DRY EYE SYNDROME o The mucus layer helps spread the watery layer over

the eye’s surface, keeping it moist. Without mucous,

Vic Santos, MD tears would not stick to the eye. Mucus is made in
the conjunctival goblet cells.

ANATOMY OF THE EYE Doc (record): The tears are not just composed of water. It is a
trilaminar fluid layer. We have the closest to the cornea which is the
mucinous layer produced by the conjunctival goblet cells. The middle
layer, the watery portion is produced by the lacrimal glands and
accessory glands. The most superficial is the oily layer produced by the
meibomian glands.

Doc (record): The lacrimal gland located at the lateral, temporal portion
of orbit. The conjunctival goblet cells which line the whole palpebral
conjunctiva. When we say palpebral and bulbar conjunctiva, the bulbar
conjunctiva aligns with the eyeball, and the palpebral conjunctiva lines
up the eyelids. The blinking mechanism causes about a suction
mechanism which drains the tears into the punctum.

DRY EYE SYNDROME

Doc (record): This is the basic anatomy of the eye. We have here
the eyelid, the eyelashes, and the glands. Our topic today is Dry Eye
Disease. However, you will note that the tears also has a drainage. Part of
the discussion is tearing. Know the physiology. It is produced by different
glands in the eye and it has a drainage which goes into the hole into the
lid margin known as the punctum, then goes into the lacrimal duct and Doc (record): We blink to about 10-15 times per minute.
then exits into the nose.
If there is a blockade from inflammation, fibrosis, or infection,
the blockade will cause a back flow causing the eyes to tear up. That is DRY EYE SYNDROME
called EPIPHORA.
• Group of disorders of the tear film that are due to reduced tear
NORMAL PHYSIOLOGY OF TEARS production or excessive tear evaporation, associated with
ocular discomfort and/or visual symptoms and possible disease
• When you blink, a film of tears spreads over the eye. This keeps of the ocular surface.
the eye’s surface smooth and clear.
• The tear film is made of three layers • Dry eye is a frequent cause of ocular irritation that leads
o The oily layer makes the tear surface smooth and patients to seek ophthalmologic care, while these symptoms
keeps tears from drying up too quickly. This layer is often improve with treatment, the disease usually is not
made in the eye’s Meibomian glands. curable, which may be a source of patient and physician
o The watery layer makes up most of what we see as frustration.
tears. This layer cleans the eye, washing away
particles that do not belong in the eye. This layer
comes from the lacrimal glands in the eyelids.

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Impact of Dry Eyes • Decreased tear secretion and clearance initiates an
• Difficulty with activities of daily living inflammatory response on the ocular surface that involves both
- reading soluble and cellular mediators
- driving
• Loss of work productivity
• Quality of life decrease SYMPTOMS OF DRY EYES
- chronic debilitating symptoms
- anxiety and depression • Burning
• Management cost • Stinging
• Itching
Doc: The impact of dry eyes will always have blurring of vision like a • Tearing
windshield in the rain that doesn't get wiped or a dried-up with full of • Sandy or gritty feeling
dust instead of being cleaned. You'll have trouble reading and driving. You • Scratchy or foreign-body sensation
have loss of work productivity and overall, it is a major cause of • Discharge
discomfort. • Frequent blinking
• Mattering of the eyelashes (usually worse upon waking)
RISK FACTORS FOR DRY EYE DISEASES • Redness
• Blurry or fluctuating vision (made worse when reading,
computer, watching television, driving or playing video games)
• Light sensitivity
• Eye pain and/or headache
• Heavy eyelids
• Eye fatigue

Doc: Majority will be discomfort, blurring of vision, itchiness and dry eye
sensation.

VICIOUS CYCLE OF DRY EYE SYNDROME

Doc: More at risk is the female gender because of the lack of testosterone
which is associated with tear production. The older the person, tear
production will be less. Hormonal deficiency which is also associated with
the female sex and menopause. We also have systemic diseases Such as
sjogren, rheumatoid and grave’s disease. Diabetes mellitus and infection
and a lot of medication use. Any of ophthalmic surgery can cause about
dry eyes also such as cataract and glaucoma surgery. We also have
nutritional deficiency cause about by lack of vitamin A and lack of omega-
3 fatty acid.

