Sabhlok The Eye Strain Book

Eye strain, computer vision syndrome, dry eyes, ocular surface disorders, eye allergy: some explorations.
A free book by Sanjeev Sabhlok

http://eyestrain.sabhlokcity.com/pics/Sabhlok-The-Eye-Strain-Book.oc
Eye strain, computer vision syndrome, dry eyes,
ocular surface disorders, eye allergy
- some explorations
A free book by Sanjeev Sabhlok, patient
his is a patients personal compilation of information from the internet !including academic
papers"# $eferencing is through hyperlinks %here possible#
This !book" has been prepare purely for my o#n benefit. $t mi%ht help others. &o' can interact
#ith me on my eye blo% eyestrain.sabhlokcity.com
This is #ork in pro%ress. (ersion ).))* ate + ,ovember -)..
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Normal Lid Margin Anatomy......................................................................................................................................4
Normal Tear Film omposition..................................................................................................................................4
)E .A/(01+ E,E 2 /3E(/0,/(4 )E &A1SE###################################################################################################5
an !e managed, not cured........................................................................................................................................"
#o not self$diagnose..................................................................................................................................................."
S&/0T1/S.......................................................................................................................................................................2
TESTS...............................................................................................................................................................................3
%smolarity of tears.....................................................................................................................................................&
Tear4ab System...................................................................................................................................................................... 3
Tear 'uantity tests.......................................................................................................................................................&
5l'orescein............................................................................................................................................................................. 3
6ose ben%al stainin% test........................................................................................................................................................ 3
4issamine 7reen..................................................................................................................................................................... 8
Tear film sta!ility tests................................................................................................................................................(
)iomicroscope..........................................................................................................................................................*+
/eibo%raphy........................................................................................................................................................................ .)
9$A7,1ST$: /ET;191417&..........................................................................................................................................)
,peed of onset...........................................................................................................................................................*+
6api onset........................................................................................................................................................................... .)
Slo# onset............................................................................................................................................................................ .)
Eye parts affected.....................................................................................................................................................*+
:A<SES =AET$1417&>......................................................................................................................................................
Auto$immune response..............................................................................................................................................**
)acterial infections...................................................................................................................................................**
Anterior Blepharitis.............................................................................................................................................................. ..
Anterior !lep-aritis..................................................................................................................................................*.
,tap-ylococcal !lep-aritis.......................................................................................................................................*.
,e!orr-eic !lep-aritis..............................................................................................................................................*.
,e!orr-eic/stap-ylococcal !lep-aritis.....................................................................................................................*.
Mei!omian se!orr-eic !lep-aritis............................................................................................................................*0
,e!orr-eic !lep-aritis 1it- secondary mei!omianitis.............................................................................................*0
Mei!omian 2eratocon3unctivitis...............................................................................................................................*0
Angular !lep-aritis...................................................................................................................................................*0
,2in disease..............................................................................................................................................................*0
Blepharitis............................................................................................................................................................................ .?
.
Eye strain, computer vision syndrome, dry eyes, ocular surface disorders, eye allergy: some explorations. A free book by Sanjeev Sabhlok
Atrop-y of Me!omian glands...................................................................................................................................*0
9ama%e %oblet cells =m'c'o's layer>................................................................................................................................. .?
7oblet cells %enerally lo# in ry eyes.................................................................................................................................. .?
$ncrease level of solvents in ry eyes can kill %oblet cells...................................................................................................*
4ess blinkin% can kill %oblet cells......................................................................................................................................... .2
#amaged lac-rymal glands......................................................................................................................................*&
#eficiencies..............................................................................................................................................................*&
$oine eficiency.................................................................................................................................................................. .3
Testosterone eficiency........................................................................................................................................................ .3
A mite in t-e eyelas-es 4demodex folliculorum5.......................................................................................................*&
9emoicosis......................................................................................................................................................................... .3
$E*E3, 0'$ A1'-/**1(E $ES.'(SE############################################################################################################67
S&/0T1/AT$: 6E4$E5: ,1,-T;E6A0E<T$: 6E9<:T$1, $, 1S/14A6$T&......................................................................8
Avoid !en6al2onium c-loride 4)A75........................................................................................................................*8
,1,-T;E6A0E<T$: 9$ETA6& S<004E/E,TS....................................................................................................................8
,1,-T;E6A0E<T$: A,T$-$,54A//AT16$ES...................................................................................................................8
$E*E3, 0'$ 8+E.)A$//S#####################################################################################################################################67
S&/0T1/AT$: 6E4$E5: ,1,-T;E6A0E<T$: 6E9<:T$1, $, 1S/14A6$T&......................................................................8
Avoid !en6al2onium c-loride 4)A75........................................................................................................................*8
,1,-T;E6A0E<T$: 9$ETA6& S<004E/E,TS....................................................................................................................8
T;E6A0E<T$: $5 :A<SE9 B& BA:TE6$A @ 4$9 S:6<B.....................................................................................................8
1c'lar =li> hy%iene.............................................................................................................................................................. .8
#o not use !a!y s-ampoo.........................................................................................................................................*8
#o not use !icar!onate of soda................................................................................................................................*(
9se only Lidare or one of t-ese.............................................................................................................................*(
T;E6A0E<T$: $5 :A<SE9 B& BA:TE6$A - A,T$B$1T$:S..................................................................................................A
:oney........................................................................................................................................................................*(
#oxycycline..............................................................................................................................................................*(
A6asite.......................................................................................................................................................................*(
?. T6EAT/E,T A,9 /A,A7E/E,T 15 A,TE6$16 B4E0;A6$T$S..................................................................................-)
$E*E3, 0'$ *E8'*/A( 4+A(3 3,S01(&/'(###########################################################################################96
S&/0T1/AT$: 6E4$E5: ,1,-T;E6A0E<T$: 6E9<:T$1, $, 1S/14A6$T&.....................................................................-.
Avoid !en6al2onium c-loride 4)A75..........................................................................................................................
,1,-T;E6A0E<T$: 9$ETA6& S<004E/E,TS...................................................................................................................--
,1,-T;E6A0E<T$: BA6/ :1/06ESS............................................................................................................................--
T;E6A0E<T$: 6ESTAS$S.................................................................................................................................................--
$,TE,SE 0<4SE 4$7;T =$04>...........................................................................................................................................--
96 /ASC$,S 96& E&E T6EAT/E,T..............................................................................................................................-?
4$0$541B T;E6/A4 0<4SAT$1, S&STE/......................................................................................................................-?
$E*E3/ES 0'$ +A&)$,*A+ 4+A(3 3,S01(&/'(####################################################################################9-
0<,:TA4 04<7/ 1::4<S$1,...........................................................................................................................................-*
$E*E3/ES 0'$ *1&/( +A,E$ 3,S01(&/'(#################################################################################################9-
$E*E3/ES 0'$ $EA/(4 )E 3E*'3E: */E############################################################################################9-
;)E( )/(4S 4E $EA++, $EA++, 8A3##########################################################################################################95
,1,-T;E6A0E<T$: S;<TT$,7 91B, 15 ,E6(E S$7,A4S..............................................................................................-2
1T;E6S..........................................................................................................................................................................-2
:ydrop-ilic !andage lenses and collagen corneal s-ields......................................................................................."
Moisture c-am!er goggles........................................................................................................................................"
Tarsorr-ap-y............................................................................................................................................................."
A..E(3/: 6< ('ES#####################################################################################################################################################9=
A. 9ES:6$0T$1, A,9 :4ASS$5$:AT$1, 15 1:<4A6 S<65A:E 9$S169E6S...................................................................-+
Mucin $#eficient #ry Eye..........................................................................................................................................(
,urface A!normalities...............................................................................................................................................(
Epit-eliopat-ies.........................................................................................................................................................(
-
ontact lens 1ear......................................................................................................................................................(
B. 1:<4A6 S<65A:E 9$S169E6S A6$S$,7 561/ 4$9-/A67$, 9$S169E6S =01STE6$16 B4E0;A6$T$S> .....................?)
B. E0$9E/$1417& 15 1:<4A6 S<65A:E 9$S169E6S...................................................................................................?)
*. #ry Eye.................................................................................................................................................................0+
.. )lep-aritis.......................................................................................................................................................0*
:. :4$,$:A4 BA:C761<,9 15 1:<4A6 S<65A:E 9$S169E6S....................................................................................?.
*. #ry Eye.................................................................................................................................................................0*
.. )lep-aritis.......................................................................................................................................................00
:A6E 061:ESS..........................................................................................................................................................??
B. /A,A7E/E,T 15 1:<4A6 S<65A:E 9$S169E6S....................................................................................................?+
A..E(3/: 9< ('ES#####################################################################################################################################################->
A..E(3/: >< ('ES#####################################################################################################################################################--
A..E(3/: -< ('ES#####################################################################################################################################################--
A..E(3/: 5< ('ES#####################################################################################################################################################-5
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A..E(3/:< 9 '&'8E$ 9@66 $EA/E; '0 '.'*E$,##################################################################################56
?
The normal eye
5or simplicity $ ass'me that everyone reain% this book kno#s abo't the anatomy of the eye. That
can be reaily iscovere on the internet. ;o#everD a s'mmary is provie here:
Normal Lid Margin Anatomy
The li mar%in is abo't - mm thick an has a thin %ray line separatin% its anterior an posterior
portions. The anterior portion has t#o or three ro#s of eyelashes. The posterior borerD in close
apposition to the %lobeD contains the orifices for the tarsal %lans. The meibomian %lansE
approFimately ?) to *) in the 'pper an -) to -2 in the lo#er liEare embee in the tarsal plates
an secrete lipis that comprise the oily layer of the tear film.
.-D.?
Altho'%h the maFim'm tear
capacity of the oc'lar s'rface an fornices is abo't -2 G4D the normal vol'me is only abo't 3 G4.
Each blink rene#s the tear film an istrib'tes a fresh layer across the eFpose cornea an
conj'nctiva.
Normal Tear Film Composition
The preoc'lar tear film =01T5> has three ientifie b't ynamically interactin% layers @ lipiD
aH'eo'sD an m'co's.
.)
The pilosebaceo's meibomian %lans in the lis pro'ce most of the
o'termost =lipi> layer. The Ieis an /oll %lans of the eyeli mar%insD #hich are associate #ith
the lashesD also contrib'te to this layer. 1ily secretions in this layer f'nction to contain the aH'eo's
phase of the 01T5 by re'cin% s'rface tension. $n aitionD the lipi layer stabiliJes an retars
evaporation of the 'nerlyin% aH'eo's layer..-D.*D.2
$n the normal healthy eyeD the lipi layer thickness is less than ).. Gm. /eibomian lipis =meib'm>
are mainly #aFy an cholesterol esters. .?D.+ ;i%h molec'lar #ei%ht an lo# polarity are important
properties for the formationD stabiliJationD an protection of the 01T5K alteration of polarity in
isease states s'ch as blepharitis may have an averse effect on its stability an lea to oc'lar
s'rface isorers an symptoms of ry eye. $nterference frin%e patterns become istorte in the
presence of a contaminate or thickene lipi layer.
.?D.3
$n aitionD meibomian secretions may be
istinctly altere in patients #ith meibomian %lan ysf'nction.
.8
The aH'eo's layer makes 'p abo't A) percent of the 01T5. The major contrib'tion to this layer
comes from the accessory eFocrine lacrimal %lans of Cra'se an Bolfrin%.
.AD-)
The aH'eo's layer
contains lysoJyme an proteinsD incl'in% lactoferrinD that eFhibit antibacterial activities.
4aboratory analysis may prove 'sef'l for ia%nostic eval'ation of the aH'eo's layer.
The innermost layer of the 01T5 is the m'co's layer. 0ro'ce primarily by the %oblet cells of the
conj'nctivaD m'c's l'bricates the lis an serves as an asorbin% interface bet#een the aH'eo's
layer an the hyrophobic corneal epitheli'm. $n aitionD it collects cell'lar ebris from the oc'lar
s'rface
.-)D-.
The %lycocalyF on the epithelial microvillae anchors the m'co's layer.
.)
The moel for
tear film break'p is base partially on thinnin% of the aH'eo's layer an s'bseH'ent contact
bet#een the lipi an m'cin layers.
AD--
1ther mechanismsD s'ch as ne'ral receptorsD may play a role
in tear film break'p.
-?
ThereforeD oc'lar s'rface isorers can res'lt from compromise to the str'ct're or f'nction of the
conj'nctivaD eyelis an their %lansD conj'nctiva an its accessory %lansD or cornea. This
7'ieline escribes the most common clinical etiolo%ies of oc'lar s'rface isorers: blepharitis an
ry eye. =See AppeniF 5i%'re . for $:9-.)- :/ :lassification.>
*
The painful eye identifying the cause
The most common oc'lar s'rface isorers stem from tear-film abnormalities an li-%lan
ysf'nction =!blepharitis">D either of #hich may lea to oc'lar s'rface isorers. The 'se of
terms s'ch as ry eye =9E>D oc'lar s'rface isease =1S9>D or eficient tear synrome =9TS>D
represents attempts to escribe si%ns of clinical ama%e to the intrapalpebral oc'lar s'rface or
symptoms of s'ch isr'ption from a variety of ca'ses. LSo'rceM
Can be managed, not cured
oc'lar s'rface iseases s'ch as ry eyes an blepharitis are chronic conitions thatD at bestD can
be controlle b't rarely c're. /ana%in% patient eFpectations is criticalD %iven the tenency for
patients to eFpect immeiate improvement an %ive 'p too soon on their therapies. Bhen
ealin% #ith oc'lar s'rface iseasesD one has to be persistent an 'se combination therapies in
orer to reach the f'll treatment effect. LSo'rceM
Do not self-diagnose
Symptomatic patients may try to solve their perceive problems #ith self treatment. S'ch
approaches may elay acc'rate ia%nosis of oc'lar s'rface isease. LSo'rceM
;o#everD it has been my eFperience that most octors ont really kno# m'ch abo't this an o not
pay m'ch attention. So yo' are #ell avise to research the topic on the internet an %et better
informe abo't #hat yo' mi%ht be eFperiencin%.
Symptoms
See this.
itchin%D especially in the inner canthal areaD is almost al#ays a si%n of aller%ic isease. 4ike#iseD
it is #ell kno#n that patients #hose symptoms are preominantly 'e to aH'eo's tear eficiency
#ill often have forei%n boy sensationD #hich is #orse later in the ay. :onverselyD patients #ith
preominantly meibomian %lan isease an concominant evaporative ry eyeD have more
b'rnin% an irritationD #hich is typically #orse in the mornin%.
5l'ct'atin% vision #ith #orsenin% vis'al ac'ity after vis'ally intensive activities is virt'ally
ia%nostic of an inaeH'ate tear film. LSo'rceM
0atients eFperience:
!'ntil yo've eFperience ry eyeD yo' cant 'nerstan ho# 'nspeakably painf'l it is" LSo'rceM
$t is like !livin% in hell" LSo'rceM
!$ #as reay to j'mp o't the #ino#" LSo'rceM
!$ felt like $ ha shars of %lass c'ttin% into my eyes. The only relief $ %ot #as #hen $ #as asleepK
my time a#ake #as tort're." LSo'rceM
$ve trie to classify the levels of pain $ve eFperience here. B't a f'rther isc'ssion #o'l be
'sef'lD since it is the most abs'rly painf'l eFperienceD #ell beyon any possible escription .
2
This %reatest problem #ith this pain is that it is locate 9$6E:T4& 1, the !#ino#" to ones
#orl @ the eyes an forebrain. The entire area insie an aro'n the eyes %ets SE(E6E4&
affecte.

A throbbin%D ti%ht pain is eFperience in the eyebro# area. Severe heaache can arise. B't basically
it feels that the !rain is eFperiencin% the pain =altho'%h that is not possible since the brain oesnt
have pain receptors>. Basically thereforeD the eFperience is one of continuous soreness insie an
aro'n the eyes @ almost as if it insie the frontal lobe.

This back%ro'n soreness =H'ite ba> can %et a%%ravate baly once the eyes %et ry eno'%h to start
b'rnin% =note that this ryness is ,1T alleviate by eye rops>.

Bitho't s'ch b'rnin% #hat is eFperience is a ti%ht pulling sensation insie the eye an aro'n the
eyelis. B't this sensation can %et astonishin%ly ba #hen the eye starts b'rnin%. At that point there
is an acute burning sensation insie the eye @ as #ell as throbbin% heaache.

Some#here bet#een the b'rnin% an the heaache is an ugly sensation #here the eye is feel as if
there is some astringent fille insie the eyes. $t is not a %ritty sensationD b't feels as if the entire
eyelis are fille #ith somethin% that is p'llin% at the pores an ca'sin% a #eir irritatin%
eFperience.

Some#here aro'n this level of ryness is associate the inability to move the eyeballs fleFibly
#ithin the eyelis. /ovin% them aro'n the eyeball =s'ch as rotatin% the eye in a circle> becomes
impossibleD stickyD an painf'l. So essentially one is force to look aheaD an narro# the eye.

The #orst sensation of all is #hen the heaache and b'rnin% reach the ac'te sta%eD and to that is
ae most 'nbelievable sensation of a !layer" or !film" of pain that fills the entire eye in the front.

