Pemicu 2 Blok Penginderaan

William Tanaka
 Dry Eye Disorders
• Occurs when there is inadequate tear volume
or function resulting in an unstable tear film
and ocular surface disease
– Keratoconjunctivitis sicca (KCS) refers to any eye
with some degree of dryness
– Xerophthalmia describes a dry eye associated with
vit A deficiency
– Sjogren Syndrome is an autoimmune inflammatory
disease of which dry eyes is a typical feature
Mechanism of disease
• Inflammation in the conjunctiva and accessory
glands is present in 80% of patients with KCS
and may be the cause and consequence of dry
eye, amplifying and perpetuating disease.
• The presence of inflammation is the rationale
for steroid therapy
• Hyperosmolarity of tears is also a key
mechanism of disease and may be the major
pathway for epithelial cell damage
• Classification of KCS
– Aqueous layer deficiency
• Sjogren syndrome
• Non-Sjogren
– Evaporative
• Meibomian gland disease
• Exposure
• Defective blinking
• Contact lens-associated
• Environmental factors
• Causes of non-Sjogren KCS
– Primary age-related hyposecretion is the most common
– Lacrimal tissue destruction
• Tumour
• Inflammation (e.g. Pseudotumour or sarcoidosis)
– Absence or reduction of lacrimal gland tissue
• Surgical removal
• Rarely congenital
– Conjunctival scarring with obstruction of lacrimal gland ductules
• Chemical burns
• Cicatricial pemphigoid
• Stevens-Johnson syndrome
• Long-standing trachoma
– Neurological lesions with sensory or motor reflex loss
• Familial dysautonomia (Riley-Day Syndrome)
• Parkinson disease
• Reduced sensation may also contribute to dry eye after refractive surgery and contact lens
wear
– Vitamin A deficiency
Causes of evaporative KCS
• Meibomian gland dysfunction
– Posterior blepharitis
– Rosacea
– Atopic keratoconjunctivitis
– Congenital meibomian gland disease
• Lagophtalmos
– Severe ptosis
– Facial nerve palsy
– Eyelid scarring
– Following blepharoplasty
• Miscellaneous
– Contactt lens wear
– Environmental factors such as air conditioning
• Sjogren syndrome is characterized by
autoimmune inflammation and destruction of
lacrimal and salivary glands
• The condition is classified as primary when it
exists in isolation, and secondary when
associated with other diseases such as
rheumatoid arthritis, SLE, primary biliary
cirrhosis, chronic active hepatitis and
myasthenia gravis
• Primary Sjogren Syndrome: female>male
• Characterized by the following:
– Presentation is in adult life with grittiness of the eyes and dryness of the mouth
– Signs
• Enlargement of salivary glands and occasionaly lacrimal glands, with secondary diminished salivary
flow rate and a dry fissured tongue
• Dry nasal passages, diminished vaginal secretions, and resultant dyspareunia
• Raynaud phenomenon and cutaneous vasculitis
• Arthralgia, myalgia and fatigue may be present
– Complications
• Dental caries in severe untreated cases
• Reflux oesophagitis and gastritis
• Malabsorption due to pancreatic failure
• Pulmonary disease, renal disease and pulmoneuropathy
• Lymphoma
– Diagnostic tests include serum autoantibodies, Schirmer test and biopsyof minor salivary
glands
– Treatment options
• Symptomatic treatments
• Salivary stimulants
• Immunosuppresion with systemic steroids and cytotoxic agents
• The most common ocular symptoms are
– Dryness
– Grittiness
– Burning that characteristically worsen during the day
• Stringy discharge, transient blurring of vision, redness
and crusting of the lids are also common
• Lack of emotional or reflex tearing is uncommon
• The symptoms of KCS are frequently exacerbated on
exposure to conditions associated with increased tear
evaporation (e.g. Air conditioning, wind and central
heating) or prolonged reading, when blink freq is
reduced
Signs
• Posterior blepharitis and meibomian gland dysfunction may be present
• Conjunctiva may show mild keratinization and redness
• Tear film
– In the normal eye, as the tear film breaks down, the mucin layer becomes
contaminated with lipid but is washed away
– In the dry eye, lipid-contaminated mucin accumulates in the tear film as particles and
debris that move with each blink
– The marginal tear meniscus is a crude measure of the volume of aqueous in the tear
film. In the normal eye the meniscus is about 1mm in height, while in dry eye it
becomes thin or absent
– Front in the tear film or along the eyelid margin occurs in meibomian gland dysfunction
• Cornea
– Punctate epithelial erosions that stain with fluorescein
– Filaments consist of mucus strands lined with epithelium attached at one end to the
corneal surface and stain well with rose bengal
– Mucous plaques consist of semi-transparent, white-to-grey, slightly elevated lesions of
various sizes. They are composed of mucus, epithelial cells and proteinaceous and
lipoidal material and are usually seen in association with corneal filaments
• Complication
– Rare
– May develop in severe cases such as peripheral superficial corneal neovascularization,
epithelial breakdown, melting, perforation, and bacterial keratitis
Special investigations
• The tests measure the following parameters:
– Stability of the tear film (break up time, BUT)
• Is abnormal in aqueous tear deficiency and meibomian
gland disorders
– Tear production (Schirmer, fluorescein clearance
and tear osmolarity)
• Measures maximum basic and reflex secretion
– Ocular surface disease (corneal stains and
impression cytology)
• There is no clinical tests to confirm the
diagnosis of evaporative dry eye
Treatment
• Dry eye is generally not curable
• Control of symptoms and prevention of surface damage
• Choice of treatment depends on the severity of the disease
• Involves one or more of the following measures alone or in
combination:
– Patient education
– Tear substitutes
– Mucolytic agents
– Punctal occlusion
– Anti-inflammatory agents
– Contact lenses
– Conservation of existing tears
– Other options
• Patient education
– Establishment of a realistic expectation of outcome
and emphasis on the importance of compliance
– Avoidance of toxic drugs or environmental factors and
discontinuation of toxic topical medication if possible
– Review of work environment
– Emphasis on the importance of blinking whilst reading
or using a VDU
– Aids should be provided for patients with dexterity
loss (e.g. Rheumatoid arthritis)
– Caution against laser refractive surgery
– Discussion of management of contact lens intolerance
• Tear substitutes
– Drops and gels
• Cellulose derivatives (e.g. hypromellose) are appropriate for mild
cases
• Carbomers adhere to the ocular surface and so are longer lasting
• Polyvinyl alcohol increases the persistence of the tear film and
useful in mucin deficiency
• Sodium hyaluronate may be useful in promoting conjunctival and
corneal epithelial healing
• Autologous serum may be used in very severe cases
• Povidone and sodium chloride
– Ointments
• Containing petrolatum mineral oil
• Can be used in bedtime
• Mucolytic agents
– Acetylcysteine 5% drops q.i.d. may be useful in
corneal filaments and mucous plaques
– May cause irritation following instillation.
– Acetylcysteine is also malodorous and has a limited
bottle life so that it can only be used for up to 2
weeks
– Debridements of filaments may also be useful
• Anti-inflammatory agents
– Low dose topical steroids
– Topical ciclosporin
– Systemic tetracyclines
• Contact lenses
– Low water content HEMA lenses
– Silicone rubber lenses
– Occlusive gas permeable scleral contact lenses
• Conservation of existing tears
– Reduction of room temperature
– Room humidifiers
• Other options
– Tarsorrhaphy
– Botox injection
– Oral cholinergic agonists
– Zidovudine
– Submandibular gland transplantation