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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 of Ophthalmology and Jain, Jaipur (India)

Email: drmrjain55@gmail.com

Dry Eye Syndrome, Dry Eye recently as a Disease (DED) (referred to Beher et al 2006; Lemp 2008), the most common disease in ophthalmology. Fortunately, only rarely is it the most difficult. Although the condition was as a clinical disease in 1920 and recognized clinically described in the early 1930s, the largest Amount of information from both epidemiological and pathogenetic perspective has emerged over the last ten years.

 

What is Dry Eye Syndrome?

Dry Eye Syndrome is a disorder of the tear film preocular that results in loss on the eye surface and is associated with symptoms of eye discomfort. Dry eyes by the instability of the tear film that its because of insufficient tear production quantity or characterize because of poor quality of the tear film, leading to increased evaporation of tears results.

Dry eyes can therefore in particular two groups divided

1. Aqueous-deficient production
2. Evaporative

The prevalence of dry eye.

No binding prevalence study has been carried out in India, but it should be noted that from the patient from the age of 30 years of participation in the outdoors, one of four has a complaint related to dry eye. A recent survey conducted in 2007 (Lemp et al 2007), based on a well - characterized population of adult men and women in the U.S., a prevalence of 5 to 30 percent of calls to the various Age groups. to extrapolate these rates to potentially 9.1 million dry eye patients in the U.S. alone. About 5 million Americans over age 50 years are mild. to dry Eye disease is moderate.

In women aged 45 to 52, when menopause sets in general, an imbalance between estrogen and androgen hormone occurs because of Androgens decrease after menopause. Decrease in androgen levels excited inflammation in lacrimal gland and ocular surface, disruption of normal homeostatic maintenance the lacrimal gland and ocular surface.

The factors that have increased the frequency of dry eye can be told as under

a. Increase the population longitivity

b.increased consumption of drugs, both systemic and topical, may have adverse effects on the production of high have high-quality tears

c. increased use of a computer (Computer Vision Syndrome)

d. increased contact lens use and cosmetic surgery LASIK / LASEK

e better understanding and diagnosis of dry eye.

f may be distorted in the food / and environmental pollution.

g. Increased use of systemic and topical medications.

Tears COMPOSITION

The tear is found to together of three groups: albumin, globulin and lysozyme. The immunoglobulins found in normal tears are LGA, IgG and IgE. IgA predominates in the secretory form. IgE levels increased in patients with allergic conjunctivitis and IgM is found in tears of patients with acute infections. Lysozyme may act synergistically with LGA in the lysis caused by bacteria. Tears also contain lactoferrin, which has some antibacterial effect.

 

Tears: Vital Statistics:

 

• Average Glucose concentration of the tears is 2.5 mg / dl.
• Average tear urea level is 0.04 mg / dl.
• Electrolytes such as K, Na and Cl occur in higher concentrations in tears than in blood.
• Average pH of tears is 7.25.
• Osmolality 309 mOsm / l (hypertensive patients with dry eye syndrome).
• The surface tension of the tear film is 40-42 mN / m.
• Refractive index of the tear film is 1.336.

Under normal conditions, the tear Liquid forms a thin layer over the cornea and conjunctiva, which is known as the tear film in mind. The mind the tear film action 8 um thick and covers the cornea and conjunctiva epithelial surface.

The pre-ocular tear film acts as an important part of the eye muscles defense Mechanism.

1. It makes the cornea a smooth optical surface.
2. It helps to moisten the cornea and conjunctiva, preventing them from drying out.
3. He rinses the dirt and germs from the corneal surface.
4. It has bactericidal properties by the presence of lysozyme, lactoferrin and beta-lysine.

1. to defend immunoglobulins (LGA) and specific antibodies in the tears of the eye to external Infections.
2. Frictional trauma between the tarsal and bulbar conjunctiva and cornea is minimized by the lubricating effect of the tear film.
3. It enables the anti-inflammatory cells in the injured areas to reach the cornea and conjunctiva.
4. It offers the epithelial cells with glucose, oxygen and Growth factors.

