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Dry Eye Syndrome

Dry Eye Syndrome: NEW CHALLENGE IN OPHTHALMOLOGY

 

Prof.Dr. MR JAIN MS, FICS (USA), FACLP (London), FAMS

 

MEDICAL DIRECTOR

MR J INSTITUTE AND JAIN EYE HOSPITAL, Jaipur (India)

Email: drmrjain55@gmail.com

Dry eye syndrome, which has recently been named as dry eye disease (DED) (Beherens et al 2006; Lemp 2008), is the most common disorder in Ophthalmology. Fortunately, only rarely becomes more serious. Although the condition is recognized as a clinical disorder in 1920 and described clinically in early 1930, the largest amount of information both from the standpoint of epidemiology and pathogenesis has accumulated over the last ten years.

 

What is dry eye syndrome?

Dry eye syndrome is a disorder of the tear film preocular resulting in damage to the ocular surface and is associated with symptoms of ocular discomfort. Dry eye is characterized by the instability of the tear film may be due to insufficient tear production or poor quality of the tear film, resulting in increased evaporation of tears.

Dry eye so everything can be divided into two groups, namely

1. Water deficiency in the production
2. Evaporative

The prevalence of dry eye.

No prevalence study Authentic has been made in India, but notes that for patients over age 30 who attend outdoor one in four has a complaint regarding dry eye. A survey recently completed in the year 2007 (Lemp et al 2007), based on a well - characterized population of adult men and women in the U.S., identified a prevalence of 5 to 30 percent in different age groups. These rates could be extrapolated 9,100,000 dry eye patients in the U.S. only. About 5 million Americans 50 years age are mild. to moderate dry eye disease.

In women age 45 to 52 when menopause usually provides an imbalance between estrogen and the hormone androgen due to the decrease in androgens after menopause. Decreased androgen levels excited in the gland inflammation lacrimal and ocular surface, altering normal homeostatic maintenance of the lacrimal gland and ocular surface.

Factors that increased the incidence Dry eye can be told as

a. longitivity growing population

b.increased drug use, both systemic and topical have an adverse effect on the production of high quality of tears

c. major equipment use (Computer Vision Syndrome)

d. more contact lens use and cosmetic surgery of LASIK / LASEK

and a better understanding and diagnosis of dry eye.

f possibly adulteration food / and pollution.

g. Increased use of topical and systemic drugs.

Tear fluid composition

The tear is found to be composed of three fractions: albumin, globulin and lysozyme. The immunoglobulins found in normal lacrimal fluid IgA, IgG and IgE. IgA predominates in secretory form. Increasing levels of IgE in patients with allergic conjunctivitis and IgM were found in the tears of patients with acute infections. The lysozyme can act synergistically with IgA in the cause of lysis of the bacteria. Tears also contain lactoferrin, which has some antibacterial effect.

 

TEARS: VITAL STATISTICS:

 

• The average concentration of glucose tears is 2.5 mg / dl.
• Average tear urea level is 0.04 mg / dl.
• Electrolytes such as K, Na and Cl are produced in higher concentrations in tears than in blood.
• The average pH of tears is 7.25.
• The osmolality is 309 mosm / liter (patients hypertonic dry eye syndrome).
• The surface tension of the tear film is 40 to 42 mN / m.
• Refractive index of the tear film is 1,336.

Under normal conditions, the tear fluid forms a thin layer over the cornea and conjunctiva, this is known as the film pre-ocular tear. The pre-ocular tear film measures 8 um thick and covers the surface of corneal and conjunctival epithelium.

The pre-ocular tear film acts as an important component of the ocular defense mechanism.

1. This makes the cornea a smooth optical surface.
2. It helps to wet the cornea and conjunctiva and prevents it from drying.
3. It cleans up debris and bodies of the corneal surface.
4. Bactericidal properties due to the presence of lysozyme, lactoferrin and betalysin.

