Dry Eye Syndrome (Keratoconjunctivitis Sicca)

emedicine.medscape.com /article/1210417-overview

Dry eye syndrome (DES), also known as dry eye disease (DED), keratoconjunctivitis sicca (KCS), and keratitis
sicca, is a multifactorial disease of the tears and the ocular surface that results in discomfort, visual disturbance, and
tear film instability with potential damage to the ocular surface. [1] Dry eye syndrome is a common form of ocular
surface disease (OSD) and may overlap with other causes of OSD, such as ocular allergy and meibomian gland
dysfunction (MGD).

The ocular surface is an integrated anatomical unit consisting of 7 key interactive and interdependent components:
the tear film, the lacrimal and accessory lacrimal apparatus, the nasolacrimal drainage system, the eyelids, the
bulbar and tarsal conjunctiva, cranial nerve V, and cranial nerve VII. [2] Abnormalities or deficiencies in any of the 7
ocular surface components may worsen dry eye syndrome, yet promise opportunities for effective therapeutic
intervention.

The image below depicts the ocular surface anatomy.

Eye tear system anatomy, (Description) a. tear gland / lacrimal gland, b. superior lacrimal punctum, c. superior
lacrimal canal, d. tear sac / lacrimal sac, e. inferior lacrimal punctum, f. inferior lacrimal canal, g. nasolacrimal canal.
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Dry eye syndrome may be subdivided into 2 main types as follows:

Dry eye syndrome associated with Sjgren syndrome (SS)

Dry eye syndrome unassociated with SS (non-SS KCS)

Dry eye syndrome can also be subdivided into pure aqueous deficiency dry eye and evaporative dry eye. [3] Eighty-
six percent of patients with dry eye syndrome also have signs of meibomian gland dysfunction.

Signs and symptoms

The following are the most common complaints associated with dry eye syndrome:

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 Foreign-body sensation and ocular dryness and grittiness

Hyperemia

Mucoid discharge

Ocular irritation

Excessive tearing (secondary to reflex secretion)

Photophobia

Fluctuating or blurry vision

See Clinical Presentation for more detail.

Diagnosis

Studies that may be used for diagnosis include the following:

Vital staining of corneal and conjunctival epithelium with fluorescein, lissamine green, or rose bengal

Tear film osmolarity

Ocular surface matrix metalloproteinase 9 (MMP-9)

Measurement of tear breakup time (TBUT)

The Schirmer test

Tear meniscus height

Quantification of tear components through analysis of tear proteins

Impression cytology to monitor progression of ocular surface changes

Additional tests that may be used in a research workup include:

The tear stability analysis system (TSAS)

The tear function index (TFI; Liverpool modification)

The tear ferning test (TFT)

Criteria for a diagnosis of dry eye syndrome associated with Sjgren syndrome (SS) include the following:

Abnormally low Schirmer test result

Objective evidence of low salivary flow

Biopsy-proven lymphocytic infiltration of the labial salivary glands

Dysfunction of the immune system, as manifested by the presence of serum autoantibodies (eg, antinuclear
antibody [ANA], rheumatoid factor [RF], and anti-Ro [SS-A] and anti-La [SS-B] antibodies)

See Workup for more detail.

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Management

Early detection and aggressive treatment of dry eye syndrome, or keratoconjunctivitis sicca (KCS), may help prevent
corneal ulcers and scarring.

Pharmacologic therapy

Lubricating supplements are the medications most commonly used to treat dry eye syndrome. Agents that have
been used to treat dry eye syndrome include the following:

Artificial tear substitutes

Gels, emulsions and ointments

Topical anti-inflammatory agents: Topical cyclosporine, [4, 5] topical corticosteroids

Topical or systemic omega-3 fatty acids: Omega-3 fatty acids inhibit the synthesis of lipid mediators and block
the production of interleukin (IL)1 and tumor necrosis factor alpha (TNF-)

Topical or systemic tetracyclines

Secretagogues: Diquafosol, which is approved in Japan [6, 7] but not in the United States

Topical hyaluronic acid, which is also approved in Japan [8]

Autologous or umbilical cord serum

Systemic immunosuppressants

Therapeutic eyewear

Specially made glasses known as moisture chamber spectacles, which wrap around the eyes to retain moisture and
protect against irritants, may be helpful in some cases of dry eye syndrome. Therapeutic contact lenses may also be
helpful.

Surgical intervention

Punctal plugs are often used in the treatment of dry eye syndrome. Available types include the following:

Absorbable plugs

Nonabsorbable plugs

Thermoplastic plugs

Hydrogel plugs

Other advanced or surgical options include the following:

Sealing of the perforation or descemetocele with corneal cyanoacrylate tissue adhesive

Corneal or corneoscleral patching for an impending or frank perforation

Lateral tarsorrhaphy - Temporary tarsorrhaphy (50%) is indicated in patients with dry eye syndrome
secondary to exposure keratitis after facial nerve paralysis and after trigeminal nerve lesions that give rise to
dry eye syndrome secondary to loss of corneal sensation
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 Conjunctival flap

Conjunctivoplasty excision of symptomatic conjunctivochalasis

Surgical cautery occlusion of the lacrimal drainage system

Mucous membrane grafting

Salivary gland duct transposition

Amniotic membrane transplantation or amniotic membrane contact lens therapy

Prosthetic replacement of the ocular surface ecosystem (PROSE) lens therapy

See Treatment and Medication for more detail.

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