 

 

Distribution System:

The distribution system for the tear film consists of the eyelids and the tear meniscus along the lid in the open eye. Each compressed blink the superficial lipid layer. The mucus layer acts as a lipid scavenger every pick with debris and carry it to the fornices. As the eyelid is open again, a new Tear-film layer spread over the surface of the eye. Inadequacy of any layer of the tear film instability and increases the speed can tear breakup time (BUT).

The system of distribution of the lids also acts as a pump mechanism to the tears in the excretory system to draw.

Excretory system:

Flashing is an important factor in crack distribution and also plays a crucial role in the drainage tear. Critical to the right lacrimal excretory function is the punctum, the entry point for the lacrimal system. Proper disposal of tear that the punctum are deposited around the globe.

Spontaneous flash fills the liquid film by a thin layer of fluid in the run-up the rims as they come together. The excess fluid is located in the lacrimal glands Lake a small triangular area in the angle of the innermost canalculi nasolacrimal duct bound on the run and then dewatered in nasopharynx and oropharynx could be swallowed.

The Drainage pathway can be up to 90% of the fate of tears account. The rest evaporates. Thus the act of flashing a wake-free action exercises in the elimination of violence, the tears in the lacrimal gland Lake and emptying them into the nasal cavity.

Functions of the Pre-ocular Tear Film

Traditionally, a tear film consists of three Layer

Outer lipid layer

It is formed by the oily secretion of the meibomian glands. It acts as a lubricant and prevents evaporation of tears.

Middle aqueous layer

It is the most important liquid released from lacrimal gland and accessory tear glands. It contains proteins, Immunoglobulins, lysozyme, lactoferrin and beta-lysine. It donates moisture to the eye, the nutrition of the cornea and antibacterial effect. It offers the epithelial cells with glucose, Oxygen and growth factors. He rinses the dirt and germs from the corneal surface and drains into the nasolacrimal canal.

Inner layer of mucus

The innermost layer of the mucosal tear film forms a highly hydrophilic wetting of the hydrophobic surface of epithelial surface of the cornea and conjunctiva. The Mucous membrane also reduces the surface tension between the lipid layer of the tear film and the water layer, and thus contribute to the stability of the tear film.

Recently, the concept of tear film

 

The modern concept of the tear film on the eye surface structure is that a metastable tear film consists of an aqueous gel with a gradient of decreasing mucin content of the eye surface, the underside of the outer Lipid layer. The latter structure interacts with the underlying aqueous and mucin components, retarding evaporation of watery tears, and helps to Stability of the tear film between blinks (Lemp, 1995).

 

 

Mucin layer

 

At least three different types of mucin have been identified: transmembrane mucins Cells produced by the conjunctiva, cornea, gel formation from the conjunctival goblet cells and soluble mucins mainly from the lacrimal gland. (Gipson et al, 2004). The transmembrane mucins contribute to the surface structure of epithelial cells, interaction with the gel-forming and soluble mucins of the tear film, to stabilize the film, and a way for the eyes flashing cleaning surface; lipid-mucin interactions between support relatively stable tear film.

Tear film not only provides lubrication and nutrition to the eye surface, but stable vision (Lemp, 2008). All tissues of the eye surface, secretary glands, Lids and drainage channels in the nasolacrimal pathway are unit-linked via a neural network (the lacrimal gland functional). sensory receptors monitor state of tears and cells, which send afferent signals to the central nervous system. This in turn sends efferent Impulses to the glands and secretary cells cause changes in the composition and volume in order to maintain the homeostasis upright and respond to stress and injury. Additional factors that support the tear film, ocular surface complex include bioavailability of hormones, especially androgens, and an intact immune system. This exquisitely balanced system is a very complex unit provides a visual access to the external environment. (Lemp et al, 2007). Disturbance of the element leads everyone to a collapse of the entire structure and function with significant clinical implications.