1. Immunoglobulins (IgA) and specific antibodies in defense of tears to the eyes from external infections.
2. trauma from friction between the tarsal and bulbar conjunctiva and cornea minimizes the action lubrication of the tear film.
3. Allows anti-inflammatory cells to reach injured areas of the cornea and conjunctiva.
4. It provides epithelial cells with factors of glucose, oxygen and growth.

 

 

Distribution system:

The distribution system of the tear film is composed of the eyelids and tear meniscus along the eye lid open. Each flash compress the superficial lipid layer. The mucus layer acts as a cleaner to pick up debris containing lipids and bring the fornices. As the lid is reopened, a new layer of the tear film spreads over the ocular surface. Inadequacy of any layer increases tear film instability and can accelerate the breakup time (BUT).

The distribution system of the eyelids acts as a pumping mechanism to bring tears in the excretion of the system.

Urinary:

Blinking is an important factor in tears distribution and also plays a role in tear drainage. Crucial for proper function is excretory lacrimal punctum, point of entry for tear drainage. Proper disposal requires the tear punctum is attached to the balloon.

Spontaneous blinking reset pushing the fluid layer a thin layer of liquid in front of the lid margins and coming together. The excess fluid is directed toward the lacrimal lake, a small area triangle at the angle required by the closest canalculi through the tear duct, then pour in the nasopharynx and oropharynx to be swallowed.

The drainage path can represent up to 90% of the target of tears. The rest evaporates. Therefore, the act of blinking exerts a suction force free in eliminating tears tear lake and its contents in the nasal cavity.

Features pre-ocular tear film

Traditionally a tear film consists of three layers

Outer layer of lipid

It consists of an oily secretion of meibomian glands. Acts as a lubricant and prevents the evaporation of tears.

Middle aqueous layer

It is the main lacrimal fluid released from the lacrimal gland and accessories glands. Contains proteins, immunoglobulins, lysozyme, lactoferrin and betalysin. Provides moisture to the eye, the nutrition of the cornea and antibacterial activity. Epithelial cells provides factors of glucose, oxygen and growth. It cleans up debris and bodies from the surface of the cornea and drains in nasolacrimal canal.

Inner mucosal layer

The innermost layer lining of the tear film forms a hydrophilic surface on highly moisturizing epithelial hydrophobic surface of the cornea and conjunctiva. The mucus also reduces the surface tension between the lipid layer of the tear film and the layer water, which contributes to the stability of the tear film.

Recent Concept of the tear film

 

The contemporary concept of rupture of the ocular surface, the structure is a metastable tear film that consists of an aqueous gel with a gradient of mucin content decrease in ocular surface to the bottom surface of the outer lipid layer. The structure of the latter base interacts with the aqueous and mucin components, which retards evaporative loss of aqueous tears and contribute to the stability of the tear film between the flashes (Lemp, 1995).

 

 

Mucin layer

 

At least three different types of mucin have been identified: mucin transmembrane produced by cells of the conjunctiva, corneal gel formation of conjunctival goblet cells and mucin mainly soluble the lacrimal glands. (Gipson et al, 2004). transmembrane mucins contribute to the structure of the surface of epithelial cells, mucins interact with training soluble gel and tear film to stabilize the film, and a way to clean the ocular surface, the lipid-mucin interactions relatively film support tear stable between blinks.

tear film not only provides lubrication and nutrition of the ocular surface, but stable vision (Lemp, 2008). All tissues of the ocular surface, secretary glands, eyelids, and the output channels of the tear duct are linked through a neural network (the lacrimal functional unit.) Sensory receptors monitor the condition of the tears and the cells, sending afferent signals to the system CNS. Which in turn sends efferent impulses to the glands and secretary cells, to make changes in the composition and volume to maintain homeostasis and respond to stress and injury. Other factors supporting the complex fracture surface of the film-ocular bioavailability include hormones, mainly androgens, and an intact immune system. This exquisitely balanced system is a highly complex unit visual access to the external environment. (Lemp et al, 2007). Tampering with any element leads to a breakdown in the overall structure and function with important clinical effects.

 

Pathogenesis of dry eye

 

It is well established that lacrimal gland damage result in a decrease in tear flow. This leads to decreased tear washing surface debris and bacteria, as well as an increased presence of inflammatory cytokines and decreased growth factors to maintain ocular surface integrity.

