Dry Eye Syndrome

Dry eye syndrome (DES), also known as dry eye disease (DED), keratoconjunctivitis sicca (KCS), and keratitis
sicca, 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 ocular surface is an integrated anatomical unit consisting of 7 key interactive and interdependent components: the tear film, the
lacrimal and accessory lacrimal apparatus, the nasolacrimal drainage system, the eyelids, the bulbar and tarsal conjunctiva, cranial
nerve V, and cranial nerve VII.[2] Abnormalities or deficiencies in any of the 7 ocular surface components may worsen dry eye
syndrome, yet promise opportunities for effective therapeutic intervention

Dry eye syndrome may be subdivided into 2 main types as follows:

Dry eye syndrome associated with Sjgren syndrome (SS)

Dry eye syndrome unassociated with SS (non-SS KCS)
Dry eye syndrome can also be subdivided into pure aqueous deficiency dry eye and evaporative dry eye. [3] Eighty-six percent of
patients with dry eye syndrome also have signs of meibomian gland dysfunction.

Signs and symptoms

The following are the most common complaints associated with dry eye syndrome:

Foreign-body sensation and ocular dryness and grittiness

Hyperemia
Mucoid discharge
Ocular irritation
Excessive tearing (secondary to reflex secretion)
Photophobia
Fluctuating or blurry vision

Diagnosis
Studies that may be used for diagnosis include the following:

Vital staining of corneal and conjunctival epithelium with fluorescein, lissamine green, or rose bengal
Tear film osmolarity
Ocular surface matrix metalloproteinase 9 (MMP-9)

Measurement of tear breakup time (TBUT)

The Schirmer test
Tear meniscus height
Quantification of tear components through analysis of tear proteins
Impression cytology to monitor progression of ocular surface changes
Additional tests that may be used in a research workup include:

The tear stability analysis system (TSAS)

The tear function index (TFI; Liverpool modification)
The tear ferning test (TFT)
Criteria for a diagnosis of dry eye syndrome associated with Sjgren syndrome (SS) include the following:

Abnormally low Schirmer test result

Objective evidence of low salivary flow
Biopsy-proven lymphocytic infiltration of the labial salivary glands
Dysfunction of the immune system, as manifested by the presence of serum autoantibodies (eg, antinuclear antibody
[ANA], rheumatoid factor [RF], and anti-Ro [SS-A] and anti-La [SS-B] antibodies)
Pharmacologic therapy
Lubricating supplements are the medications most commonly used to treat dry eye syndrome. Agents that have been used to treat
dry eye syndrome include the following:

Artificial tear substitutes

Gels, emulsions and ointments
Topical anti-inflammatory agents: Topical cyclosporine, [4, 5] topical corticosteroids
Topical or systemic omega-3 fatty acids: Omega-3 fatty acids inhibit the synthesis of lipid mediators and block the
production of interleukin (IL)1 and tumor necrosis factor alpha (TNF-)
Topical or systemic tetracyclines
Secretagogues: Diquafosol, which is approved in Japan [6, 7] but not in the United States
Topical hyaluronic acid, which is also approved in Japan [8]
Autologous or umbilical cord serum
Systemic immunosuppressants
Therapeutic eyewear
Specially made glasses known as moisture chamber spectacles, which wrap around the eyes to retain moisture and protect against
irritants, may be helpful in some cases of dry eye syndrome. Therapeutic contact lenses may also be helpful.
Surgical intervention
Punctal plugs are often used in the treatment of dry eye syndrome. Available types include the following:

Absorbable plugs
Nonabsorbable plugs
Thermoplastic plugs
Hydrogel plugs
Other advanced or surgical options include the following:

Sealing of the perforation or descemetocele with corneal cyanoacrylate tissue adhesive

Corneal or corneoscleral patching for an impending or frank perforation
Lateral tarsorrhaphy - Temporary tarsorrhaphy (50%) is indicated in patients with dry eye syndrome secondary to
exposure keratitis after facial nerve paralysis and after trigeminal nerve lesions that give rise to dry eye syndrome secondary to
loss of corneal sensation
Conjunctival flap
Conjunctivoplasty excision of symptomatic conjunctivochalasis
Surgical cautery occlusion of the lacrimal drainage system
Mucous membrane grafting
Salivary gland duct transposition
Amniotic membrane transplantation or amniotic membrane contact lens therapy
Prosthetic replacement of the ocular surface ecosystem (PROSE) lens therapy

Background
Dry eye syndrome (DES) 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. It is accompanied by
increased osmolarity of the tear film and inflammation of the ocular surface. Multiple causes can produce either inadequate tear
production or abnormal tear film constitution, resulting in excessively fast evaporation or premature destruction of the tear film.
Dry eye syndrome may be subdivided into 2 main types as follows:

Dry eye syndrome associated with Sjgren syndrome (SS)

Dry eye syndrome unassociated with SS (non-SS KCS)