 

Pathogenesis of Dry Eye

 

It is a proven fact that any damage would be a tear duct decreased tear production. This leads to a reduced washout of the crack surface dirt and bacteria and the increased presence of inflammatory cytokines and Growth fell to obtain ocular surface integrity.

Almost all the tears flow is sent to a reflex mechanism by stimuli from corneal impulses to the brain and the lacrimal gland. Every thing that disturbs corneal sensations such as a hormonal imbalance that may contact lenses, LASIK or other injuries of the eye, it was surgically or accidental.

Infection of the lacrimal gland, it may be primary (dacryoadenitis) or immunological or prolonged because of rheumatoid arthritis Conjunctivitis can result in decreased formation of aqueous results. was identified as a result of inflammation, activation of matrix metalloproteinase enzymes (MMP-9), the surface has further potential to damage the eye des It is now accepted 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 caused by a background of to support androgenic hormones, inflammation and an intact corneal sensation that stimulates secretion by the lacrimal gland tears nourish and protect that prevents the eye surface to produce. When there is a disruption of normal homeostatic control, dry eye occurs either as an aqueous tear deficiency or Excess evaporation, with subsequent damage to the eye surface. This disease state creates a vicious circle of increasing inflammation of the lacrimal gland and ocular surface that further suppresses normal corneal sensation and leads not only to the tear, but to suppress further damage to the Ocular surface.

The aqueous deficient dry eye (keratoconjunctivitis sicca) is a disorder of the neuro-humoral interaction of the ocular surface, secretomotor interrupts nerve impulses to the lacrimal gland that results in inflammatory suppression of aqueous secretion, a necessary component of the tear film, with subsequent damage to the eye surface, producing symptoms of ocular irritation and discomfort. The evaporative dry eye is a Disturbance of the stability of the tearfilm that is normally by meibomian gland secretion anomalies or abnormal eyelid position and movement. Both types of dry eye damage affect on the ocular surface and symptoms of ocular discomfort and visual function.

Classification by Etiology

 

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

1. Age are related. Lacrimal secretion begins to decline after 30 Age years. At the age of 6o, we reach the boundary between production and demand. At the age of 90, almost all persons of dry eye.
2. Hormona l. At the age of menopause, almost every woman dry eye developed either mild or moderate. Recent research has shown that it is because the androgen levels in the Ovaries produced lowering. Men to develop dry eye associated with hormones with less frequency and intensity than women.
3. Pharmacological. There is negative impact on the production of tears by preservatives in Tear Drops used for a long period of time. Glaucoma patients are more susceptible to this Problem due to prolonged therapy.

Systemic medications such as antidepressants, antihypertensive, antihistamines, Anticholinergics, neuroleptics to angiolytics, antiparkinsonians, diuretics and hormones can cause dry eyes.

4 Immunological: I This is related to body autoimmune response in exocrine glands outside influence secretion as secretion of tears, saliva, sweat and vaginal secretions. Sjogren's syndrome are those in which patients the immune system attacks its own exocrine glands. Rheumatism, scarred, and erythema multiforme, pemphigoid can Sjogren's syndrome . Lead

5 infection. Conjunctival Chronic infection can affect mucus secretion leading to deficiency and infection of the lacrimal glands Mucin may influence aqueous secretion. Inflammation of the eyelids can influence oily secretion. Each component is affected if the disturbed tearfilm.

6 Hypo diet. Avitaminosis A and alcoholism, which leads to poor absorption in the intestine may cause for dry eye.

Traumatic 7: Any trauma to the eye, it may be accidental or surgical, can precipitate a dry eye. Major operations such as removal of tumors has etc to create more opportunities dry eye. may be even a cataract or glaucoma surgery phaco responsible to give dry eye symptoms, especially in older people.