Almost all the tears flow due to a mechanism reflex due to stimulation of the cornea by sending impulses to the brain and the lacrimal gland. Anything that disrupts the corneal sensation of hormonal imbalance, contact lenses, LASIK surgery or other trauma to the eye, may be surgical or accidental.

Lacrimal gland infection can be primary (dacryoadenitis) or immune due to rheumatism of the joints or conjunctivitis time could result in decreased formation of aqueous humor. As result of inflammation, activation of matrix metalloproteinase enzymes (MMP-9) was identified that has more potential to damage the ocular surface. Today is now recognized that inflammation is an integral part of the pathogenesis of dry eye disease and a target for the treatment of dry eye.

The normal interaction of the tear film and ocular surface is conditioned by a support fund androgenic hormone that prevents swelling and a feeling intact cornea stimulates secretion by the lacrimal gland to produce tears that nourish and protect the ocular surface. When there is no disturbance of the controls normal homeostatic, dry eye occurs either as an aqueous tear deficiency or excessive evaporation loss with further damage to the ocular surface. This disease state creates a vicious cycle of increased inflammation of the lacrimal gland and ocular surface that suppresses the feeling most of the normal cornea and leads not only to the removal of tear secretion, but further damage to the ocular surface.

Aqueous deficient dry eye (keratoconjunctivitis dry) is a disorder of the neuro-humoral interaction of the ocular surface that interrupts nerve impulses secretomotor to the lacrimal gland resulting in the removal inflammatory watery secretion, a necessary component of the tear film, with consequent damage to the ocular surface, causing skin irritation and ocular discomfort. Evaporative dry eye is a disorder of the tear film stability, which is usually due to abnormalities of the meibomian gland secretion or abnormal eyelid position and movement. Both types of dry eye results in damage to the ocular surface and symptoms of ocular discomfort and visual function reduced.

Classification based on etiology

 

Murube (1996) is divided dry eye in the monitoring of 10 families. These are:

1. Related to age. Lacrimal secretion begins to decrease after age 30 years. At the age of the 6th, we reached the border between production and need. At the age of 90, most people have dry eye.
2. Hormone l. At the age of menopause, most women develops mild to moderate dry eye. Recent research has shown that it is due to decreased levels of androgens produced by the ovaries. Men develop hormone-related dry eye less frequently and intensely than women.
3. Pharmacology. No adverse effects on tear production due to preservatives used in tears for a long time period. Patients with glaucoma are more likely this problem due to prolonged therapy.

Systemic drugs such as antidepressants, antihypertensives, antihistamines, anticholinergics, antipsychotics, angiolytics, antiparkinsonian agents, diuretics and hormones can also cause dry eye.

4 Immunological: I This is related to the autoimmune reaction that affects the exocrine glands of the body outside the secretion and the secretion of tears, saliva, sweat and vaginal secretions. Sjogren's syndrome are those in which the patient's immune system attacks its own exocrine glands. Rheumatism, cicatricial pemphigoid and erythema multiforme may lead to Sjogren's syndrome.

5 infection. The chronic infection of the conjunctiva may affect mucus secretion leading to mucin deficiency and infection of the lacrimal glands may affect the watery discharge. Inflammation of the eyelids may affect the secretion of fat. Any component if affected, the tear film is altered.

6 Hippo nutrition. Avitaminosis A and alcoholism which leads to malabsorption can result in dry eye.

7 traumatic: Any trauma to the eye can be accidental or surgical may precipitate dry eye. major surgery such as removing tumors, etc. is more likely to cause dry eyes. Even a cataract or glaucoma surgery Phaco may be liable to dry eye symptoms, especially in the elderly.