This !layery" sensation has been #ell escribe here: "menthol sensationD" like a colD mint #in
is blo#in% ri%ht in to yo'r eyesD even if yo're j'st stanin% stillD inoorsD in a perfectly calm-aire
room." ",astyD nasty sensation". "as if $ #as !stickin% my hea in a freeJer #ith my eyes #ie
open"
$f yo' po'r isopropyl alcohol over the back of yo'r hanD it evaporates veryD very H'ickly. Bhat yo'
feel is a !severe" coolin% sensation that s'rely co'l be escribe as a !menthol moment." That
s're so'ns like severe evaporative ry eye =very short tear break'p time> to me N an mines
's'ally less than t#o secons. LSo'rceM
This kin of sensation %enerally arises #hen one is reain% the comp'ter screen after a lon% ay of
#ork. At that point one kno#s that is simply not possible to contin'e. L,ote: this apparently is fiFe
best by moist're chamber %lassesM

There is ,1 relief for the entire ay the moment one %ets 'p. The only time one oesnt eFperience
pain is 'rin% sleep.

+
Tests
smolarity of tears
ear+ab System
(al'es 4$EAE$ )A( >6= m'smolB+ are ia%nostic of ry eye isease. LSo'rceM
See etails on this blo% post. $n /elbo'rneD /ark 6oth of Armaale has access to s'ch a machine.
Tear !uantity tests#
0luorescein
All ophthalmolo%y offices 'se fl'orescein to look for stainin% on the cornea. ;o#everD 6ose
Ben%al an 4issamine 7reen are act'ally more sensitive than fl'orescein an can be 'se to
ia%nose ry eye isease at an earlier sta%e by lookin% for stainin% in the conj'nctiva #ith #hite
li%ht. This may be 'sef'lD for instanceD #hen screenin% patients before refractive s'r%ery.
$ prefer 4issamine 7reen since it is tolerate better by the patient. Both can be p'rchase in
impre%nate strips an 'se in a manner similar to fl'orescein strips. LSo'rceM
5l'orescein stainin% that is more prominent in the s'perior cornea =#hich is typically covere by
the 'pper eyeli> is almost never j'st 'e to ry eyes. Stainin% from ry eyes typically affects the
interpalpebral Jone m'ch more si%nificantly. ThereforeD one sho'l have a hi%h ineF of
s'spicion in patients #hose stainin% is more prominent s'periorly.
Aitional investi%ations sho'l incl'e evertin% the 'pper eyeli to check for floppiness an/or
chan%es on the palpebral conj'nctiva. 4ike#iseD s'perior limbic keratoconj'nctivitis sho'l be
consiere by checkin% for stainin% an re'nancy of the s'perior conj'nctiva.
5inallyD contact lens-in'ce limbal stem cell eficiency #ill typically present #ith stainin% in a
#horl pattern startin% in the s'perior cornea an limb's. LSo'rceM
$ose bengal staining test
See this.

The p'rpose of this test is to ascertain indirectly the presence of reduced tear volume through
detection of damaged epithelial cells.
The eye is anesthetiJe topically #ith proparacaine ).2O. Tetracaine or cocaine may %ive false-
positive tests beca'se of their softenin% effect on corneal epitheli'm.
1ne rop of .O rose ben%al sol'tion or a rop from a saline-#ette rose ben%al strip is instille in
each conj'nctival sac. 6ose ben%al is a vital stain taken 'p by ea an e%eneratin% cells that have
been ama%e by the re'ce tear vol'meD partic'larly in the eFpose interpalpebral area. This test
is partic'larly 'sef'l in early sta%es of conj'nctivitis sicca an keratoconj'nctivitis sicca synrome.
3
A positive test #ill sho# trian%'lar stipple stainin% of the nasal an temporal b'lbar conj'nctiva in
the interpalpebral area an possible p'nctate stainin% of the corneaD especially in the lo#er t#o-
thirs.
5alse-positive stainin% may occ'r in conitions s'ch as chronic conj'nctivitisD ac'te chemical
conj'nctivitis seconary to hair spray 'se an r'%s s'ch as tetracaine an cocaineD eFpos're
keratitisD s'perficial p'nctate keratitis seconary to toFic or iiopathic phenomenaD an forei%n
boies in the conj'nctiva.
The stain #ill also color m'c's an epithelial ebrisD #hich may mask the res'lts. :ertain patients
#ho are normal #ill sho# some positive stainin% to rose ben%al on the cornea.
Beca'se of thisD conj'nctival as #ell as corneal stainin% sho'l be present before the ia%nosis of
keratoconj'nctivitis sicca is mae.
See this: http://###.ryeyes'mmit.or%/articles/pros-an-cons-ry-eye-tests
+issamine 4reen
Tear H'antity tests are 'sef'l in confirmin% the ia%nosis of aH'eo's-eficient ry eyes. The most
freH'ently 'tiliJe proce'res are:
Schirmer tear test# The Schirmer testD either #ith topical anesthesia =basic secretion test> or
#itho't =Schirmer $>D can be 'se to eval'ate the H'antity of the aH'eo's layer of the tear
film.
.)
$n this testD the eFaminer places filter paper in the lo#er forniF to meas're the vol'me
of tears pro'ce 'rin% a fiFe time perio. Bhen performe 'sin% a topical anestheticD it
p'rportely meas'res the tear secretion of the accessory lacrimal %lansK #itho't anestheticD
it meas'res the tear pro'ction of the lacrimal %lan by stim'lation of the lacrimal refleF arc.
Altho'%h it is controversial beca'se the res'lts are often inconsistentD the Schirmer tear test
can provie 'sef'l clinical information.
0luorescein-enhanced assessment# After ain% fl'oresceinD a #ater-sol'bleD inert ye =not
fl'orescein-anesthetic sol'tion> to the oc'lar s'rfaceD the clinician can observe the rate of
il'tion of the aH'eo's component of the 01T5D especially #ith enhancement by cobalt-
filtere ill'mination. $n aitionD s'bclinical isr'ption of the oc'lar s'rface #ill be reveale
by stainin% vie#e #ith the cobalt-filtere ill'mination. Acceptance of this metho has been
hampere by lack of a stanar.
.)D.)?
Evaluation of the tear prism# The tear menisc's hei%ht can be assesse #ith biomicroscopic
eFamination both #ith an #itho't instillin% fl'orescein ye.
.)3
A tear menisc's hei%ht %reater
than
).- millimeters =mm> sho'l be consiere normal.
.)8
A scanty or absent tear menisc's is an
inication of an aH'eo's tear eficiency.
.)A
5't're irections in tear meniscometry may combine the
'se of interference patterns.
..)
ear-film debris# EFcessive partic'late matter in the tear filmD visible by biomicroscopic
eFaminationD may inicate inaeH'ate fl'shin% action 'e to re'ce tear flo#.
$ose bengalB lissamine green staining# A 'sef'l test for ientification of oc'lar s'rface
isorers has been rose ben%al stainin%. $t hi%hli%hts oc'lar s'rface chan%es associate #ith
ins'fficient tear flo# an conj'nctival an corneal esiccation. 1ne scorin% system for rose
ben%al stainin% assi%ns val'es of ) to ? for each of the lateral an meial corneal an
8
conj'nctival re%ions of the eFpose intrapalpebral oc'lar s'rface.
...
A maFim'm score of A
inicates severe stainin%K ) inicates complete absence of rose ben%al stainin%. A more
etaile techniH'e for H'antitative assessment of rose ben%al stainin% enables escription of
the intensity an eFtent of involvement an may be more 'sef'l in oc'mentin% s'btle
chan%es in response to treatment strate%ies.
...
The intro'ction of lissamine %reen stain has offere an alternative to rose ben%al that is less
irritatin% to the patient an eH'ally efficacio's in emonstratin% isr'pte oc'lar s'rface
characteristics.
..-D..?
ThereforeD lissamine %reen is preferable to rose ben%al. The 1Ffor scale has
been propose to stanariJe the eFtent an location of lissamine %reen as #ell as fl'orescein
stainin%.
..*
1ther tests that may be 'se to eval'ate tear H'antity are:
E Schirmer $$ =irritation>
E :otton threa test
..*
E 4issamine %reen stainin%
..2D..+
E 0henol re threa test ..3
E Tear vol'me meas'rements
E 5l'orophotometryK fl'orescein il'tion.
.8
E 4acrimal eH'ilibration time.
.A
E Temporary p'nctal occl'sion.
Tear film stability tests"
Several proce'res are commonly 'se to eval'ate tear film stability:
ear film breakup time !81"# The time reH'ire for the tear film to break 'p follo#in% a
blink is normally .2P-) secons .-)K TB<T val'es of less than .) secons may represent a
practical ineF for an abnormal tear film. Some optometrists rely on an empirical test of the
inte%rity of the tear film bein% maintaine #ithin the blink interval. The most recent
s'%%estion is that val'es bet#een 2 an .) secons are threshols b't vol'me-epenent
.3D.-.

Beca'se lipi contamination of the m'cin layer ecreases the s'rface tension an eliminates
the aH'eo's portion of the tear film in that areaD re'ce B<T may also inicate m'cin
eficiency. Some clinicians prefer to meas're the noninvasive B<T =,$B<T>. Tear-film
break'p is observe #itho't the aition of fl'orescein to the tear film.
ear-thinning time# This noninvasive test involves a keratometer to vie# the mire ima%e an
meas're the time from a complete blink to istortion of the ima%e ..--
1ther tests that may be 'se to eval'ate the H'ality of the 01T5 are:
E Tear osmolarity test8*D.-?D.-*
E $mpression cytolo%y
.-2
E :onj'nctival scrapin% an biopsy
E Tear protein analysis .-+
E /'cin assay test =tear fernin%>
.-3
E 4ipi layer interference patterns .+D.)3D.-8
E Spec'lar reflection of the tear s'rface .-AD.?) E E4$SA tear protein profile. .?.
A
After nearly a cent'ry of research attemptin% to characteriJe clinical si%ns amon% patients #ith ry
eyeD the consens's is that tear film ysf'nctions are seconary to li an li-%lan isr'ptions. S'ch
isr'ption leas toD or is a conseH'ence ofD osmolarity chan%es in the aH'eo's layer of the tear filmK
it may lea toD or be a conseH'ence ofD inflammatory components in the tear film an on the oc'lar
s'rface. <nfort'natelyD no sin%le tear H'antity or tear H'ality test is capable of assessin% the
inte%rity of the tear film or oc'lar s'rface. 9ia%nosis is more likely to be acc'rate #hen it is base
on m'ltiple abnormal test res'lts.
.D3D.)D.)-
1c'lar s'rface isorersD #hether ca'se by aH'eo'sD
m'c'sD or lipi eficiencies or abnormalitiesD m'st be ia%nose an treate as early as possible to
prevent f'rther chan%es in the eFpose oc'lar s'rface. Table . s'mmariJes normal val'es that have
been establishe for selecte tests.
#iomicroscope
This is 'se to test for blephratis. See this @ a 'sef'l article.
9ifferentiatin% amon% the vario's presentations of blepharitis reH'ires the 'se of a biomicroscope to
contrast the appearance of the anterior an the posterior li mar%ins. Eval'ation of the patient #ith
blepharitis may incl'eD b't is not limite to the follo#in%:
EFternal eFamination of the eyeD incl'in% li str'ct'reD skin teFt'reD an eyelash appearanceD
an eval'ation for clinical si%ns of rosacea =i.e.D telan%iectasiaD p'st'lesD rhinophyma>.
Biomicroscopic eFamination of the li mar%insD the base of the lashesD an the meibomian
%lan orifices an their contents. Telan%iectasia posterior to the meibomian %lans may be a
key finin% in ientifyin% posterior blepharitis seconary to meibomian %lan ysf'nction.
EFamination of the tear film for lipi layer abnormalities.
Eval'ation of the palpebral an b'lbar conj'nctiva.
*eibography
This checks the H'ality of mebimian %lans
Diagnostic methodology
$peed of onset
$apid onset
$f the onset is very rapiD inication is an auto-immune inflammatory response orbacterial. $n my
case there #as rapi onsetD so $ s'spect a'to-imm'ne or bacterial ca'se.
Slo% onset
$f onset is slo#D then co'l be relate to poor iet/ eficiency/ ropo't of mebomian %lans/
slo#in% o#n of lachrymal %lans/ somethin% that is affectin% %oblet cells =m'cin>.
%ye parts affected
/<:1<S 4A&E6 %oblet cells Lalmost certainly affecteM
BATE6 4A&E6 lachrymal %lans
1$4 4A&E6 mebomian %lans
.)
Causes (aetiology)
Each ca'se has a ifferent set of symptoms an ifferent sol'tions. ;ence it is :6<:$A4 to
ia%nose the correct ca'se.
Auto-immune response
#acterial infections
4emps ry eye st'y sho#e that in patients #ith ry eye iseaseD virt'ally 3)O of them have an
associate blepharitis.
-
4i mar%in c'lt'res are positive in virt'ally .))O of these patients. 0atho%enic strains can occ'r
bet#een ?2 an A2O. $ts important to remember that bacteria have lipolytic eFoenJymes an
colla%enases that e%rae the lipiD formin% an inflammatory so'p that is 'mpe on the corneal
s'rface an leas to the problems #e see in o'r patients.
$f #e c'lt're o'r patientsD even normal patients #ill ten to have involvement #ith several bacteria.
The most common ones that are seen are coa%'lase-ne%ative staphylocciD ,. aureusD ;. acneD an
oryne!acterium species. $ts interestin% to note that in the patients #ith the vario's forms of
blepharitisD these bacteria are present in very hi%h amo'nts.
$n cases of chronic blepharitisD the pathophysiolo%y leas 's to believe there is no sin%le bacteria
thats responsible. 6ather its a pro'ction of the bacteria in terms of their lipolytic effect on the
meib'm that is present an the chan%es that occ'r in the lipi at the base of the lashes. ,tap-
aureusD oryne!acterium speciesD an ;. acne all have effects on these lipolytic enJymes. These all
act to%ether in concert to create an increase in free fatty acis.
This increase is central to the theme of the patholo%y that occ'rs in this isease. Bhat #ere havin%
is saponification. The problem that occ'rs in o'r patients is that theres a eter%ent action to the tear
film #hich leas to a recalcitrant s'perficial p'nctate keratopathy.
Anterior 8lepharitis
ca'se by staphylococcal bacteria. Staphylococci are becomin% increasin%ly resistant to many
commonly 'se antibiotics incl'in% penicillinsD macrolies s'ch as erythromycinD tetracyclines an
amino%lycosies.
$ recommen the %entle 5oamin% Eyeli :leanser by 1c'softD beca'se it oesnt ry the skin
an it oesnt ama%e the oc'lar s'rface if it %ets into the eye. LSo'rceM
There is no !c're" for blepharitisD beca'se the ca'sative a%ent #ill al#ays be on the skin. 7oo
hy%iene practicesD s'ch as #ashin% the eyelisD %enerally #ill keep it 'ner control.
6oyal Eye an Ear ;ospital blepharitis fact sheet =095>
This recommens baby shampoo/ bicarbonate of soa.
;o#everD the follo#in% #ebsite says thats not a %oo iea:
..
Henry D. Perry, M.D.
1ptometrists are oin% more harm than %oo by avisin% patients to employ home-mae
treatments s'ch as baby shampoo or bicarb scr'bs for li an lash conitions.
$nepenent Best :o'ntry 11 Sarah 5arrant sai that some practices #ere oin% more harm than
%oo by avisin% patients to 'se baby shampoo or bicarbonate of soa to #ipe lis an lashes.
Baby shampoo is abo't as isr'ptive to the lipi as yo' can %et. She also ca'tione a%ainst the 'se
of bicarb escribin% it as: the lesser of t#o evils
8icarbonate of soda
;o# m'chQ <se a teaspoon of bakin% soa =soi'm bicarbonate> in a pint of boile #ater:
this sol'tion can be 'se over a #eek if refri%erate. LSo'rceM
Antibiotics etc. see this

