1. DRY EYE:
AN OVERVIEW
Dr.Gayatree Mohanty
Dept. of Ophthalmology, KIMS

2. DRY EYE
Occurs when
 Inadequate tear production
 Inadequate function
Results in Unstable Tear Film and
Ocular Surface Disorder.

3. TEAR PRODUCTION &
TEAR FUNCTION
Healthy tear film Dry eye

4. TEAR PRODUCTION
 Secreted by the
lacrimal glands
 Spreads over the
ocular surface
 Drained the
lacrimal canaliculi
into the
nasolacrimal duct.

5. TEAR FILM
• Lipid layer (meibomian
glands in the eyelid):
Outermost surface of the
tear film; 0.1um
• Aqueous layer (lacrimal
gland): Middle layer; 7um
• Mucus layer (goblet cells
of conjunctiva): Inner
most; 0.2um.

6. FUNCTIONS OF THE TEAR
FILM
• Lipid layer: Prevents evaporation of tears and acts as an
surfactant allowing spread of the tear film.
• Aqueous middle layer: Provide atmospheric O2 to the
corneal epithelium; Antibacterial
activity(Interleukins, lysozymes, IgA & lactoferrin);
Cleanses the eye and washes away foreign particles or
irritants; Provide a smooth optical surface to cornea by
abolishing the irregularities.
• Mucus layer: Allows the watery layer to spread evenly over
the surface of the eye and helps the eye remain moist.

7. FACTORS AFFECTING THE
SPREAD OF TEAR FILM
Normal lacrimal
neural arc.
Contact between
the ocular
surface & the
eyelids
Normal corneal
epithelium.

8. OCULAR SURFACE
Conjunctival
epithelium
Limbal Epithelium
Corneal
epithelium
Eyelids
(Mucocutaneous
junction)

9. ETIOPATHOGENESIS
Aqueous tear deficiency
Sjogren’s Dieseases
Non-Sjogren’s Diseases
Lipid tear deficiency
Mucin deficiency
Kinetic disorders of lacrimal fluid

10. SJOGREN’S SYNDROME
 Autoimmune inflammation of the
lacrimal glands and the salivary
glands.
 Primary or Secondary
(RA,SLE, Systemic sclerosis, primary
biliary cirrhosis, chronic active
hepatitis, myasthenia gravis etc)
 Most common symptoms are dry eyes
and dry mouth.

12. COMMON NON-SJOGREN’S CAUSES
 Vitamin A deficiency,
 Stevens Johnson syndrome and
 Ocular Cicatricial Pemphigoid (OCP).
Affects the inner mucous layer of the tear film and
prevents the natural tear film from adhering to the
eye.
 Prolonged computer hours: Evaporative dry eye
 Allergic conjunctivitis: Altered tear function due to
conjunctival & limbal inflammation.

13. VITAMIN A DEFICIENCY
Xerosis of the
conjunctiva
resulting in
goblet cell
destruction &
mucin layer
deficiency.

14. STEVEN JOHNSON SYNDROME
 Mucocutaneous vesicullobullous
disease.
 MC Drugs: Sulfa
drugs(Acetazolamide), Penicillin, Barb
iturates, Salicylates
 Acute vasculitis affecting conjunctiva
& other mucous membranes.
 Membranous muco-purulent
conjunctivitis leading to scarring of
conjunctiva & lid margin.
 Destruction of meibomian
glands, conjunctival goblet cells &
limbal stem cells.

15. OCULAR CICATRICIAL PEMPHIGOID
 Autoimmune muco-
cutaneous blistering
disease.
 Cicatrization of the
conjunctiva & lacrimal
ductules result in both
mucin layer & aqueous
layer deficiency of tear
film.

16. COMPUTER VISION SYNDROME
 Variety of vision related
symptoms that may be
aggravated by regular
use of a computer for
two or more hours a
day.
 Reduced blinking
leading reduced
spreading of fresh tear
film results in dry
eye, blurring of
vision, red
eye, watering &
asthenopia.

17. ALLERGIC CONJUNCTIVITIS &
VERNAL KERATOCONJUNCTIVITIS
 Recurrent inflammation
of conjunctiva & limbus
leading to cicatrization
and mucin deficiency
dry eye.
 Rubbing of the eye
causes meibomian
gland disease causing
lipid deficiency dry eye.

18. MEDICATIONS CAUSING
DRY EYE
•Diuretics
• Beta-blockers
• Antihistamines
• Sedatives
• Anti-Anxiety medications
• Analgesics

19. LIPID LAYER DEFICIENCY
 Blepharitis,
 Meibomitis and
 Rosacea.
Affect the outer lipid layer of the tear
film, causing excessive evaporation
of the natural tears from the eye.