PATHOGENESIS

The ocular surface and tear-secreting glands function as an integrated

unit. Damage or dysfunction leads to an unstable and poorly maintained
film that causes ocular irritation symptoms and possible damage to the
ocular surface epithelium. MAIN SUBTYPES OF DRY EYE DISEASE /
DYSFUNCTIONAL TEAR SYNDROME
Doc: The basic symptom is deficiency in tear production which causes
dryness, which causes inflammation, and the inflammation causes Aqueous Tear Deficiency
decreased production in tears. It is essentially a vicious cycle. • Lacrimal gland dysfunction
• Neurotrophic corneas
• Sjogren syndrome
DYSFUNCTION MAY DEVELOP FROM

• Aging Blepharitis/ Meibomian Gland dysfunction

• Decrease in supportive factors (such as androgen hormones) • Anterior/ Posterior Blepharitis
• Systemic inflammatory disease (such as Sjogren syndrome or
rheumatoid arthritis)
• Ocular surface disease (herpes simplex virus [HSV] keratitis) Goblet Cell/ Mucin Deficiency
• Surgeries that disrupt the trigeminal afferent sensory nerves • Steven-Johnson syndrome
(e.g., LASIK) • Vitamin A deficiency
• Systemic diseases or medications that disrupt the efferent • Contact lens wear
cholinergic nerves that stimulate tear secretion • Thermal and chemical injuries

WHISKY, SWIRLY DRY EYE SYNDROME OPHTHA ROTATION 2 | 7

Exposure related
• Bell’s Palsy
• Parkinson’s disease
• Ectropion
• Lagophthalmos
• “Focus” activities

Co-conspirators
• Medicamentosa
• Ocular allergy
• Mucus fishing syndrome
• Conjunctivitochalasis
• Floppy eyelid syndrome

QUESTIONNAIRES

OCULAR SURFACE DISEASE INDEX (OSDI)

• Used to assess the symptoms of ocular irritation in dry eye

disease and how they affect functioning related to vision
• 12-item questionnaire assesses dry eye symptoms and effects it
has on vision-related function in the past week of the patient’s
life
• The questionnaire has 3 subscales:
• Ocular symptoms
• Vision-related function, and
• Environmental triggers

• The OSDI limits itself by assessing a small variety of dry eye

symptoms including sensitivity to light, grittiness, and pain. The
questionnaire lacks different symptoms such as tearing and
foreign body sensation. The lack of these fields makes the
questionnaire less accurate in assessing specific symptoms that
the patient may describe
DIAGNOSTIC TEST
• The OSDI has demonstrated good specificity (0.83) and a
moderate sensitivity (0.60) when distinguishing between
• Evaluation of the face and eyelids, blinking patterns, eyelid
patients with dry eye disease and normal subjects.
margins, eyelashes, conjunctiva, cornea and tear film
o Tear Break Up Time (TBUT)
▪ Function of dry spots caused by
IT IS A SUBJECTIVE MEASUREMENT
withholding the blink
o Ocular surface staining (Fluorescein sodium, Rose
Bengal, Lissamine green)
▪ Dry spots by certain dyes in cornea
o Schirmer test
▪ Amount of tears in mm by the spread of
OTHER QUESTIONNAIRES FOR DRY EYE DISEASE
wetness in the litmus paper
o Tear Osmolarity (TearLab Osmolarity System)
• 5-item Dry Eye Questionnaire (DEQ-5)
▪ More advanced, amount of solutes in the
• McMonnies questionnaire (MQ)
tears
• Impact of Dry Eye Institute Visual Function Questionnaire-25
o Tear Film Interferometry
(NEi-VFQ-25)
o Keratograph
• Standardized Patient Evaluation of Eye Dryness (SPEED)
▪ Measurement of tear spread in cornea
Questionnaire
o HD Analyzer
• Symptom Assessment in Dry Eye (SANDE)
▪ Effect of dry eyes into the vision

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TEAR BREAK UP TIME (TBUT) OCULAR SURFACE STAINING

• It checks tear film instability FLUORESCEIN SODIUM

• The proper method of TBUT testing is using a fluorescein- • Fluorescein dye is the most commonly used stain in
impregnated strip wet with non-preserved saline solution ophthalmology. Areas in which the corneal or conjunctival
• The dye is distributed by blinking, and the patient is then asked surface epithelial cells are loos or desquamated will stain with
to stare straight ahead without blinking fluorescein
• The tear film is observed under the cobalt blue light of a slit
lamp, and the time between the last blink and the appearance
of the first dry spot or hole in the tear film is measure and
equal to the TBUT
• Normal subjects show variability in TBUT, although 10 seconds
is the typical cutoff between normal and abnormal results and
has been found to be relatively specific in screening patients for
tear film instability. LISSAMINE GREEN
• Lissamine green has similar staining characteristics but is much
better tolerated than Rose Bengal. Lissamine green is also
available in dye-impregnated paper strips