ACasite See this
/ajor contrib'tin% factors to the alteration of lipi secretion are li an lash isorersD #hich may
be potentiate by inflammatory elements. Any of the forms of blepharitis may represent the initial
si%n of altere lipi secretions that res'lt in premat're evaporation of aH'eo's tear components.
Anterior blepharitis# 9ermatolo%ic manifestations of anterior blepharitis involve the
keratiniJe li skin an may incl'e ecJemaD #hich is typically seconary to aller%ic contact
ermatitis.
*+-*8
1ther etiolo%ies of anterior blepharitis incl'e infectionD seborrheaD an the
combination of both.
-+
$taphylococcal blepharitis# <s'ally ca'se by one of t#o ,tap-ylococcus speciesD ,. aureus
or ,. epidermidisD staphylococcal blepharitis is an inflammation of relatively short 'ration. $t is
more prevalent in #armer climates an often occ'rs in mile-a%e #omen #ho have no other skin
abnormalities. $n aition to the hallmark si%ns of li s#ellin%Eerythema of the li mar%insD scaly
collarettes at the base of the lashesD an possible skin 'lcerationEa freH'ent res'lt is evaporative
ry eye 'e to the inefficient lipi-layer f'nction. An aH'eo's-eficient component accompanies
this sit'ation.
*AD2)
;oreola an chalaJia are potential coeFistin% conitions.
$eborrheic blepharitis# Also calle sH'amo's blepharitisD seborrheic blepharitis is part of a
ermatolo%ic conition that incl'es the scalpD faceD an eyebro#s =seborrheic ermatitis>D all of
#hich have c'lt're #ith pop'lations of normal s'rface or%anisms. $t is present in . to ? percent of
imm'nocompetent a'ltsD an is more prevalent in men than in #omen. Altho'%h skin
inflammation is not necessarily evientD %reasyD foamy scales calle sc'rf s'rro'n the bases of the
cilia. Seborrheic ermatitis may be seen in conj'nction #ith other skin iseasesD s'ch as rosaceaD
an acne v'l%aris. Malasse6ia yeasts have been associate #ith seborrheic ermatitis. Abnormal or
inflammatory imm'ne system reactions to these yeasts may be relate to evelopment of seborrheic
ermatitis.
2.
$eborrheic&staphylococcal blepharitis# Another common form of anterior blepharitis is
combine seborrheic/staphylococcalD or miFeD blepharitis.
2-
Associate #ith seborrheic ermatitisD
it is characteriJe by seconary keratoconj'nctivitisD papillary an follic'lar hypertrophyD
conj'nctival injectionD an miFe cr'stin%. $ts severity #aFes an #anes
over its chronic co'rse. Bacterial c'lt'res are positive in approFimately A8 percent of cases. The
or%anisms fo'n most freH'ently have chan%e from ,. aureus to ,. epidermidisD ,treptococcus =A
an B>D )acillus sp.D oryne!acterium sp.D ;ropioni!acteriumD Esc-eric-ia coli, ;seudomonas sp.D
itro!acter sp.D and andida sp.
2?
;istolo%ical eFamination reveals chronicD moerateD
non%ran'lomato's inflammation.
.-
Meibomian seborrheic blepharitis# /eibomian seborrheic blepharitis can be ientifie by
the presence of increase meibomian an seborrheic secretions #itho't inflammation. Tears are
foamy an s'syD res'ltin% in b'rnin% symptomsD especially in the mornin%. $tchin% an tearin% are
common conc'rrent symptoms. The meibomian %lans are ilateD leain% to copio's secretions
an b'lbar conj'nctival injection. The clinical si%ns are consistent #ith ist'rbe meibomian %lan
f'nction. This form of blepharitis may be more appropriately %ro'pe #ith the posterior variety.
$eborrheic blepharitis 'ith secondary meibomianitis# Seborrheic blepharitis #ith
seconary meibomianitis =meibomitis> is similar in clinical presentation an symptoms to
seborrheic blepharitis. ;o#everD it has episoic inflammation an meibomianitis that res'lt in a
spotty presentation of clo%%e meibomian %lans an anterior seborrhea. 4ipi secretions are of
toothpaste consistencyD contrib'tin% to an 'nstable 01T5. :'lt'res reveal the presence of normal
flora. This form of blepharitis may also be %ro'pe #ith the posterior variety. The clinical si%ns are
consistent #ith ist'rbe meibomian %lan f'nction.
Meibomian (eratocon)uncti*itis# /eibomian keratoconj'nctivitis =primary meibomianitis>
is the most severe li mar%in inflammation. Typically occ'rrin% 'rin% the fo'rth ecae of lifeD it
has no preilection for %ener b't is more common in coler climates. $t is freH'ently associate
#ith rosacea an is part of a %eneraliJe sebaceo's %lan ysf'nction pattern that clo%s the
meibomian %lan openin% #ith esH'amate epithelial cells. This is most likely 'e to altere
polarity of the lipi secretion.
.-
Beca'se lipi secretions have a hi%her meltin% point than the oc'lar
s'rface temperat'reD sta%nation of free fatty acis #ithin the %lans inspissate openin% res'lts in a
lipi-eficient tear film. $t is very likely that this form of blepharitis sho'l also be %ro'pe#ith the
posterior variety. The clinical si%ns are consistent #ith ist'rbe meibomian %lan f'nction.
Angular blepharitis# An%'lar blepharitis is localiJe to the li at the o'ter canth's. The
staphylococcal form is typically ry an scaly #hile the form ca'se by Moraxella 4Morax$
Axenfeld> iplobacill's is #et an macerateD an has a #hitish frothy ischar%e. There is the
possibility of seconary bacterial conj'nctivitis or keratitis res'ltin% from the Moraxella or%anism.
2*
$(in disease
8lepharitis
Atrophy of Mebomian glands
3amaged goblet cells !mucuous layer"
4oblet cells generally lo% in dry eyes
:onj'nctival %oblet cell ensity in normal s'bjects an in ry eye synromes. by 6 A 6alph $nvest.
1phthalmol. (is. Sci. April .A32 vol. .* no. * -AA-?)-
Serial sections prepare from biopsies of the eep tarsal portion of the inferior nasal conj'nctival
forniF in normal s'bjects an in patients #ith vario's ry eye synromes #ere analyJe #ith
respect to the %oblet cell ensities. Bhen compare to normal s'bjectsD inivi'als #ith keratitis
siccaD Stevens-Rohnson synromeD oc'lar pemphi%oiD an ac'te alkali b'rn all emonstrate
.?
pro%ressively lo#er %oblet cell ensities per millimeter of epithelial s'rface. These isease entities
canD thereforeD be consiere %oblet cell-eficient synromes. L5'll TeFtM
there is increasin%ly reco%nition of the importance of %oblet cell ensity in many persistent ry eye
cases. The clinical trials 7ary 5o'lks i on 9akrina act'ally sho#e an increase in %oblet cell
ensity =$ ont have the info hany b't $ believe this #as a st'y on Sjo%rens patients>.
Aitionally $ have hear from a fe# octors #ho sa# presentations by Aller%an statin% that
6estasis is believe to increase %oblet cell ensity. LSo'rceM
/ncreased level of solvents in dry eyes can kill goblet cells
$ncrease tear osmolarity can potentially in'ce patholo%ical chan%esD incl'in% loss of
conj'nctival %oblet cells an esH'amation of conj'nctival epitheli'mD to the oc'lar s'rface
LSo'rceM
From T-eraTears 1e!site:
The tears are a salt sol'tion. As an eye becomes ryD the tears lose #ater an become too salty. An
j'st like #hen yo' thro# salt on a #o'nD it stin%s an b'rns #hen yo'r tears become too saltyD
yo'r eyes stin% an b'rnD an later there is a sensation of ryness an sany-%ritty irritation.
9ry eye is a conition characteriJe by loss of #ater from the tear film. As a res'lt the tear film
becomes saltier an more concentrate. /ost of 's #ill remember !osmosis" from hi%h school
chemistry. Bhen the tear film becomes too concentrateD osmosis p'lls #ater o't of the s'rface of
the eyeD makin% it ry.
$n ry eye the hi%h salt concentration in the tear film =the hi%h !tear osmolarity" or hypertonicity>
an the chan%es on the s'rface of the eye ca'se the stin%in% an b'rnin%D ryness an sany-%ritty
irritation. An beca'se evaporation from the eyes is %reater #hen the eyes are open than #hen they
are closeD the symptoms of ry eye %et #orse as the ay %oes on.
.*
1ne of the most important chan%es that occ'r in ry eye is a re'ction in the n'mber of
conj'nctival %oblet cells on the s'rface of the eye. &o're probably #onerin% #hat a conj'nctival
%oblet cell is. 9i yo' ever #oner #hy yo'r eyes ont sH'eak #hen yo' blinkQ $ts beca'se on the
s'rface of the eye there are tho'sans of m'c's-containin% cells calle !%oblet cells." /'c's is the
most slippery s'bstance in the h'man boy. Think of these %oblet cells as the !ball bearin%s" of the
eye s'rface E instea of containin% stainless steel they contain m'c's. An this is #hy normal eyes
ont sH'eak #hen they blink an one of the reasons #hy ry eyes are so 'ncomfortable.
L+isten to 3r 4ilbard of hera earsM
+ess blinking can kill goblet cells
LS'r%eryM keeps the lis seperate> ca'ses tra'ma to the conj'nctiva. The conj'nctiva is #here most
%oblet cells are replenishe. LSo'rceM
)E$A EA$S &A( )E+.D
TheraTears =Avance (ision 6esearch>. This hypotonic sol'tion is esi%ne to enhance tear
vol'me an re'ce the osmolarity of the tear film. Reffrey 7ilbarD /.9.D #ho create TheraTearsD
s'%%ests that !sat'ration osin%" #ith this pro'ct can iminish symptoms of ryness an help
restore the normal physiolo%y an health of the oc'lar s'rface. A st'y of post-4AS$C patients
emonstrate that prolon%e therapy #ith TheraTears helpe restore normal conj'nctival %oblet cell
ensityD #hile treatment #ith a preservative-free control i not.
4E0A$(AE< $egenerating goblet cells
7efarnate stim'lates %oblet cell repop'lation follo#in% an eFperimental #o'n to the tarsal
conj'nctiva in the ry eye rabbit. Toshia ;D ,akata CD ;amano TD ,akam'ra /D ,%'yen 9D
Be'erman 6. LSo'rceM
7efarnate increases 0AS positive cell ensity in rabbit conj'nctivaD Br R 1phthalmol
.AA8K8-:.?-)-.?-?
Anot-er article:
Effect of %efarnate on the oc'lar s'rface in sH'irrel monkeys. Toshia ;D ,akata CD ;amano TD
,akam'ra /D ,%'yen 9D Be'erman 6B. :ornea. -))- AprK-.=?>:-A--A.
.2
Topical application of %efarnate #as not associate #ith any averse oc'lar s'rface effects. 7oblet
cell repop'lation after inj'ry #as si%nificantly %reater in the %efarnate-treate eyes compare #ith
the vehicle-treate eyes. $n the %efarnate-treate eyesD tear m'cin content #as si%nificantly %reater
at . #eek after inj'ry. 5l'orescein stainin% #as si%nificantly re'ce at ? #eeks after inj'ryD an
rose ben%al stainin% #as si%nificantly re'ce in the area of the #o'n at - #eeks in the %efarnate-
treate eyes compare #ith the vehicle-treate eyesK at other timesD conj'nctival stainin% in the t#o
%ro'ps of eyes #as not si%nificantly ifferent. :1,:4<S$1,S: 7efarnate promotes %oblet cell
repop'lation an increases m'cin pro'ction after a conj'nctival inj'ry. ,o averse affects of the
treatment #ere fo'n# hus, this agent may be useful in conditions that diminish goblet cell
function#
4et 4efarnate from cabbage
:abba%e contains potent s'bstances in it s'ch as amino acisD 4-%l'tamine an 7efarnate. These
s'bstances help protect the linin% of the i%estive tract so the 'lcers can heal an ne# ones can be
prevente. They also help increase the m'c's pro'ction in the stomachD #hich helps coatD an
protect the 'lcers that have alreay forme on the linin% of the stomach so they o not become
#orse an have a chance to heal. The best #ay to %et cabba%e into yo'r iet to help heal an treat
yo'r peptic 'lcers is by eatin% - to ? c'ps of ra# cabba%e a ay #ith a sala or meal. $f yo' o notD
like eatin% ra# cabba%eD yo' can al#ays rink a co'ple %lasses of ra# cabba%e j'ice each ay an
that #ill o the trick as #ell. LSo'rceM
/t is possible that sEueeCing cabbage juice and applying to the eyes %ill help# (eed to try#
refoil factor family peptide >
Trefoil factor family peptie ? at the oc'lar s'rface. A promisin% therape'tic caniate for patients
#ith ry eye synromeQ by Sch'lJe <D Sel SD 0a'lsen 50. 9evD 1phthalmol. -).)K*2:.-... Ep'b
-).) /ay .8. 9epartment of AnatomyD /artin 4'ther <niversity ;alle-Bittenber%D ;alle/SaaleD
7ermany. 'te.sch'lJeSmeiJin.'ni-halle.e
Abstract
9ry eye synrome is a #iesprea isease accompanie by iscomfort an potential vis'al
impairments. Basic ca'ses are tear film instabilityD hyperosmolarity of the tear filmD increase
apoptosis as #ell as chronic inflammatory processes. 9'rin% the last ecaesD o'r 'nerstanin% of
ry eye synrome has consierably increase. ;o#everD the molec'lar mechanisms of the isease
remain lar%ely el'sive. $n this conteFtD o'r %ro'p foc'ses on trefoil factor ? =T55?>. Amon% other
factorsD T55? performs a broa variety of protective f'nctions on s'rface epitheli'm. $ts main
f'nction seems to be in enhancin% #o'n healin% by promotin% a process calle restit'tion.
St'ies eval'atin% T55? properties an effects at the oc'lar s'rface 'sin% in vivo as #ell as in vitro
moels have reveale a pivotal role of 00> in corneal %ound healing. S'bseH'ent st'ies in
osteoarthritic cartila%e seem to ra# a ifferent pict're of T55?D #hich still nees f'rther
el'ciation. This man'script s'mmariJes the finin%s concernin% T55? in %eneral an its role in the
cornea as #ell as artic'lar cartila%e @ t#o tiss'es #hich have some thin%s in common. $t also
isc'sses the potential of T55? as a caniate therape'tic a%ent for the treatment ofD for eFampleD
oc'lar s'rface isorers.
Ophthalmic compositions comprising trefoil factor family peptides
See this. "compositions comprisin% trefoil family factor pepties #ill be 'sef'l in preventin% or
treatin% ry eye by topical aministration of the composition to eye of the patient."

refoil peptides promote restitution of %ounded corneal epithelial cells#
7Tke /,D :ook R6D C'nert CSD 5ini /ED 7ipson $CD 0oolsky 9C.
So'rce
7astrointestinal <nitD /assach'setts 7eneral ;ospital an ;arvar /eical SchoolD BostonD
/assach'setts )-..*D <SA.