 

 

8 neurological.

a. Post LASIK. Lasik leads to the development of temporary dry eye by 4 percent patients. Wilson (2001), spots and punctate erosions rose bengal without pre-existing dry eye and neurotrophic epitheliopathy tagged. He believes this change in the epithelium is attributed to the transection of a significant number of afferent sensory nerves in the cornea during the formation of the flap, and therefore the gland arc interruption corneal trigeminal nerve-brainstem-facial nerve reflex tear affecting both basal and stimulated tear production. Lasik induced dry eye to be resolved approximately 6 months. Laser in situ keratomileusis cause dry eye symptoms in 50 percent of the eyes.

1. 1. contact lenses. Contact lenses when used for an extended period affects corneal sensation and therefore decrease tear secretion.

Semi-hard and soft contact lenses cause corneal anesthesia marked. On the other hand, soft lenses absorb tears and tears cause hypertonic, which still affects the corneal epithelium. semi-soft lens also affects the lipid layer of the tear film.

1. defective glands. Responsible for mucin, aqueous and lipid secretions.
2. Inability to use the tears. There normal production of tears, but the cornea is not able to use due to:
   1. Epitheliopathy and corneal dystrophy, which decreases the ability the cornea and humid.
   2. Due to a defect in lipid caps are not able to distribute tears over the entire ocular surface (paralysis cover, extortion, lagophthalmos)

B. Classification Based on the pathophysiology of the film tear

 

1. Aqueous tear deficiency (ATD)
   1. Idiopathic senile atrophy lacrimal gland
   2. Menopause
   3. Hypo lacrimal gland function associated with autoimmune diseases like Sjogren's syndrome

2 lacrimal surfactant (mucin) deficiencies

1. Trauma to the conjunctiva
2. Vitamin A deficiency
3. Conjunctival infections, trachoma, diphtheria
4. Pemphigoid, rash, Stevens Johnson syndrome
5. Chemical, thermal injury, radiation
6. Induced drugs, sulfa drugs, epinephrine

3. Abnormal lipid layer:

1. Chronic blepharitis
2. Acne rosaecea

4 functions cover improper or intermittent

Neuropralytic injury trigeminal, facial, greater superficial petrosal nerve, etc.

5 epitheliopathy

Diseases of the cornea epithelium

6. Other causes

1. Drugs
2. VDT: Acquired Visual Display Terminal Vision Syndrome Computer
3. Contact Lenses

 

 

Symptoms

dry eye patient may have either one or multiple symptoms:

Itching, burning, irritation, pain, foreign body sensation of discomfort. There may be pain and photophobia and blurred vision that improves with blinking. In general, fibrous mucus viscous, which can increase in the afternoon. Discomfort in the eye usually rises during reading, watching TV, air conditioning (low humidity) or work on your computer. A Sometimes there may be over watering, especially during the breeze. The main cause of eye discomfort is high concentration of electrolytes in the tears that leads to hyperosmolarity and further damage to the ocular surface.

All these symptoms are exaggerated in dry and windy conditions. The patient has a frequent urge to download to clear mucus from the eyes. Some patients give a typical story of desire often spray water on the eyes. Visual acuity can be significantly affected, particularly where corneal staining. In the early stages, there may be mild blurred vision that requires frequent blinking, resulting in eyestrain.

Signs

 

Teardrop Lake. Usually in the lower eyelid there is a torn meniscus is concave from 0.3 to 0.5 mm, which is called tear lake. In dry eye, is usually less than 0.1 mm.

Debris. There is an increase of waste in the lake decreased tear. mucous threads (strings of mucus) can be seen.

Other signs. Redundant conjunctiva, the injection of the conjunctival vessels, chemosis, mild and sometimes may be present. In the fornix of the conjunctiva, the threads form due to slow flow tear and partly by the increased number of sloughed epithelial cells. In advanced cases, conjunctival and corneal dryness can be very obvious and may be associated with chronic blepharitis blepharospasm.

Staining.

