University of missan

College of medicine

Depardement of opthalmology
5th stage

Dry eye

Supervised by:Dr.Hassan Abd_Almeer

:Prepared by ‫نور الهدى رحيم جبار حسن‬

:INTRODUCTION

Dry eye occurs when there is inadequate tear volume or function

resulting in an unstable tear film and ocular surface disease. It is

an extremely common condition, particularly in postmenopausal

women and the elderly.

Dry eye disease is a multifactorial disease of the ocular surface

and tear film accompanied by increased osmolality of the tear film and
inflammation of the ocular surface.

•Keratoconjunctivitis sicca (KCS) refers to any eye with some degree of dryness.

• Xerophthalmia describes a dry eye associated with vitamin A

deficiency.

• Xerosis refers to the extreme ocular dryness and keratinization

that occurs in eyes with severe conjunctival cicatrization.

• Sjögren syndrome is an autoimmune inflammatory disease of which dry eyes is

a feature.

•it's prevalence about 10_30% depending on society and environment .

Physiology :
Tear film constituents

The tear film has three layer:

• Lipid layer secreted by the meibomian glands.

• Aqueous layer secreted by the lacrimal glands.

• Mucous layer secreted principally by conjunctival goblet cells.

The constituents are complex, with as many as a hundred distinct protein
identified.

Spread of the tear film:

The tear film is mechanically distributed over the ocular surface

through a neuronally controlled blinking mechanism. Three

factors are required for effective resurfacing of the tear film:

1• Normal blink reflex.

2• Contact between the external ocular surface and the eyelids.

3• Normal corneal epithelium.

Three layer of tear film

_Regulation of tear film components:

• Hormonal

○ Androgens are the prime hormones responsible for regulation of lipid

production.

○ Oestrogens and progesterone receptors in the conjunctiva

and the lacrimal glands are essential for the normal function of these tissues.

• Neural via fibres adjacent to the lacrimal glands and goblet

cells that stimulate aqueous and mucus secretion.

Classification:
The classification of dry eye usually applied is that of the 2007

International Dry Eye Workshop (DEWS), with a basic division

into aqueous-deficient and evaporative types. Most individuals

have considerable overlap between mechanisms and it is important to be aware

during patient assessment of the likely presence of multiple contributory factors.

1.Aqueous layer deficiency :

A.Sjogren syndrome

B.Non_Sjogren dry eye .

○ Lacrimal deficiency: primary (e.g. age-related dry eye,

congenital alacrima, familial dysautonomia) or secondary

(e.g. inflammatory and neoplastic lacrimal gland infiltration, acquired

immunodeficiency syndrome (AIDS), graftversus-host disease, lacrimal gland or
nerve ablation).

○ Lacrimal gland duct obstruction, e.g. trachoma, cicatricial

pemphigoid, chemical injury, Stevens–Johnson syndrome.

○ Reflex hyposecretion: sensory (e.g. contact lens wear, diabetes, refractive

surgery, neurotrophic keratitis) or motor

block (e.g. seventh cranial nerve damage, systemic drugs).

2.Evaporative :

1.Intrinsic

○ Meibomian gland deficiency, e.g. posterior blepharitis,

rosacea.

○ Disorders of lid aperture, e.g. excessive scleral show, lid

retraction, proptosis, facial nerve palsy.

○ Low blink rate, e.g. Parkinson disease, prolonged computer monitor use,
reading, watching television.

○ Drug action, e.g. antihistamines, beta-blockers, antispaspmodics, diuretics.

2. Extrinsic

○ Vitamin A deficiency.

○ Topical drugs including the effect of preservatives.

○ Contact lens wear.

○ Ocular surface disease such as allergic conjunctivitis.

Sjogren syndrome
•Primary:it is characterized by autoimmune inflammation and destruction of
lacrimal and salivery gland .

•secondary:associated with other diseases such as rheumatoid arthritis,

SLE,systemic sclerosis,and other connective tissue diseases
 Clinical features of dry eye

Symptoms: the most common symptoms are feeling of dryness ,grittiness

and burning that characteristically worsen during the day associated with stringy
mucoid discharge and redness ,Lack of emotional tear is uncommon .

Signs:that move with each blink…thin marginal tear meniscus or absent…froth

in the tear film or along the eyelid margin…punctate epithelial erosions that
stained with flourescein…filaments of mucous strands that stained with rose
bengal.

Investigation

1.tear film break_up time :use flourescin eye and slit _lamp with
cobalt blue filter_appearance of black spots or dry areas (abnormal
if appear after10 seconds)

2.schirmer test:useNo.41 what man filter paper and it can be

performed with or without topical anesthesia then measure of
wetting after 5 minutes (abnormal if 10mm without anesthesia)

3.ocular surface staining :use fluroescein and rose Bengal eyes

(staining of inter-palperbal area )

Treatment

Level1
.Education and environmental /dietary modification Dry eye is generally curable
.lifestyle review including the importance of blinking whilst reading watching
television or using a computer screen and the management of contact lens
wears .environmental review e.g. increasing humidity .caution the patient that
last refractive surgery can exacerbate dry eye.
 Level 2
1.Non_preserved tear substitute 2.Anti _inflammatory agent 3.Tetracyclines
4.punctal plug 5.secretogogues 6.Moisture chamber spectacles and spectacles
side shields

Level 3
1.serum eye drops 2.contact lens 3.permanent punctual occlusion

Level 4
1.systemic anti_inflammatory agent 2.surgery such as tarsorrhaphy

Referance
Kanski & bowling seventh edition2011

Kanski clinical opthalmology ninth edition