Dry eye

I. What’s the dry eye ?

➔ Dry eye : is eye disorder by a reduction in tear volume or alteration in
tear composition.
➔ It is characterised by :
- Burn (េ ្ត្ក្នុង គាប់ែភ្នក) - Feel tired (េរោយ គាប់ែភ្នក)
- Itchy (រមាស់ក្នុង គាប់ែភ្នក) - Photophobia (ខ្ល្ចពន្លឺ)
- Irritated or gritty (មានអោរម្មណ៍ ចាក់ៗក្នុង គាប់ែភ្នក)
- Ocular dryness or Excessive tearing ( កញ្ចក់ែភ្នកស្ងួត ឬ េហៀរទឹកែភ្នក)
- Symptoms worsening throughout the day
- Redness
- Mucoid discharge
 Dry eye
I. What’s the dry eye ?
➔ Dry eye may be cause by :
- Increased evaporation from the eye
- Increased tear drainage
- Decrease in tear production
 Dry eye
II. How to differential diagnosis of dry eye
Question Relevance

Clarifying questions Have you had daily, persistent, troublesome dry eyes for more than 3 months?
Do you have a recurrent sensation of sand or gravel in the eyes?
A positive response to at least one of these questions would indicate dry eye syndrome

Aggravating factors Dry eye is worsened by dry air, wind, dust and smoke

Associated symptoms Normally no other symptoms are present in dry eye.

If the patient complains of a dry mouth, check for medication that can cause dry mouth

Amount of tears produced If the patient complains of watery eyes but states that the eyes are dry and sore, check
for ectropion

Other trigger differentiation - Blepharitis : Chronic disease of eyelashes, eyelids or margins of eyelids
- Sjögren’s syndrome : dryness of mouth and other mucous membranes with rheumatic
conditions
 Dry eye
III. The strategy therapeutic of dry eye

Symptomatic treatment
- Burn → Anti-inflammatory agents ( Cyclosporine or Corticosteroid)
- Itchy → Antihistamines / not use because of their side effects
- Irritated or gritty →Anti-inflammatory agents ( Corticosteroid)
- Ocular dryness or Excessive tearing → artificial eye / decrease tear

Etiologic treatment
- Increased evaporation from the eye → inhibition of water losing/Tear
Artificial (ocular lubricants, and
astringents )
- Increased tear drainage → decrease tear
- Decrease in tear production→ Increase tear production :Secretagogues
 Dry eye
IV. Pharmacotherapy of dry eye
1.Symptomatic treatment
- Burn +Itchy +Irritated or gritty → Anti-inflammatory agents
( Cyclosporine or Corticosteroid)
Drug Dose Pregnancy & breastfeeding

Cyclosporine ophthalmic - Instill 1 gtt BID in each eye ~12 hr apart - acceptable
- Or used concomitantly with artificial tears / 15-minute
interval between products

Loteprednol ophthalmic - Apply 1-2 drops into the conjunctival sac of affected - acceptable
eye(s) QID

Fluorometholone - Instill 1-2 gtt into conjunctival sac or affected eye(s) - acceptable
q6hr; may use q2hr during first 24-48 h
- Ointment: Apply 0.5 in ribbon to conjunctival sac 1-3
times daily; may increase application to q4hr during
initial 24-48hr
 Dry eye
IV. Pharmacotherapy of dry eye
2. Etiologic treatment
- Increased evaporation from the eye → Tear artificial (ocular lubricants, astringents )

Drug Dose Pregnancy & breastfeeding

Ocular lubricants/artificial tears

Tears Naturale II Dry eyes - acceptable

Dextran 70-Hypromellose - Solution: Instill 1-2 gtt into eye(s) as necessary
to relieve symptoms

Lacrisert Dry eyes - acceptable

hydroxypropyl cellulose ophthalmic - Using supplied applicator, place 1 ophthalmic
insert in each eye qDay; some patients may
require twice daily dosing
 Dry eye
IV. Pharmacotherapy of dry eye
2. Etiologic treatment
- Increased evaporation from the eye → Tear artificial (ocular lubricants, astringents )

Drug Dose Pregnancy & breastfeeding

Ocular lubricants

Clinitas Carbomer Dry eyes including keratoconjunctivitis sicca, unstable tear film - acceptable
Carbomers - Child: Apply 3–4 times a day or when required
- Adult: Apply 3–4 times a day or when required

Cellusan Dry eye conditions - acceptable

Carmellose Na - Child: Apply as required
- Adult: Apply as required

Hypromol Tear deficiency - acceptable

Hypromellose - Child: Apply as required
- Adult: Apply as required
 Dry eye
IV. Pharmacotherapy of dry eye
2. Etiologic treatment
- Increased evaporation from the eye → Tear artificial (ocular lubricants, astringents )
Drug Dose Pregnancy & breastfeeding