1. Fluorescein stain. fluorescein can spot any area devoid of corneal epithelium. Staining is graded as 0,1,2 and 3. 0 = no staining of the cornea, 1 = 1 / 3 of the corneal epithelium Color, 2 = ½ of the corneal surface and 3 = severe staining of the corneal epithelium half. The reduction in tear lake can be easily appreciated with fluorescein.
2. Rose Bengal Stain. Rose Bengal (1% solution or strip) stains devitalized damaged skin cells of the conjunctiva and cornea. It can detect even mild cases of Keratoconjunctivis Seca (KCS) by staining of the conjunctiva palpabral as two triangles with their base towards the limbus. Rose Bengal da anesthetic burning sensations, but should not be used because it can give false results. Alcian Blue has properties similar to Rose Bengal, but usually not available.

3 Film breakup time. (TRL)

This is a quantitative measure the stability of the tear film. Is a deficiency of mucus in the departure of the watery tear around the small amount of mucus on the epithelial surface available and reduction of TRL. The test is performed by asking the patient not to blink for 10 seconds after instillation of fluorescein. The appearance of a dark spot (Dry zone) within 10 seconds is abnormal. Mild to moderate dry eye patients usually have 2-3 seconds TRL.

Diagnosis.

Diagnosis is often based on the complaint of patient without obvious cause in the eye. Very often, fishing persistent secretion viscous mucus is very classic and so is the importance of reporting of increased discomfort in dry and windy.

Diagnostic tests in Most used are the following

1. Schirmer test. The test is used to quantitatively measure the tear secretions lacrimal gland, and should be done before any other consideration as the manipulation of the eyelid and the eye may alter the results of the test.

Shirmer I test. It is used to measure the rate of tear secretion without anesthesia.

Shirmer II test is similar to a Shirmer but after the instillation of drops anesthetic.

After instillation of anesthetic drops, the amount of tear secretion is the closure of the basal secretion rate should not stimuli having filter paper strip placed in the inferior fornix. A value of less than 5.0 mm is considered abnormal. The test is often inconclusive.

b Tear Function Index (TFI) of the test. This is a more specific and sensitive test to measure quantitatively the tears. Has into account the influence of tear drainage in the measurement of test Shirmer tears. Its numerical value is obtained by dividing the value Shirmer II trial in millimeters tear clearance rate. The larger the numerical value of TFI, the best of the ocular surface. Values below 96 suggest dry eye.

c Fluophotometery. It's another way of measuring tear secretion. It uses the decomposition of sodium fluorescein to measure tear flow and tear volume. This test is expensive and not very informative.

d tear osmolarity. Provides a qualitative assessment of tear formation. The reference value of 312 mosm / L. This value increases with the severity of dry eye.

and impression cytology, the conjunctiva and salivary gland biopsy lateral can be used to diagnose the etiology of the disease. In dry eye states there is a marked decrease in goblet cell count.

 

Classification of Dry Eye Syndrome:

Mild dry eye syndrome, can be defined in patients who have evidence of Shirmer less than 10 mm in 5 minutes and less than one quadrant of the corneal staining

Moderate dry eye syndrome:

Shirmer test results of 5-10 mm in 5 minutes with or without punctate staining of more than one quadrant of the corneal epithelium.

Eye syndrome severe dry: can be defined as diffuse or confluent punctate corneal staining, often their filaments. Schirmer test, usually less than 5 mm in 5 minutes. Sjogren syndrome is classically associated with severe dry eye symptoms.

  

 

 

 

Treatment

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Conservative

1. Patient information. Patients should be educated and fully informed about the disease and should be explained the limitations of medical management. This keeps the patient's confidence in its line of treatment.
2. The control of the surroundings. The special stress should be placed to control the environment to minimize the severity of the condition.

a.       Still air. The patient should avoid sitting in front flow direct air from air conditioners, fans, windows or fans. It's better than the patient to avoid sitting in front of the door of a room. While driving the car, the car window should be closed and the patient should wear goggles. Car AC not blow wind in your face.

1. Wet Air. Even if no error of refraction, the patient should wear goggles. Only with the use of glasses, moisture between the eyes and glasses stands at 2%. Shows side moist chamber panels and can be reserved for severe cases. Humidifiers should be used in all rooms. Air conditioning is available with humidifiers herein.