 

 

8 Neurological.

a. Post LASIK. Lasik leads to the development of temporary dry eye in about 4 percent of patients. Wilson (2001) observes Rose bengal staining and punctate erosions without pre-existing dry eye, and she called neurotrophic epitheliopathy. He believes that this change attributed to the epithelium division by a significant number of afferent sensory nerves in the cornea during the formation of the flap and thus a disruption of corneal trigeminal brainstem facial lacrimal gland reflex arc, which affect both basal and stimulated tear production. The Lasik induced dry Eye tends to resolve within approximately 6 months. Laser in situ keratomileusis cause of dry eye symptoms in 50 percent of the eyes.

1. 1. Contact lens wear. Contact lenses, if worn for a long time affect corneal sensation and thus decrease tear secretion.

Hard and soft lenses cause corneal anesthesia semi highlighted. In addition, soft lenses absorb tears and tears cause hypertension, which further impact the corneal epithelium. Semi soft lenses also affects lipid layer of the tear film.

1. Defects glands. Responsible for water, Mucin and lipid secretions.
2. Inability to use tears. There are normal production of tears, cornea, but is incapable of it by the Use:
   1. Epitheliopathy or corneal dystrophy of the cornea, wet ability decreases.
   2. Due to lack lipid The lids are not the tears in circulation over the entire surface of the eye (lid paralysis, extortion, lagophthalmos)

B. Classification Based on the pathophysiology of tear film

 

1. Aqueous tear deficiency (ATD)
   1. Senile or idiopathic atrophy of the lacrimal gland
   2. Menopause
   3. Hypofunction of the lacrimal gland with autoimmune diseases such as Sjogren's syndrome

2 Lacrimal Surfactant (mucin) defects

1. Trauma to the conjunctiva
2. Vitamin A deficiency
3. Infections of the conjunctiva: trachoma, diphtheria
4. Pemphigoid, erythema, Stevens-Johnson Syndrome
5. Chemical, thermal, radiation injuries
6. Drug: sulfonamides, epinephrine

3rd Lipid layer Abnormality:

1. Chronic blepharitis
2. Acne rosaecea

4 Impaired lid function, or flashing

Neuropralytic lesions of the trigeminal nerve, Facial, Greater N. superficial petrosal etc.

5 epitheliopathy

The disease of the corneal epithelium

6th Other causes

1. Drugs
2. Screen equipment: Visual display terminal syndrome, computer vision Syndrome
3. Contact Lenses

 

 

Symptoms

Dry eye patients can present one of them or more symptoms occur:

Itching, burning, irritation, pain, Complaints foreign body sensation. It can cause pain and photophobia and visual disturbances, which improve with blinking. It is usually stringy stringy mucous discharge, the increase in the afternoon can. The discomfort in the eyes of the rule is growing while reading, watching TV, air conditioning (low humidity) or work on the computer. At times there may be more than irrigation, particularly in the wind. The main cause of discomfort in the eyes is increased electrolyte concentration in tears, to hyperosmolarity and subsequent damage to the eye surface.

All these symptoms are excessive in dry and windy weather. Patient has frequent need to remove mucous discharge from the eyes. Some of the patients give a typical story of desire often sprinkle water in the eye. The visual acuity can be significantly affected will be especially when corneal staining occurs. In early stages it may flash in mild blurring of vision, which requires frequent, resulting in ocular fatigue.

Signs

 

Tear Lake. Normally at are the lower lid margin, there are concave meniscus tears 0.3 to 0.5 mm, that is Lake Tear. In dry eye, it is usually less than 0.1 mm.

Debris. It is in ruins sank the lake could break. be Mucous threads (strings of mucous discharge seen).

Other characters. Redundant Conjunctiva, conjunctival injection of the vessels, and sometimes slight chemosis be present. In the fornix of the conjunctiva, the threads form the basis of a slow tearing and partly because the increased number of exfoliated epithelial cells. In advanced cases, the conjunctival and corneal dryness very well and can be associated with chronic Blepharitis and blepharospasm.

