DRY-EYE SYNDROME

NIKA BELLARINATASARI

DEFINITION

"a multifactorial disease of the tears and ocular surface that

results in symptoms of discomfort, visual disturbance, and
tear-film instability with potential damage to the ocular
surface. It is accompanied by increased osmolarity of the
tear film and inflammation of the ocular surface" (DEWS,
2007).

 Dry eye represents a disturbance of the lacrimal

functional unit (LFU), an integrated system comprising
the lacrimal glands, ocular surface (cornea, conjunctiva,
and meibomian glands), and eyelids, as well as the
sensory and motor nerves that connect them
Its overall functions are
to preserve tear-film integrity: lubricating, antimicrobial,
and nutritional roles
ocular surface health: maintaining corneal transparency and
surface stem cell population

quality of image projected onto the retina

MECHANISM OF DRY EYE

The core mechanisms of dry eye are driven by tear
hyperosmolarity and tear-film instability
Tear hyperosmolarity causes damage to the surface
epithelium by activating a cascade of inflammatory
events at the ocular surface and release of inflammatory
mediators into the tears
Epithelial damage involves cell death by apoptosis, a
loss of goblet cells, and disturbance of mucin expression
leading to tear-film instability
The instability of tear film exacerbates oculer surface
hyperosmolarity and completes the vicious cycle.

 Tear-film instability can also be initiated by several

etiologies :
Xerosing medication
Xerophthalmia
Ocular allergy
Topical preservative use
Contact lens wear

TEAR-FILM EVALUATION

The best approach is to combine information from the

history and examination with the results of one or more
of the fo llowing diagnostic tests.

 Inspection
Signs of associated systemic disease (rheumatoid arthritis)
Indications of personal habits (smoking)
Signs of associated ocular disease (pseudoptosis,
blepharospasm)
Characteristic facial telangiectasia & eyelid margin
hyperemia associated with ocular rosacea
Tear meniscus between the globe and the lower eyelid
(normally 1.0 mm in height and convex)
Tear breakup is a functional measure of tear stability; if
stability is perturbed (as in lipid or mucin deficiency), the
tear breakup time (TBUT) can become more rapid

 Tear Breakup Time (TBUT)

The examiner moistens a fluorescein strip with sterile saline
and applies it to the tarsal conjunctiva (fluoresceinanesthetic combination drops are not suitable for this
purpose).
After several blinks, the tear film is examined using a broad
beam of the slit lamp with a blue filter.

The time lapse between the last blink and the appearance
of the first randomly distributed dry spot on the cornea is
the tear breakup time.
Dry spots appearing in less than 10 seconds are considered
abnormal.

TBUT should be measured before any eyedrops are

instilled and before the eyelids are man ipulated in any
way.
It is best to wait at least 1 minute after fluorescein
instillation to evaluate the corneal su rface for
fluorescein staining

 The eye should be carefully

Tear-film debris
Conjunctivochalasis (complain of epiphora)
Floppy eyelid syndrome
Multiple concretions (chronis blepharitis)

TESTS OF TEAR PRODUCTION

Schirmer testing is performed by placing a thin strip of
filter paper in the inferior cul-de-sac. The amount of
wetting can be measured to quanti fy aqueous tear
production
The basic secretion test is performed following the
instillation of a topical anesthetic, followed by lightly
blotting residual fluid out of the inferior fornix. A thin
filter-paper strip (5 mm wide, 35 mm long) is placed at
the junction of the middle and lateral thirds of the lower
eyelids to minimize ir ritation to the cornea during the
test. The test can be performed with open or closed
eyes, although some recommend the eyes be closed to
limit the effect of blinking.

 The Schirmer I test, which is si milar to the basic

secretion test but without topical anesthetic, measu res
both basic and reflex tearing combined
The Schirmer II test, wh ich measures reflex secretion,
is performed in a similar manner without topical
anesthetic. However, after the filter-paper strips have
been inse rted into the in ferior fornices, a cotton-tipped
applicator is used to irritate the nasal mucosa.

