THE DRY EYE

The dry eye per se is not a disease entity, but a

symptom complex occurring as a sequelae to
deficiency or abnormalities of the tear film.

Dry eye occurs when there is inadequate tear volume or function

resulting in an unstable tear film and ocular surface disease.
1 Keratoconjunctivitis sicca (KCS) refers to
any eye with some degree of dryness.

2 Xerophthalmia describes a dry eye associated with

vitamin A deficiency.

3 Xerosis refers to the extreme ocular dryness and keratinization

that occurs in eyes with severe conjunctival cicatrization.
4 Sjögren syndrome is an autoimmune inflammatory
disease of which dry eyes is a typical feature
 The lacrimal apparatus comprises
(1) Main lacrimal gland,
(2) Accessory lacrimal glands, and
(3) Lacrimal passages, which include:
Puncta,
Canaliculi,
Lacrimal sac and
Nasolacrimal duct (NLD)
Physiology of the lacrimal drainage system
Functions of tear film
* Keeps the cornea and conjunctiva moist.
* It provides oxygen to the corneal epithelium.
* Washes away debris and noxious irritants.
* Prevents infection due to presence of antibac-terial
substances.
* Facilitates movements of the lids over the globe
Dry eye (known by doctors as keratoconjunctivitis sicca)
is a chronic lack of sufficient lubrication and moisture in
the eye.

Its consequences range from subtle but constant irritation

to ocular inflammation of the anterior (front) tissues of the
eye.
The dry eye symptom complex occurring as a sequelae to
deficiency or abnormalities of the tear film.
Etiology
1. Aqueous tear deficiency. known as keratoconjunctivitis
sicca.
It is seen in conditions
Congenital alacrimia,
Paralytic hyposecretion,
Primary and Secondary Sjogren’s syndrome, and
Idiopathic hyposecretion.
2. Mucin deficiency dry eye.
It occurs when goblet cells are damaged,
as in hypovitaminosis A
(xerophthalmia) and
conjunctival scarring diseases
Stevens-Johnson syndrome,
Trachoma,
Chemical burns,
Radiations and
Ocular pemphigoid.
3. Lipid deficiency and abnormalities.
Lipiddeficiency is extremely rare.
congenital anhydrotic ectodermal dysplasia along with
absence of meibomian glands.
Lipid abnormalities are quite common in patients with
Chronic blepharitis and
Chronic meibomitis.
4. Impaired eyelid function.
Bell’s palsy,
Exposure keratitis,
Dellen,
Symblepharon,
Pterygium,
Nocturnal lagophthalmos and
Ectropion.
5. Epitheliopathies.
The corneal surface and tear film,
alterations in corneal epithelium affect the stability
of tear film.
Clinical features
* Irritation,
* Foreign body (sandy) sensation,
*Feeling of dryness,
*Itching,
*Non-specific ocular discomfort and
*Chronically sore eyes not responding to a variety of
drops instilled earlier.

Signs of dry eye include:

Presence of stringy mucus and particulate matter in the
tear film,
* Lustureless ocular surface,
*Conjunctival xerosis, reduced orAbsent marginal tear stripa
* Corneal changes in the form of punctate epithelial erosions
and filaments
1. Tear film break-up (BUT).
It is the interval between a complete blink and appearance
of first randomly distributed dry spot on the cornea.
It is noted after instilling a drop of fluorescein and examining in a
cobalt-blue light of a slit-lamp.
BUT is an indicator of adequacy of mucin component of tears.
Its normal values range from 15 to 35 seconds.
Values less than 10 seconds imply an unstable tear film.
2. Schirmer-I test. It measures total tear secretions.
The patient is asked to look up and not to blink or close the
eyes After 5 minutes wetting of the filter paper strip from the
bent end is measured.
Normal values is more than 15 mm.
Values of 5-10 mm are suggestive of moderate to mild
keratoconjunctivitis sicca (KCS) and
Less than 5 mm of severe KCS.
3. Rose Bengal staining.
It is a very useful test for detecting even mild cases of KCS.
Depending upon the severity of KC three staining patterns A, B
and C