.+
$s this relevantQ http://###.osns'persite.com/vie#.aspFQriU88??.
Damaged lachrymal glands
Deficiencies
/odine deficiency
estosterone deficiency
A mite in the eyelashes +demode, folliculorum-
See this for etails.
9emoeF follic'lor'mD a mite that lives at the base of the lashesD is present in 2O of normals an
?2O of patients #ith blepharitis.
3emodicosis# 9emoicosis is the inflammatory reaction to a common mite that inhabits the
eyelash follicles in persons over the a%e of 2) years. There are t#o species of miteD #emodex
folliculorum an #emodex !revis. #. folliculorumD #hich is present in hair an eyelash folliclesD
cons'mes epithelial cellsD pro'ces follic'lar istension an hyperplasiaD an increases
keratiniJationD leain% to c'ffin% at the base of the cilia. #. !revisD #hich is present in sebaceo's
an meibomian %lansD may estroy the %lan'lar cellsD pro'ce %ran'lomas in the eyeliD an pl'%
the 'cts of the meibomian an other sebaceo's %lans that affect formation of the lipi layer.
#emodex has been associate #ith rosaceaD b't a ca'sal relationship has yet to be establishe.
22D2+
3emodicosis# #emodex are present in the lash follicles of most elerly persons.
.??
This conition is
's'ally innoc'o's. Bhen the mite pop'lation reaches critical proportionsD symptoms res'lt. There is
a cr'stin% of the li mar%inD trichiasisD maarosisD loss of lashesD an c'ffin% at the base of the
lashes. The ia%nosis can be confirme by epilatin% a lash from the affecte area an eFaminin% the
follicle 'ner a clinical microscope for the presence of mites. 0atients #ith rosacea may be more
prone to #. folliculorum than those #itho't this ia%nosis.
3emodicosis. Treatment #ith a *O pilocarpine %el =b.i.. F - #k> mayD in some casesD be
s'pplemente by the application of antibiotic ointment
.-)*D-)2
,i%htly li hy%ieneD follo#e by the
application of blan ophthalmic ointment tens to inhibit the proliferation of #emodex. The
ointment is remove the neFt mornin% #ith li hy%iene. -)+D-)3
.3
.emedy for auto-immune response
Symptomatic relief: Non-therapeutic reduction in osmolarity
Take thera tears preservative free
A*oid ben/al(onium chloride +#A0-
patients #ith oc'lar s'rface isease are m'ch more sensitive to preservativesD partic'larly
benJalkoni'm chlorie =BAC>. $n aition to 'sin% non-preserve topical l'bricantsD #hen
prescribin% antibioticsD sterois or %la'coma meicationsD $ prefer to 'se non-preserve or non-
BAC preserve eye rops #henever possible. LSo'rceM
Non-therapeutic dietary supplements
Apparently Thera tears n'trition is %ooD b't any combination of flaF/fish/primrose oilD an key
vitamins sho'l s'ffice. This 91ES ,1T :<6E T;E 061B4E/.
Non-therapeutic anti-inflammatories
A %oo n'mber of anti-inflammatory rops are 'se b't these ont seem to aress the 'nerlyin%
ca'se.
.emedy for blepharitis
Therapeutic if caused by bacteria lid scrub
'cular !lid" hygiene# 9aily cleanin% of acc'm'late ebris from the li mar%ins removes a
potential c'lt're mei'm for microor%anisms. ,ormal face #ashin%D #ith attention to the oc'lar
aneFaD is s'fficient for most peopleK ho#everD commercial li scr'bs are available.
Do not use baby shampoo
.8
Do not use bicarbonate of soda
1se only LidCare or one of these
Sterli is available in A'stralia.
Eye Scr'b ,ovartis 0re-moistene pas.
4i;y%eniF 4i;y%eniF $nc. 5l'i cleanser for 'se #ith cotton balls or sterile pas =pas
not incl'e>.
4i Scr'b 5oamin%
Eyeli :leanser
1c'Soft 5oamin% cleanser.
4i Scr'b 0re
/oistene 0as
1c'soft 0re-moistene pas.
4i Scr'b Sol'tion 1c'soft 5l'i cleanser for 'se #ith pas.
!Effectively removes oilD ebris an esH'amate skin from
the eyelis =:ocamiopropyl ;yroFys'ltaine>"
Sterili Avance (ision
6esearch
5oamin% cleanser =packa%e in spray bottle>. 4on% list of
in%reients =see link> incl'in% tea tree oil.
Sty%iene Sterile
Eyeli :leanser
9el 5l'i cleanser #ith pas.
0'rifie BaterD 0E7 8) Sorbitan 4a'rateD 0olysorbate -)D
Soi'm :hlorieD 0otass'im :hlorieD V'aterni'm-.2D
9isoi'm E9TAD Soi'm :itrate.
Therapeutic if caused by bacteria - antibiotics
2oney
;oney is an eFcellent antibiotic. Even s'perb'%s can be kille by it. See etaile blo% post here.
Do,ycycline
There is eno'%h evience to inicate that meications s'ch as oFycycline can be effective for
the mana%ement of meibomian %lan isease at m'ch lo#er oses than previo'sly tho'%ht.
Altho'%h more eFpensive, doxycycline can be prescribed at 9@ mg t%ice a day. /f not
affordable to the patient, then 5@ mg t%ice a day generic version is also an option# <sin%
lo#er osa%es #ill improve compliance by minimiJin% the sie effectsD partic'larly
%astrointestinal sie effects. LSo'rceM
A/asite
AJaSite =aJithromycin .O ophthalmic sol'tion>. Availa!le as <it-romax in Australia. )9T N%T A,
AN E=E#>%; ,%L9T?%N
AJaSite not only attacks the most common patho%ensD namely Staphylococc'sD Streptococc'sD an
;emophil'sD b't it as the aitional action of interr'ptin% the inflammatory cascae. $t
s'ppresses cytokines an chemokines an other inflammatory constit'entsD an it re'ces matriF
metalloproteinase =//0>. $t oes all this anti-inflammatory activity #itho't the risk of slo#in% the
healin% process or hi%her intraoc'lar press're that comes #ith topical corticosterois.
.A
Another benefit $ve fo'n #ith AJaSite is its seven-ay osin% sche'le for bacterial
conj'nctivitis. The re%imen is only nine ropsEt#o a ay for the first t#o aysD then once a ay for
the remainin% five ays. TypicallyD topical antibacterials reH'ire fo'r-times-a-ay applicationD if not
moreD for a loain% ose. :ompliance is a bi% iss'eD especially #ith yo'n%er chilrenD b't AJaSites
simplifie osin% sche'le resolves that in many cases. LSo'rceM
AJasite st'ies sho# promisin% res'lts for treatment of meibomian %lan isease an blepharitis
Th'rsayD -2 September -))8 --:))
6es'lts from t#o sin%le-center st'ies inicate that topical aJithromycin .O ophthalmic sol'tion
=AJaSite> sho#s potential as a safeD #ell-tolerate an hi%hly effective treatment for meibomian
%lan isease =posterior blepharitis> an anterior blepharitis.
1ne st'y of -. patients sho#e that the compo'nD in combination #ith #arm compressesD
provie a si%nificantly %reater clinical benefit than #arm compresses alone in treatin% the si%ns
an symptoms of posterior blepharitisD an that patients rate efficacy #ith aJithromycin in
combination #ith #arm compresses as better than #arm compresses alone.
Another st'y eval'ate aJithromycin .O for 'se in treatin% chronicD miFe =Staphylococcal an
seborrheic> anterior blepharitis 'sin% an off-label aministration techniH'e involvin% irect
application to the eyelis. The res'lts sho#e that aJithromycin ophthalmic sol'tion #as better than
erythromycin in treatin% si%ns an symptoms of anterior blepharitis.
3 Treatment and !anagement of "nterior #lepharitis
a. Basis for Treatment
Anterior blepharitis 's'ally is the irect res'lt of isr'ption or infection of the lipi-pro'cin%
%lans that open to the li mar%in. :linical presentation may incl'e internal an eFternal horeola.
The treatment is relatively strai%htfor#ar. Tho'%h essentialD li hy%iene alone may not resolve the
problem. 9epenin% 'pon the clinical finin%sD appropriate anti-infective r'%s can be aministere
topicallyD systemicallyD or in combination. A%%ressive therapy sho'l initially incl'e a minim'm of
+ #eeks of li hy%iene an appropriate anti-infective meications to %ain control of the conitionD
follo#e by maintenance therapy.
b. Available Treatment Options
Beca'se every cate%ory of anterior blepharitis is act'ally a separate conitionD each nees to be
aresse inivi'ally. ;o#everD the 9elphi report ientifie anterior blepharitis as an incl'sive
cate%ory in patients #ith ysf'nctional tear synrome an recommene li hy%iene an topical
antibiotic treatment initially. 5or patients #itho't li mar%in iseaseD the initial treatment consists of
topical tear s'pplements an imm'nomo'lators.
.
5ail're to respon sho'l prompt p'rs'it of si%ns
of posterior blepharitis.
Staphylococcal blepharitis# Treatment of staphylococcal blepharitis incl'es an antibiotic
ointment to control the infection as #ell as li hy%iene.
.A.D.A-
4i hy%iene can be performe #ith a
commercially available li scr'b form'lation or by 'sin% il'te baby shampoo =.:.) in #ater>
applie #ith a facial cloth. ErythromycinD bacitracinD polymyFin B-bacitracinD %entamicinD an
tobramycin are all effective antibiotics for treatment of staphylococcal blepharitis. Each of these is
available in ointment form. Another ointment that may have application to these sit'ations is
tacrolim'sD #hich the 59A has approve for ecJema.
.A?
Antibiotic eye rops can be 'seD b't they
o not #ork as #ell as ointmentsD 'e to re'ce contact time. Tear s'pplements may also be
reH'ire to alleviate symptoms. $f peripheral corneal infiltrates are present #itho't epithelial
efectsD topical sterois may be 'se for a limite time.
-)
Seborrheic blepharitis# $n the treatment of seborrheic blepharitisD the application of #armD moist
compresses to soften an loosen the cr'sts is follo#e by #ashin% #ith a commercial li scr'b or
il'te baby shampoo =.:.) in #ater> on a facial cloth or cotton s#abD takin% care not to involve the
%lobe. The scalp an eyebro#s sho'l be #ashe #ith a seleni'm anti-anr'ff shampoo.
.A*
The
emphasis for treatment of seborrheic blepharitis has shifte to incl'e oral antibioticsD especially
minocycline.
.A2-.A3
The p'rpose of 'sin% minocycline is to alter the polarity of the meibomian
secretion composition.
.A8
SeborrheicBstaphylococcal blepharitis# The 'se of appropriate ophthalmic antibiotic ointments is
reH'ire. 4aterD #hen the li is more comfortableD #arm compresses an li scr'bs can be ae.
Barm compresses an li #ashin% are the same as for seborrheic blepharitis. Tho'%h servin% as an
acceptable means of controlD this treatment rarely effects a c're for seborrheic/staphylococcal
blepharitis.
*eibomian seborrheic blepharitis# The treatment incl'es the same #arm compress an li
hy%iene re%imen as for seborrheic blepharitis. $n aitionD the meibomian %lans may be massa%e
or eFpresse to remove the pl'%s at the openin%s. Antibiotic or antibiotic/steroi ointments may be
ae #hen the infection has been ientifie clinically.
.?2D.AA
Seborrheic blepharitis %ith secondary meibomianitis# Treatment be%ins #ith li hy%iene.
Antibiotic or antibiotic/steroi therapy may be ae #hen a clinical infection has been ientifie.
6esistant cases of seborrheic blepharitis #ith seconary meibomianitis may reH'ire systemic
tetracycline ='p to . %/ay> or oFycycline =.)) m%/ay> for at least + #eeks.
-))D-).
$t is not 'n's'al
for patients #ho have this conition to reH'ire lo#er maintenance oses after taperin%. ,either
tetracycline nor its erivatives sho'l be %iven to chilren 'ner the a%e of 8 years or to pre%nant or
n'rsin% #omen. 1ther antibiotic form'lations may be 'se as #ell. These incl'e erythromycin
ethyls'ccinate =EES> an minocycline. 9osin% sche'les #ill vary epenin% 'pon the patients
presentation.
*eibomian keratoconjunctivitis# This conition respons to #arm compresses an massa%e of the
li to eFpress the meibomian contents. Bhen infection is presentD topical antibiotic or
antibiotic/steroi ointments sho'l be 'se. 9iabetes sho'l be a consieration #hen other
conc'rrin% conitions s'ch as rosacea are absent an the conition is 'nresponsive to treatment.
1ral tetracycline may be beneficialD by inhibitin% lipolytic enJymesD especially #hen rosacea is
present. The conition sho'l be stable or improve in + #eeks
-)-
K ho#everD some patients may
nee a lo#er maintenance ose for a lon%er perio. $f keratitis or keratoconj'nctivitis is presentD the
clinician sho'l be a#are of the possibility that methicillin-resistant ,tap-ylococcus aureus
=/6SA> is the responsible or%anism.
-)?
A prospective st'y has inicate the efficacy =improve si%ns an symptoms> of topical
cyclosporine =).)2O> in treatin% posterior blepharitis. .*+
Angular blepharitis. Both forms of an%'lar blepharitis are treate #ith antibiotic ointment.
.emedy for mebomian gland dysfunction
-.
Non-therapeutic $arm compress
6e%'lar 'se of #arm compresses is often helpf'l to inivi'als #hose ry eye conition is
eFacerbate by the inspissation of meibomian secretion. This strate%y is most 'sef'l in posterior
blepharitis #ith a positive effect on the meibomian %lans.
Therapeutic %estasis
A lar%eD placebo-controlle st'y fo'n that the imm'nomo'latorD cyclosporineD can both
ameliorate symptoms an re'ce the clinical si%ns of ry eye.
.*)
:yclosporine ophthalmic sol'tion
).)2O has been approve by the <.S. 5oo an 9r'% Aministration =59A> for the treatment of
C:S. $ts inflammation-re'cin% potential is partic'larly beneficial in patients #ith SjT%rens
synrome.
.*.-.*?
Evience has s'%%este that topical cyclosporine in combination #ith p'nctal occl'sion may have a
favorable syner%istic effect.
.**
&ntense pulse light (&'()
$n <SA treatment is available here: http://kremereyecenter.com/o'r-proce'res/ry-eye-treatment/
+ight .ulse reatment Eases 3ry Eyes Th'rsayD .? 1ct -).. by Scott Basserman / 51W A ,e#s

She is tryin% o't a ne# treatment calle !intense p'lse li%ht" treatmentD or $04. The same treatment
#as once 'se by ermatolo%ists to treat skin conitionsD an octors later learne it can also help
#ith ry eyes.

!$04 is a therapy #here #e 'se li%ht that is absorbe by the oFihemo%lobal in the capillariesD" sai
9r. &. 6alph :h'. !$t helps %ro# more colla%enD b't it helps heal the %lans in ry eye isease."

:h' sai more than ?) percent of his patients s'ffer from ry eyeD an his clinic became one of .*
in the co'ntry to offer the service over the s'mmer.

!$ think it really helps them see better an live more comfortable lives #ith their eyesD" he sai.

Bri%et 0on is an avi neele#orker #ho relies on her eyes b't str'%%le #ith ry eye symptoms
for years. 4ess than t#o months a%oD she #ent in for her first treatmentD an sai the metho has
mae a #orl of ifference in j'st three treatments. LSo'rceM

&ase report< 3ry2eye symptoms improve %ith intense pulsed light treatment by $olando
oyos, *#3#, &hristopher *# 8uffa, Sara *# ,oungerman
--

Several st'ies have ientifie s'ccessf'l p'lse li%ht treatment of rosacea associate facial
erythema an telan%iectasia.*-+ Be have observe similar res'lts in rosacea patients treate #ith
intense p'lse li%ht for facial erythema an telan%iectasia. Be have also observe improvement of
ry-eye symptoms in these laser treate patients.

3iscussion
These preliminary res'lts inicate a potential 'se for intense p'lse li%ht treatment for ry-eye. 1'r
initial 'se of intense p'lse li%ht for ry-eye patients be%an #hen a patient rosacea inicate
improvement of ry-eye symptoms since receivin% $04 treatment.

