TEAR FILM & DRY EYE

DR. Dr. Winarto, SpMK, SpM(K)

Dept. Ophthalmology, Fac. of Medicine

Diponegoro University/Dr Kariadi
Hospital, Semarang
Most dynamic structure
 Role of the tear film
1. Protect the Cornea from drying
2. Maintain the refractive power of Cornea
3. Defend againts eye infection
4. Allow gas to move between the air and
avascular cornea
5. Support corneal dehydration
6. Provides the nutrients
7. Maintain the health of ocular surface
8. The tear film-air interface is the initial and
most powerful refractive surface.
9. The cornea-air interface is the strongest
diopter of the optical system (45D)
DRY EYES
 Definition

Prognosis
Aetiology

Treatment Disease Pathology

Symptom
& Sign Classification

Epidemiology
 Definition

Prognosis
Aetiology

Treatment Disease Pathology

Symptom
& Sign Classification

Epidemiology
 DEFINITION

NEI-Industry Workshop 1995 DEWS Report 2007

Dry eye is a multifactorial

Dry eye is a disorder of the
disease of the tears and
tear film due to tear
ocular surface that results in
deficiency or excessive
symptoms of discomfort,
tear evaporation which
visual disturbances, and
causes damage to the
tear instability with potential
interpalpebral ocular
damage to ocular surface. It
surface damage and is
is accompanied by
associated with symptoms
increased osmolarity of the
of ocular discomfort
tear film and inflammation of
the ocular surface
 DEFINITION

NEI-Industry Workshop 1995 DEWS Report 2007

Dry eye is a multifactorial

Dry eye is a disorder of the
disease of the tears and
tear film due to tear
ocular surface that results in
deficiency or excessive
symptoms of discomfort,
tear evaporation which
visual disturbances, and
causes damage to the
tear instability with potential
interpalpebral ocular
damage to ocular surface. It
surface damage and is
is accompanied by
associated with symptoms
increased osmolarity of the
of ocular discomfort
tear film and inflammation of
the ocular surface
PATHOLOGY

Vascular Inflammation
Infection Neoplasma
Trauma Degenerative
Autoimmune Dystrophy
Metabolic
 Conditions associated with Dry Eye

Chronic Systemic inflammation

Sjogrens Syndrome, rheumatroid arthritis, lupus
Ocular surface inflammation
Meibomian gland disease, keratitis, infection
Hormonal changes
Menopause, oral contraceptives, pregnancy, lactation
Systemic disease
Diabetes, thyroid
Environment
Smoke, air pollution, wind, heat, air-conditioning, air travel,
light, dry climate
Medications
Anti-depressants, decongestants, antihistamines,
antihypertensives, diuretics
Blink disorder
Anatomical, surgical (LASIK)
Traditional Tear Film Model Updated Tear Film Model
(3 Distinct Layers)
 Glycocalyx

Mucin Layer Corneal Epithelium

Glycocalyx

Gipson, Joyce. In Albert, Jakobiec (Eds). Principles and Practices of Ophthalmology 2002.
 How Tear Film Instability Occurs
Mucins cannot
Desiccation of Tear film destabilizes,
attach and the
the corneal increasing
water repellant
epithelial cells evaporation and
corneal
due to varied diffusion, exposing
surface is
causes the cornea
exposed

Damaged corneal cells show up

as dry spots during corneal
staining.
Damaged corneal epithelial cell
(loss of microvilli and glycocalyx)
Systane Mechanism of Action
SYSTANE has a pH of 7.0
in the bottle (liquid). Upon
contact with the pH of the
human tear (7.4), the borate
in SYSTANE crosslinks
with the polysaccharide of
the HP Guar to form a
protective network and
shield, thereby acting
similar to the glycocalyx
SYSTANE Coats the Eye
Diagnosis Of Dry Eye
 DIFFERENTIAL DIAGNOSIS

If it itches, it is allergy

If it burns, it is probaly dry eye

If the eyelids are stuck together in the

morning, it is a bacterial infection
 Clinical Features

PATIENT SYMPTOMS CLINICAL SIGNS

Dryness Hyperemia
Itchiness or scratchiness Low tear meniscus
Photophobia Tear debris
Contact lens intolerance Abnormal tear osmolarity
Burning or stinging Fast tear break up time
Foreign body sensation Conjunctival staining
Grittiness Blepharitis
Fluctuating visual acuity Increased cytokines
Tired eyes Corneal surface damage
General discomfort
 Clinical Features

Ocular Discomforts
Visual Degradation
Ocular Surface Disorders
Tear Film Instability
 Sequence of Tests

Clinical History and symptoms

Ocular surface examination
Fluorescein BUT
Ocular surface staining
Schirmer 1 (with/out anaesthetic)
Tear film break up viewed with fluorescein stain
on a patient with dry eye

0 seconds 1 seconds 2 seconds 3 seconds

4 seconds 5 seconds 6 seconds 16 seconds

Clinical Management Of Dry Eye
 Goals of Treatment
Alleviate symptoms
Improve quality of life
Improve productivity
Reduce ocular morbidity

Maximise:
benefit and relief
Minimise:
symptoms
inconvenience
cost
 Therapeutic Strategy DEWS

Tear
Lubricate,
smooth, protect
Steroids Cyclosporin
cytokines and goblet cells,
MMPS-membrane apoptosis
stability

Tetracyclines Omega 3 EFA

MMPs and cytokines cytokines,

Plugs stabilizes lipid daily

tear volume,
retain homeostatic factors

Strategy DEWS Report. Ocul Surf. 2007;5(2):163-178Steroids

 Approach to Treatment
1. Artificial tears:
Preserved vs non-preserved
2. Alternative topical Rx:
Anti-inflammatories (low dose steroids,
cyclosporine), acetylcesteine
3. Dietary changes and supplements
4. Lifestyle adjustments
5. Treat coexisting lid disease
6. Exclude and treat systemic causes
7. Surgical intervention
 Artificial Tears

Hydroxypropyl Methylellulose (HPMC)

Polyvinyl Alcohol (PVA)
Carboxyl Methylcellulose (CMC)
Glycerine Artificial Tears & Others
Eye Ointments & Gels
 New on the Market

1. Systane
Polyethylene Glycol 400 0.4% (lubricant),
Propylene Glycol 0.3% (lubricant),
Hydroxypropyl Guar (Gel forming Matrix)
Polyquaternium-1 as preservative.

2. Refresh Endura
Castor oil, polysorbate-80, Carbomer 1342 &
Glycerin Preservative Free.
 Surgical therapy of dry eyes
Primary goals:
relieve discomfort
provide a smooth optical surface
prevent structural damage to the cornea

Reserved for severe disease

or poor/non-compliance :
1. Punctal Plug
2. Surgical/Thermal/Laser occlusion of the
puncta
 Advantages:
Prolongs tear retention
Reduces frequency of artificial tears needed
for symtomatic relief

Disadvantages:
Cost
Retains inflammatory mediators
Epiphora
Infection/discomfort (Plugs)
Canalicular or NLD obstruction
Surgical therapy of dry eyes

Parotid duct translocation

Scleral contact lens

Tarsorrhaphy