Ocular lubricants

Liquifilm Tears Tear deficiency - acceptable

Polyvinyl alcohol - Child: Apply as required
- Adult: Apply as required

Clinitas Dry eye conditions - acceptable

Sodium hyaluronate - Adult: Apply as required

Lacri-Lube Tear deficiency - acceptable

Liquid paraffin with white soft - Child: Apply as required, best suited for
paraffin and wool alcohols application before sleep
- Adult: Apply as required, best suited for
application before sleep
 Dry eye
IV. Pharmacotherapy of dry eye
2. Etiologic treatment
- Decrease in tear production→ Increase tear production :Secretagogues
Drug Dose Pregnancy & breastfeeding

Ocular lubricants

Diquafosol Tear deficiency - Not well establish

- Usually, instill 1 drop a time 6 times daily

Rebamipide eye drops Tear deficiency - Not well establish

- Usually, instill 1 drop three or four times a day
 Dry eye
Case study 1:
កញ្ញ្ A ចូលមក ឱសថសា្ថ្ន របស់ អ្នក ចង់បានថ្ន្ំបណ្តក់ែភ្នក េ ព្រោះគាត់ មានបញ្ហ្
េ ្ត្ក្នុង គាប់ែភ្នក
1. េតើ អ្នក តូវេធើការសន្ទនា សាកសួរពីគាត់នូវព័ត៌មានេដើម្បី េអោយដឹងពី ជំងឺែភ្នក គាត់
( diagnostic ) ?
2. េដើម្បី េអោយ បាកដ ពីមូលេហតុ ែដលបញ្ត្លេអោយ េកើតជំងឺជំងឺ Dry eye េតើ
អ្នក តូវ សាកសួរ អី បែនន្ថែមេទៀត ?
3. េតើ អ្នក តូវសួរ ព័ត៌មានអីខ្លះេទៀតេដើម្បី ដឹងពីកំរត នឹងរយៈេពល េ បើ បាស់ថ្ន្ំ ?
 Otitis
I. What’s otitis ?
➔ Refers to generalised inflammation and is often associated with infection
of ear ( external and middle)
➔ តេចៀកេហើម,ការរលាក តេចៀក, អំេបៅអំែបក
 Otitis
I. What’s otitis ?
➔ Otitis externa is characterised by :
● Ear pain (more severe in chronic and
malignant cases) ➔ Otitis externa is characterised by :
● Ear discharge ● Fever
● Hearing loss ● Irritability
● Itching (swimmer’s ear or allergic) ● Lethargy
● Burning or stinging (allergic or dermatitis) ● Anorexia
● Fever (chronic) ● Vomiting
● Pain

➔ Otitis externa may be cause by :

● Bacteria infection : Pseudomonas aeruginosa, Staphylococcus spp. and
Streptococcus pyogenes
● Fungal infection : Aspergillus niger
 Otitis externa
II. Question to ask to make sure of otitis externa ?
Question Relevance

Symptom presentation Principal symptom of acute otitis externa is itch/irritation and pain

Discharge Otitis media is the most common cause of ear discharge and is
usually mucopurulent. If discharge is present with otitis externa,
then discharge would not be mucopurulent

Systemic symptoms Otitis externa should not present with any systemic symptoms
fever and cold symptoms are often present in otitis media
In all forms of dermatitis, systemic symptoms should not be present
 Otitis externa
III. How to differential diagnosis of otitis externa ?
Question Relevance

Symptoms/signs Possible danger/ reason for referral

Generalised inflammation of the pinna Possibly indicates perichondritis

Impaired hearing in children not associated Development of glue ear

with ear wax

Mucopurulent discharge Systemically unwell Otitis media

Slow-growing growths on the pinna in elderly Possibly indicate malignancy

people
 Otitis externa
IV. The strategy therapeutic of otitis externa
Symptomatic treatment
● Ear pain and Fever → Analgesics or antipyretic
● Ear discharge→Washing
● Burning or stinging (allergic or dermatitis), Itching→anti-inflammatory

Etiologic treatment
●Bacteria infection→ ATB
●Fungal infection → antifungal
 Otitis externa
V. Pharmacotherapy of otitis externa
1.Symptomatic treatment

Drug Dose Pregnancy & breastfeeding

Ear pain and Fever → Analgesics or antipyretic

Paracetamol Child under 1 month: 10 mg/kg 3 or 4/d May be acceptable
Child 1 month and over: 15 mg/kg 3 or 4 /d
Adult: 1 g 3 or 4 times daily (max 4g/d)

