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1/30/2021 1. Terminology related to dry eyes 2. Anatomy of the eye 3. Anatomy of the tear and impact on vision 4. Clinical evaluation of the ocular The Final Objectives surface 5. Causes of dry eyes Front Tear 6. Tear testing Lynn E. Lawrence, CMSgt(ret), USAF 7. Dry eye treatment MSOL, CPOT, ABOC, COA, OSC Anatomy • Dry Eye • Inflammatory Dry Eye • Aqueous Insufficiency • Evaporative Dry Eye • Sjogrens Disease • Keratitis Sicca • Osmolarity • Tear Break-Up Time Punctum What function does the punctum have? Terms Industry Issues Terms • AD Aqueous Deficiency • OSD - Ocular Surface • DED – Dry Eye Disease Disease • If left undiagnosed, this can cause • DES – Dry Eye Syndrome • OSDI - Ocular Surface • Patients are leaving the office Disease Index complications with eye surgery • DEWS – Dry Eye Work undiagnosed in too many cases • POTF – Pre-Ocular Tear Shop Film • Systemic diseases can exacerbate the • DTS – Dysfunctional Tear • Patients are not volunteering the System • SPEED – Standard issue Patient Evaluation of Eye necessary information • Lipid Insufficiency Dryness • MDG – Meibomian • Medications can cause a significant • Expression • Gland Dysfunction Staff members are not asking the decline in the condition • Homeostasis of the tear necessary questions • NLDO – Nasal Lacrimal film Duct Obstruction • Symptoms correlation • Too many products to choose from • Too much mis-information 1 1/30/2021 Anatomy and Physiology of the ocular adnexa • Eyelids • Corneal • Eyebrows sensitivity • Eyelashes (permanent make- up) • Lacrimal gland innovation • Accessory glands • Lacrimal Apparatus th What is the opening between 5 Cranial Nerve - the upper and lower lid called? Trigeminal Lacrimal Apparatus • Sometimes a person cannot produce natural tears they might need punctal plugs to prevent the tears from draining off the eye. • Lacrimal gland • Reflex tearing • Faucet • Too much tearing…epiphora • Gland of Krause • Action • Superior fornix • Gland of Wolfring • Drain • Superior tarsal plate Obstructive – vs- non-obstructive Tear Production – Secretory A complex mixture of proteins, mucins, and electrolytes coated by a lipid layer Tear Anatomy • Antimicrobial proteins • Growth factors & suppressors of inflammation • Soluble mucin helps stabilize tear film • Electrolytes for proper osmolarity (295-300) • pH slightly alkaline (7.4) 2 1/30/2021 Lacrimal System: Tear Film Layers • Refractive Status • Health of the Cornea, oil the most refractive aqueous surface of the eye • Visual Acuity snot The Impact Of Tears On • Fluctuating vision Vision What functions does each layer of the tear perform? What are functions of tears? Two Primary Forms of Dry Lacrimal System: Tear Film Layers Eye LIPID DEFICIENCY - evaporates TEAR DEFICIENCY – fails to hydrate properly oil aqueous snot 800 nm 8,000 nm 100 nm The two primary forms of dry eye are Evaporative Dry Eye, also known as What functions does each layer of the tear perform? Meibomian Gland Dysfunction or MGD and Aqueous Dry Eye. The majority of What are functions of tears? dry eye sufferers have MGD. The Meibomian Glands Immunological Synapse Triggers • T-Cell activation and recruitment to target tissue • Release of proinflammatory The meibomian cytokines glands are located in the eyelids • Lymphocyte Function Associated Antigen-1 • In Vitro data shows T-cells can live up to 6 months once activated 3 1/30/2021 LipiView II: Interferometer Lipid Secretion: Meibomian Glands Avg LLT 35 nm Avg LLT 90 nm Left: Transillumination of eyelid showing meibomian glands Right: Secretion of lipid Avg LLT – Average Lipid at lid margin Layer Thickness (LLT) in nanometers (nm). Number less than 90 indicates increased • The lipid layer restricts evaporation to 5-10% of tear flow probability for MGD. – Also helps lubricate LipiView II: Dynamic Meibomian Imaging Intervention & Prevention Meibomian gland structure is observed with Dynamic Meibomian Imaging (DMI). DMI produces three Upper Eyelid images (surface illumination, transillumination and merged) to capture a comprehensive view of meibomian gland structure. If left untreated, the glands can shrink and deteriorate. The loss of glands is unlikely to be reversible. Failure to treat blocked glands is likely to lead to further structural compromise. Meibomian Surface Illumination Transillumination Merged (Surface + Transillumination) Lower Eyelid Glands Over Time Normal Gland Structure Prevention Intervention Current model of treatment is interventional. Gland Truncation & Dilation Future of MGD treatment must be preventative. Severe Gland Drop Out • Lipid Layer – prevents • Pump Action evaporation • Lids • Lateral/medial • Aqueous Layer - • Muscles hydration • Disease • Punctum • Mucus Layer – sticks • Canniculli tear to the eye (goblet • Lacrimal Sac