20. CLINICAL FEATURE:
SYMPTOMS
 Burning sensation
 Foreign body sensation (exaggerates
over the day)
 Stringy mucus discharge
 Transient blurring of vision
 Redness
 Difficulty wearing contact lenses
 Crusting of the lids

21. CLINICAL MANIFESTATION:
SIGNS
 Tear meniscus at the
inferior eye lid margin
<1mm.
 Tear Breakup Time <10sec
 Punctate corneal &
conjunctival fluorescein.
Rose bengal staining esp.
inferiorly & interpalpabral
area.
 Excess mucus & debris in
the tear film & filaments on
the cornea.

22. WORK-UP
 History with external examination
 Slit lamp examination with Fluorescein stain to
examine TBUT, Conjunctive & Cornea.
 Schirmer’s test:
Schirmer filter paper placed at the angle of middle &
lateral 1/3rd of the lower lid in each eye for 5 min.
Schirmer I: Unasthetized; Basal+reflex; N:15mm/5min.
Schirmer II: Anaesthetized: Basal; Abnormal:
5mm/5min.

23. TREATMENT
Increase tear film volume:
 Artificial tears(Carboxymethyl
Cellulose/ Hypromellose)
 Temporary insertion of punctal plugs
Improve Lubrication:
 Artificial Tear Substitutes
To break the sticky mucin:
 Acetylcysteine

24. TEAR SUBSTITUTES
Cellulose derivatives: Carboxymethyl
cellulose 1%, Hypromellose 0.5%
Carbomers(Polyacrylic acid)
Polyvinyl alcolhol, Povidone, sodium
Hylauronate
Lipids & Oil:
Acetylcysteine 5% with
Hypromellose.

25. TREATMENT
Improve Corneal epithelium (In
severe dry):
 Artificial Tear Substitutes in gel form
with pad & bandage
 Bandage contact lens
 Amniotic membrane grafting
 Limbal stem cell transplant

26. TREATMENT
 Reduce Evaporation:
 Protective glasses
 Reduce room temperature with humidifier.
 Lipidic artificial tear substitutes
 Lid massage for mechanical expression of
the meibomian gland expression
 Lateral tarsorrhaphy
 For Computer vision syndrome:
 Computer screen should be 15 to 20 degrees
below eye level.
 Use of anti-glare screen.

27. TREATMENT
 Treatment of Lids:
 T/t of Blepharitis: Lid hygiene, Lid massage,
Doxycycline 100mg BD
 Control of Inflammation:
 Topical steroids
 Topical cyclosporine A 0.5% BD
 Supplement Growth Factors: To increase
goblet cell expression & improvement of ocular
surface.
 Autoserum Eye Drops

28. DEWS CLASSIFICATION

29. DEWS RECOMMENDATION OF
TREATMENT
Level 1 treatment consists of the following:
 Education and environmental or dietary
modifications
 Elimination of offending systemic medications
 Preserved artificial tear substitutes, gels, and
ointments
 Eyelid therapy
.

30. DEWS RECOMMENDATION OF
TREATMENT
If level 1 treatment is inadequate, level 2
measures are added, including the following:
 Nonpreserved artificial tear substitutes
 Anti-inflammatory agents
 Tetracyclines (for meibomitis or rosacea)
 Punctal plugs (after inflammation has been
controlled)
 Secretagogues
 Moisture chamber spectacles

31. DEWS RECOMMENDATION OF
TREATMENT
If level 2 treatment is inadequate, level 3
measures are added, including the following:
 Autologous serum or umbilical cord serum
 Contact lenses
 Permanent punctal occlusion
 If level 3 treatment is inadequate, level 4
treatment, consisting of the administration of
systemic anti-inflammatory agents, is added.

32. CONCLUSION
 Dry eye complaints are a frequent
presentation at Ophthalmic OPD due our
current environment, pollution & life style.
 Prevalence(DEWS):35%
 The management of Dry Eye is simple if
diagnosed early but tedious and difficult as
the severity of the dry eye increases.
 Any patient with C/o red eye, grittiness, FB
sensation & photophobia along with
predisposing factors should be referred to the
Eye clinic for further management.

33. REFERENCE;
 2007 Report of the International Dry Eye Workshop
(DEWS). The OcularSurface. 2007;5:65-204.
 Systemic Approach to Clinical Ophthalmology.
Kanski. 6th edition,2008.