Ibuprofen Child over 3 months: 5 to 10 mg/kg 3 to 4/d -Avoid. Contraindication from the
Child 12 year and over and adult: 200 to beginning of the 6th month
400 mg 3 to 4 times/d -Breast-feeding: No contraindication
(short term treatment)

Diclofenac 100 mg PO once, then 50 mg PO q8hr PRN Avoid unless the potential benefit
outweighs the risk ( the third trimester)
 Otitis externa
V. Pharmacotherapy of otitis externa
1.Symptomatic treatment

Drug Dose Pregnancy & breastfeeding

Ear discharge→Washing
Acetic acid in aluminum To be inserted into meatus or apply on a ribbon gauze - acceptable
acetate (Borofair) dressing or sponge wick which should be kept saturated with
the ear drops

Sodium bicarbonate To be inserted into meatus or apply on a ribbon gauze - acceptable

dressing or sponge wick which should be kept saturated with
the ear drops

Olive oil Child: Apply twice daily for several days (if wax is hard - acceptable
and impacted)
Adult: Apply twice daily for several days (if wax is hard
and impacted)
 Otitis externa
V. Pharmacotherapy of otitis externa
1.Symptomatic treatment

Drug Dose Pregnancy & breastfeeding

Burning or stinging (allergic or dermatitis), Itching→anti-inflammatory

Betnesol Adult: Apply 2–3 drops every 2–3 hours, reduce May be acceptable
Betamethasone frequency when relief obtained

Predsol Child: Apply 2–3 drops every 2–3 hours, frequency to May be acceptable
Prednisolone be reduced when relief obtained
Adult: Apply 2–3 drops every 2–3 hours, frequency to
be reduced when relief obtained

Flumetasone Child 2–17 years: 2–3 drops twice daily for 7–10 days, to May be acceptable
pivalate with be instilled into the ear
clioquinol Adult: 2–3 drops twice daily for 7–10 days, to be
instilled into the ear
 Otitis externa
V. Pharmacotherapy of otitis externa
1.Symptomatic treatment

Drug Dose Pregnancy & breastfeeding

Burning or stinging (allergic or dermatitis), Itching→anti-inflammatory

Betamethasone with neomycin Child: Apply 2–3 drops 3–4 times a day May be acceptable
Adult: Apply 2–3 drops 3–4 times a day

Dexamethasone with Adult: Apply 4 drops twice daily for 7 days May be acceptable
ciprofloxacin

Dexamethasone with Child: 2–3 drops 3–4 times a day May be acceptable
framycetin sulfate and Adult: 2–3 drops 3–4 times a day
gramicidin
 Otitis externa
V. Pharmacotherapy of otitis externa
2.Etiologic treatment

Drug Dose Pregnancy & breastfeeding

Bacteria infection→ ATB

Gentamicin Child: Apply 2–3 drops 4–5 times a day, (including a May be acceptable
dose at bedtime)
Adult: Apply 2–3 drops 4–5 times a day, (including a
dose at bedtime)

Gentamicin with Child: Apply 2–4 drops 4–5 times a day, (including a May be acceptable
hydrocortisone dose at bedtime)
Adult: Apply 2–4 drops 4–5 times a day, (including a
dose at bedtime)

Neomycin sulfate usually used 3 or 4 times a day May be acceptable

 Otitis externa
V. Pharmacotherapy of otitis externa
2.Etiologic treatment
Drug Dose Pregnancy & breastfeeding

Bacteria infection→ ATB

Ciprofloxacin Child 1–17 years: Apply 0.25 mL twice daily for 7 days, May be acceptable
each 0.25 mL dose contains 0.5 mg ciprofloxacin
Adult: Apply 0.25 mL twice daily for 7 days, each
0.25 mL dose contains 0.5 mg ciprofloxacin

Chloramphenicol Child: Apply 2–3 drops 2–3 times a day May be acceptable
Adult: Apply 2–3 drops 2–3 times a day

Fungal infection → antifungal

Clotrimazole Child: Apply 2–3 times a day continue for at least 14 days after May be acceptable
disappearance of infection
Adult: Apply 2–3 times a day continue for at least 14 days after
disappearance of infection
 Otitis externa
Case study 1:
អ្នកមីង B គាត់ចូលមក ឱសថសា្ថ្ន របស់ អ្នក ចង់បានថ្ន្ំ បំបាត់ឈឺ តេចៀកកូនគាត់
1. េតើ អ្នក តូវេធើការសន្ទនា សាកសួរពីគាត់នូវព័ត៌មានេដើម្បី េអោយដឹងពី ជំងឺ តេចៀក
គាត់ ( diagnostic ) ?
2. េតើ អ្នក តូវសួរ ព័ត៌មានអីខ្លះេទៀតេដើម្បី ដឹងពីកំរត នឹងរយៈេពល េ បើ បាស់ថ្ន្ំ ?