The EBAI CME 2013 - 21st and 22nd of September 2013, Golden Valley Resort, Ghodbunder Road, Thane West, Mumbai.

1. DRY EYE
Dr Sheetal Deolekar
MS DNB FCPS DOMS
Fellow Disha Eye Hospitals

2. DEFINITION
 NEI/Industry definition: A syndrome in which an unstable
tear film inadequately supports the health of ocular surface
epithelium, promotes ocular surface inflammation, and
stimulates eye pain.
 International DEWS Report : 2007
Dry eye is a multifactorial disease of the tears and ocular
surface that results in symptom of discomfort and visual
disturbance, and tear film instability with potential damage
to ocular surface.
 It is accompanied by increased osmolarity of tear film and
inflammation of the ocular surface.

3. LACRIMAL FUNCTIONAL UNIT

4. PATHOGENESIS
Secretory dysfunction
Ocular surface inflammation Altered tear composition
Tear film instability
Ocular surface disease Ocular discomfort
Chronic pain symptoms
Lacrimal keratoconjunctivitis sicca

5. CLASSIFICATION

6. OCULAR SURFACE MANIFESTATION
Corneal
epithelial
disease
•Tear film unstability
•Disrupted epithelial barrier
•Increased corneal
permeability
•Sterile keratolysis
Conjunctival
epithelial
disease
•Squamous metaplasia –
decreased mucin and
number of goblet cells
•Increased expression of
genes- increased apoptosis
of conj. Epithelial cells
inflammation
•Cellular and soluble
inflmmatory mediators
•Increased number of T
lymphocytes and change in
their distribution
•Immune activation-
increased proinflammatory
cytokines
DRY
EYE

7. SEVERITY GRADING SCHEME
Dry eye severity level 1 2 3 4
Discomfort:severity
&frequency
Mild, episodic under
stress
Mod episodic/
chronic
Severe frequent/
constant
Severe &/or disabling
& constant
Visual symptoms -/ mild episodic Annoying and/or
activity limiting
Annoying chronic/
constant
Constant &/ or
disabling
Conj injection -/ mild -/mild +/- +/++
Conj staining -/ mild Variable Mod/ marked Marked
Corneal staining -/ mild Variable Mod/ marked Punctate erosions
Corneal & tear signs -/ mild Mild debris, variable
meniscus
Filamentary keratitis,
mucous clumps
3+ ulceration
Lid & meb glands + variable + variable Frequent Trichiasis,
keratinisation
TBUT Variable < 10 < 5 Immidiate
Shirmer score variable <10 < 5 <2

8. TREATMENT
Treatment
1
2
3
4
Education
Enviornmental factors
Offending medications
Preserved tear substitutes
Unpreserved tears
Anti-inflammatory
Secretogauges
Tetracyclines
Autologous serum
Punctal plugs
Topical vit A
Moisture goggles
Surgery

9. ANTI-INFLAMMATORY THERAPY
 Cyclosporin A- 0.5%, 1% and 2%
 Inhibits T cell activation and cytokine production
 Topical tacrolimus increases aqueous tear
secretion and can be used in keratoconjunctivitis
sicca refractory to topical cyclosporin.
 Severe dry eye
 Stevens-Johnson Syndrome
 Ocular cicatrical pemphigoid
 Post transplant immunosuppression

10. TOPICAL TACROLIMUS
 Available as Ointment in 0.1% and 0.03 % concentrations for
dermatological use.
 100 times more potent in inhibiting IL2 than cyclosporine A
 Not approved by FDA for use in children < 2yrs
 Contraindicated in
 Pregnancy
 Lactation
 Active ocular infection
 Patient on phototherapy
 Patient on other immunosuppressive drugs
 Children less than 2 yrs

12. DOSAGE
 5mm ribbon of ointment to be applied in the conjunctival fornix
 Twice a day application
 Continuous application for 3 months after a washout period of
2 weeks
 Decrease the frequency to once a day or alternate day
application
 Long term intermittent use up to 4 yrs seen to be safe in
clinical trials
12

13. AUTOLOGOUS SERUM
 Serum = fluid component of full blood
which remains after clotting
 Use first described in 1984 by Fox et al
(for keratoconjunctivitis sicca)
 Unpreserved, non-antigenic
 Biomechanical and biochemical
properties similar to natural tears

14. AUTOLOGOUS SERUM
 Contains epithelio-trophic / modulating factors
 Promotes growth and migration of ocular
surface epithelial cells in vitro
 Maintains corneal epithelial cell morphology
and function better than pharmaceutical tear
substitutes (Geerling et al)
 Increases transcription of RNA for nerve growth
factor and transforming growth factor-beta in
cultured human keratocytes (Ebner et al)

15. PRE-OP CONSIDERATION IN TRANSPLANT
Adequate stem
cell supply
Anatomically
functioning
lids
Adequate
tear film
function
LSCT
AMT
Punctal occlusion
Tarsorraphy
Botulinum injection in LPS
Correction of
entropion
Ectropion

16. SURGICAL OPTIONS
 Sealing of the perforation or descemetocele
with corneal cyanoacrylate tissue adhesive
 Tarsorrhaphy
 Surgical occlusion of the lacrimal drainage
system
 Amniotic membrane transplantation

17. TARSORRHAPHY
 To reduce the area of exposed ocular surface
indicated in
 Severe epitheliopathy
 Persistent epithelial defects
 Frank stromal ulceration
 Corneal perforation

18. TRANSPLANT IN DRY EYE
 Good donor epithelium with no sloughing
 Shortest donor tissue preservation time
 Check teflon cutting block for irregularities
before harvesting donor button
 Keeping the epithelial surface well lubricated
preferably by viscoelastics

19. Thank You All!!!
We all know… when to operate and when NOT to!