Staining is devitalized areas

ROSE BENGAL
• Rose Bengal is more sensitive for conjunctival staining, but also
more difficult to visualize and less well tolerated compared to
fluorescein. Rose Bengal stains devitalized epithelial cells that
lack a healthy mucin coating. It is applied using a dye-
impregnated paper strip.
SCHIRMER TEST • In aqueous tear deficiency, the interpalpebral conjunctiva is
the most common location for Rose Bengal staining
• It is performed by placing a paper test strip in the lateral third • The severity of staining has been shown to correlate with the
of the lower eyelid after drying the inferior fornix and then degree of aqueous deficiency, tear film instability, and reduced
measuring the length of the moistened portion of the strip mucin production by conjunctival goblet and epithelial cells
after 5 minutes
• The Schirmer I test is performed without anesthesia and thus
measures reflex tearing
• The Schirmer II test also lacks anesthesia but is done following
nasal stimulation
• “Schirmer with anesthesia” is also commonly performed and
measures basal tear secretion
• The Schirmer test is often criticized for its variability and poor
Devitalized epithelial cells will stain red.
reproducibility
• It is most useful in the diagnosis of patients with severe
aqueous deficiency, but is relatively insensitive for patients
VAN BIJSTERVELD OCULAR DYE SCORE
with mild dry eye

Anything above 10mm is considered normal

Measure of dry eye disease based on the dryness pattern.

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TEAR OSMOLALRITY (TEARLAB OSMOLARITY SYSTEM) KERATOGRAPH 5M

Will show the different areas of dryness.

Right lower frame: meibomiography

Similar to schirmer’s test, only this one measures the amount of solutes. A • Keratography 5M combines corneal topography and dry eye
HYPEROSMOLAR tear will connote dry eyes, whereas a low analysis in one machine. The machine uses Placido disc
osmolarity/HYPOOSMOLAR will show a normal tear production. illumination to make measurements of the ocular surface, and
More reliable than the tear film, which can be altered by humidity and different colors of light emitting diodes (LEDS) are used
reaction of eye to the irritation of the paper. depending on the application
• The Keratograph 5M offers Meibo-Scan for meibography of the
TEAR OSMOLARITY upper and lower eyelid to check for Meibomian Gland
• Patients with dry eye disease have been found to have elevated Dysfunction (MGD), TF-Scan for evaluation of the tear film
tear film osmolarity (TFO). Tear hyperosmolarity can induce break-up time, and R-Scan for automatic bulbar redness
tear film instability by modifying the interaction between tear classification.
film lipids and proteins, damaging the epithelial cell
membranes, triggering inflammation and stimulating corneal
nerves ASSESSMENT RESULTS
• Tear osmolarity can be determined easily in the office using the
point of care TearLab Osmolarity System (TearLab, San Diego,
CA), which measures the osmolarity of a 50-nL tear sample.
Normal values are considered to be 296±9.8 mOsm/L.
• Greater than 308 mOsm/L is considered to indicate at least
mild dry eye and has been demonstrated to serve as an early
indicator of ocular surface instability.
• The test is performed by placing the tip of the handheld device
at the lateral tear meniscus and then docking the sampler into
the reader
• The device contains a gold-plated microchip that measures
electrical impedance in the sample and displays the osmolarity
measurement within seconds

TEAR FILM INFEROMETRY

Corneal mapping of the non-invasive TBUT. Non-invasive because nothing
is put to the eye, which can alter the results.
That’s what we do in different types of dyes, we put in anesthetic and
there’s no reaction, but then we put in a paper, and that will cause
alteration in the actual surface of the cornea.

Measures the blockade in the meibomian gland. The gray spots, is the
meibomian gland drop-out or the blockade.

• This technique permits determination of the thickness of the

superficial lipid layer that floats upon the normal tear film and
of the fluid layer that covers the anterior surface of contact This is the tear meniscus level. There is a fluid level: if too low, it is an
lenses. indicator of dry eyes.
• In general, these thickness estimates have been based upon
the general hue (color) of the reflected interference patterns

