Dry Eye

Question 1

what is dry eye disease?

Answer 1

a multifactorial disease that results in symptoms of discomfort, visual disturbances, tear film instability

Question 2

what are some subjective (symptoms)?

Answer 2

dryness, red eyes, general irritation, gritty sensation, burning, FB sensation, excessive tearing, light sensitivity and blurred vision

Question 3

what is a subjective test that you can give patients and what is a normal score?

Answer 3

Ocular surface disease index survey (OSDI) = normal is less than 13 points

Question 4

what is the TearLab test?

Answer 4

an objective test = measures osmolarity or saltiness of tears

Question 5

what is a normal result for the TearLab test?

Answer 5

308mOsm/L or less

inter-eye difference of less than 8mOsm/L

Question 6

what are some external observations that can be associated with dry eyes?

Answer 6

objective - lagophthalmos, ectropion, pterygium, blepharitis, meibomitis

Question 7

what are some signs of anterior blepharitis?

Answer 7

collarettes, increased vascularization, trichiasis, irregular lid margin

Question 8

how do you grade meibomitis (posterior blepharitis)?

Answer 8

based on expressibility = percentage of glands secreting and secretion quality (clear vs. white/thick)

Question 9

what is a normal result for TBUT?

Answer 9

objective test - 10 seconds or longer

Question 10

what is a normal tear meniscus height?

Answer 10

0.2mm and convex shape (concave is abnormal)

Question 11

what is a normal schirmer I result?

Answer 11

objective - more than 15mm in 5 minutes

Question 12

what are 3 non-specific tests used in assessment of dry eye?

Answer 12

OSDI, TearLab, and external exam

Question 13

what are 2 tests used for aqueous deficient dry eye?

Answer 13

schirmer and TMH

Question 14

what are the 2 layers affected in aqueous deficient dry eye?

Answer 14

aqueous and mucin

Question 15

what are the 2 categories within aqueous deficient dry eye?

Answer 15

sjogren syndrome dry eye and non-sjogren dry eye

Question 16

what are some causes of non-sjogren dry eye?

Answer 16

lacrimal deficiency, lacrimal gland duct obstruction, reflex block or due to systemic drugs (antihistamines, beta-blockers, diuretics, antidepressants)

Question 17

what is the test used to test for evaporative dry eye and which layer is affected?

Answer 17

TBUT and lipid layer

Question 18

what are some intrinsic causes of evaporative dry eye?

Answer 18

meibomian oil deficiency, disorders of lid aperture, low blink rate, Accutane

Question 19

what are some extrinsic causes of evaporative dry eye?

Answer 19

vitamin A deficiency, topical drug preservatives, CL’s, ocular surface disease (allergy)

Question 20

what is sjogren’s syndrome?

Answer 20

a chronic inflammatory disorder where the lacrimal and salivary glands are involved

Question 21

what is a major long-term concern in sjogren’s syndrome?

Answer 21

lymphoma - NHL risk is 5% (16-44 times higher than normal population)

Question 22

what ocular feature is needed to make a sjogren’s diagnosis?

Answer 22

keratoconjunctivitis sicca with ocular staining score 3 (fluorescein and lissamine green)

Question 23

what is the level 1 plan for dry eye treatment?

Answer 23

education, environmental/dietary modifications, elimination of systemic medications, artificial tears, gels/ointments, and eyelid therapy

Question 24

what are some environmental modifications?

Answer 24

minimize stressors, add humidifier, avoid air conditioning/fans, lower monitors below eye level, add periodic breaks while reading

Question 25

what are some dietary modifications?

Answer 25

decrease omega-6 and increase omega-3

Question 26

what is the level 2 plan for dry eye treatment?

Answer 26

anti-inflammatories, tetracyclines (meibomianitis, rosacea), punctal plugs, scretogogues, and moisture chamber specs

Question 27

what is the level 3 plan for dry eye treatment?

Answer 27

serum, CL, permanent punctal occlusion

Question 28

what is the level 4 plan for dry eye treatment?

Answer 28

systemic anti-inflammatories, surgery (lid surgery, tarsorrhaphy, mucus membrane, salivary gland, amniotic membrane transplants)

Question 29

according to the treatment flowchart - what are you supposed to start with when treating dry eye?

Answer 29

CMC (Refresh optive, Liquigel), HPMC (GenTeal), Hyaluronic acid (Blink)

Question 30

what do you use when the patient is resistant to CMC, HPMC, and Hyaluronic acid?

Answer 30

need stronger active ingredients = PEG 400 or PG/Glycerin

Question 31

if symptoms persist after using PEG 400 or PG/Gylcerin what do you turn to?

Answer 31

gel/lipid formulations and increase the frequency and length of therapy (at least 60 days)

Question 32

what are some ancillary options when gel/lipid formulations do not seem to work for dry eye?

Answer 32

prescription medications, ointments, liposomal sprays, prescription inserts

Question 33

what type of eyelid therapy do you use for anterior blepharitis?

Answer 33

topical antibiotic ointment - erythromycin or bacitracin QHS OU

Question 34

what type of eyelid therapy do you use for posterior blepharitis?

Answer 34

(Meibomitis) = warm compress and lid massage

Question 35

what are 3 treatment options for evaporative dry eye?

Answer 35

eyelid therapy, anti-inflammatories, oral tetracyclines

Question 36

what do oral tetracyclines treat when prescribed for evaporative dry eye?

Answer 36

treats meibomitis, reduces lid and conjunctival bacteria, decreases keratinization and bacterial lipase production, reduces matrix metalloproteinase activity

Question 37

what are 2 treatment options for aqueous deficient dry eye?

Answer 37

anti-inflammatories and punctal plugs