‘C’ pattern represents mild or early cases with fine punctate

stains in the interpalpebral area;
‘B’ the moderate cases with extensive staining; and
‘A’ the severe cases with confluent staining of conjunctiva and
cornea
Treatment
At present, there is no cure for dry eye.
1. Supplementation with tear substitutes.
Artificialtears remains the mainstay in the
treatment of dry eye.
. Mostly available artificial tear drops contain either
* Cellulose derivatives
(e.g., 0.25 to 0.7% methyl cellulose and
0.3% hypromellose) or
* Polyvinylalcohol (1.4%).
2. Topical cyclosporine (0.05%, 0.1%) is reported to
be very effective drug for dry eye in many recent studies.

It helps by reducing the cell-mediated inflammation of the

lacrimal tissue.

3. Mucolytics, such as 5 percent acetylcystine used

4 times a day help by dispersing the mucus threads
and decreasing tear viscosity.

4. Topical retinoids have recently been reported to

be useful in reversing the cellular changes
(squamous metaplasia) occurring in the conjunctiva of dry
eye patients.
Punctal occlusion
*Punctal occlusion reduces drainage and thereby preserves
natural tears and prolongs the effect of artificial tears.
* It is of greatest value in patients with moderate to severe
KCS who have not responded to frequent use of topical
treatment.
Temporary occlusion can be achieved by inserting collagen plugs
into the canaliculi; these dissolve in 1–2 weeks.
*The main aim is to ensure that epiphora does not occur
*Following permanent occlusion.
* Initially the inferior puncta are occluded and the patient is
reviewed after 1 or 2 weeks.
*If the patient is now asymptomatic and without epiphora,
the plugs can be removed and the inferior canaliculi
permanently occluded.
•
In severe KCS both the inferior and superior canaliculi can be
plugged.
2 Reversible prolonged occlusion can be achieved with silicone
or long-acting (2–6 months) collagen plugs.

“Problems include extrusion, granuloma formation and distal

migration.”

Plugs that pass into the horizontal portion of the canaliculus

cannot be visualized and although they can usually be flushed
out with saline, if they cause epiphora this is not always
possible.
Permanent occlusion should be undertaken only in patients with
*Severe dry eye with repeated Schirmer test values of 5 mm
or less, and
*Who have had a positive response to temporary plugs
without epiphora.
*It should not be performed if possible in young patients who
may have reversible pathology.

“All four puncta should not be occluded at the same time.”

Permanent occlusion is performed following punctal dilatation

successful occlusion, it is important to watch for signs of
recanalization.

*Diode laser cautery is less effective than thermal coagulation,

with higher rates of recanalization.
by coagulating the proximal canaliculus with cautery
Contact lenses
Although long-term contact lens wear may increase tear film
evaporation,
Reduce tear flow and increase the risk of infection,
these effects can be outweighed by the reservoir effect of
fluid trapped behind the lens.

Low water content HEMA lenses may be successfully fitted to

moderately dry eyes.

Silicone rubber lenses that contain no water and readily transmit

oxygen are effective in protecting the cornea in extreme tear film
deficiency,although deposition of debris on the surface of the lens
can blur vision and be problematic. The continued availability of
these lenses is in doubt.

Occlusive gas permeable scleral contact lenses provide

a reservoir of saline over the cornea.
They can be worn on an extremely dry eye with exposure.
Contact lenses
Although long-term contact lens wear may increase tear film
evaporation,
Reduce tear flow and increase the risk of infection,
these effects can be outweighed by the reservoir effect of
fluid trapped behind the lens.

Low water content HEMA lenses may be successfully fitted to

moderately dry eyes.

Silicone rubber lenses that contain no water and readily transmit

oxygen are effective in protecting the cornea in extreme tear film
deficiency,although deposition of debris on the surface of the lens
can blur vision and be problematic. The continued availability of
these lenses is in doubt.