WHISKY, SWIRLY DRY EYE SYNDROME OPHTHA ROTATION 5 | 7


Showing different degrees of blockade
LEFT MOST: normal
RIGHTMOST: most abnormal
HD ANALYZER
A measurement of a high
order aberration. It will
show the effect of dry
eyes on the vision based
on the concept of ocular
scatter index. The ocular
scatter index is a
measurement that shows
the quality of vision. This
is more accurate than
the traditional Snellen’s
test.
It shows stability of the vision after the patient holds the blink or holds
the stare. If the vision or quality of vision doesn’t change, we can deduct
that the patient has no problem with dry eyes. However, if the vision
changes, there is the effect of dry eyes.
WHISKY, SWIRLY DRY EYE SYNDROME
MANAGEMENT
MANAGEMENT BASED ON PATHOPHYSIOLOGY
Doc: How do we manage dry eyes? The simplest answer is replacement –
artificial tears. Though there are subtleties in the prescription of
lubricants. Most are OTC, believed not to cause serious side effects.
However, because of the way they are prescribed – liberally, in other
words, if it’s a good enough lubricant, you don’t have to worry about
overdose. You can put it as often as you want based on the symptoms you
are feeling. However, if you are a bit obsessive compulsive, it can form
into a habit of dry eye, blinking, and putting drops – which is
counterproductive. They are OTC because they are relatively cheaper,
laden with preservatives to keep bottles in stock. However, the
preservatives can cause irritation and dry eyes as well. Now, you’re
hooked in the vicious cycle of buying lubricants because there is
something in the lubricant causing dry eyes as well. So, when you buy,
make sure it is preservative free and appropriate to your condition. Also,
there is a degree of severity where you give the appropriate type of
lubricant.
• Adding Tears
o Using artificial tears
o Use preservative-free tears if patient is allergic
• Conserving Tears
o Blocking the tear ducts
o Tiny silicone or gel plugs (punctal plug) may be
inserted in the tear ducts
Blocking the punctum
to have an intentional
epiphora to dry eyes.
• Increasing your tears
o by using a special eyedrop medication
• Treating dry eye culprits
o prescription eye drops or ointments
▪ ointment if a very severe meibomian gland
dysfunction
▪ gel-like so that it stays longer in the eye
o warm compresses on the eyes
o massaging your eyelids
o certain eyelid cleaners
▪ can release the blockade
OPHTHA ROTATION 6 | 7
 • Dry Eye Prevention CATEGORIES OF DRY EYE TREATMENTS
o try not to use a hair dryer, if possible
o stay away from very warm rooms Type of Therapy Treatment
o in the winter, add moisture to the air with the Environmental/ • Education and Environment modifications* (eg
humidifier. Or put a pan of water near your heater or Exogenous humidifier)
radiator • Elimination of offending topical and/or systemic
o protect your eyes from drying wind by wearing wrap- medications
around glasses outside Medication
o talk to your ophthalmologist about adding omega-3 Topical • Artificial tear substitutes; gels/ointments*
fatty acids for dry eye relief. They are found naturally • Anti-inflammatory agents (topical cyclosporine
in oily fish (such as tuna, salmon, sardines, tuna, and corticosteroids)
trout, and anchovies), and in flaxseeds. Omega-3 • Mucolytic agents
fatty acids can be added as a dietary supplement (pill • Autologous serum tears
or tablet). Systemic • Omega 3 fatty acids*
o Use artificial tear ointment or thick eye drops just • Tetracyclines* (for meibomianitis, rosacea)
before you go to bed to prevent waking up with dry • Systemic anti-inflammatory agents
and scratchy eyes.
Surgical • Punctal plugs
• Permanent punctal occlusion
* If you are fond of devices, especially in the pandemic, you tend to look
• Tarsorrhaphy*
at the devices from much longer time, and the blink rate diminishes. You • Repair of eyelid (malpositions or exposure)*
are staring at the screen for a long time – you will have symptoms of dry
• Mucus membrane, amniotic membrane
eyes. Rest and put on some lubricant. transplantation
Other • Eyelid therapy (warm compress and eyelid
hygiene)*
• INTENSED PULSED LIGHT
• Contact lenses
o The light is absorbed by the blood vessels, it
• Moisture chamber spectacles*
generates heat in the dermal layer that melts the
* Particularly helpful for increased evaporative loss
secretions and opens the glands
o The absorption of light and thermal action inside the
Data from Pflugfelder SC (Chair). Management and Therapy
blood vessels result in vasoconstriction to the vessel
Subcommittee of the International Dry Eye Workshop. Management and
endothelial lining, hence it decreases the
Therapy of dry eye disease: report of the Management and Therapy
inflammatory cytokines that contribute to
Subcommittee of the International Dry Eye Workshop (2007). Ocul Surf
Meibomian gland dysfunction
2007;5:163-78.

First one is topical medications.

Secretagogue – which not only replaces but pumps up the tears. One
brand – Diquas by Santen.

Anti-inflammatory agents like steroids with the provision that you

monitor the patient for adverse effect.

Topical interferon which aids in inflammation. Surgical – punctal plug.

Tarsorrhaphy – in cases of patient who cannot blink their eyes.

Gel-like usually reserved for severe dry eyes

*********END OF LECTURE*********

Heat and massaging function of meibomian gland, which helps in the Reference: PPT and lecture video
production of the oily layer of tear film.

If you notice the meibomian graph, if you see a lot of drop out, we
recommend this. The results are quite dramatic – you have subjective
feelings of relief and there is an objective measurement in the meibomian
graph, that some meibomian glands are liberated.

Lower left pic: The white is the patch of the eye. Because we do not want
any retinal toxicity. The arrow is where the light pulse is applied. About 5
applications in the lower eyelid is done. It causes liberation of the
gland/block.

WHISKY, SWIRLY DRY EYE SYNDROME OPHTHA ROTATION 7 | 7