Staining.

1. Fluorescein stain. Fluorescein anyone can spot the area denuded corneal epithelium. The color is classified as 0,1,2 and 3. 0 = no corneal stain, 1 = 1 / 3 of the corneal epithelium stained, 2 = ½ the cornea, and 3 = strong staining of the corneal epithelium ½. The reduced wear on the lake could easily be assessed with fluorescein.
2. Rose Bengal Stain. Rose Bengal (1% solution or stripes) stains the damaged devitalized epithelial cells of the conjunctiva and cornea. It can detect even mild cases Keratoconjunctivis of Sicca (KCS) by staining of the conjunctiva palpabral in the form of two triangles with their base towards the limbus. Rose Bengal is stinging sensations but anesthetics it should not be used can lead to false results. Alcian blue has properties similar to Rose Bengal is not usually available.

3 Film Break Up Time. (TBUT)

It is a quantitative measurement of tear film stability. A deficiency leads to mucosal corrugation of the aqueous Tear around the small amount of available mucosa on the epithelial surface and reduce the TBUT. The test is the question of the patient for 10 seconds after instillation of fluorescein performed blink. Appearance of a dark spot (dry) before 10 seconds is abnormal. Mild to moderate dry eye patients are usually TBUT of 2-3 seconds.

Diagnosis.

Diagnosis is based on the most common complaint of patients without apparent reason in the eyes. Often, persistent Fishing ropy mucous discharge is very classic and so is the importance of the appeal of increased discomfort in dry and windy environment.

Diagnostic tests usually employed, as in

1. Schirmer test. The test is used for the quantitative determination of tear secretion by the lacrimal gland, before any other and should examine how the manipulation of the eyelid and the eye can be done to change the test results.

Shirmer I test. Used for the measurement of tear secretion rate without anesthesia.

Shirmer II test is similar Shirmer only one, but after the instillation of anesthetic drops.

After instillation of anesthetic drops, the amount of tear secretion is the closure of the basal rate as there should be no impetus from the filter paper in the lower conjunctival sac placed. A value of less than 5.0 mm is considered normal. The test is very often not convincing.

b Tear Function Index (TFI) to test. It is a specific and sensitive test for the quantitative measurement of tears. It takes into account the influence of wear drainage in the measurement of tears with Shirmer Test. Its numerical value is obtained by dividing the Shirmer II test value in millimeters of wear clearance rate. The higher the numerical value of the TFI, the better the surface of the eye. Values below 96 suggest dry eyes.

c Fluophotometery. There is another way to measure tear secretion. It uses the decay of sodium-fluorescein Measurement of the tearing and the crack volume. This test is expensive and not very informative.

d Tear osmolarity. It provides qualitative assessment the crack formation. The reference value is 312 mOsm / L. This value increases with the severity of dry eye.

e impression cytology, conjunctival and lateral Salivary gland biopsy used to diagnose the etiology of the disease process. In dry eye states, there is decrease the number of cells marked cups.

 

Classification of Dry Eye Syndrome:

Mild Dry Eye Syndrome: the test can be defined in Shirmer patients have a less than 10 mm in 5 minutes and less than one quadrant of the staining of the cornea

Moderate Dry Eye Syndrome:

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

Severe Dry Eye Syndrome: Can be defined as diffuse punctate or confluent staining of the corneal epithelium, often their threads. Schirmer's test in most cases less than 5 mm in 5 minutes. Sjogren's syndrome is classically associated with severe symptoms of dry eye.

  

 

 

 

Treatment

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Conservative

1. Patient information. Patient must be educated and fully informed of the disease as well as he has explained the limits are Medical information management. This keeps the patient's confidence in your line of treatment.
2. Controlling the environment. Particular emphasis must , Set to control the environment to minimize the severity of the disease.

a. Still Air Patients must avoid sitting in front of direct airflow of air conditioners, fans, windows or ventilators. It is better that the patient is sitting in front of the door into a room to be avoided. While moving car, the car must be closed window and the patient should use glasses. Car AC wind should blow not directly to the face.