Be s'spect $04 treatment improve meibomian %lan pro'ction 'e to either meibomian %lan
stim'lation or effectively ecreasin% telan%iectasia. ;o#everD aitional investi%ation is necessary
to etermine the eFact effects of the $04 on s'rro'nin% tiss'e.
Dr !as)in*s dry eye treatment
6ea this blo% post an #atch the associate vieos.
(ipiflo$ Thermal 'ulsation System
&o't'be: http://yo't'.be/l;/eT'rB9bc
TearScience %aine <.S. 59A clearance for its 4ipi5lo# Thermal 0'lsation System on R'ne -8D
-)... The company is c'rrently rampin% 'p its man'fact'rin% capabilities. As a res'ltD the 4ipi5lo#
System #ill be available on a limite basis in the <.S. thro'%h the en of -)...
The 4ipi5lo# treatment is available at the follo#in% eye care practices amon% others:
Cornmehl 4aser Eye :enterD BellesleyD /A
:arolina (ision :enterD 5ayettevilleD ,:
0ark 1phthalmolo%yD 9'rhamD ,:
;erJi% Eye $nstit'teD TorontoD 1ntario
(alley 4aser Eye :enterD AbbotsforD British :ol'mbia
Cin%ston Eye $nstit'teD Cin%stonD 1ntario
:entral /eical Eye :enterD 6ichmonD British :ol'mbia
-?
.emedies for lachrymal gland dysfunction
'unctal plug+ occlusion
<se primarily for lachrymal %lan isorer.
Bhen s'rface treatments o not relieve symptomsD preoc'lar moist're can be retaine by blockin%
the o'tflo# of tears to the nasolacrimal system.
.
This blocka%e can be accomplishe by issolvableD
removableD or permanent p'nct'al occl'sion. The clinical efficacy of silicone p'nct'al pl'%s may
be limite in both 'ration =X- years> an rate of retention =Y2)O>.
.28
:omplications incl'eD b't are not limite toD total eFtr'sion epiphoraD partial eFtr'sionD
s'bconj'nctival hemorrha%eD conj'nctival erosionD an fra%mentation of the pl'%.
.28
Aitional
avanta%es an limitations of p'nctal occl'sion have been chronicle as #ell.
.2A-.+?
4acrimal pl'%s
mae of silicone or a thermoynamic acrylic polymer appear to be safe an effective. Each patient
sho'l be follo#e on a lon%-term basis to eFcl'e chronic inflammatory reactionsD eFtr'sionD or
mi%rationD all of #hich may lea to iscomfort.
.+*
ThereforeD recommenation to patients sho'l be
mae on a case-by-case basis after caref'l selection. Table ? lists contemporary means of p'nctal
occl'sion
able F >
*eans of .unctal 'cclusion
:olla%en implantsEissolvable pl'%s that provie preliminary res'lts as to the potential
effectiveness of 'sin% more permanent means of p'nctal or canalic'lar obstr'ction to re'ce tear
loss thro'%h raina%e.
Tapere shaft silicone p'nctal pl'%s
.+2D.++
:ylinrical shaft silicone p'nctal pl'%s
$ntracanalic'lar implants
Thermo-sensitive p'nctal pl'%s
.+3
Thermal ca'tery an other forms of permanent occl'sionE may be inicate #hen the patients
preisposin% conition is permanent
Electroesiccation 'sin% an electroca'tery 'nitE permanently scars the p'nct'm an
canalic'l's
4aser p'nctal occl'sion
.+8
=p'nctoplasty> 'sin% the ar%on laserEless efficacio's than thermal or
electric ca'tery
S'r%ical repositionin% of the p'nct'm
.+A
anteriorly o't of the lacrimal tear menisc'sEminimiJes tear o'tflo#
an allo#s for f't're s'r%ical aj'stmentsD if necessary
.emedies for mucin layer dysfunction
.emedies for treating the demode, mite
4ast yearD Shaeffer Tsen% sho#e a %ro'p of patients in a retrospective st'yD siF in allD #ho ha
severe blepharitis that #as 'nresponsive to sterois an systemic tetracyclines =vario's man'fac-
t'rers>.
*
$n this %ro'p he epilate their lashesD st'ie the baseD an fo'n heavy 9emoeF
infestations. ;e treate these #ith tea tree oil an fo'n a very %oo response #ithin a siF-#eek
-*
perio. These #ere severe patients #ho ha si%nificant corneal finin%sK three #ere tho'%ht to have
limbal stem cell eficiency an they all respone to this therapy.
3hen things get really really bad
Non-therapeutic shutting do$n of ner,e signals
The opthalmalo%ist/ne'rolo%ist that $ see tol me that the cornea is linke to the tri%eminal nerve
an if the cornea %ets ry an starts b'rnin%D it sens those si%nals to the tri%eminal nerve an that is
#hen all that other st'ff kicks in. ;e p't me on TrileptalD #hich is an anti-seiJ're meicine an that
has helpe tremeno'sly. $t is j'st a small oseD b't the res'lts are amaJin%. LSo'rceM
Also:
he trie the Trileptal ?)) m% per ay . ho'r before betime an it sh'ts that nerve irritation o#n
for the neFt -* ho'rs. 5or me it tr'ly #as a miracle. ;e tol me that there are so many of these
r'%s an there is no ri%ht one for everyone. &o' kin of j'st have to try a fe# 'ntil yo' fin the
one that #orks. $ ha tho'%ht $ #as %oin% craJy tooD beca'se no one kne# #hat $ #as %oin% thro'%h
an tho'%h it so'ne a little #eir. /y ori%inal octor =#ho $ have 'mpe> basically tol me it
#as all in my hea. B't my 7.0. listene to me an referre me to the 1pthalmalo%ist/,e'rolo%ist
#ho tol me that my case #as classic @ not as severe as some peopleD b't very efinitely Tri%eminal
,e'ral%ia @ ca'se by the irritation of the ry eye. LSo'rceM
-thers
Alternative methos for relievin% symptoms specific to oc'lar isorers incl'e:
2ydrophilic bandage lenses and collagen corneal shields# .3)D.3. <se #ith
sporaic s'ccessD they may have partic'lar application to filamentary keratitis follo#in%
ebriement or #hen m'c's strans are present. .3-D.3?
Moisture chamber goggles#
.3*
As a means of re'cin% evaporationD sie an top shiels are
commercially available to moify a patients %lasses. S#immin% %o%%les accomplish the same %oal.
Tarsorrhaphy# S'r%ical clos're of the lis is reserve for cases of severeD 'nresponsive isease.
$nitially the lateral thir of the palpebral fiss're is s't're sh't. Bhen this meas're is ins'fficientD
complete tarsorrhaphy is performe. .32
-2
Appendi, 45 Notes
:onitions that alter the pro'ctionD compositionD or istrib'tion of the preoc'lar tear film =01T5>
may res'lt in symptoms or si%ns of ama%e to the str'ct'res of the oc'lar s'rface. These sit'ations
may lea to noticeable irritationD re'ction of vis'al f'nctionD an even chronic tiss'e chan%es.
S'ch conitions are often relate to abnormalities of the str'ct're or f'nction of the eyelisD %lans
of the li an their secretionsD conj'nctivaD or cornea. Aitional conseH'ences of chronic
compromise to the oc'lar s'rface incl'e risk of infection an chronic inflammation that may not
respon to treatment. A classification scheme 'ses the term eficient tear synrome =9TS> to
encompass these !ry eye" etiolo%ies.
.
An $nternational 9ry Eye BorkShop =9EBS> report has separate ry eye systematically into
aH'eo's-eficient an evaporative. S'bclassifications of the former incl'e those associate #ith
the SjT%rens synrome =SS> an non- SjT%rens ry eyeD #hich incl'es lacrimal-%lan ysf'nction
of both primary an seconary etiolo%ies. The evaporative isorers are s'bivie into intrinsic
an eFtrinsic cae%ories.
-
The role of inflammation in ry eye an oc'lar s'rface isorers has been
emphasiJe as a conseH'ence of hyperosmolarity.
?D*
The reporte epiemiolo%y of ry-eye conitions varies. 9epenin% on the efinitionD pop'lation
st'ieD criteria of incl'sionD an other factorsD the incience an prevalence are often iffic'lt to
estimate. 5or eFampleD the prevalence of ry eye amon% the Asian pop'lation may be %reater than
that of :a'casian pop'lations.
2
$t has been estimate that 2 million Americans over the a%e of 2)
years have ry eyeD
-
an -2O of the <S pop'lation reports or s'ffers from ry eyes or some
abnormality of the eFpose oc'lar s'rface.
+D3
Beca'se there are many 'nia%nose casesD 'e to
sit'ational or environmental contrib'torsD the act'al n'mber is probably m'ch %reater.
A complete %ro'p of tests for oc'lar s'rface isorers has been reporte by the 9ye Eye BorkShop
=9EBS>.
8
These incl'e b't are not limite to patient historyD H'estionnaireD tear film break 'p time
'sin% fl'orescein vital ye stainin%D Schirmer testin%D an eval'ation of li an meibomian
%lan morpholo%y an eFcretion. This practical seH'ence #as base on earlier protocols.
AD.)
:aref'l
clinical observation an acc'rate ia%nosis alon% #ith timely an appropriate intervention can
eliminate or minimiJe the eleterio's effects of oc'lar s'rface isorers an improve the patients
H'ality of life.
..
This 7'ieline #ill offer a brief historical o'tline of earlier classifications an a s'mmary of the
c'rrent 'nerstanin% re%arin% ia%nosis an mana%ement of oc'lar s'rface isorers. $entifyin%
patients at risk for these conitions an offerin% appropriate treatment options #ill help to ens're
cost-effective care an improvement in the H'ality of life.
" Description and Classification of -cular Surface Disorders
># Dry %ye-.elated cular $urface Disorders
The term !ry eye" refers to oc'lar s'rface isorers in #hich the common etiolo%y is aH'eo's
eficiency or isr'ption. The 9EBS efinition of ry eye isease encompasses both symptoms an
objective evience of oc'lar s'rface isr'ption an characteriJes the breath of the problem: !9ry
eye is a m'ltifactorial isease of the tears an oc'lar s'rface that res'lts in symptoms of iscomfortD
vis'al ist'rbanceD an tear film instabilityD #ith potential ama%e to the oc'lar s'rface. $t is
accompanie by increase osmolarity of the tear film an inflammation of the oc'lar s'rface."
-*
Beca'se ry eye involves more than aH'eo's eficiencyD the term !ry eye" alone is inaeH'ate to
escribe oc'lar s'rface isorers. At least three classification schemes have been propose to help
-+
clarify the compleFity of oc'lar s'rface isorers an ry eyes =AppeniF 5i%'res --*>.
.D-*D-2
Each
has its 'niH'e aspects an is #orthy of consieration by the practicin% clinician.
The .AA2 :lassification Scheme base on the ,ational Eye $nstit'te =,E$>/$n'stry Borkshop
separate ry eye into eficient aH'eo's tear pro'ction an increase evaporative loss .
-2
$ncrease
evaporative tear loss is associate #ith eyeli isorers an meibomian %lan ysf'nction =/79>D
as #ell as eFpos'reD contact-lens #earD an environmental sit'ations =AppeniF 5i%'re ->. Anterior
blepharitisD as classifie by Thy%essonD involves ecJema an lash manifestations b't has been
s'persee by an emphasis on posterior blepharitis.
-+
$n -))+D a 9elphi panel propose a classification scheme for !ysf'nctional tear synrome" =9TS>D
#hich comprises a ran%e of isorers. 9TS is s'bivie into %ro'ps #ith an #itho't li mar%in
isease as #ell as tear istrib'tion abnormalities. $n aitionD this %ro'p evelope a severity scale
base on symptoms an si%ns =AppeniF 5i%'re ?>. This report also propose treatment %'ielines
that represent perhaps the most 'sef'l mana%ement al%orithm for practicin% optometrists..
The -))3 9EBS report eFpane on the .AA2 classification scheme of the ,E$ an $n'stry %ro'ps
to eFpan the ca'ses of oc'lar s'rface isease to incl'e aller%ic conj'nctivitisD chronic
keratoconj'nctivitisD conj'nctivitisD an post-refractive s'r%ery =AppeniF 5i%'re *> .
-*
Each of
these classifications s'%%ests that oc'lar s'rface isorers are compleF manifestations that have
n'mero's etiolo%ies #hich may interact #ith each other. These interactions are the res'lt of the
m'ltiple components of the oc'lar s'rface that protect its physiolo%ical inte%rity.
Bhat has also emer%e is the importance of 'nerlyin% inflammatory processes in oc'lar s'rface
isorers. This has been emphasiJe in vario's p'blications an revie#s as a basis for
etiopatholo%y an treatment.
-3--A
$ncl'e amon% ry eye-relate oc'lar s'rface isorers are the follo#in%:
AH'eo's-eficient ry eye associate #ith the SjT%rens synrome
,on-SjT%rens aH'eo's eficiency =e.%.D a%e-relate>
Blepharitis
Anterior =lash- an li-associate>
0osterior =li mar%in- an meibomian %lan-associate>
:ontact lens-relate evaporative tear isr'ption
Blink an li anatomy abnormalities
Sit'ational an environmental evaporative tear loss
:onj'nctivochalasis =re'nant b'lbar conj'nctival tiss'e>
Aller%icD chronic infectiveD an non-infective conj'nctivitis an keratoconj'nctivitis
0ost refractive-s'r%ery isr'ptions of the oc'lar s'rface or 01T5.
These isorers may overlap as #ell as co-eFist. /ana%ement reH'ires precise ia%nostic criteria
an specific interventional strate%ies.
1ne paraoF is that patients #ho have increase refleF tearin% may s'ffer from oc'lar s'rface
isorers for #hich the irritation serves as the stim'l's. /oreoverD patients #hose p'ncta have
collapse =stenosis> may have re'ce tear clearanceD #hich may compensate for re'ce aH'eo's
pro'ction.
?)
a. A!ueous -Deficient Dry %ye
-3
The symptoms of aH'eo's eficient ry eye are 's'ally bilateral an may pro'ce forei%n-boy
sensation an lacrimation. AH'eo's-eficient ry eye res'lts from re'ce aH'eo's pro'ction an
may be seconary to lacrimal-%lan o'tp't eficiency as seen in SjT%rens synrome. Appearin%
clinically #ith re'ce tear menisc'sD an ebris an strans of m'co's in the tear filmD it can lea
to the formation of corneal filaments =filamentary keratitis> in avance cases. Aitional clinical
si%ns incl'e re'ce tear break'p time an ecrease #ettin% on Schirmer testin%D as #ell as
oc'lar s'rface stainin%D altho'%h these latter si%ns are not specific to aH'eo's eficient ry eye.
SjT%rens synrome =SS> is a chronic systemic inflammatory isorer characteriJe by lymphocytic
infiltrates in eFocrine or%ans. /ost s'fferers present #ith symptoms s'ch as Ferophthalmia =ry
eyes>D Ferostomia =ry mo'th>D an paroti %lan enlar%ement. EFtra%lan'lar feat'res may
evelopD incl'in% arthropathies s'ch as arthral%iaD arthritisD an myal%ia. $n aitionD 6ayna's
phenomenonD p'lmonary iseaseD %astrointestinal iseaseD le'kopeniaD anemiaD lymphaenopathyD
ne'ropathyD vasc'litisD renal t'b'lar aciosisD an lymphoma may be accompanyin% manifestations.
;rimary SS occ'rs in the absence of other 'nerlyin% rhe'matic isorers. $n contrastD secondary
SS is associate #ith at least one other 'nerlyin% rhe'matic iseaseD s'ch as systemic l'p's
erythematos's =S4E>D rhe'matoi arthritis =6A>D or scleroerma. 7iven the overlap of SS #ith other
rhe'matic isorersD it may be challen%in% to etermine #hether a partic'lar clinical si%n is
eFcl'sively a conseH'ence of SjT%rens synrome or accompanies an isorer.
AH'eo's eficiency seconary to SS res'lts from lacrimal %lan inflammationD infiltrationD an
atrophy.
?.
Tho'%ht to be a'toimm'ne in ori%inD primary SS is associate #ith colla%en-vasc'lar or
connective tiss'e iseaseD most freH'ently rhe'matoi arthritis. BrieflyD primary SS involves the
%lans of the lis an mo'th. Seconary SS involves a
Y http://emeicine.mescape.com/article/??-.-2-overvie# accesse 2/.?/-).) .
systemic a'toimm'ne isease s'ch as rhe'matoi arthritisD #hich then res'lts in the symptoms of
ry eye or ry mo'th.
?.D?-
A etaile revie# of the istinction bet#een primary an seconary forms
of SS is beyon the scope of this 7'ieline b't can be fo'n in literat're revie#s. ?.D?- 9ry eye
symptoms may be the first manifestation of SS.
4acrimal ins'fficiency occ'rs most often in menopa'sal #omenK its onset is typically 'rin% the
fifth ecae of life. :linical si%ns an severe symptoms have been associate #ith estro%enD taken
alone or in combination #ith pro%esterone or pro%estin as hormone replacement therapy =;6T>.
??
$t
also may occ'r in #omen #ho are pre%nant or takin% birth control pillsD in #hom estro%en an
prolactin levels are
elevate.
?*D?2
1ther localD systemicD an eFo%eno's conitions that can aversely affect tear pro'ction incl'e:
Z 9acryoaenitis
5acial nerve paralysis
:hemical b'rns
:on%enital alacrima
7amma raiation
To varyin% e%reesD systemic meications: antihypertensives =i'reticsD arener%ic
anta%onistsD an beta-blockers>K antihistamines =especially first-%eneration ;-. inhibitors>K
meications that have anticholiner%ic effects =tricyclic antiepressantsD phenothiaJinesD etc.>K an
hormone replacement therapy =estro%enD pro%esterone>
-8
:on%enital ysa'tonomia =6iley-9ay synrome>
Mucin -Deficient Dry %ye
6e'ction in the n'mber of conj'nctival %oblet cellsD res'ltin% in a ecrease in m'cin pro'ctionD
can be ca'se by conitions that ama%e the conj'nctiva. /'cin-eficient ry eye conitions
incl'e aller%ic conj'nctivitisD
?+
oc'lar cicatricial pemphi%oi =1:0>D erythema m'ltiformae
=Stevens-Rohnson synromeK SRS>D severe trachomaD or chemical =especially alkali> b'rns. $mpaire
%oblet cell f'nction can also res'lt from marke vitamin A eficiencyD altho'%h it is rare in
evelope co'ntries. /ost recently m'cin-eficient ry eye has been reporte as a conseH'ence of
facial nerve paralysis.
?3
$n 1:0 an SRSD %oblet cell loss is 'e to an a'toimm'ne response that eposits imm'no%lob'lins
at the basement membrane Jone of the conj'nctiva.
?8
This then leas to the clinical pict're of b'llae
at the s'bepithelial level. 0ro%ressive infiltration res'lts in contraction of the conj'nctiva #ith
symblepharon formation.
?A
0araoFicallyD 7oblet cell ensity may increase seconary to thermal or chemical inj'ry .
*)
The
res'ltin% oc'lar s'rface isorers iffer from 1:0 or SRS at the cell'lar level tho'%h appearin%
clinically similar. A %rain% system is available for the ophthalmic manifestations in patients #ith
chronic SRS.
*.
This incl'es conj'nctival ama%e s'ch as the evelopment of symblepharon an
anklyoblepharon as #ell as corneal vasc'lariJation an conj'nctivaliJation. The scale is H'antitative
an contin'o's =ran%eD )-?A>.
$urface Abnormalities
Any str'ct'ral efect of the li can interfere #ith tear film istrib'tion. $mpairment of normal blink
action 's'ally res'lts in an irre%'lar m'cin layer. A term that may represent these sit'ations
incl'sively is !li-#iper epitheliopathy."
*--*2
$ncomplete or infreH'ent blinkin%D #hich res'lts in
eFcessive tear evaporation an eFpos're keratopathyD can be ca'se by Bells palsyD la%ophthalmosD
thyroi-relate eye iseaseD forei%n boyD or li tra'ma. 1ther li abnormalities that prevent
efficient res'rfacin% of the tear layer incl'e ptosisD trichiasisD an maarosis.
%pitheliopathies
:orneal epitheliopathies are characteriJe by an irre%'lar epithelial s'rface #here microvilli are
prevente from allo#in% m'cin to ahere to the cornea. The ca'ses incl'e corneal scarsD chemical
b'rnsD rec'rrent corneal erosionsD contact lens complicationsD tra'ma from entropion or refractive
s'r%eryD incomplete blinkin%D or lash abnormalities s'ch as trichiasis an istichiasis. 4i-#iper
epitheliopathy is an all-incl'sive term for s'ch isorers that are relate to contact lens #ear or
occ'r follo#in% refractive s'r%ery.
2+-2A
Contact lens 'ear
:ontact lens #ear can in'ce ry eye symptoms in patients #ho have a pre-eFistin%D asymptomaticD
mar%inally ry eye conition.
+)
,ot only o contact lens materials reH'ire %reater s'rface #ettin%
than the corneal epitheli'mD b't #earin% contact lenses thins the 01T5 an interferes #ith the
spreain% of m'cin onto the cornea. 6efittin% a ry eye patient #ith silicon-hyro%el lenses has
been fo'n to provie symptomatic relief of ryness for 'p to three years follo#in% refittin%.
+.
-A
b -cular Surface Disorders "rising from (id-!argin Disorders
('osterior #lepharitis)
0osterior blepharitis is reco%niJe as a si%nificant ca'se of isr'ption of the tear film.
23
/eibomian
%lan secretions represent a compleF f'nctionin% 'nit that interacts #ith the lis as #ell as the
aH'eo's layer of the tear film. Some moels s'%%est that the appropriately f'nctionin% lipi layer
comprises both non-polar an polar components.
.-
Abnormal f'nctionin% of the meibomian %lans
res'lts in the clinical si%ns an symptoms of meibomian %lan ysf'nction =/79>D incl'in%
istinct chan%es in viscosity an clarity of eFpresse contentsD increase tear film osmolarityD #hich
may be reflecte by complaints of b'rnin% an stin%in%D an premat're evaporationD leain% to
ecrease tear-film stability.
28D2A
:linical si%ns of oc'lar s'rface ama%e incl'eD for eFampleD
epithelial stainin%. :linicians sho'l observe the lis for apposition to the %lobeD telean%iectasis at
the li mar%inD an obstr'cte meibomian %lan orifices.
# .pidemiology of -cular Surface Disorders
4" Dry %ye
a. Prevalence
$n terms of prevalence an characteriJationD ry eye may be the most ill efine of all oc'lar
isorers. :ontrib'tin% factors incl'e the lack of a efine ia%nostic test or protocol an the lack
of con%r'ity bet#een patient symptoms an clinical tests.
Severe forms of aH'eo's-eficient ry eye can be associate #ith systemic iseasesD especially
colla%en-vasc'lar iseases. <p to -) percent of persons #ith rhe'matoi arthritis have
keratoconj'nctivitis sicca =C:S>.
*+D+-
0atients #ith SjT%rens synrome have the classic tria of ry
eyeD ry mo'thD an arthritis. 1ther systemic conitions that may res'lt in aH'eo's-eficient ry eye
incl'e l'p's erythemato's an oc'lar rosacea. $n aition to systemic conitionsD other ca'ses may
incl'e r'%s s'ch as antiepressantsD beta blockersD i'reticsD oral contraceptivesD an topical beta-
blockers 'se to treat %la'coma. $nivi'als likely to be affecte incl'e: postmenopa'sal #omenD
patients #ith :elico!acter pyloriD oler peopleD comp'ter 'sersD an lon%-term contact lens
#earers.
+?-+2
Tr'e m'cin eficiency is rareK one report estimates the prevalence of 1:0 to be . in -)D)))
persons.
++
:icatricial pemphi%oi is the most common of the imm'nob'llo's isorers ca'sin%
conj'nctival cicatriJation seconary to estr'ction of %oblet cells. The isease is 's'ally bilateral
an more common in femalesD #ith most cases occ'rrin% bet#een ?) an A) years of a%eD b't most
freH'ently in the seventh ecae of life.
+3
4oss of %oblet cells occ'rs as a complication of
inflammatory inj'ries to the conj'nctiva or 1:0. $t is also a possible sie effect of prolon%e topical
choliner%ic an anticholinesterase aministration 'se in the treatment of %la'coma.
+8-3-
This
meically
in'ce complication is rarely seen since the intro'ction of contemporary %la'coma treatment
options.
/ost problems involvin% lipi layer instability are relate to %lan'lar ysf'nctions that pro'ce
thickene meib'mD leain% to accelerate s'rface evaporation. This complication leas to an
'nstable or ysf'nctional tear film. ThereforeD there is a close association of vario's forms of
meibomianitis especially #ith posterior blepharitis. 4ipi layer abnormalities res'ltin% from
complete absence of meibomian %lan secretion are rare.
.*
/eibomian %lan eficiencies have been
eval'ate by eyeli transill'mination an classifie as atrophic or ysf'nctional =rosacea> amon%
patients #ith symptoms consistent #ith oc'lar irritation. This form of %lan'lar ysf'nction has
no# been reco%niJe as posterior
?)
blepharitis.
*-D3?
b. Risk Factors
Amon% the common risk factors for ry eye are avancin% a%eD the presence of rhe'matoi arthritisD
7raves iseaseD the 'se of r'%s that ecrease aH'eo's or m'co's membrane secretionsD eyeli or
blinkin% abnormalitiesD an a history of tra'ma to the lis.
3)-3-
Environmental an post-refractive
s'r%ery can also be ca'ses of ry eye.
3*-38
6" #lepharitis
a. Prevalence
Epiemiolo%ic characteristics of blepharitis varyD epenin% on the type. Types of blepharitis ran%e
from ac'te to chronic isorersD #ith inflammation affectin% the anterior or posterior li mar%insD
alon% #ith involvement of both skin an m'co's membranes.
The prevalence of ry eye an blepharitis is 'nkno#n. The 9EBS %ro'p has compile a report
evote to the prevalence of ry eye.
-
The %ro'p concl'e that bet#een 2 an ?2 percent of
patientsD epenin% on a%eD %eo%raphic locationD efinition 'se in the st'yD an episoic
contrib'tin% factors may eFhibit ry eye =incl'in% blepharitis> si%ns or symptoms.
/ost staphylococcal blepharitis occ'rs in yo'n%er #omen =mean a%eD *- years>D
3AD8)
#hereas the
seborrheic variations ten to occ'r in oler inivi'als. 6osaceaD a isease of 'nkno#n prevalenceD
is more common in fair-skinne persons bet#een the a%es of ?) an 2)D especially #omen.
8-
7ross
oc'lar lesions occ'r in many cases of rosaceaD an almost all affecte persons event'ally evelop
rec'rrent or chronic blepharitis an meibomianitis. There is a stron% association bet#een C:S an
staphylococcal blepharitis.
8-
b. Risk Factors
<nerlyin% ermatolo%ic conitions may represent risk factors for blepharitis. Seborrheic
blepharitis is associate #ith seborrheic ermatitis. /eibomianitis occ'rs approFimately t#ice as
freH'ently #ith rosacea as it oes #ith seborrheic ermatitis.
?3
0atients #ith atopic ermatitis an
psoriasis may also have a blepharitis as a complication. 0atients #ith SS-relate C:S appear more
likely to evelop meibomian
%lan isease.
.?D3?D8?
C Clinical #ac)ground of -cular Surface Disorders
The oc'lar s'rface reH'ires a re%'lar res'rfacin% of tears to provie comfort an clear vision. The
pro'ction of s'fficient lacrimal fl'i of normal composition an its istrib'tion by re%'lar blinkin%
are essential to oc'lar s'rface inte%rity an comfort. Any ecrease or alteration in the pro'ction of
any component of the tear filmD especially the lipi layerD or interference #ith the res'rfacin%
process can impair any of the f'nctions of the 01T5.
4" Dry %ye
a. Natural istory
$n the earliest sta%es of ry eyeD an ins'fficient or 'nstable tear film may pro'ce infreH'ent an
insi%nificant symptoms. Early si%ns or mil symptoms may be seconary to hyperosmolarity of the
tear film an be the ca'se or res'lt of inflammation.
?D*
Some symptoms may occ'r only 'ner
conitions of stress. These conitions may incl'eD b't are not
?.
limite toD lo# h'miityD smoky environmentD recirc'late air environmentD an prolon%e
comp'ter
'se.-8D3*D33D8*-83
As the conition pro%ressesD the eye cannot maintain the vol'me of moist're
reH'ire an the symptoms become more common an more bothersome. !0araoFical epiphora"
=hypersecretion> from irritation-in'ce refleF tearin% may be the presentin% symptom.
$n severe 9E conitionsD symptoms of b'rnin% an vis'al interference can be ebilitatin%.
88
The
cornea appears 'llD the conj'nctiva an li mar%ins may be hyperemic an eemato'sD an
s'perficial p'nctate stainin% may be present. 5ilamentary keratitisD a painf'l corneal response
characteriJe by strans of partially esH'amate epithelial cellsD can res'lt from corneal
esiccation an acc'm'lation of sta%nant m'cin an she epithelial cells. $n aition to the li
infections commonly associate #ith ry eyeD the patient #ith 9E has a hi%her likelihoo of havin%
conj'nctivitis an keratitis. ThereforeD moerate or severe ry eye may aversely affect the H'ality
of life.
b. !igns" !ymptoms" and #omplications
$n mil cases of 9ED symptoms of scratchinessD b'rnin%D or stin%in% may be accompanie by mil
an/or transient sit'ational bl'rrin% of vision #hen the tear film is isr'pte. $n moerate casesD
oc'lar iscomfort becomes marke an vis'al ac'ity may be re'ce. As the ry eye becomes more
severeD observable si%ns may incl'e rapi tear film break'pD ebris in the tear filmD a minimal
lo#er li tear menisc'sD increase m'co's threas in the tear filmD corneal an conj'nctival
stainin%D filamentary keratitisD an loss of corneal l'ster.
$nstability of the tear film can initiate oc'lar s'rface complications.
8A
9ecrease aH'eo's vol'me is
associate #ith re'ce oc'lar s'rface efense an increase s'sceptibility to irritationD aller%yD an
infection 'e to tear sta%nation an epithelial compromise.
A)-A?
A major conseH'ence of re'ce
aH'eo's vol'me is re'ce antibacterial f'nction beca'se of ecrease lactoferrin an lysoJyme
levels.
A*-A+
$n aitionD staphylococcal or%anisms can pro'ce toFins that can ca'se s'perficial
p'nctate keratopathy.A3
Seborrheic blepharitis can ca'se an inferior stainin% pattern from an alteration of the li-tear
interfaceD perhaps beca'se of lost tear retentionD ecrease tear vol'meD an intrapalpebral
esiccation.
A8DAA
0ersistent ry spotsD a more si%nificant conseH'ence of an 'nstable tear filmD may be
associate #ith either abnormalities of the tear istrib'tion system or re'ce tear flo#.
SH'amo's metaplasia of the conj'nctiva occ'rs seconary to chan%es in the oc'lar s'rfaceD perhaps
as a res'lt of environmental eFpos're.
.))
$mpression cytolo%y st'ies s'%%est abnormal conj'nctival
epitheli'm as #ell as chan%es in the %oblet cells.
.).D.)-
T#o possible etiolo%ies have been propose:
=.> loss or re'ction of conj'nctival vasc'lariJationD #hich prevents normal epithelial
ifferentiationD an =-> inflammatory chan%es that in'ce epithelial alteration. SH'amo's chan%es
have also been reporte in m'cin- an aH'eo's-eficient conitions.
2-
c. $arly %etection and Prevention
5actors beyon the patients control ca'se some forms of 9E. ;o#everD appropriate action can help
to elay the onset or minimiJe the e%ree of symptoms for a lar%e portion of the affecte
pop'lation. The 'se of tear s'pplements may make symptoms tolerable in miler sit'ations.
SpecificallyD nonpreserve tear s'pplements also play a role in the relief of moerate an avance
cases. 4i hy%ieneD an #hen appropriate antibiotic intervention for anti-inflammatory effectsD
minimiJes the effects of altere lipi secretion an re'ces the possibility of seconary infection.
?-
0rompt ia%nosis an mana%ement of any chan%e in the appearance or comfort of the eye can also
limit the occ'rrence of complications.
6" #lepharitis
a. Natural istory
:hronic blepharitis #ith seconary oc'lar s'rface manifestations is not an isolate problem. 6atherD
it is one of a %ro'p of isorers res'ltin% from isr'ption of the compleF an elicate balance
amon% the eyelisD tear filmD an oc'lar s'rface. The eyelis are vital to the health of the
oc'lar s'rface beca'se of their protective f'nction an their contrib'tion to the pro'ction an
ispersal of the tear film. The miler forms of blepharitis often are annoyin% beca'se of mil
cr'stin% an irritation of the li mar%ins. /oerate an severe forms are associate #ith bacterial
infections an chronic meibomian %lan chan%es. ,ot only can they be painf'l an cosmetically
'nappealin%D b't they also ca'se instability of the 01T5 an become the so'rce of relate problems.
b. !igns" !ymptoms" and #omplications
The spectr'm of visible si%ns of blepharitis varies #ith the e%ree of inflammation. $n mil cases of
seborrheic blepharitisD biomicroscopic eFamination may be necessary to vie# the scales on or at the
base of the eyelashes. Aitional inflammatory forms of the conition pro'ce more noticeable
si%ns. $n severe meibomianitisD the meibomian %lans are clo%%e an the tear film is eficient in
normal lipis.
Severity of the symptoms may also be relate to the e%ree of inflammation. $n its miler formsD
seborrheic blepharitis may have no associate symptoms. $nflammation of the eyeli mar%in an
skin can pro'ce vario's levels of irritation an oc'lar iscomfort. Associate tear film isorersD
s'ch as lipi eficiency an eFcessive tear film ebrisD can isr'pt the stability of the 01T5 an
affect vision.
:omplications may occ'r 'rin% the ac'te phase of blepharitis or in response to inaeH'ate
mana%ement of the chronic form of the isease. Acc'm'late secretions may pro'ce localiJe
reactions an s'pport the %ro#th of other or%anisms. The most common complication of blepharitis
is alteration of the 01T5 #ith conseH'ent si%ns an symptoms. $n severe forms of blepharitisD
seconary conj'nctivalD cornealD an eyeli-mar%in inflammation may occ'r.
c. $arly %etection and Prevention
:'rrentlyD no prophylactic meas'res eFist to control the conseH'ences of blepharitis. Treatments are
aime at reversin% the severity of the inflammation. 4i hy%ieneD consistin% of #arm compresses
an li scr'bsD is the basis for treatin% all forms of blepharitis. $n aitionD
associate conitionsD s'ch as seborrheaD staphylococcal involvementD an rosaceaD sho'l be
treate. These conitions may reH'ire topical or oral antibiotics. $n the event of eFacerbationD early
reco%nitionD ia%nosisD an treatment can help minimiJe the e%ree of inflammation an potential
for infection. /oreoverD clinical reco%nition of posterior blepharitis as a complication of
malsecretion of lipis by the meibomian %lans s'%%ests the nee for early intervention.
??
C"%. '%-C.SS
This 7'ieline escribes optometric care provie to a patient #ith oc'lar s'rface isorers. The
components of patient care escribe are not intene to be comprehensiveD beca'se professional
j'%ment an the inivi'al patients symptoms an finin%s may have a si%nificant impact on the
nat'reD eFtentD an co'rse of the services provie.
A# 3iagnosis of 'cular Surface 3isorders
0atients #ith compromise oc'lar s'rfaces have %reater potential for iscomfort or f'rther oc'lar
ama%e. Early reco%nition of the si%ns of infection an prompt ia%nosis minimiJe the potential for
severe or chronic complications. Eval'ation of a patient eFhibitin% ry eye symptoms or si%ns
consistent #ith blepharitis incl'es many of the elements of a comprehensive eye an vision
eFamination
an a more in-epth eval'ation of the oc'lar s'rface an aneFa. The eval'ation for
oc'lar s'rface isorers incl'es a caref'lly etaile patient historyD assessment of associate risk
factorsD an eFamination of the anterior oc'lar str'ct'res an their f'nctions.
6# .atient )istory
9emo%raphic ata abo't the patient sho'l be collecte prior to takin% the patient history. $ncl'e
in the patient history are the chief complaintD history of the present illness or conitionD oc'lar
historyD %eneral health history =#hich may incl'e a social history an an eFtene revie# of
systems>D an family oc'lar an meical history. $n aitionD environmental factors relatin% to
climateD seasonD vocational settin%D an avocational p'rs'its sho'l be revie#e.
The patients history an symptoms are effective ia%nostic tools in ientifyin% the presence of tear
film ins'fficiency. The history sho'l oc'ment associate conitions that make an inivi'al more
likely to evelop tear film abnormalities. :ommon oc'lar complaints incl'e b'rnin% or stin%in%D
itchin%D scratchinessD irritationD tearin%D increase m'c's an re'ce contact lens tolerance. A
symptom ineF specific to oc'lar s'rface isorers has been propose an valiate =AppeniF
5i%'re 2>. .)?D.)*
0atients #ith SjT%rens synrome may %ive paraoFical reports of iscomfort #ith certain
instr'ments.
.)2
1#in% to the visible nat're of some forms of anterior blepharitisD the patient can
's'ally escribe the onset an co'rse of the conition. Ac'te-onset inflammation of relatively short
'ration often respons to treatment better than the chronic lon%-term forms of the isease. A
thoro'%h meical history helps ientify any 'nerlyin% systemic ca'se. The effects of previo's
treatments an the patients compliance in follo#in% recommenations may be %oo inicators of
the pro%nosis of ne# treatment plans.
9# 'cular Examination for 'cular Surface 3isorders
1bservationsD 'sin% eFternal oc'lar eFamination techniH'esD both #itho't ma%nification an #ith
the biomicroscopeD sho# characteristic early chan%es of the eFternal eye. Eval'ation for s'specte
oc'lar s'rface isorers may incl'eD b't is not limite toD the follo#in%:
EFternal vie# of the eyeD notin% li str'ct'reD positionD symmetryD an blink ynamics
Biomicroscopic eFamination of the li mar%insD meibomian %lan orificesD an their contents
Biomicroscopic eFamination of the tear filmD notin% m'c'sD ebrisD interference patterns in
the lipi layerD an tear menisc's hei%ht
Biomicroscopic eFamination of the cornea an conj'nctivaD both #ith an #itho't soi'm
fl'orescein =S5> an lissamine %reen =47> stainin%. 6ose ben%al =6B> has been replace by 47D
beca'se there is less iscomfort or stin% associate #ith its 'se.
?*
Bith moerate manifestations of oc'lar s'rface isorersD there may be obvio's chan%es in tear film
stability =as manifeste by inconsistent b't re'ce break'p time>D s'btle or transient corneal
s'perficial p'nctate keratopathyD or more apparent conj'nctival stainin%. $n more severe casesD tear
film ebris may be accompanie by corneal m'c's stransD filamentsD f'rro#sD ellenD stainin%D or
erosionD all of #hich contrib'te to an overall lack of l'ster. The cornea may become thickene or
sho# thinnin% in areas of ellen. The conj'nctiva may be hyperemic an have fols in the eFpose
b'lbar portion
.)+
K this is typically observe in the lo#er temporal areaD #here the eyeli meets the
%lobe. The 01T5 may have increase viscosityD ebris an a foamy secretion that spills onto the
eyelisD as #ell as a scantyD inferior tear prism. The lis often have thickene mar%insD cr'stin%D an
maarosis. The more severe the tear film eficiencyD the more prono'nce the si%ns #ill appear.
># -cular ./amination for #lepharitis
A thoro'%h eFternal eFamination of the lis an other parts of the aneFaD incl'in% comparison of
the eyesD helps etermine the severity of inflammation. 9ifferentiatin% amon% the vario's
presentations of blepharitis reH'ires the 'se of a biomicroscope to contrast the appearance of the
anterior an the posterior li mar%ins. Eval'ation of the patient #ith blepharitis may incl'eD b't is
not limite to the follo#in%:
EFternal eFamination of the eyeD incl'in% li str'ct'reD skin teFt'reD an eyelash appearanceD
an eval'ation for clinical si%ns of rosacea =i.e.D telan%iectasiaD p'st'lesD rhinophyma>.
Biomicroscopic eFamination of the li mar%insD the base of the lashesD an the meibomian
%lan orifices an their contents. Telan%iectasia posterior to the meibomian %lans may be a
key finin% in ientifyin% posterior blepharitis seconary to meibomian %lan ysf'nction.
EFamination of the tear film for lipi layer abnormalities.
Eval'ation of the palpebral an b'lbar conj'nctiva.
able 6
ear 0unction ests and (ormal Aalues
est Significance (ormal Aalues
Tear menisc's AH'eo's H'antity 6an%e: ).. - ).+ mm
Schirmer $ ,o ia%nostic val'e [.2 mm in 2 min
Schirmer basic AH'eo's eficiency #hen [2 mm in 2 min
secretion test re'ce =accessory lacrimal
%lan ysf'nction>
4actoferrin 4acrimal %lan f'nction ..*- m%/m4 =X..))
m%/m4 is abnormal>
Tear osmolarity 4acrimal %lan f'nction X?.- m1sm/4
Break'p time =B<T> Tear film stability/m'c's eficiency [.) sec
,oninvasive break'p /icroepithelial efects/aH'eo's *) sec
time =,$B<T> aeH'acy
5l'orescein /icroepithelial efects/m'c's ,o stainin% visible
eficiency
6ose ben%al/ ,on-m'c's-coate epitheli'm ,o stainin% visible
?2
lissamine %reen
$mpression Epithelial cell ,ormal microscopic
cytolo%y appearance/%oblet cell ensity appearance
$nterference frin%e pattern 4ipi layer inte%rity <niform biomicroscopic appearance
/eibomian %lan eFpression /eibomian %lan f'nction :lear
4acrimal %lan Total lysoJyme reactivity X..)
f'nction =T46>
Each type of anterior blepharitis has specific characteristics that help in makin% the appropriate
ia%nosis:
Staphylococcal blepharitis# $n the early sta%esD the symptoms are a forei%n boy sensationD
irritationD itchin%D an mil stickin% to%ether of the lis. $f the conition becomes chronicD
thickene li mar%insD trichiasisD li-mar%in notchin%D maarosisD ectropionD or entropion may
res'lt. The lo#er thir of the cornea may have p'nctate stainin%D erosionsD an infiltrates
from eFotoFins or a isr'pte 01T5. An associate bacterial conj'nctivitis may evelop.
Seborrheic blepharitis# The symptoms may incl'e b'rnin%D stin%in%D itchin%D an oc'lar
irritation or iscomfort. The lis may appear hyperemic at the anterior mar%inD #ith the
hallmark appearance of scales on the lashes. This conition is 's'ally chronicD b't there may
be perios of eFacerbation an remission. Altho'%h there is very little inflammation of the
lid marginD C:S may be a seconary presentation an may eFacerbate tear film instability.
SeborrheicBstaphylococcal blepharitis# There are freH'ent eFacerbations of a mil to
moerate inflammatory reaction.
*eibomian seborrheic blepharitis# $n this conition associate #ith seborrheic ermatitisD
meibomian openin%s are ilate. A istin%'ishin% clinical feat're is increase meib'mD
#hich ca'ses a foamy tear film alon% the li mar%insD especially at the lateral canth's. This
observation is characteristic of staphylococcal coloniJation of the li mar%inD as #ell.
.??
The
b'lbar conj'nctiva is injecteD an there may be conc'rrent C:S.
Seborrheic blepharitis %ith secondary meibomianitis# This chronic conitionD #ith
eFacerbationsD also incl'es sporaically blocke an inflame meibomian %lans. This
sit'ation potentiates an 'nstable tear film an ry eye symptoms.
*eibomian keratoconjunctivitis# As part of a %eneraliJe sebaceo's %lan ysf'nctionD
meibomian keratoconj'nctivitis is freH'ently associate #ith rosacea. The %lan openin%s are
obstr'cte by esH'amate epithelial cellsD res'ltin% in a poor 01T5 that can be ientifie by
lissamine %reen or rose ben%al stainin%. The meibomian secretions have a hi%her meltin%
point than the oc'lar s'rface temperat'reD #hich res'lts in re'ce seb'm secretion an
pl'%s of free fatty acis at the
%lan openin%s that are often inflame an po'te. The tear film is very 'nstable. This
constellation of si%ns probably si%nals meibomian %lan ysf'nction an #o'l be consistent
#ith the 9elphi panels escription of ysf'nctional tear synrome.
.
Angular blepharitis# The t#o appearances of an%'lar blepharitis are the ryD scaly form
ca'se by ,tap-ylococcus an the #etD macerate type ca'se by Moraxella.
?+
# !anagement of -cular Surface Disorders
Treatment an mana%ement strate%ies for oc'lar s'rface isorers can vary an may reH'ire
cons'ltation #ith or referral to the patients primary care physicianD a ermatolo%istD a corneal
specialistD or other health care provierD as appropriate. AppeniF 5i%'re ? presents a classification
for treatin% an mana%in% patients #ith oc'lar s'rface isorers.
4eneral &onsiderations
A comprehensive approach to treatin% an mana%in% eyeliD tear filmD an conj'nctival or corneal
abnormalities is important. 0erioic reeval'ation is neee beca'se a primary ysf'nction of any
one of these components often affects the others. The approach to mana%in% a patient #ith
blepharitis is epenent 'pon ientification of the type an severity of the conition so that the
appropriate therapy may be instit'te. Anterior forms of blepharitis %enerally have a %reater impact
on the skin of the eyeli than on the oc'lar s'rface. 0osterior blepharitis has a %reater potential to
pro'ce ry eye symptoms an
si%ns.*-D3-D.-*D.?2
Bhen eval'atin% patients for oc'lar s'rface isorersD
the clinician m'st pay special attention to the li mar%ins an the preoc'lar tear film.
:ontact lens #ear may pose a risk to the compromise oc'lar s'rface. $n aitionD s'ccess #ith
contact lens #ear may be atten'ate by complications of tear film eficiency. :onverselyD contact
lenses may play a role in the mana%ement of selecte isorers of the tear film an oc'lar s'rface.
$entifyin% an treatin% conitions prior to fittin% contact lenses an mana%in% potential problems
a%%ressively are prereH'isites for s'ccessf'lly #earin% contact lenses. 6ecommenations for
s'ccessf'l contact lens #ear incl'e a TB<T %reater than .) secons. /il or moerate cases of
tear eficiency often can be mana%e #ith tear s'pplementation or by tear conservation. /ore
severe cases of tear eficiency are less likely to be associate #ith s'ccessf'l contact lens #earK the
clinical presence of rosaceaD 'e to li-%lan ysf'nction may complicate contact lens #ear.
The strate%y to help ens're s'ccessf'l contact lens #ear by patients #ith compromise oc'lar
s'rfaces also reH'ires a comprehensive approach to contact lens fittin%.
\
This strate%y incl'es:
9eterminin% lens iametersD thicknessesD an e%e esi%ns that #ill achieve aeH'ate
lens/cornea relationships an minimiJe blink inhibition
6ecommenin% appropriate #earin% sche'lesD s'ch as mi-ay removal of lenses #ith
rehyration of hyro%el lenses
Selectin% materials #ith both #ater content an s'rface characteristics to match the patients
conition =in the case of hyro%el lenses>
:onsierin% a more compatible lens material s'ch as siliconehyro%el polymer
$n all casesD consierin% tear s'pplementation for patients #hose oc'lar s'rface becomes
compromise as a res'lt of contact lens #ear.
Altho'%h tear film eficiencies may complicate or contrainicate contact lens #earD contact lenses
may have a role in the mana%ement of certain forms of ry eye. Applyin% a hyro%el or silicone-
hyro%el lens to a ry eye can provie a stableD moist environment for esiccate epitheli'm.
,everthelessD there are associate risksD incl'in% s'rface epositsD increase inflammationD an
infection.
9# reatment and *anagement of 3ry Eye
a. Basis for Treatment
Step#ise etermination of the minim'm intervention reH'ire to achieve res'lts #ill help ens're a
balance of patient complianceD lon%-term s'ccessD an cost effectiveness. The mana%ement of ry
eye is esi%ne to re'ce symptoms an inflammation an to re-establish a normal oc'lar s'rface.
?3
Efforts sho'l be aime at maintainin% or restorin% the 01T5 an riin% the lis of potential
so'rces of tear film estabiliJation. Bhenever possibleD environmental factors contrib'tin% to ry
eye sho'l be ientifie an either moifie or eliminate. Bhen associate meical conitions are
ientifieD cons'ltation #ith or referral to the patients primary care physician or other health care
provier may be inicate.
b. Available Treatment Options
Attempts to relieve ry eye symptoms an re-establish a normal oc'lar s'rface have pro'ce a
myria of possible remeies. Traitional approaches incl'e both tear s'pplementation an tear
conservation meas'res. Several alternatives have been 'se #ith varyin% e%rees of clinical
s'ccess:
opical treatment# A n'mber of pharmace'tical preparations
\
have %aine acceptance as temporary
s'bstit'tes for the tear layer. These incl'e tear s'pplementsD ointmentsD an sol'ble polymeric
inserts. The efficacy of commercially available pro'cts has been oc'mente.
.?+D.?3
$n aitionD
issolvable an silicone removable pl'%s have been 'se to retain or conserve tears by retarin%
raina%e. T#o st'ies have reporte the efficacy of apparently safer issolvable colla%en materials
over the removable silicone application.
.?8D.?A
Since inflammation has been ientifie as a si%nificant component of oc'lar s'rface isorersD it
may seem lo%ical that topical anti-inflammatory treatments other than cyclosporine are effective.
1ne st'y investi%ate the comparative efficacy of topical sterois an non-steroial anti-
inflammatory r'%s =,SA$9> compare #ith tear s'pplementation. .*2 Symptoms #ere re'ce
an clinical stainin% scores improve amon% the topical steroi treate %ro'p b't not the ,SA$9
%ro'p. This evience may serve as the basis for 'sin% topical steroi rops to limit the inflammatory
response for short-term improvement 'rin% ry-eye therapy.
$n a ?-month prospective st'yD topical ).)2O cyclosporine performe better for clinical si%ns an
symptoms than i a combination of topical ).?O tobramycin pl's )..O eFamethasone for the
treatment of posterior blepharitis.
.*+
The potential sie effect of increase intraoc'lar press're =$10>
#ith lon%-term steroi 'se #arrants a baseline $10 reain%D #ith appropriate follo#'p reain%s.
Tear s'pplements can be esi%ne to mimic the tonicityD p;D retention timeD m'comimetic
propertiesD an l'bricatin% feat'res of the 01T5D an to increase the hei%ht of the tear menisc's.
Available in a variety of form'lationsD tear s'pplements have active in%reients representin% a #ie
spectr'm of polymeric components =Table ->. 59A reH'ires that all m'ltiose ophthalmic sol'tions
be preserve a%ainst contamination from a stanar %ro'p of patho%ens. Bith chronic 'seD ho#everD
these preservatives may ca'se averse effectsD incl'in% re'ction of the esire effectD aller%ic
responseD an toFic reaction. <npreserve 'nit-ose containers prevent the preservative problem b't
are more costly. Tear s'pplements also 'se preservatives thatD #hen instille onto the oc'lar s'rfaceD
rapily break o#n into innoc'o's compo'ns. These so-calle transiently preserve sol'tions
offer economy of vol'me an freeom from the averse effects of preservatives. 1phthalmic
preservatives 'se in artificial tear sol'tions an their potential averse effects incl'e:
E T-imerosalrm. A hypersensitivity reaction occ'rs in an estimate .)P-2 percent of 'sers.
.*3

