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Dry eye syndrome (DES) is an eye disease characterised by eye dryness which is caused by either decreased tear production or increased tear evaporation. In this definition, the term, tear deficiency, implies a deficiency of aqueous tears secreted by the lacrimal gland. It is a multifactorial disease of the tears and the ocular surface that results in discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface.
The medical name for dry eye syndrome is keratoconjunctivitis sicca (KCS) and may be subdivided into 2 main forms.
There are two main types of dry eye.
Many people have both problems.
Dry eye syndrome is very common with approximately 20% of the Australian adult population suffering from dry eyes.
Research suggests that up to 48% of office workers could experience dry eyes, due to their long exposure to air-conditioning and computer screens.
Other groups more likely to report dry eyes include:
Normally, the eye constantly bathes itself in tears by producing tears at a slow and steady rate. In this way the eye stays moist and comfortable.
The eye uses two different methods to produce tears
The tear film consists of three layers
The oily layer, produced by the meibomian glands, forms the outermost surface of the tear film. Its main purpose is to smoothe the tear surface and reduce evaporation of tears. Evaporative dry eye occurs when meibomian glands, located in the upper and lower eye lids, don't produce enough oil, or the oil isn't of high quality. This causes the watery layer of the tears to evaporate more quickly.
The middle or aqueous layer is the largest and the thickest. This layer is essentially a very dilute saltwater solution. The lacrimal glands under the upper lids and the accessory tear glands produce this watery layer.
This layer functions to keep the eye moist and comfortable, as well as to help flush out any dust, debris, or foreign objects that may get into the eye.
Defects of the aqueous layer are the most common cause of dry eye syndrome.
The inner layer consists of mucus produced by the conjunctiva. Mucus allows the watery layer to spread evenly over the surface of the eye and helps the eye remain moist. Without mucus, tears would not stick to the eye.
With each blink of the eyelids, tears are spread across the front surface of the eye, known as the cornea. Tears provide lubrication, reduce the risk of eye infection, wash away foreign matter, and keep the surface of the eyes smooth and clear. Excess tears in the eyes flow into small drainage ducts, in the inner corners of the eyelids, which drain to the back of the nose.
Dry eye syndrome has many causes. One of the most common reasons for dryness is simply the normal aging process that is associated with less oil production. This is more pronounced in women. The oil deficiency affects the tear film. Without as much oil to seal the watery layer, the tear film evaporates much faster, leaving dry areas on the cornea.
Tear secretion also may be reduced by certain conditions that decrease corneal sensation. Diseases such as diabetes and herpes zoster are associated with decreased corneal sensation as is long-term wear of contact lenses and surgery that involves making incisions in or removing tissue from the cornea (such as LASIK).
A wide variety of common medications, both prescription and over-the-counter, can cause dry eye by reducing tear secretion:
Since these medications are often necessary, the dry eye condition may have to be tolerated or treated with eye drops called artificial tears.
Dry eye syndrome not associated with Sjögren's syndromeis mostly found in postmenopausal women, women who are pregnant, women who are taking oral contraceptives, or women who are on hormone replacement therapy (especially estrogen-only pills). The common denominator is a decrease in androgens, either from reduced ovarian function (in postmenopausal women) or from increased levels of the sex hormone–binding globulin (in women who are pregnant or are taking birth control pills).
Other causes for dry eye include exposure to a dry, windy climate or smoke or air conditioning, which can speed tear evaporation. Avoiding these irritants can offer dry eye relief.
Patients with primary Sjögren syndrome have evidence of a systemic autoimmune disease, as manifested by the presence of serum autoantibodies and severe aqueous tear deficiency (ATD) and dry mouth (xerostomia). Secondary Sjögren syndrome is defined as dry eye syndrome that is associated with a diagnosable connective tissue disorder, which is most commonly rheumatoid arthritis but could also be systemic lupus erythematosus or systemic sclerosis.
Dry-eye sufferers may find that they feel like they cannot keep their eyes open for very long. They may also find their eyes feel more uncomfortable after reading or watching television. Other symptoms include:
While it may seem contradictory, people with dry eye may find that their eyes water quite a bit. This is because their eyes are responding to the irritation of this condition. Because individuals who work long hours at a computer are less likely to blink often, they are more susceptible to getting dry eye than others who do not spend long periods in front of a computer monitor.
Dry eye is essentially a clinical diagnosis, made by combining information obtained from the history and from the physical examination and performing one or more tests to provide some objectivity to the diagnosis.
No single test is sufficiently specific to permit an absolute diagnosis of DES.
Symptom questionnaires can be used to help establish a diagnosis of DES and to assess the effects of treatments or to grade disease severity.