1. Humid Air Even if there is no refractive error, the patient must wear glasses. Only by the wearing of glasses, the humidity between the eyes and the glasses increases by 2%. Glasses with side protection panels and moist chamber can be reserved for more serious cases . Remain Humidifiers are used in rooms. There is air conditioning available with attached humidifier.

Special glasses with wet applications Interventions improve symptoms of severe dry eye. The wet pages to increase the humidity, resulting in a decrease in the evaporation of tears surface of the eye. Another type of moist chamber is easier and less expensive to get goggles. The lowest offer of the relative humidity to minimize wear Evaporation is reported that 40% to 50%. Wet gauze mask is an alternative treatment method.

1. Pure Ai r. contaminated air is very harmful for dry eye patients. Palpabral aperture must remain open as little as possible. Closed windows in the car, a helmet with a shield while driving Roller and covering your eyes with goggles while riding a bike is some relief. While reading books, the book should be as close as possible to the chest, so that at least palpabral aperture have to be kept. While down, eye surface is exposed to the air only 1 square centimeter, whereas when looking straight ahead, 2.0 sq. cm. and while looking up, 3.0 sq. cm.

Computer Vision Syndrome. While I was the monitor, are on the eyes tend to the screen, making flash, flashes by about 6-7 stare for a minute. If the computer is on a higher level than the eye can see there is more evaporation of tears increased. To prevent computer vision syndrome, one has to keep the computer on the lower level as the eyes and a habit must be formed to flash at about 10-12 times per minute. At Work over a longer period, we must close the eyes for some time or on an artificial tears.

Medical Management

 

Artificial tears.

 

Artificial tears are the mainstay in the medical management of dry eye. Variety of artificial tears is available. Hypotonic non-viscous solutions hyper tone in dry eye syndrome and can counter up to two hours. Viscous solution containing cellulose as a base and thus longer. Preservatives added, to increase the durability and stability of the solution. The most commonly used preservatives include benzalkonium chloride, thiomersal, and Chlorhexidine. Despite their low concentration, they can produce toxic effect on the cornea and conjunctiva and affect the dry eye condition.

Preservative Drops

The use of eye drops preserved and recently preservatives that are transient or non-toxic compounds quickly oxidize in air and surface of the eye, has become routine for patients who are more than three or four drops of lubricant per day. The tear supplements are on the maintenance a hypotonic collyrium with normalization of electrolyte concentration for the control of harmful effects of hyper-focused tone.

In India, tear down this non-reactive are marketed as substitutes:

Refresh Tear Drops (Allergan) It contains carboxymethylcellulose sodium 5 mg with stabilized Oxychloro Complex 0.05 mg. (Purite)

Gen Teal drops and gel (Novartis) It contains 0.3% hydroxypropylmethylcellulose stabilized with H2O2.

            Eyemist Drops (Avesta) It contains hydroxypropylmethylcellulose

Cellulose with 0.3% stabilized Oxychloro Complex 0.005%.

Tear Drops (Milmet) Contains sodium carboxymethylcellulose 5.0 mg Oxychloro complexes with stabilized 0.005%)

Celluvisc 1% (Allergan) It contains carboxymethylcellulose

1 percent.

Liquigels Refresh (Allergan) It contains carboxymethyl

Cellulose Sodium 1%.

1. Hyvisc 0.1 and 0.18 percent sodium hyaluronate more than reassuring to the conjunctival epithelium. It has Ph of 7.3. Increases TBUT and AIDS cure superficial keratitis.

Ocumoist, Ecotear, Lubrex, Aquaray, Vel Drops, CMC, my tears, Tear Drops, Flogel, Moisol-Z are some of the other drops of preservative-free.

Systane (Alcon) contains polyethylene glycol and propylene glycol.

