3 Dry eye disease

Question 1

DED key features:

Answer 1

Loss of tear film homeostasis
Visual disturbance
Hyperosmolarity
Ocular surface inflammation

Question 2

DED definitions

Answer 2

multifactorial disease of ocular surface by loss of homeostasis in tear film, accompanied by ocular symptoms of tear film instability, hyperosmolarity, surface inflammation / damage, and neurosensory abnormalities.

Question 3

Causes of ADDE:

Answer 3

Sjogren’s (primary/secondary), lacrimal deficiency, lacrimal duct occlusion, reflex block, systemic drugs (antidepressants, birth control, pain killers)

Question 4

Causes of EDE:

Answer 4

most common DED
Intrinsic: meibomian oil def. lid def. low blink rate, drug action Accutane(acne medication)
Extrinsic: Vit A def. Topical drug preservatives, CL’s, ocular surface disease (allergies)

Question 5

Sjrogren’s on dry eye

Answer 5

Autoimmune disorder against lacrimal gland (and salivary) decreasing secretion (ADDE) and slight MGD (EDE). 
Occurs independently (primary), or with (secondary) disorder: 
RA, systemic lupus/sclerosis

Question 6

DED treatment options:

Answer 6

Artificial tears (variable viscosity agents)
Punctal occlusion (plug or surgery)
Moisture chamber
Oral secretagogues (increase either aqueous/lipid/mucin secretion)
Lid hygine (blepharitis DED)
CL's (soft bandage/Ridgid tear holder)
Lid surgery (age dermatochalasis/blapharoptosis)
Gland transplant (salivary to lacrimal)

Question 7

Viscosity agents in dry eye drops and purpose:

Answer 7

Carboxymethyl cellulose (1%), Moderate DED. binds to epithelial cell for healing.
Hydroxypropyl methylcellulose (0.5%), Mild DED.
Hyaluronic acid (3%), present in aqueous/vit. Humor. Binds to epithelial
Hydrocypropyl-guar (0.3%), in systane ultra
Hydroxypropyl cellulose, Slow release

Question 8

Corticosteroids in eye drops and purpose:

Answer 8

Anti-inflammatory, cytokine suppression, to escape the vicious cycle
Methylprednisolone (1%), 4 times a day for 2 weeks
Flurometholone (0.1%),
dexamethasone (0.1%), increased iop
Prednisolone (0.1%), conjunctivitis

Question 9

Corticosteroid complications:

Answer 9

Ocular hypertension, cataracts, infections,

Question 10

Preservatives and their effect in dry eye

Answer 10

Benzalkonium chloride
Epithelial cell apoptosis, corneal nerve damage / poor wound healing, decrease tear film stabilit and decrease goblet cell density.
Pres. Free drops decrease inflammation and increase antioxidant levels

Question 11

Punctal occlusion contradictions:

Answer 11

CL’s, surgery, ADDE secondary to systemic disease (autoimmune), systemic medications for tear film, ocular surface instability/damage.
Can leads to plug extrusion, infection

Question 12

Oral secretagogues:

Answer 12

Pilocarpine, cevimeline, cholinergic agonists. Sjrogrens and autoimmune treatment.
Muscarinic acetylcholine receptor agonist, counters antibody assault on receptors.

Question 13

Lid hygiene for DED

Answer 13

For MGD and blepharitis

Scrub, massage, antibiotics (fusidic acid), tea tree oil, antiparasitic (ivermectin)

Question 14

MGD treatments:

Answer 14

Lipid eye drops, warm compress, moisture chamber, massage, forceful expression

Question 15

Dietary modifications for DED

Answer 15

Hydration, essential fatty acids (omega 3), antioxidants

Question 16

Systemic medications increasing risk of DED:

Answer 16

Antihistamines, beta-blockers, antidepressants, diuretics, chemotherapy

Question 17

DED management process

Answer 17

Questionnaire, risk factor analysis, diagnostic tests, subtype classification (ADDE/EDE and severity 1-4)

Question 18

DED treatment severity level 1

Answer 18

Education of DED/diet, local environment change, systemic drug elimination, eye drops (lipid for MGD), lid hygiene/compress

Question 19

DED treatment severity level 2:

Answer 19

Preservative free drops, tea tree oil for demodex, punctual occlusion / moisture chamber, ointments, short term topical antibiotic/steroid/secretagogue.

Question 20

DED treatment severity level 3:

Answer 20

Oral secretagogue, serum drops, soft bandage/ridgid scleral CLs

Question 21

DED treatment severity level 4:

Answer 21

Topical corticosteroid long term, membrane graft (damaged cornea), surgical punctal occlusion, surgical transplant/lid)

Question 22

Surgical treatment for DED:

Answer 22

Tarsorraphy, closure of eyelids (suture/tape)
Conjunctivochalasis cauterization (excess conjunctiva removal)
Blepharoplasty, removal of dermatochalasis (excess eyelid) / blepharoptosis (low eyelid)
Membrane graft, bandage damaged epithelia of cornea/conjunctiva
Salivary transplant/gland transposition

Question 23

Cyclosporine treatment

Answer 23

Immunomodulatory / anti-inflammatory fungal product, 0.1% emultion inhibits IL-2 lymphocyte activation.

Question 24

Presenting complaint for dry eye:

Answer 24

Gritty, burning, foreign body, watery, blur, photophobia

Question 25

DED risk factors:

Answer 25

Age, lid abnormality, females, pterygium, sjrogrens, TED, estrogen (birth control), ocular surgery, corneal anaethesia. Asian, blink rate, CLs, environment, smoking, makeup, low fatty acid diet.

Question 26

Liquid production of tear layer (glands/constitution)

Answer 26

Lipid - Meibomian in tarsal plate: cholesterols/esters Aqueous - lacrimal gland (ion/water/protein): lysozyme (Amicrobial), IgA (immunoglobin) Mucous - Goblet cells: MUC1/4/16 (membrane bound glue to glycocalyx to epithelium)

Question 27

The vicious cycle

Answer 27

Hyperosmolarity > inflammation (proteases/cytokines) > goblet/epithelial damage > tear film instability > reduced TBUT > hyperosmolarity