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Common Ophthalmic Conditions in Primary Care - Management of Dry Eyes

Common Ophthalmic Conditions in Primary Care - Management of Dry Eyes. Mr Yajati K Ghosh FRCSEd Consultant Ophthalmic Surgeon Birmingham & Midland Eye Centre. Affiliations. BMI Droitwich BMI Priory , Edgbaston Spire Parkway, Solihull. Subspeciality interests. Lid and lacrimal surgery

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Common Ophthalmic Conditions in Primary Care - Management of Dry Eyes

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  1. Common Ophthalmic Conditions in Primary Care - Management of Dry Eyes Mr Yajati K GhoshFRCSEd Consultant Ophthalmic Surgeon Birmingham & Midland Eye Centre

  2. Affiliations • BMI Droitwich • BMI Priory, Edgbaston • Spire Parkway, Solihull

  3. Subspeciality interests • Lid and lacrimal surgery • Periocular cancer surgery • Phacoemulsification Cataract surgery • Management of watery eyes

  4. Common Ophthalmic Conditions Red Eye • Blepharitis • Conjunctivitis • Dry eyes • Watery eyes • Foreign body • Keratitis • Uveitis • Lumps & Bumps • Cataracts

  5. Blepharitis

  6. Conjunctivitis

  7. Dry eye

  8. Watery eye

  9. Foreign body

  10. Keratitis

  11. Uveitis

  12. Cataracts

  13. Lumps & Bumps

  14. What to do? 50% of ALL red eyes and irritable eyes are due to Dry Eye related conditions ………..

  15. Overview http://www.virtualcancercentre.com

  16. Roles and Characteristics of the eyelids • Eye protection • Regular blink: protection and stability of the tear film • Rich of glands • Adequate blood supply

  17. The Anatomy • Corneal epithelium • Conjunctival epithelium • Tear film • Clinical ocular surface consist of conjunctiva cornea eyelids lacrimal gland lacrimal passages

  18. www.virtualmedicalcentre.com Tear Secretion • Lacrimal gland Producing the watery part of the tear film called the aqueous. • Meibomian glands Producing lipids which keep the tear film from evaporating. • Goblet cells of the conjunctiva Producing mucin which allows the wetting of the ocular surface as well as stabilizes the tear film.

  19. Tear Film in relation to Cornea

  20. Tear and the Tear Film • Function : 1.Cleaning 2.Wetting ocular surface 3.Bacteriostasis 4.Supporting the cornea (oxygen supply) http://www.drmalcolmmckellar.co.nz

  21. Concept • The ocular surface is a complex biological continuum responsible for the maintenance of corneal clarity, elaboration of a stable tear film for clear vision, as well as protection of the eye against microbial and mechanical insults. • Comprising a variety of disorders on cornea, eyelid, conjunctiva, lacrimal apparatus and tear film.

  22. Healthy tear film Dry eye Dry Eye http://www.chronicdryeye.com

  23. http://www.drmalcolmmckellar.co.nz Etiological factor & Classification • Aqueous tear deficiency • Lipid tear deficiency • Mucoprotein deficiency • Kinetic disorders of lacrimal fluid

  24. Conception • Dry eye - is a chronic lack of sufficient lubrication and moisture in the eye. • Its consequences range from subtle but constant irritation to ocular inflammation of the anterior (front) tissues of the eye.

  25. Clinical Manifestation • Dry eye symptoms asthenopia irritation, grittiness dryness burning light sensitivity pink-eye • Do you regularly experience one or several symptoms above? • Some diseases and conditions (like Rheumatoid arthritis, Lupus and Sjögren’s Syndrome) also cause chronic Dry Eye in many patients. • Activities like Reading, Wearing contact lenses or Working on the Computer may cause Dry Eye.