Imported tear substitutes

Refresh PM (Allergan)

Viscous gel Tear (Ciba)

Tears Naturale Free (Alcon)

Bion Tears (Alcon)

Lagricel Ofteno (Sophia Laboratories) it contains sodium

Hyaluronate.

Mini Hyalein 0.1% and 0.3% Hyalein Mini (Santen

Japan) contain hyaluronic acid.

Refresh Endura drops (Allergan). It is lipid emulsion, the tear evaporation and reduce the tearfilm stabilize, thereby reducing the frequency of tear instillation.

                      Artificial tears are instilled in the eyes of days 3 to 6 times,

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

Liquigels Celluvisc or before bed is learned.

Androgens

The role of androgens as therapy is not well established although it it is known that in women, the absence of androgens play an important role in the etiology.

News seems androgenic supplementation of artificial tears the osmolarity of the patient, either by retarding evaporation, lower tear or possibly stimulating tear secretion. This gives an indication that the Add androgenic hormones, artificial tears may benefit patients with dry eyes.

Tear Stimulants

The use of oral or sublingual pilocarpine (Salagen, MGI Pharma) has proven useful in some patients, but has systemic side effects of sweating, and gastrointestinal disorders associated. Cevimeline (Evosac, Daiichi Pharmaceuticals, Inc) stimulate tear secretion and saliva also can and will be better tolerated than pilocarpine.

Systemic administration of bromhexine congeners were tried in Europe, with unsatisfactory results.

Recent studies of purinergic P2Y2 agonist, the phase three studies achieved in the U.S.. The drug called diquafosol tetrasodium (Inspire Pharmaceuticals, USA) was very well tolerated and increased tear film volume and mucin content. The pharmacological Effect of the fluid transport is to increase the conjunctiva and to promote mucin release from goblet cells.

Cyclosporin A

 

In view of the immunological aspect of the disease, cyclosporine A in the form of topical drops (0.05% and 0.1%) is in moderate to severe form of DES used to treat inflammation of the ocular surface and lacrimal gland. The drops are instilled twice a day, and observed the positive results are within four minutes six months ago. The drug can be used for life. Cyclomune is an immunomodulator. It selectively suppresses lymphatic functions involved in suppressing a disease without actually the entire immune system. It inhibits T-helper cells, which is known to cause inflammation of the eye surface and cause lacrimal glands in patients with dry eye. The main indication for the use of land is Cyclomune staining of the cornea. Instillation of the drops is stinging sensations that diminish gradually.

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

Omega 3 fatty acids (Omecard) or Cap. CSNnbsp, given orally, said the dependence of Tear substitutes reduce. Fish to eat dry relatively resistant to the eye. Cod liver oil can be useful.

Meibomitis.

A recent study in the U.S. has shown that about 38% of patients with dry eye meibomian gland competing commitment. (Mathers MD 2000). Hot moist compresses, betadain exfoliation, massage and lower eyelid oral tetracycline or doxycycline treatment of meibomian inflammation. Tetracycline is effective as an antibacterial and it makes the oily secretions and hence it is more fluid flows freely from meibomian glands. Tetracycline is 2 hours before meals given in divided doses. It is 500 mg given as capsules BD

Topical steroids (soft steroids)

 

  Topical steroids are trying Etabonat in some of the resistant or advanced cases of dry eye, or in patients who loteprednol have severe itching. 0.2% is a good choice for long-term use. It is soft steroid that is activated by enzymes as it passes through the cornea. It seems very have little effect on IOP. It is marketed as Alrex (0.2%) Bausch & Lomb and as Lotepred Drops 0.5 percent of Sun Pharmaceutical in India.

Immunosuppressive therapy

In advanced cases of DES, systemic cyclosporin A, prednisolone, methotrexate, infliximab may have to be given.

