Tetracyclines
• Minocycline or doxycycline ( 100 mg bd for 3 mnths)
• Mainly in meibomian gland dysfunction
• Acts as anti bacterial
anti inflammatory ( dec collagenase, IL1, TNFa)
anti angiogenic
decrease lipase production
Also useful in acne rosae and chronic posterior blepharitis
d. Androgen treatment to ocular surface improves function of
both Lacrimal gland & meibomian gland &alleviate both
aqueous deficient and evaporative dry eye

74. 6. Nutrition
Omega-6 and omega -3 fatty acids:
Omega-6 fatty acid (linoleic acid)-
*present in evening prime rose and black current seeds and
fish oils
*increases amount of anti inflammatory prostaglandin PGE1
there by increasing cAMP levels
*increasing aqueous tear secretion.

75. • Omega -3 fatty acid-
*present in flax seeds and fish oils(alpha linolenic acid)
*increases the amount of anti inflammatory PGE3 and LTB5,
*decreases cholesterol levels and thereby improves quality of
meibomian secretion
*long term use of omega -3 depletes serum vitamin E
• Also effective in recurrent erosion syndrome and
phylyctenular keratitis

76. 7. Surgical intervention
a. Amniotic membrane grafting:
 used in severe dry eye –SJS.
 facilitates migration of epithelial cells, prevents their apoptosis,
reinforces adhesion of basal epithelial cells and produce growth
factors-TGF,FGF
- Amniotic membrane and stem cell transplantation are useful in
severe dry eye , chemical burns & neurotrophic ulcers
b. Tarsorraphy (medial or lateral )
c. Ectropion surgery
d. Corneal transplantation and keratoprosthesis

77. Other interventions
• Anti allergics :
• -allergy causes dry eye by causing loss of conjunctival
goblet cells
• -allow higher concentration of allergen to come in contact
with the ocular surface
use of topical medications
-nedocromil (a mast cell stabiliser)
-olopatadine (mast cell stabiliser/ antihistamine
combination)
-levocabastine (mast cell stabiliser)

78. • Non-steroidal anti-inflammatories –
• useful in filamentary keratitis secondary to dry eye
syndrome
• Have inhibitory effect on fibroblastic activity at the base
of the filaments
• May result in a reduced blink rate, which in turn would
lead to a reduction in the number of filaments produced
• Diclofenac sodium 0.1%

79. • Mucolytic agent :
- acetylcystein 5% or 10% drops qid
-may be useful for corneal filaments and mucus plaques
-has an unpleasant sulfurous odour
-may cause irritation on instillation
.

80. • LIPOSOMAL LIPID SPRAY:
• - active component is Phosphatidyl choline
• phospholipid liposomes (94%),which is also the most
common phospholipid in natural tears
• - sprayed onto the closed eyelids from the distance of
approximately 10cms
- After a few minutes the liposomes start migrating from lid
margin into the tear film
- improve the quality or quantity of the polar surfactant layer of
the tears
- shelf life 3 yrs.

81. Others that can be used
• Botulinum toxin- -
Injection to orbicularis oculi controls blepharospasm in
severe dry eye
• - When injected at medial canthus,it reduces tear drainage
by blocking lid movement
• Topical Vitamin A
-Tretinoin topically is useful in reversing squamous
metaplasia seen in various dry eye condition
-Dose- 0.01% to 0.1% One to Three times Per day
Vitamin C, E, zinc and selenium : improves tear film
quality and quantity

82. Thank you