  26. Diagnostic Tests for Dry Eye • Dry Eye questionnaire • Lacrimal river width • Schirmer test – uses paper strips under eyelid to measure the wetness that collects over a specific period of time. • Break-up time of tear film (BUT) • Staining – uses special dyes to highlight areas of possible damage to the eye surface. • Tear lab – measuring tear osmolarity • Tear ferning test • Lactoferrin contents • Tear penetration pressure test • Corneal tonographic map • Impression cytology

  27. Diagnosing • Schirmer test, BUT, Staining • Foundation Symptom Instability of tear film Damage to epithelium Tear penetration pressure increasing

  28. SchirmerTest • Normal：≥10mm/5min

  29. Tear break-up time, BUT

  30. 0分 1分 3分 2分 Staining • Using special dyes to highlight areas of possible damage to the eye surface.

  31. Lacrimal river width

  32. Tear Osmolarity measurement

  33. http://www.dryeyezone.com Meibomian Gland Dysfunction

  34. http://www.revophth.com Etiological Factor • Failure of the glands to produce or secrete lipids. • Wax ester declining and cholesterol increasingmake the symptoms worse . • Lack of tears and tear penetration pressure increasing. • Lupus, brandy nose etc.

  35. Figure: Notching of the lid caused by loss of meibomian glands. http://www.eyehealthnutrition.com Clinical Manifestation • Common in aged people and who livedin cold region. • No specific symptoms. • Lid-margin mostly thickening; abnormal secretion while pressurizing. • Disorder in Meibomian gland, eyelid, conjunctiva.

  36. Figure: No visible meibomian gland orifices: Eversion of the lower lids in both eyes showed atresic meibomian glands. http://www.ophmanagement.com Diagnosing • Absence of Meibomian gland. • The gland orifices are often compromised due to stenosis or closure. • A declining quality and quantity of lipid secretion. Any one of the physical signs can make the diagnosis of Meibomian gland dysfunction if the patient has clinical symptoms.

  37. Ocular Surface Disease ★

  38. Treatment Clearing • Hot fomentation on eyelids for 5~10mins. • Massaging the eyelids. • Swabbing the lid-margin with mild cleaning solution.

  39. Treatment • Antibiotics oral administration. • Local Medication Antibiotic eye drops Glucocorticoid eye drops (short term) Artificial tears

  40. Classification • Corneal, conjunctival lesion Squamous epithelization type Limbal stem cell deficiency type • Tear film disorders Aqueous tear deficiency Lipid tear deficiency Mucoprotein deficiency Kinetic disorders of lacrimal fluid

  41. Treatment • Reconstruction Epithelium, limbal stem cells Lacrimal secretion, tear film Innervation (nerve restore) Structure and function of eyelid • Surgical operation To re-establish conjunctiva, cornea, tear film and eyelid.

  42. Dry Eye Disease Workshop

  43. Treatment • According to the clinical category For tear deficiency: Maintain moisture in the eyes; reducing the evaporation; increasing the secretion; controlling inflammation & immunoreaction. For excess-evaporation: Therapy of Meibomian gland dysfunction; controlling inflammation; cleaning eyelid; decreasing the evaporation; lipid replacement. • According to the eye conditions For intermittent symptoms: Artificial tears add volume to the tear film as long as they remain in contact with the surface of the eye. For midrange dry eye: Artificial tears and punctal occlusion. For Severe dry eye: Appending cyclosporin, surgery.

  44. A Simple Treatment chart

  45. Literature Artificial tears potpourri: a literature review Majid Moshirfar,1Kasey Pierson,2,*Kamalani Hanamaikai,3,*Luis Santiago-Caban,1Valliammai Muthappan,1 andSamuel F Passi1 Clin Ophthalmol. 2014; 8: 1419–1433. Published online 2014 Jul 31. doi:  10.2147/OPTH.S65263 PMCID: PMC4124072

  46. Artificial Tear Groups HPMC Carboxy Methyl Cellulose PVA Liquid Polyols Hyaluronic acid Inserts Miscellaneous

  47. Too many choices …..

  48. Tear substitutes

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