"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 the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface" (DEWS, 2007). Dry eye represents a disturbance of the lacrimal functional unit (LFU), an integrated system comprising the lacrimal glands, ocular surface (cornea, conjunctiva, and meibomian glands), and eyelids, as well as the sensory and motor nerves that connect them Its overall functions are to preserve tear-film integrity: lubricating, antimicrobial, and nutritional roles ocular surface health: maintaining corneal transparency and surface stem cell population quality of image projected onto the retina MECHANISM OF DRY EYE
The core mechanisms of dry eye are driven by tear
hyperosmolarity and tear-film instability Tear hyperosmolarity causes damage to the surface epithelium by activating a cascade of inflammatory events at the ocular surface and release of inflammatory mediators into the tears Epithelial damage involves cell death by apoptosis, a loss of goblet cells, and disturbance of mucin expression leading to tear-film instability The instability of tear film exacerbates oculer surface hyperosmolarity and completes the vicious cycle. Tear-film instability can also be initiated by several etiologies : Xerosing medication Xerophthalmia Ocular allergy Topical preservative use Contact lens wear TEAR-FILM EVALUATION
The best approach is to combine information from the
history and examination with the results of one or more of the fo llowing diagnostic tests. Inspection Signs of associated systemic disease (rheumatoid arthritis) Indications of personal habits (smoking) Signs of associated ocular disease (pseudoptosis, blepharospasm) Characteristic facial telangiectasia & eyelid margin hyperemia associated with ocular rosacea Tear meniscus between the globe and the lower eyelid (normally 1.0 mm in height and convex) Tear breakup is a functional measure of tear stability; if stability is perturbed (as in lipid or mucin deficiency), the tear breakup time (TBUT) can become more rapid Tear Breakup Time (TBUT) The examiner moistens a fluorescein strip with sterile saline and applies it to the tarsal conjunctiva (fluorescein- anesthetic combination drops are not suitable for this purpose). After several blinks, the tear film is examined using a broad beam of the slit lamp with a blue filter. The time lapse between the last blink and the appearance of the first randomly distributed dry spot on the cornea is the tear breakup time. Dry spots appearing in less than 10 seconds are considered abnormal. TBUT should be measured before any eyedrops are instilled and before the eyelids are man ipulated in any way. It is best to wait at least 1 minute after fluorescein instillation to evaluate the corneal su rface for fluorescein staining The eye should be carefully Tear-film debris Conjunctivochalasis (complain of epiphora) Floppy eyelid syndrome Multiple concretions (chronis blepharitis) TESTS OF TEAR PRODUCTION Schirmer testing is performed by placing a thin strip of filter paper in the inferior cul-de-sac. The amount of wetting can be measured to quanti fy aqueous tear production The basic secretion test is performed following the instillation of a topical anesthetic, followed by lightly blotting residual fluid out of the inferior fornix. A thin filter-paper strip (5 mm wide, 35 mm long) is placed at the junction of the middle and lateral thirds of the lower eyelids to minimize ir ritation to the cornea during the test. The test can be performed with open or closed eyes, although some recommend the eyes be closed to limit the effect of blinking. The Schirmer I test, which is si milar to the basic secretion test but without topical anesthetic, measu res both basic and reflex tearing combined The Schirmer II test, wh ich measures reflex secretion, is performed in a similar manner without topical anesthetic. However, after the filter-paper strips have been inse rted into the in ferior fornices, a cotton-tipped applicator is used to irritate the nasal mucosa. AQUEOUS TEAR DEFICIENCY
Definiton : decreased aqueous tear production, as
measured by Schirmer testing, pattern of conjunctival &/ corneal staining with lissamine green or rose bengal, corneal staining by fluorescein, and filamentary keratopathy Symptoms Burning, photophobia, dry sensation, blurred vision, foreign body sensation Signs : Conjunctival hyperemia, conjunctivochalasis, decreased tear meniscus, iregular corneal surface, debreis in tear-film Epithelial keratopathy Filaments & mucous plaques , filamentary keratopathy, marginal or paracentral thinning & perforation corneal (more severe dry eye states) EVAPORATIVE TEAR DYSFUNCTION Increased tear-film evaporation is most commonly caused by MGD but may also be caused by disease of the meibomian glands, poor apposition of the eyelids to the ocular surface, increase of the palpebral aperture, and contact lens wear. Symptoms consist of burning, foreign-body sensation, redness ofthe eyelids and conjunctiva, filmy vision, and recurrent chalazia. Signs of ETD include decreased TBUT, MGD, abnormal aqueous tear production, and a characteristic linear pattern of rose bengal/lissamine green staining of the inferior conjunctiva and cornea and eyelid margin. MEIBOM GLAND DYSFUNCTION Meibom Gland Dysfunction Terjadi akibat obstruksi progresif lubang kelenjar meibom karena keratinisasi. Sehingga ada penurunan lapisan lipid permukaan mata dan peningkatan inflamasi pada kelopak yang ditandai : Hiperemia tepi kelopak dan konjungtiva tarsal Sekresi meibom bisa jernih, keruh atau kental. Lubang kelenjar meibom tertutup plug dan terletak lebih ke posterior akibat terbentuk sikatrik pada tepi kelopak dan tarsal Patogenesis Tjd obstr/hiposekresi akibat penyakit blefaritis anterior, rosacea acne, pemfigoid Non obstr/ hipersekresi akibat meibomian seborrhea Pasien MGD akan menjadi defisiensi air mata lipid yang akan menyebabkan instabil lapisan air mata, peningkatan penguapan tear film, dan peningkatan osmolaritas air mata Gejala & tanda Terasa terbakar/panas Sensasi benda asing, merah kelopak dan konjungtiva Filmy vision Kalazion rekuren Inflamasi tepi posterior kelopak mata, konjungtiva dan kornea Telangiectasi (brush marks) pada tepi anterior-posterior Plug putih protein keratin menutupi lubang kelenjar meibom Sekresi meibom berubah warna dan viskositasnya Bila inflamasi berlangsung th, terjadi atrofi kelenjar meibom Terbentuh buih busa pada tear meniscus Rapid TBUT Bisa terjadi peradangan pd permukaan mata (konjungtivits, episcleritis, erosi epitel punctat kornea, pannus kornea, penipisan kornea) Management Eyelid hygiene (1-2x/hari), dengan cara : kompres hangat beberapa menit dilanjutkan dg Gentle massage dengan menekan sekresi meibom, diikuti dengan membersihkan dengan washcloth, cotton ball, atau pad Shampo noniritasi atau pengenceran cairan sodium bicarbonat (1 sdt dalam 0,5 liter air mendidih) Antibiotika topikal Tetrasiklin sistemik 250 mgx4/hari untuk 3-4 minggu pertama, bila membaik dosis diturunkan 250-500 mg/hari. Atau Doxycyclin 100 mg dan minocyclin 50 mg diberikan 2x/hari utk 3-4 minggu, ditaper 50-100 mg/hari Eritromisin bila anak2 atau alergi tetrasiklin dan doxycyclin Pengobatan ini tujuannya utk mengontrol bukan menyembuhkan penyakitnya Steroid topikal diperlukan bila inflamasinya sedang smp berat, terutama bila ada infiltrat kornea dan vaskularisasi Omega 3 TERIMA KASIH