 

Lasik Dry Eye Induced

 

Clinically, post-LASIK patients may show punctate epithelial erosions and rose bengal staining of the flap. (Malum Epitheliopathy). All cases of Lasik has tear will be made to the generous use of preservatives replacement continued drops immediately after the operation and for a period of 4 to 6 months. It is noted that almost all cases recover within six months. Only a few patients even before symptoms of dry eye the operation may require timely plugs.

Mucolytics.

We have 5 percent drop acetylcysteine Recommended instillation of four times a day. It is effective in the eyes with excessive mucus.

Future therapies.

Apart from tear substitutes, anti-inflammatory therapy, androgen hormone replacement therapy and tear stimulant can make diquafosol tetrasodium most important therapeutic measures. Herbal Supplements as oil of evening primrose and flax seed oil as reported, that Meibomitis will help in alleviating the symptoms of dry eye and. Essential fatty acids of omega-3 and omega-3-specific category as a food supplement show some promising results.

 

Surgical Management

1. Canalicular Handicap Punctal plug

It is a simple procedure that takes the tear drainage and improves the qualitative and quantitative component of tears. A decrease in the osmolarity of the tear is noted. Improvement is Shirmer and TBUT test can be seen.

Various methods of punctal occlusion also soluble collagen stent, cyanoacrylate adhesive, silicone or Teflon removable plugs, sockets or intracanalicular been described. The recently approved Innovation Smart Plug (Medennium Inc) that is a polymer that thermolabile when inserted into the canaliculus equal to the diameter of the tube to produce occlusion.

Canalicular block is obtained by inserting a silicon plug into the puncta. There are two types of connectors:

1. Punctal Plug A. This is part of the plug visible on the puncta
2. Punctal connector is located entirely within the canalicular canal. (Herrick plug)

Nearly 75 percent of the patients, the plug is well tolerated. In some patients we can remove the plug. The usable variety from the tube be removed by irrigation of the canal with saline solution.

1. Canalicular obstruction by cautry. Puncta can temporarily thermal or cautry diathermy or argon laser can be blocked. An argon laser focused on the punctal surface overheating and destroys the punctum. (Results not reliable)
2. Punctal Patch Technique This is the most effective surgical technique for permanent occlusion of the lacrimal system. This technique is a raw area created surrounding the upper and lower puncta. A piece of bulbar conjunctiva are removed and transplanted to the wound punctal with its raw surfaces in contact with the cover and sutured to it with four 9th 0 stitches.

Summary

Dry Eye Disease seems to be increased due to multiple Factors. Despite great progress in the understanding and diagnosis of the disease, the disease remains a challenge for physicians. Preservative-free drops have significantly improved the quality of life of patients dry eye. Anti-inflammatory therapy, androgen hormones and stimulants tear, namely diquafosol tetrasodium and probably some herbal drugs hold great hope for a DES patients. Cyclosporine proved to be a blessing for the management of moderate to severe, dry eyes.

ILLUSTRATIONS

Fig See all components of the Secretary Lacrimal System. Fig ads damaged tear film.

Dry Eye View Rose Bengal staining

Fig Tear film shows three layers of tears.

Use goggles when dry eye condition

Further Reading

Foulks GN, the Eye, Part I: Understanding the epidemiology and pathogenesis. Highlights of Ophthalmology. Vol.31 (1) 2003, 21-26 Pg

Boyd BF New Horizons in the relief and control of Dry Eye Vol 29 (5) 2001 Pg 55-65

Bairagi D Dry Eye Syndrome. Sight, Mediworld Year 2004 Pg 6-10

Symposium on Paradigm shift in diagnosis and treatment of dry eye. World Eye View July 2004. Pg2-11.

Pflugfelder SC: Anti - inflammatory Treatment of dry eye. The surface of the eye in 2003: 1: 31-36

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

Murube J, Tsubota K: Dry Eye: What is the understanding of its nature and its effective management new? Highlights Summary Journal of Ophthalmology Vol 24, No 5, 1996.

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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

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