Special glasses with wet inserts relieve severe symptoms of dry eye. The moisture inserts on side panels increased humidity, resulting in a decrease in the evaporation of tears from the ocular surface. Another type of moist chamber more easily obtained and lower cost through the use of swimming goggles. The most favorable range of relative humidity to minimize evaporation of tears was reported that 40% to 50%. mask wet gauze is a form of alternative treatment.

1. Ai r pure. Air pollution is very harmful for patients with dry eye. Palpabral opening must remain open to a minimum. closed window in the car, with a protective helmet when riding motorcycles and covering your eyes glasses, while driving the bike gives a little relief. While reading books, the book should be as close to the chest to be open palpabral minimum. While looking down, the ocular surface is exposed to air only one square centimeter, while at the same time looking at, 2.0 cm square. and while looking top, 3.0 cm square.

Computer Vision Syndrome. While watching the monitor, the eyes have the tendency to look to the screen which reduces flicker about 6-7 flashes per minute. If the computer is on a higher level than the eye, not even increased evaporation of tears. To prevent computer vision syndrome, we must have the equipment on the lower level of the eyes and the habit is formed to flash about 10-12 times per minute. When working for a long period of time, close your eyes for a while or use some artificial tears.

Medical Management

 

Substitutes tear.

 

Tear substitutes are the mainstay in the medical management of eye dry. Variety of tear substitutes are available. hypotonic solutions inviscid counteract the hyper tone in dry eye syndrome and can last up to two hours. solution viscose containing cellulose as the base and therefore last longer. Preservatives are added to increase shelf life and stability of the solution. The frequency preservatives used are benzalkonium chloride, thimerosal, and chlorhexidine. Despite its low concentration, can produce toxic effects on the cornea and conjunctiva and affect negatively dry eye.

Preservative Free Drops

The use of eye drops without preservatives, and more recently condoms which are transient or rapidly oxidized to toxic compounds in contact with air and the ocular surface, has become routine for patients requiring more than three or four drops of Oil per day. The tear supplements have focused on maintaining a standard hypotonic eye drops the concentration of electrolytes to counter the harmful effects of hyper tone.

In India, as tear substitutes nonreactive traded as

Refresh Tear Drops (Allergan) contains 5 mg sodium carboxymethylcellulose with 0.05 mg oxychloro stabilized complex. (Purite)

Gen Teal drops and gel (Novartis) hydroxypropyl cellulose containing 0.3% H2O2 stabilized.

Eyemist Drops (Avesta) contains hydroxypropyl

0.3% cellulose stabilized 0.005% oxychloro Complex.

Tear Drops (Milmet) contains 5.0 mg sodium carboxymethyl cellulose with complex oxychloro stabilized 0.005%)

Celluvisc 1% (Allergan) containing carboxymethylcellulose

1 percent.

Reload Liquigel (Allergan) containing carboxymethyl

Sodium cellulose 1%.

1. Hyvisc 0.1 and 0.18 percent sodium hyaluronate is considered more tranquil conjunctival epithelium. PH has 7.3. TRL increases and helps the healing of superficial keratitis.

Ocumoist, ECOT, Lubrex, Aquaray, Speed Drops, CMC, Add Tears tears, Flogel, Moisol-Z are some of the other drops without preservatives.

Systane (Alcon) containing polyethylene glycol and propylene glycol.

Imported tear Substitutes

Refresh PM (Allergan)

Tear viscous gel (Ciba)

Tears Naturale Free (Alcon)

Bion Tears (Alcon)

Lagricel Ofteno (Laboratorios Sophia) containing sodium

Hyaluronate.

Hyalein Mini Mini 0.1% and 0.3% Hyalein (Santen of

Japan) containing sodium hyaluronate.

Refresh Endura drops (Allergan). Is lipid emulsion, reducing tear evaporation and stabilize the tear film, reducing the frequency of instillation of tears.

tear substitutes are instilled in the eyes 3-6 times a day

depending on the severity of the disease. If necessary, update

Celluvisc Liquigel or Bred to bedtime.

Androgens

Role of androgen therapy is not yet well established, although it is known that in women, the lack of androgens play an important role in its etiology.