Occlusive gas permeable scleral contact lenses provide

a reservoir of saline over the cornea.
They can be worn on an extremely dry eye with exposure.
Conservation of existing tears
*Reduction of room temperature to minimize evaporation of
tears.
*Room humidifiers may be tried but
 PTERYGIUM
Pterygium (L. Pterygion = a wing) is a wing-shaped
fold of conjunctiva encroaching upon the cornea from
either side within the interpalpebral fissure
 Etiology.

Etiology of pterygium is not definitely known.

.
Therefore, the most accepted view is that it is a
response to prolonged effect of environmental factors
such as
Living in hot climates
Exposure to sun (ultraviolet rays),
Dry heat, high wind and
Abundance of dust.
 Clinical features.
Symptoms.
*Asymptomatic condition in the early stages,
*Except for cosmetic intolerance.
* Visual disturbances corneal astigmatism due to
fibrosis- regressive stage.
*Occasionally diplopia --> limitation of EOM
Clinical features.
Signs
More common in elderly males doing outdoor work.
It may be unilateral or bilateral.
It presents as a triangular fold of conjunctiva
encroaching the cornea
*In the area of palpebral aperture,
*Usually on the nasal side,
*But may also occur on the temporal side.
*Deposition of iron ----> stocker's line.
Clinical features.
Signs
More common in elderly males doing outdoor work.
It may be unilateral or bilateral.
It presents as a triangular fold of conjunctiva
encroaching the cornea
*In the area of palpebral aperture,
*Usually on the nasal side,
*But may also occur on the temporal side.
*Deposition of iron ----> stocker's line.
Complications
* Cystic degeneration an
* Infection are infrequent.
* Rarely, neoplastic change to
Epithelioma,
Fibrosarcoma or
Malignant melanoma,
Differential diagnosis.
Must bedifferentiated from pseudopterygium.
Treatment.
Surgical excision is the only satisfactory treatment,
(1) cosmetic reasons,
(2) continued progression threatening to encroach onto the
pupillary area
(3) diplopia due to interference in ocular movements.
Recurrence of the pterygium after surgical excision
is the main problem (30-50%).
1. Transplantation of pterygium in the lower fornix
(McReynold's operation) is not performed now.
2. Postoperative beta irradiations.
3. Postoperative use of antimitotic -> mitomycin-C or thiotepa.
4. Surgical excision with bare sclera.
5. Surgical excision with free conjunctival graft
6. In recurrent recalcitrant pterygium,
Surgical excision should be coupled with
Lamellar keratectomy and lamellar keratoplasty.
Surgical technique of pterygium excision
i. In simple excision the conjunctiva is sutured back to cover the
sclera.
ii. In bare sclera technique, some part of conjunctiva is excised
and its edges are
sutured to the underlying episcleral tissue
iii. Free conjunctival membrane graft may be used to cover the
bare sclera.
This procedure is more effective in reducing recurrence.
iv. Limbal conjunctival autograft trans- plantation (LLAT) to cover
the defet after pterygium excision is the latest and most effective
technique in the management of pterygium
A. Type 1 extends less than 2 mm onto the cornea.
A deposit of iron (Stocker line) may be seen in the cornea epithelium
anterior to the advancing head of the pterygium.

B.Type 2 involves up to 4 mm of the cornea and may be primary or

recurrent following surgery

C. Type 3 encroaches onto more than 4 mm of the cornea and involves

the visual axis.

D. Pseudopterygium is caused by a band of conjunctiva adhering to an

area of compromised cornea at its apex.
Surgical technique of pterygium excision :

A, dissection of head from the cornea;

B, excision of pterygium tissue under the conjunctiva;

C, direct closure of the conjunctiva after undermining;

D, bare sclera technique–suturing the conjunctiva to the

episcleral tissue;

E, free conjunctival graft after excising the pterygium.

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