Dry Eye Disease

Question 1

most current dry eye definition

Answer 1

dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles

Question 2

two main types of dry eye

Answer 2

• evaporative (~80%)

- aqueous deficient (~20%)

Question 3

two layers of tear film

Answer 3

• lipid layer: superficial layer, 42 nm thick

- mucoaqueous gel layer: mix of mucin and aqueous layers, 2-6 um thick

Question 4

evaporative dry eye

Answer 4

excessive water loss from the exposed ocular surface in the presence of normal lacrimal secretion

Question 5

intrinsic causes of evaporative dry eye

Answer 5

• MGD (posterior blepharitis); most commonly*
• disorders involving lid aperture and lid apposition
• low blink rate

Question 6

extrinsic causes of evaporative dry eye

Answer 6

• vitamin A deficiency
• topical drugs and preservatives, oral drugs
• CL wear (approx 50% of CL wearers report DES)

Question 7

aqueous deficient dry eye

Answer 7

due to failure of lacrimal tear secretion secondary to destruction of acinar cells or dysfunction of acinar cells (inflammation vs. infiltration); this leads to an increased tear film hyperosmolarity secondary to reduced tear “water” production in the environment of normal tear film evaporation; tear film hyperosmolarity leads to hyperosmolarity of the corneal epithelial cells, stimulating a cascade of inflammatory events

Question 8

causes of aqueous deficient dry eye

Answer 8

• Sjogren’s syndrome
• primary lacrimal gland deficiencies
• secondary lacrimal gland deficiencies
• obstruction of the lacrimal gland ducts
• reflex hyposecretion
• exposure to systemic drugs

Question 9

Sjogren’s syndrome

Answer 9

• a systemic chronic autoimmune disorder of the exocrine glands with associated lymphocytic infiltrates in affected glands; involvement of the lacrimal and salivary glands leads to the classic symptoms of dryness of the eyes and mouth
• frequency of MGD is greater than in normal population
• average delay in getting diagnosed is approx 10 years
• patients may experience extreme fatigue and joint pain and have a higher risk of developing lymphoma (~10% develop lymphoma)

Question 10

dry eye symptoms

Answer 10

• redness
• dryness/watering
• burning
• FB sensation (“trash”)
• blurred vision
• allergies
• progression throughout the day
• associated work environment (computer use, air conditioned building)

Question 11

Ocular Surface Disease Index

Answer 11

12 question quiz that scores patient’s dry eye symptoms/complaints to a severity scale

Question 12

dry eye signs

Answer 12

• visual acuity
• anterior blepharitis
• demodex
• posterior blepharitis/MGD
• lid laxity
• punctal apposition
• intra-palpebral fissure height
• papillae
• conj staining
• osmolarity testing: TearLab, Tear Osmometer
• tear quantity: prism height, Schirmer testing, phenol red thread test
• tear quality: TBUT
• inflammatory assessment: InflammaDry
• corneal staining
• lacrimal gland evaluation (not done commonly)

Question 13

some common conditions to consider when evaluating patients with dry eye syndrome

Answer 13

• rheumatoid arthritis
• DM
• thyroid
• acne rosacea

Question 14

labwork to consider in select dry eye cases

Answer 14

• CBC w/ diff
• blood glucose and A1c
• thyroid panel
• autoimmune markers (ANA, RF, anti-CCP, SSA/SSB, ESR, ACE)
• Sjo test

Question 15

dry eye treatment options

Answer 15

• modifiable environmental changes
• artificial tears
• lid scrubs
• warm compresses (includes LipiFlow, iLux)
• intense pulsed light
• meibomian gland probing or manipulation
• moisture shields and goggles
• topical steroids
• topical antibiotic
• oral tetracyclines
• omega-3/fish oil
• immunosuppressants: Restasis, Cequa, Xiidra
• punctal plugs
• TrueTear
• contact lenses
• amniotic membranes
• autologous serum
• tarsorrhaphy