Topical androgen supplementation of tears man appears to reduce the osmolarity of the tears of the patient, either by evaporation or possibly slow stimulate tear secretion. This gives an indication that the addition of androgenic hormones to artificial tears may benefit patients with dry eye.

Tear Stimulants

The use of oral or sublingual pilocarpine (Salagen, MGI Pharma) has proven useful in some patients but has been associated with systemic side effects of sweating and gastrointestinal discomfort. Cevimeline (Evosac, Daiichi Pharmaceuticals, Inc) breaking and also stimulate salivary flow and may be better tolerated than pilocarpine.

the systemic use of bromhexine congeners in Europe have been tested with unsatisfactory results.

Recent testing has come P2Y2 purinergic agonists to phase three trials in the U.S.. The drug designed diquafosol tetrasodium (Inspire Pharmaceuticals, USA) has been well tolerated and increases the tear film volume and mucin content. The pharmacological action is to increase fluid transport across the conjunctiva and stimulate the release of goblet cell mucin.

Cyclosporine A

 

Looking to the immunological aspects of disease, cyclosporine A in the form of topical drops (0.05% and 0.1%) is being used in moderate to severe DES to treat ocular surface inflammation and the lacrimal gland. Placing drops twice daily and the beneficial results are seen within four to six months. The drug can be used for a lifetime. Cyclomune is an immunomodulator. It selectively suppresses lymphocyte functions involved in a disease without actually immune system suppression. Helper T cells inhibits known to cause inflammation of the ocular surface and lacrimal glands of patients with dry eye. The main indication for use is surface staining Cyclomune of the cornea. Instillation of drops is associated with feelings of stinging, gradually declining.

Cyclosporine drops are marketed by Allergan as ResStasis U.S. Avesta and in India as Cyclomune (0.05 and 0.1% drops)

Omega 3 fatty acids (Omecard), or Cap. CSNnbsp said via orally to decrease dependency on tear substitutes. fish eaters are said to be relatively resistant to dry eye. Cod liver oil may be helpful.

Meibomitis.

A recent study in the U.S. has shown that about 38% of patients with dry eye concurrent involvement of meibomian gland. (Mathers MD 2000). The moist hot packs, scrubs betadain, massage of the eyelids and oral tetracycline or doxycycline, can treat inflammation of meibomian. Tetracycline is effective as an anti-bacterial and causes the secretion of fat and therefore more free-flowing liquid from glands meibomian. Tetracycline is administered 2 hours before meals in divided doses. It is given as 500 mg capsule BD

Topical steroids (Soft drugs)

 

  Topical steroids are being tested in some cases resistant or advanced dry eye in patients with severe itching. Loteprednol etabonate 0.2% is a good choice for long use term. It is mild steroid that is activated by enzymes as it passes through the cornea. Seems to have little effect on IOP. It is marketed as Alrex (0.2%) by Bausch & Lomb as Lotepred Drops 0.5 percent by Sun Pharmaceutical in India.

Immunosuppressive therapy

In cases of DES, systemic cyclosporin A, prednisone, methotrexate, infliximab may have to be determined.

 

Lasik induced dry eye

 

Clinically post LASIK patients may show epithelial erosions Rose Bengal dotted and the flap. (Neurotrophic epitheliopathy.) All cases of LASIK has to be put to use preservative-free tear substitute drops immediately after surgery and continued for a period of 4-6 months. It should be noted that most cases recover within six months. Only a few patients, who already had the dry eye symptoms before surgery, may require specific caps.

Mucolytics.

Topical 5 by percent fall acetylcysteine instillation is recommended four times daily. It is effective in eyes with excessive mucus.

Future therapies.

Apart from tear substitutes, anti-inflammatory therapy, androgen hormone replacement, and wear diquafosol tetrasodium stimulants may be the main therapeutic measures. Herbal supplements such as evening primrose oil and oil Flax seed is reported to help relieve dry eye symptoms meibomitis. Essential fatty acids, especially omega -3 fatty acids omega-3 category as food supplements are showing some promising results.