Thimerosal may be 'se in ophthalmic ointment preparations that are available #itho't
prescription =i.e.D over the co'nter>.
E )en6al2onium c-loride. 01T5 instabilityD lo#ere B<TD an isr'pte corneal epithelial cell
f'nctions occ'r #hen benJalkoni'm chlorie is ose at commercial concentrations. These
effects seem to be concentration an chronicity epenent.
.*8-.2.
The averse effect on the
oc'lar s'rface may be 'e to alteration of epithelial m'cin.
.2-
E -loro!utanol. Evaporation an corneal epithelial cell chan%es occ'r. .2?
?8
E Et-ylenediaminetetraacetic acid 4E#TA5. Averse effect is contact aller%y.
.2*D.22
Stora%e in the
corneal an conj'nctival epitheli'm res'lts in keratitis.
.*AD.2+
Effective mana%ement of ry eye may reH'ire the instillation of tear s'pplements as freH'ently as .
rop every ?) min'tes or as infreH'ently as . rop aily at betime. 5or the patient #ho reH'ires
osin% more than ? times a ayD preservative-free or transiently preserve tears sho'l be
recommene. 1nly eval'ation an contin'al monitorin% can establish the freH'ency an 'ration
of treatment neee. $n mil casesD the simple recommenation of repeate blinkin% may contrib'te
to relief. Table - lists the in%reients of contemporary tear s'pplements.
Z 'intments# Bhen place in the lo#er c'l-e-sacD ointments containin% emollients issolve
at boy temperat're an isperse in the tearsD proviin% l'brication an protection.
0etrolat'mD mineral oilD an lanolin are typically incl'e in the form'lation of ointments
esi%ne for retention of oc'lar moist're. <s'ally 'se at betimeD ointments may also be
'se by seentary patients 'rin% the aytime. Beca'se of ointments viscosityD they can bl'r
visionK th'sD a very small amo'nt of ointment may be s'fficient for aytime 'se. 0atients
aller%ic to #ool may react aversely to lanolin. 0reservative-free form'lations sho'l be
recommene for patients #ho 'se these pro'cts chronically.
able 9
&omponents in ear Supplements, 3rop or 4el 0orm
&ellulose ethers ;yroFypropyl cell'lose
;yroFypropyl methylcell'lose =;0/:> =fo'n in many preparations>
/ethylcell'lose hyroFyethyl cell'lose
:arboFymethyl cell'lose =:/:> =fo'n in many preparations>
;ypermellose
=fo'n in many preparations>
.olyvinyl polymers 0olyvinyl alcohol =0(A>
=fo'n in many preparations>
0olyvinyl pyrrolione =0(0> =fo'n in many preparations>
*ucolytic agents ,-acetylcysteine
.23
\
)yposmotic tear 7lycerinD eFtran
supplements
Aitamin A 6etinol
'thers /ineral oil
\A m'colytic a%ent that isr'pts formation of filaments an may increase TB<T by alterin% lipi secretions.
$evie% of medications# A revie# of meications sho'l be con'cte to ientify an
eliminate potential r'%-relate ca'ses of ry eye. Estro%en replacement therapy may be
beneficial in patients #ith C:S
.3+
$n aitionD systemic testosterone in combination #ith
esterifie estro%en may sho# similar benefits. .33 :onverselyD for postmenopa'sal #omen
'sin% estro%en alone or in combination #ith pro%esterone/pro%estinD the risk for clinically
ia%nose ry eye synrome or severe symptoms rises by 'p to .2 percent for each ? years on
hormone replacement therapy =;6T> .*3 1ne st'y has sho#n that this specific hormonal
imbalance may benefit from ome%a-? lon%-chain poly'nsat'rate fatty aci s'pplementation.
.38
?A
Salivary gland transplant#
.3A
The placement of salivary %lan tiss'e in the conj'nctiva has
been attempte as a means of pro'cin% preoc'lar secretion.
.8)
A'tolo%o's s'bmanib'lar
%lan transplantation to the temporal fossa has also been s'%%este. .8.
+imbal grafts. 0ropose for severe cases of oc'lar s'rface iseaseD limbal %rafts remain
eFperimentalD #hile %'ielines for their implementation evolve
..8-D.8?
This may be a
partic'larly important area for the f't're treatment of oc'lar s'rface isorers relate to
limbal stem cell eficiencyD an emer%in% ia%nostic cate%ory. .8*
4imbal stem cell eficiency is no# reco%niJe as a ia%nostic cate%ory. Treatment involves
transplantation of harveste or transplante limbal cells to the oc'lar s'rface by a variety of
vehicles. .82-.83
Autologous blood serum and other nutrient drops# Topical application of rops of ser'm
from the patients o#n blooD #hich are 'npreserve an non-anti%enic in nat'reD is a means
of proviin% %ro#th factorsD fibronectinD imm'no%lob'linsD an vitamins at similar =or hi%her>
concentrations than eFist in tears. These are applie in cases of severe ry eye #ith p'nctate
epithelial efects an corneal ama%e to promote reepithelialiJation.
-3
,o commercial pro'ct
is yet availableD nor has the 59A approve this treatment. ;o#everD the emer%ence of
hyal'ronate-base topical rops may offer still another treatment optionD beca'se both their
n'trient capabilities an their l'bricatin% H'alities have favorable treatment attrib'tes. .88-
.A)
-# *anaging and reating the /nflammatory &omponent of 'cular Surface 3isorders
Bith ne# information emer%in% on the inflammatory contrib'tions to oc'lar s'rface isorersD a
m'ltifacete approachD incl'in% anti-inflammatory therapy may be in orer. The 'se of oral
ome%a-? fatty acis may be beneficial.
.38
$n aitionD topical application of cyclosporine has been
sho#n to be effective.
.**-.*+D-)8--.)
Aj'nctive anti-inflammatory therapies may provie immeiate
relief an lay the fo'nation for more tar%ete therapies. These incl'e the 'se of topical
corticosterois in aition to the anti-inflammatory strate%ies cite above.
-)8--.)
5# .atient Education
0atient e'cation is essential an #ill assist in compliance. :ompliance #ith mana%ement re%imens
is partic'larly important in chronic isorersD especially those that may res'lt in consierable
morbiity. This concept is applicable to persons #ith oc'lar s'rface isorersD of #hom many have
'nerlyin% systemic conitions. Bhen there is no previo'sly kno#n local or systemic ca'se for the
oc'lar finin%sD the patient sho'l be e'cate abo't other conitions possibly associate #ith the
oc'lar s'rface isorer an assiste in obtainin% f'rther ia%nostic eval'ations.
The clinician prescribin% topical treatment for ry eye sho'l %ive the patient the rationale for
treatmentD alon% #ith the specific osa%esD freH'encyD an 'ration. The patient sho'l be
mae a#are of the eFpecte res'lts an %iven instr'ctions to follo# in case of averse effects.
A follo#-'p eFamination of the patient sho'l be sche'le to assess the treatment
effectiveness.
The treatment of oc'lar s'rface isorers reH'ires closeD on%oin% cooperation bet#een the
patient an the practitioner. Thoro'%h isc'ssion of the ca'sesD the rationale for treatmentD an
the eFpecte res'lts is essential in the mana%ement of this conition. /ost patients #ith oc'lar
s'rface isorers eFperience si%nificant improvement in their symptoms #hen the appropriate
hy%ieneD topicalD an/or systemic treatments are instit'te.
*)
Beca'se there is no c're for the chronic forms of many oc'lar s'rface isorersD patients m'st
actively participate in steps to control the inflammatoryD infectio'sD or irritative processes.
Thoro'%h eFplanation of both the chronicity of the isease an the rationale for the therapy
helps enco'ra%e patient compliance. Specific instr'ctions an realistic eFpectations for the
abatement of symptoms sho'l be reinforce by a sche'le follo#-'p.
=# .rognosis and 0ollo%-up
0or many of the forms of ocular surface disorders, the prognosis is guarded, because the
treatment represents only a maintenance strategy. 0atient compliance is a major factor in
s'ccessf'l mana%ement an sho'l be stresse as a component of the care process. Bhen there is
an associate systemic ca'se for the isorerD remission is eFpecte #hen the 'nerlyin%
conition improvesD altho'%h intermeiary palliative treatment may relieve some symptoms.
/'ltiple eval'ations may be necessary to establish the ia%nosis an etermine the minim'm
treatment re%imen that pro'ces res'lts. 1nce a treatment plan has been sho#n to be effectiveD the
clinician sho'l provie follo#'p care at appropriate intervals to enco'ra%e compliance an
contin'e effectiveness =see AppeniF 5i%'re +D A )rief Flo1c-art>.
5ollo#-'p visits for treatment of oc'lar s'rface isorers may be as freH'ent as every fe# ays at
the o'tsetD taperin% off to once or t#ice a year after stabiliJation of the conition =see AppeniF
5i%'res 3 an 8>. $n the absence of other li or systemic abnormalitiesD the first ac'te staphylococcal
episoe 's'ally can be eFpecte to resolve completely. The chronic forms of oc'lar s'rface
isorers may be controlle #ith aily hy%iene an topical meicationD anD #hen inicateD
co'rses of systemic meication.
0igure 9
6GG5 &lassification Scheme 8ased on (E/B/ndustry ;orkshop
$eprinted %ith permission from +emp *A# $eport of the (ational Eye /nstituteB/ndustry ;orkshop
on &linical rials in 3ry Eyes# &+A' H 6GG5I 96<996->9#
*.
*-
Appendi, 65 Notes
3iagnosis and classifying
;o# o #e make a blepharitis ia%nosisQ Symptoms #aF an #ane. 0atients complain of b'rnin%D
irritationD an forei%n boy sensationK it especially seems prominent in the mornin%. 0atients say
their lis stickD an they have cr'stin%.
Be are all familiar #ith the n'mero's si%ns s'ch as collaretteD sc'rfD lash chan%esD inspissation in
meibomian %lansD an neovasc'lariJation of li mar%insD characteristic inferior s'perficial p'nctate
keratopathyD chalaJiaD an not infreH'entlyD mar%inal 'lceration.
StaphylococcalD seborrheicD occ'rrin% alone or in combination #ith staph iseaseD an occ'rrin% in
combination #ith primary meibomitis.
?