AQUEOUS TEAR DEFICIENCY

Definiton : decreased aqueous tear production, as
measured by Schirmer testing, pattern of conjunctival &/
corneal staining with lissamine green or rose bengal,
corneal staining by fluorescein, and filamentary
keratopathy
Symptoms
Burning, photophobia, dry sensation, blurred vision, foreign
body sensation

Signs :
Conjunctival hyperemia, conjunctivochalasis, decreased tear
meniscus, iregular corneal surface, debreis in tear-film
Epithelial keratopathy
Filaments & mucous plaques , filamentary keratopathy,
marginal or paracentral thinning & perforation corneal
(more severe dry eye states)

EVAPORATIVE TEAR
DYSFUNCTION
Increased tear-film evaporation is most commonly
caused by MGD but may also be caused by disease of
the meibomian glands, poor apposition of the eyelids to
the ocular surface, increase of the palpebral aperture,
and contact lens wear.
Symptoms consist of burning, foreign-body sensation,
redness ofthe eyelids and conjunctiva, filmy vision, and
recurrent chalazia.
Signs of ETD include decreased TBUT, MGD, abnormal
aqueous tear production, and a characteristic linear
pattern of rose bengal/lissamine green staining of the
inferior conjunctiva and cornea and eyelid margin.

 MEIBOM GLAND DYSFUNCTION

Meibom Gland Dysfunction
Terjadi akibat obstruksi progresif lubang kelenjar meibom karena
keratinisasi.

 Sehingga ada penurunan lapisan lipid permukaan mata

dan peningkatan inflamasi pada kelopak yang ditandai :
Hiperemia tepi kelopak dan konjungtiva tarsal
Sekresi meibom bisa jernih, keruh atau kental.
Lubang kelenjar meibom tertutup plug dan terletak lebih ke
posterior akibat terbentuk sikatrik pada tepi kelopak dan
tarsal

Patogenesis
Tjd obstr/hiposekresi akibat penyakit blefaritis anterior,
rosacea acne, pemfigoid
Non obstr/ hipersekresi akibat meibomian seborrhea

 Pasien MGD akan menjadi defisiensi air mata lipid yang

akan menyebabkan instabil lapisan air mata,
peningkatan penguapan tear film, dan peningkatan
osmolaritas air mata
Gejala & tanda
Terasa terbakar/panas
Sensasi benda asing, merah kelopak dan konjungtiva
Filmy vision
Kalazion rekuren
Inflamasi tepi posterior kelopak mata, konjungtiva dan
kornea
Telangiectasi (brush marks) pada tepi anterior-posterior

 Plug putih protein keratin menutupi lubang kelenjar

meibom
Sekresi meibom berubah warna dan viskositasnya
Bila inflamasi berlangsung th, terjadi atrofi kelenjar
meibom
Terbentuh buih busa pada tear meniscus
Rapid TBUT
Bisa terjadi peradangan pd permukaan mata
(konjungtivits, episcleritis, erosi epitel punctat kornea,
pannus kornea, penipisan kornea)

 Management
Eyelid hygiene (1-2x/hari), dengan cara :
kompres hangat beberapa menit dilanjutkan dg
Gentle massage dengan menekan sekresi
meibom, diikuti dengan membersihkan dengan
washcloth, cotton ball, atau pad

Shampo noniritasi atau pengenceran cairan

sodium bicarbonat (1 sdt dalam 0,5 liter air
mendidih)
Antibiotika topikal
Tetrasiklin sistemik 250 mgx4/hari untuk 3-4 minggu
pertama, bila membaik dosis diturunkan 250-500
mg/hari. Atau
Doxycyclin 100 mg dan minocyclin 50 mg diberikan
2x/hari utk 3-4 minggu, ditaper 50-100 mg/hari

Eritromisin bila anak2 atau alergi tetrasiklin dan

doxycyclin
Pengobatan ini tujuannya utk mengontrol bukan
menyembuhkan penyakitnya
Steroid topikal diperlukan bila inflamasinya sedang
smp berat, terutama bila ada infiltrat kornea dan
vaskularisasi
Omega 3

TERIMA KASIH