 

Surgical treatment

1. Lacrimal canalicular obstruction by plugs

It is a simple procedure that reduces lacrimal drainage component significantly improves the quality and quantity of tears. A decrease in the osmolarity of tears is observed. The improvement may be Shirmer and test seen TRL.

Several methods for punctal occlusion have been described as stents soluble collagen, cyanoacrylate glue, removable silicon or Teflon caps, or intracanalicular plugs. The most recent innovation is adopted Smart Plug (Medennium Inc) which is a thermolabile polymer that when inserted into the canaliculus is consistent with the diameter of the canaliculus to produce occlusion.

canalicular block is obtained by inserting a silicone plug punctal. There are two types of plugs:

1. A. punctal plug In this part of the plug is visible in puncta
2. punctal plug resides entirely in the canalicular canal. (Plug Herrera)

Nearly 75 percent of patients tolerate the caps. In some patients, you may need to remove the caps. The variety insertable canaliculus can be removed from the canal irrigation with saline.

1. Canalicular obstruction by cautry. Puncta can be temporarily blocked by cautry heat or diathermy or argon laser. An argon laser was focused on the surface punctal causes overheating and destroys the punctum. (Results not reliable)
2. Lacrimal technical review This is the surgical technique more effective for long-term occlusion of the lacrimal drainage system. In this technique, a raw area is created around upper and lower puncta. A bulbar conjunctiva piece is taken and transplanted into the injured lacrimal raw surface in contact with the lid and sutured with four 9. 0 points.

Summary

Dry eye disease may be increasing due to several factors. Despite great advances in the understanding and diagnosis of disease the disease remains a challenge to the medical profession. Preservative free drops significantly improve the quality of life of patients with dry eye. Anti-inflammatory therapy, androgen hormones and stimulants of tear, ie diquafosol tetrasodium and probably some herbal medicines have a great hope for a patient DES. Cyclosporine has proven to be of great help in the management of moderate to severe dry eyes.

ILLUSTRATIONS

Fig Showing all components of the lacrimal system Secretary. Showing Fig. damaged the tear film.

Dry Eye Rose Bengal List

Tear Film of the figure shows three layers of tears.

The use of glasses in the dry eye condition

Readings

Foulkes GN Der eyes Part I: Description of the epidemiology and pathogenesis. Atlas of Ophthalmology. Vol.31 (1) 2003, p. 21-26

Boyd BF New Horizons in relieving dry eye and control Vol 29 (5) 2001 p. 55-65

D Bairagi dry eye syndrome. The view, Mediworld Report 2004 Pg 6-10

Symposium on Changing paradigms in the diagnosis and treatment of dry eye. Eyes of the World View July 2004. PG2-11.

Pflugfelder SC: Anti - inflammatory therapy dry eye. Ocular Surface 2003: 1: 31-36

Foulkes GN: Dry Eye, Part II: Management and new treatment options. Atlas of Ophthalmology. Vo. 31 (2), 2003, p.1-8

Murube J, Tsubota K: Dry Eye: What is new in the understanding of its nature and management efficiency? Atlas of Ophthalmology Bimonthly Journal Vol 24, No 5, 1996.

Wilson is: Lasik-induced neurotrophic epitheliopathy. Ophthalmology, June 2001.

J Murube Progress in the diagnosis and management of dry eye. Highlights of Ophthalmology 1993: 21: 10: pg.81-88.Dilly P. N: Structure and function of the tear film. Adv Exp Med Biol 1994, 350:239-247.

Clinical Ophthalmology Kanski JJ ed. 4 Butterworth, 1999.

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About the Author

Prof Dr M. R. Jain has received LIFE TIME ACHIEVEMENT AWARD fro All India Ophthalmological Society for his contribution in the field of Ophthalmology in India and abroad.He is leading Phaco and Glaucoma surgeon og India. He has been Prof and Head of various nedical colleges in Rajasthan for 17 years.He is presently Medical Director, Dr M. r. J Institute & Jain Eye Clinic & Hospital Jaipur. Link: www. mrj-jaineye.com