The Schirmer test is used to test aqueous tear production. Traditionally, the basic secretion test is performed by instilling a topical anesthetic and then placing a thin strip of filter paper under the lower eyelid. The patients’ eyes are then closed for 5 minutes, and the amount of wetting in the paper strip is measured. Less than 5 mm of wetting is abnormal.
Tear breakup time (TBUT) is determined by measuring the time lapse between instillation of fluorescein and appearance of the first dry spots on the cornea. Measure it prior to instillation of any anesthetic eye drops. A fluorescein strip is moistened with saline and applied under the lower eyelid. After several blinks, the tear film is examined using a broad-beam of slit lamp with a blue filter for the appearance of the first dry spots on the cornea. Decreased TBUT of less than 10 seconds is considered abnormal, indicative of tear instability.
Epitheliopathy is a general term for diseases of the epithelium, the surface layer of cells of the cornea. From the patient's perspective, it causes blurred vision. Rose bengal, lissamine green, and fluorescein staining are used to evaluate epitheliopathy. Rose bengal and lissamine green stain not only dead and devitalized cells but also healthy cells that are protected inadequately by a mucin coating. Fluorescein pools in epithelial erosions and stains exposed basement membrane; generally, it stains the cornea more than the conjunctiva.
Approved by the FDA in 2013, InflammaDry® is the first and only, rapid, in-office test that detects MMP-9, an inflammatory marker that is consistently elevated in the tears of patients with dry eye disease. The test, which takes less than 2 minutes to perform, uses tear samples to detect the inflammatory marker matrix metalloproteinase-9. Matrix metalloproteinase-9 has been shown to be consistently elevated in the tears of patients with dry eye disease.
Early detection and aggressive treatment of dry eye syndrome is intended to prevent corneal ulcers, scarring and visual loss.
The two most common methods of dry eye treatment are to replace tears or to conserve them. In most cases, artificial tears are used as tear replacement, which mimic the composition of natural tears, and are available over the counter.
People with dry eye are often more likely to experience the side effects of eye medications, including artificial tears. For example, the preservatives in certain eye drops and artificial tear preparations can irritate the eye. These patients may need special, preservative-free artificial tears. Lubricating ointments can be used for more severe cases, but they tend to blur vision and so should be applied at bedtime.
If artificial tear drops do not relieve the symptoms, tears may be conserved by plugging the tear drain holes, called puncta, with tiny plugs made of collagen or silicone. In the worst cases, the holes can be closed permanently using electric cauterization.
The essential omega-3 fatty acids, such as eicosapentaenoic acid (EPA) and docosahexanoic acid (DHA) found in fish oil and alpha-linoleic acid (ALA) in flax seed oil, are also thought to improve evaporative dry eye. Omega-3 fatty acids are believed to competitively inhibit the production of proinflammatory mediators, such as interleukin-1 and tumor necrosis factor-alpha. With fewer proinflammatory compounds available, the ocular tear film is thought to be able to better promote a healthy ocular surface. A higher intake of omega-3 fatty acids has been associated with a decreased incidence of dry eye syndrome in women.
Restasis® Ophthalmic Emulsion is a prescription eye drop indicated to increase tear production which may be reduced by inflammation on the eye surface in patients with dry eye.11, 12 It has been reported that Restasis® works both as an immune system modulator and as an anti-inflammatory drug. Unfortunately, Restasis® is not listed on Australia's Pharmaceutical Benefits Scheme, however some trials are being conducted and access is available for those on these trials.
Evaporative dry eye is caused by blockages in the meibomian glands, which create the lipid (oil) layer of the tear film and are located in the eyelids. This condition of obstructed glands leads to insufficient tear film oil. An insufficient oil layer can cause tears to evaporate four to six times faster than normal. More than 65% of patients suffering from dry eye syndrome have evaporative dry eye. LipiFlow® is intended to treat patients with blocked meibomian glands, called meibomian gland dysfunction, by unblocking the glands and allowing them to resume the secretion of oily lipids needed for a healthy tear film.
Hormonal changes in women during menopause, particularly decreasing levels of estrogen, can cause thickening of the oils secreted by the meibomian glands, which results in blockages. Decreased estrogen levels may enhance conditions under which staphylococcal bacteria can proliferate in meibomian glands. This results in a decreased oil secretion rate. Additional factors that may cause or exacerbate meibomian gland dysfunction include age, contact lens use and hygiene, cosmetic use, and illnesses, particularly diabetes.
Lipiflow is a non-invasive, in-office treatment that takes only minutes to complete for each eye, as both eyes are normally affected by dry eye. During the procedure, the doctor applies controlled heat to the inner eyelid and mild intermittent pressure to release lipids from blocked glands, treating both the upper and lower lid simultaneously