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Dry eyes

Dry eyes. Dr R R Sudhir Dr. G. Sitalakshmi Memorial Clinic for Ocular Surface Disorders Prof G Falcinelli MOOKP centre. Medical Research Foundations, 18, College Road, Chennai 600 006,Tamil Nadu, India. Dry eye.

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Dry eyes

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  1. Dry eyes Dr R R Sudhir Dr. G. Sitalakshmi Memorial Clinic for Ocular Surface Disorders Prof G Falcinelli MOOKP centre. Medical Research Foundations,18, College Road, Chennai 600 006,Tamil Nadu, India

  2. Dry eye Disorder of tear film due to tear deficiency or increased evaporation which damages the inter palpebral ocular surface and is associated with symptoms of discomfort. (NEI1993workshop ). Lacrimal keratoconjunctivitis Dysfunctional lacrimal functional unit which causes unstable tear film which promotes ocular surface inflammation, epithelial disease and symptoms of discomfort DEWS: Multifactorial disease of tears and ocular surface resulting in symptoms of discomfort, visual disturbance and tear film instability with potential damage to ocular surface with increased tear film osmolarity and surface inflammation

  3. Ocular surface • Conjunctiva • Limbus • Cornea • Close interaction between the ocular surface and the adnexae (lids, lacrimal glands) • Ocular surface disease Dry eye • Holistic approach essential • Compositional factors • Dynamic factors • Neurotrophic state • Tear clearance

  4. Lipids Mebomian gland Compositional factors Aqueous Lacrimal gland Mucin Ocular surface epithelia Tear spread Eyelid blinking Tear clearance Hydrodynamic factors Decreased evaporation Eye lid closure

  5. Dry eye: more than an annoyance… Can cause functional and occupational disability

  6. Dry eye can cause serious corneal disease ! Irregular corneal surface or altered barrier function

  7. Dry eye can also besight-threatening ! Infective keratitis Sterile Melting

  8. Simulators Lid margin disease Allergic conjunctivitis Infective etiology Conjunctivitis Medicamentosa Work-related symptoms

  9. Convergence insufficiency Thyroid eye disease Conjunctivochalasis Superior limbic keratoconjunctivitis Mucus fishing syndrome Floppy eyelid syndrome Simulators

  10. EXACERBATORS Lid margin disease Superior limbic keratoconjunctivitis Conjunctivitis medicamentosa Work-related exacerbation Nocturnal lagophthalmos

  11. Assessment before Treatment Is there tear insufficiency ? Exacerbating factors ? What is the severity ? Is there associated systemic disease ? How does the patient perceive his problem ?

  12. Approach to itchy burny eyes

  13. What are the symptoms ? … stinging or burning eyes … scratchiness … mucus accumulation … eye irritation from wind / smoke … difficulty in contact lens wear … EXCESS TEARING ?

  14. History Itching –seasonal/perineal Burning- morning/evening Tearing h/o systemic problems Joint pains Dry mouth Any other systemic disease Age- Sex- Onset Duration Progress Drug allergy Systemic medications

  15. itching Young age Seasonal/perineal Perilimbal pigmentation Papillary reaction Horner trantas dots. Allergic diathesis Flexural crease changes Skin lesions Rhinitis Seasonal Hay fever AKC VKC VKC with perilimbal pigmentation

  16. Burning morning evening Lid margin disease- MGD Conjunctivochalasis Convergence and accomodation insufficiency Decreased tears ATD Normal tears- floopy eyelid

  17. External examination Structure and function of lids Entropion Ectropion Lagophthalmos Proptosis Ptosis Blink Rate Completeness Essential Blepharospasm Skin changes atopy/eczema Infections Acne Rosacea Floppy eye lid

  18. Meibomitis- plugged orifice ,telengiectatic vessels, thick secretions Blepharitis Scaling and crusting Lid margin keratinisation

  19. 4 conj./ cornea

  20. Phlycten Papillae Follicles OCP SLKC Herbets pits

  21. Filaments Marginal infiltrate SPK Phlycten Melts Conjunctivalisation

  22. 5.Tear film

  23. Tear film Tear film break up Invasive/non invasive methods < 10 seconds – unstable tear film Height • low – dry eyes • High-tear stasis Quality: • Oily tear film- Mebomian gland dysfunction

  24. Schirmers test Fluorescein clearance test

  25. Patients with dry eye 6 Surface staining

  26. Fluorescein staining

  27. Rose Bengal staining

  28. Lissamine green staining

  29. 7 lab investigations

  30. Systemic investigation CBC ESR CRP RA ANA Referral to Rheumatologist Referral to dermatologist Local investigations • Conjunctival swab- infections • Conjunctival scrapping Eosinophills/Inclusion • Impression cytology-squamous metaplasia goblet cell density • Conjunctival biopsy- IF-OCP

  31. Clinical measures of dry eye

  32. Management strategies Treat symptoms Treat the aggravating factors Treat the associated ocular problems Treat the ocular surface- decrease inflammation, prevent cicatrising changes Treat the systemic factors Treat the patient

  33. DRY eye Severity- Delphi Panel

  34. DEWS Study- Signs and symptoms

  35. Dry eye- treatment plan

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