Be see patients #ith primary meibomitis most freH'ently.
&hronic blepharitis
herapy is directed at control, not cure# / tell my patients that the difference bet%een
blepharitis and true love is that one is forever#
$n the ac'te phaseD #e try to brin% the isease 'ner control. Be then have the chronic phase of
therapy #here #e #ant to maintain control.
The key factor is li hy%iene. This is the basic therapy that #e sho'l impress on all of o'r patients.
Be also enco'ra%e #arm salt #ater soaks fo'r times ailyD an in this process there is a chan%e in
the o#nership of treatment from the physician to the patient. This helps the patient realiJe that it is
not only the physician #ho is responsible for improvement.
The patients #ho reH'ire topical antibiotics are those #ith staphD coa%'lase-ne%ative staphylocciD
an patients #ith miFe Staphylococcal an seborrheic isease. (irt'ally all patients #ith chronic
blepharitis nee antibiotics at least intermittently in some form.
*?
Appendi, 75 Notes
Ten years a%oD not many clinicians #ere intereste in ry eye or blepharitis. 9ry eye really came to
the forefront #ith refractive s'r%ery patients. Be be%an talkin% abo't ho# to properly ia%nose an
treat it. $n the neFt ? to * yearsD these isc'ssions #ill become even more prevalent as cataract an
refractive s'r%eons realiJe that one of the leain% ca'ses of ecrease vision in o'r patients is the
health of the oc'lar s'rface. This is eFtremely important for o'r m'ltifocal $14 patients. 0osterior
li mar%in isease is probably the most common misia%nose an prevalent conition that affects
o'r patients vis'al ac'ity.
$t is critical to ifferentiate the finin%s of the oc'lar s'rfaceD #hether its aH'eo's tear eficiencyD
blepharitisD or both. The majority of the patients #ith blepharitis #ill have anterior or posterior
meibomian %lan isease. 0atients #ith posterior li mar%in isease have chronic complaints. Be
look for inspissation of %lansD erythema an telan%iectasia aro'n the %lansD the po'tin% of oilD
an the rapi tear break 'p time. That really ientifies the 'nstable tear film an #hy these patients
have fl'ct'ation in vision.
:orneal specialists see complications of chronic blepharoconj'nctivitis. These patients are in
chronic iscomfort. Be o see corneal involvement #ith scarrin% an neovasc'lariJation an
si%nificant loss of vision in some patients.
reatment options
Anterior blepharitisD #hile not very common in my practiceD is certainly
'e to Staph isease. Treatment options are li hy%iene #ith hot compresses an commercial li
scr'bs. Be o 'se antibiotic ointmentsK corticosterois are rarely inicate. Sometimes in anterior
li mar%in isease #ell have an associate conj'nctivitis an iscomfort.
5or those #ho present #ith posterior li mar%in iseaseD patient e'cation is vitally important.
These patients have chronic iscomfortD chronic re eyesD an #aFin%/#anin% vision. They are
lookin% for a c're an there isnt any. B't #e o have #ays to make these patients more
comfortable an improve their vis'al ac'ity. A%ainD li hy%iene an #arm compresses are the
cornerstone for treatment. 0atients prefer commercial li scr'bs to tryin% to miF 'p some kin of
sol'tion on their o#n. $ often tell them to 'se hot compresses in the sho#er an make it simpleD
typically t#ice a ay. 0atients are j'st not compliant beyon t#ice aily.
Be 'se to recommen rotatin% an antibiotic to re'ce the colony co'nts of bacteria on li s'rfacesD
b't $ have not been that impresse
Appendi, 85 Notes
The first principle in treatin% oc'lar infectio's iseases is to kno# the enemy before en%a%in% in
battle. That implies an 'nerstanin% of the epiemiolo%y of the patterns of oc'lar infectio's
isease as #ell as the s'sceptibility patterns of the a%ents that ca'se the isease.
The secon principle is to respect the enemy beca'se #e are clearly o'tn'mbere. 1c'lar patho%ens
#ill chan%e co'rse to aapt H'ickly to o'r efforts at eliminatin% them. They represent the 'ltimate
opport'nists an s'rvivalists.
Be kno# there is an emer%ence an sprea of antimicrobial resistance. $ts an increasin% %lobal
concern. /'tations happenD leain% to ne# resistant bacteria. Be al#ays felt imm'ne to the
problem of resist-
ance in ophthalmolo%y beca'se #e can apply o'r a%ents topically. &et ata from the :ampbell lab
an others have sho#n recently that there is an alarmin% increase resistance amon% isolates
ca'sin% oc'lar infectionsD incl'in% keratitisD enophthalmitisD conj'nctivitisD an blepharitis.
.-?
**
The neFt principle is to kno# the a%ents. $f #e co'l pick the ieal a%entD it #o'l be broa
spectr'mD bactericial in actionD biocompatibleD meanin% non-cytotoFicD an bioavailableD havin%
favorable pharmacoynamics.
Antibiotic parameters
Bacitracin =vario's man'fact'rers> has been aro'n for a#hile an is 'se freH'ently to treat
blepharitis. B't its insol'ble an only available in ointment formD havin% a ne%ative effect on
vision. Erythromycin =vario's man'fact'rers> is 'se #ielyD b't itD tooD is insol'ble an is only
available as an ointment.
The real problem #ith theseD tho'%hD is a consierable resistanceD especially amon% ,tap-ylococci.
Amino%lycosies are mainly %ram-ne%ative actin% a%ents: They are very toFic an rapily create
keratopathyD an they inhibit #o'n healin%. $nterestin%lyD chloramphenicol =vario's man'fact'rers>
is the most #iely 'se anti-infective %lobally beca'se of its relative ineFpensiveness. ;o#everD it
can ca'se a rare b't evastatin% bone marro# iiosyncratic toFicity that co'l be fatal.
S'lfacetamie =vario's man'fact'rers>D o'r ol frien from the .A*)sD is still 'se occasionally. $t
has reasonable effect b't can ca'se a hypersensitivity.
Be no# have some very potent 8-methoFy fl'oroH'inolones that have improve spectr'm of
activity a%ainst ,treptococci an other %ram
Appendi, 95 Notes
V'ality of vision is %oin% to be most important for all yo'r cataract patientsD especially yo'r
refractive cataract patientsD premi'm $14 patientsD 4AS$C an 06C patients. Be nee to remember
the refractive s'rface of the eye is the tear filmD not the cornea or lens.
9ry eye synrome an blepharitis are t#o of the most common iseases #e eal #ith. Blepharitis
really is a type of ry eyeD an evaporative ry eye. Beve been traine for years that #hen #e
eval'ate cataractsD #e
p't the slit lamp ri%ht back to the lens an #e bypass the li.
$f the oc'lar s'rface is not healthyD vis'al istortions #ill follo# 4AS$CD 06CD an m'ltifocal $14
s'r%eries.
9ry eyeD as #e typically think abo't itD is a'to-imm'ne relate. /ost clinicians 'se corticosteroisD
like 4otemaF =loteprenol etabonate ).2OD Ba'sch ] 4ombD 6ochesterD ,.&.>D or 6estasis
=cyclosporine ophthalmic em'lsionD Aller%anD
$rvineD :alif.>. :linicians sho'l apply the same methos 'se to treat aH'eo's ins'fficiency to li
mar%in isease an blepharitis.
3ry eye and surgery
9ry eye is the most common complication #e see @ one in fo'r patients #ill have ry eye
symptoms or complaints. Beve learne that the H'ality of the tear film an health of the
corneal epitheli'm are eFtremely important in obtainin% %oo o'tcomes.
To o thisD clinicians m'st treat the 'nerlyin% problem pre-opD protect 'rin% s'r%eryD an mana%e
appropriately after s'r%ery.
.
:ataract s'r%ery is likely to in'ce ry eye or eFacerbate pre-eFistin%
ry eye in a si%nificant portion of patients .-
Be are familiar #ith the si%ns an symptoms of blepharitisD as #ell as the seH'elaeD both anterior
an posterior li mar%in isease. /'ch of the ry eye #e see is relate to blepharitis by itself or in
combination #ith aH'eo's ins'fficiency.
:onventional mana%ement incl'es #arm compresses an li scr'bs. The ieal mechanism in my
opinion for AJaSite =aJithromycinD $nspire 0harmace'ticalsD 9'rhamD ,.:.> is not bacterial
conj'nctivitis b't blepharitis. 1ne rop %ives .))- fol concentration that #ill last for a very lon%
time on the eyeli.
*2
8EA panel recommendations Basically #ere talkin% abo't stanariJin% #hat #e are oin% for
li mar%in iseaseD in the eFact same #ay as #eve stanariJe for ry eye.
The panel recommens li hy%iene #ith commercial scr'b b.i.. for t#o aysD then V9 for one
month. /y preference is to 'se Steri4i =Avance (ision 6esearchD
Bob'rnD /ass.>. :onverselyD $ o not believe baby shampoo is nearly as effective. This
stanariJe ro'tine #ith AJaSite is easy for patients to follo#. $ tell patients to take it at ni%ht. $ts
%ot a %oo l'bricant an is #ell tolerate.
Bhen recommenin% n'tritional s'pplements to yo'r patientsD remember ome%a-?s are effective.
Even #ith lo#-ose tetracyclines =vario's man'fact'rers>D s'pplement once a%ain #ith topical
loteprenol as neee.
5or anterior blepharitisD o'r treatment recommenations are AJaSite b.i.. for t#o aysD then once
aily for a month. 5or li hy%iene its the sameD li hyperthermia an n'tritional s'pplements.
5or posterior blepharitisD treatment recommenations are very similar. Therape'ticallyD #e recom-
men AJaSite t#ice a ay for t#o aysD then ain% oral oFycycline =vario's man'fact'rers> as a
secon-line treatment. $f the conition is still not resolveD thir-line treatment sho'l be the
aition of anti-inflammatory corticosterois an/or cyclosporine.
$n concl'sionD the appropriate mana%ement of the oc'lar s'rface #ill improve a clinicians s'r%ical
o'tcomes an patient satisfaction.
*+
5'rtherD a stable tear film is essential for %oo f'nctional vis'al ac'ity.
Appendi, :5 2oney
http://###.abc.net.a'/catalyst/stories/sA38A-..htm
;eres the secret:
)oney more effective than antibiotics
0'blishe on R'ne .3D -))A