cells) • Nasolacrimal Duct • Facial Nerve Palsy (7th CN) Tear Components Review • Other components Lacrimal Pump 4 1/30/2021 Mucin Secretion: Goblet Cells in conjuctiva Superficial layer of bulbar conjunctiva. Goblet cells violet, epithelial cells blue. • Soluble mucins – Lower surface tension allowing tear film to spread over surface Mucus Problems Exist Lipid Aqueous Mucin Meibomian Gland • Cleansing Dysfunction • Removal of old flora • New fresh flora • Draining of a tear • See the difference in • Use of the lacrimal gland structure? system • Eye, nose, and throat • Normal glands look like piano keys With Every Blink Formaldehyde Free Eyelash Extension Glue Reviews - FDA Safe? - Minki Lashes Time With The Patient • Keep the products that you want your patients to use on hand • The amount of time spent with the patient correlates into a higher level of • Don’t expect them to go out patient education and purchase the products that you desire them to use • The better educated the patient is the • Economical minded patients more likely they will be compliant to will purchase what cost less their wishes • Bolo on preservatives and • The more time you spend with the allergies to mineral/castor oil patient, the more patient satisfaction Lessons Learned • Research rumors… you are likely to have 5 1/30/2021 • Tear evaluation • Lipid layer • Aqueous layer • Mucus layer • Tear Break-up Time What structure produces mucin? • Lid evaluation a.The cornea • Meibomian gland b.The meibomian glands evaluation/expression c.The lacrimal gland • Meibography d.The conjunctiva • Lid position evaluation Tear System Evaluation Tear System Testing Tear System Treatments • Thermal Expression • Slit Lamp exam • Heat treatments • Schirmer Testing (quantity) • Lower Level Light Therapy • Tear Break-Up Time (quality) • Lid scrubs • Lipi-View (blink, LLT, Meibography) • IPL • Placido testing • LipiFlow • Speed/OSD questionnaire Many Conditions and Risk Factors for Dry Eye • Meibomian Gland Disfunction (MGD) • Lid Margin Hygiene; Blepharitis; Stye / Hordeola; Chalazion • Medications (i.e. Blood Pressure, Diuretics, Antihistamines, Antidepressants, ADHD, and more) • Hyperosmolarity, Scleroderma, HIV, Lupus, Bell’s Palsy, RA, Bone Marrow TP /grafts, Diabetes, Sjogrens Syndrome; Forms of Arthritis; Some Autoimmune diseases • Contact Lenses Wearers • General Aging for All (Menopause; Hormonal Changes for All) • Lifestyle (Dehydration, Lack of Sleep, Nutrition, Overuse of Digital Screens); Environment • Surgeries Pre & Post (Cataract, Lasik, Cosmetic, and more); Injections (Botox, Fillers, and more) • Allergies; Allergic Conjunctivitis; Contact Dermatitis; Rosacea • Additional Uses For Compress: Headaches / Migraines, Sinus Issues, TMJ, • Preventative Medicine Good practice for all Patients is daily moist heat for Lid Margin Maintenance and surrounding areas to promote continued healthiest outcomes; prevents New Technology foreseeable conditions from developing rapidly. Toll Free: 833-4DRYEYE www.thedryeyedoctor.net Product Code: 6001 Local: 470-374-5305 6 1/30/2021 One key component of DED is a breakdown of the mucin layer that is responsible for converting the hydrophobic (repels water) corneal surface of the eye to one that Mucus Layer is hydrophilic (attracts water). This allows the pre- corneal tear film (PCTF) to coat the surface of the eye filling in surface irregularities and providing optimal coverage • a genus of mites parasitic within the hair follicles of the host, including the species D. folliculo´rum in man, Demodex and several other species in Blepharitis domestic and other animals. 7 1/30/2021 Blepharitis is an inflammatory condition of the eyelids leading to red, irritated, itchy, and dandruff- like scales that form on the eyelashes. It is a common eye Not only in humans disorder caused by bacteria or a Blepharitis The skin condition, such as dandruff of – believe to come the scalp or acne rosacea.1 No from dogs Disease matter the cause, the only way we can beat blepharitis is to determine the location as anterior, posterior, or mixed; differentiate among the causative factors, and treat according to the severity of the condition. • Reoccurring eye infections Nursing Homes • Obvious observations • Surgical intervention http://optometrytimes.modernmedicine.com/optometrytimes/news/ods-look-lid- scrubs-first-blepharitis-treatment Meibomian Gland Evaluator Temporal Nasal Central Meibomian gland function is evaluated by assessing how glands respond to gentle force, imitating that of a deliberate blink. CLEAR OIL SECRETION NO OIL SECRETION (BLOCKED) OPAQUE SOLID SECRETION Glands are functioning using the No oil is expressed using the MGE Glands not functional; requires more MGE force than the MGE 8 1/30/2021 MeiboGrade LipiFlow: Cross
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