Dry Eyes

• Definition: Multifactorial disease of the ocular surface due to loss of tear film homeostasis, leading to ocular symptoms and visual disturbances.
• Common Forms: Includes keratoconjunctivitis sicca (KCS) and overlaps with other ocular surface diseases (OSD).

Ocular Surface Components

1. Tear film
2. Lacrimal and accessory lacrimal apparatus
3. Nasolacrimal drainage system
4. Eyelids
5. Bulbar and tarsal conjunctiva
6. Cranial nerve V
7. Cranial nerve VII

Tear System Anatomy

• Lacrimal gland
• Superior and inferior lacrimal puncta
• Superior and inferior lacrimal canals
• Lacrimal sac
• Nasolacrimal canal

Types of DED

1. Aqueous Deficient Dry Eye (ADDE)
2. Evaporative Dry Eye Disease (EDE)
3. Sjogren Syndrome-associated (SS) DED
4. Non-SS KCS

Signs and Symptoms

• Foreign-body sensation
• Burning, itching, gritty or sandy sensation
• Hyperemia
• Mucoid discharge
• Ocular irritation
• Excessive tearing (secondary to reflex secretion)
• Photophobia
• Blurry vision (improves with blinking)

Diagnosis

• Vital staining (fluorescein, lissamine green, rose bengal)
• Tear film osmolarity measurement
• Detection of MMP-9
• Tear breakup time (TBUT)
• Schirmer test
• Tear meniscus height
• Tear protein analysis

Sjogren Syndrome Diagnosis Criteria

• Low Schirmer test result
• Low salivary flow
• Biopsy-proven lymphocytic infiltration of labial salivary glands
• Presence of serum autoantibodies (ANA, RF, anti-Ro [SS-A], anti-La [SS-B])

Management

Pharmacologic Therapy:

• Lubricating supplements: Artificial tears, gels, emulsions, ointments
• Topical anti-inflammatories: Cyclosporine, lifitegrast, corticosteroids
• Omega-3 fatty acids (topical or systemic)
• Tetracyclines (topical or systemic)
• Secretagogues: Diquafosol, rebamipide, varenicline nasal spray
• Hyaluronic acid (topical)
• Autologous or umbilical cord serum
• Amniotic membrane extract eye drops
• Eye-platelet rich plasma (E-PRP) drops
• Systemic immunosuppressants
• Investigational agents: Oral lactoferrin, topical lubricin, lacritin, thymosin β-4

In-office Procedures:

• Vectored thermal pulsation (LipiFlow)
• Meibomian gland probing
• Meibomian gland liquefaction and expression
• Intense pulsed light therapy
• Intranasal tear neurostimulator
• Lid-margin scrubbing (BlephEx)

Therapeutic Eyewear:

• Moisture chamber spectacles
• Therapeutic contact lenses

Surgical Interventions:

• Punctal plugs: Absorbable, nonabsorbable, thermoplastic, hydrogel
• Lateral tarsorrhaphy
• Lid malposition repair
• Conjunctival flap
• Conjunctivoplasty
• Lacrimal drainage system cautery occlusion
• Mucous membrane grafting