/n the first study of its kind 1niversity of Sydney researchers have found proof that some
honeys can be more effective than antibiotics in treating surface %ounds and infections#
<nlike antibioticsD #hich only #ork on some bacteriaD the honeys #orke on all of the infectio's
b'%s testeD incl'in% one that #as resistant to .? ifferent antibiotics. :riticallyD the bacteria i
not aapt an evelop resistance to the honey as they o #ith antibiotics.

The honeys teste by the researchers #ere variations of /an'ka honey an jelly b'sh honeyD from
,I an A'stralia respectivelyD both of #hich are c'rrently available in meicinal versionsD b't are
not #iely 'se in hospitals.

!/ost bacteria that ca'se infections in hospitals are resistant to at least one antibioticD an there is
an 'r%ent nee for ne# #ays to treat an control s'rface infectionsD" sai Associate0rofessor 9ee
:arterD from the <niversity of Syneys School of /olec'lar an /icrobial Biosciences. ",e#
antibiotics ten to have short shelf livesD as the bacteria they attack H'ickly become resistant. /any
lar%e pharmace'tical companies have abanone antibiotic pro'ction beca'se of the iffic'lty of
recoverin% costs. 9evelopin% effective alternatives co'l therefore save many lives.
!1'r research is the first to clearly sho# that these honey-base pro'cts co'l in many cases
replace antibiotic creams on #o'ns an eH'ipment s'ch as catheters. <sin% honey as an
intermeiate treatment co'l also prolon% the life of antibiotics."

The common enominator in the honeys teste is that are pro'ce by bees #hich fee on
4eptosperm'm plantsD commonly kno#n as tea treesD fo'n in native A'stralian an ,e# Iealan
b'shes.

The honeys #orke on patho%ens kno#n to have a hi%h level of acH'ire an/or intrinsic resistanceD
incl'in% s'perb'%s s'ch as flesh-eatin% bacteriaD or /6SAD sai A/0rofessor :arter.
!Be ont H'ite kno# ho# these honeys prevent an kill infectionsD b't a compo'n in them calle
methyl%lyoFal seems to interact #ith a n'mber of other 'nkno#n compo'ns in honey to prevent
infectio's bacteria evelopin% ne# strains that are resistant to it."

The research has j'st been p'blishe online in the E'ropean Ro'rnal of :linical /icrobiolo%y an
$nfectio's 9iseasesD in a paper title: The 'n's'al antibacterial activity of meical-%rae
4eptosperm'm honey: antibacterial spectr'm resistance an transcriptome analysis.
http://###.'sy.e'.a'/

Addendum
http://###.smh.com.a'/#orl/science/honey-may-hol-key-to-beatin%-hospital-s'perb'%-
-))A)+.3-chiA.html

Also this:
*3
8A&E$/AJ
Featuring an e&clusive intervie' 'ith distinguished Associate Professor %ee #arter
()ead of the 3iscipline of *icrobiology, 1niversity of Sydney"

/ost of the bacteria that inhabit the planet play a vital part in its or%anic an carbon cycles.
They replenish the supply of nutrients in the soil, performing a very important role for human
formationK ho#ever there are also some bacteria that threaten our lives %ith disease#
The latter bacterial patho%ensD apart from infectio'sD can sometimes be eFtremely r'%
resistant. Among them the so-called superbugs have developed resistance to almost every
antibiotic ever evelope by any pharmace'tical company.
Their very rapi evelopment of resistance is #hat has le most pharmace'tical companies to stop
employin% their reso'rces on the antimicrobial research.
A sit'ation of meical emer%ency has establishe 'e to the fact that superbugs can be
particularly prevalent in hospitals, and are responsible for killing patients, particularly those
in intensive care.
he essential need for an agent that effectively kills these organismsD especially in the treatment
of #o'nsD has been the n'mber one priority that has driven many scientists %ithin the
microbiology field to research every option available#
B'tD if there is no drug that can stop these plagues, %hat else there isD
An all time natural remedy< *anuka honey#
*anuka honey and jelly bush honey are produced by bees that feed off tea trees in (e%
Kealand and Australia #
;ere is #hen #e seem to #itness ho# the c'stoms of ini%eno's tribesD #ho have kno#n abo't the
healin% properties of the honey as #ell as many other nat'ral remeies for as lon% as they
rememberD beat the attempts of the pharmace'tical companies to man'fact're the nemesis of the
s'perb'%s.
+eading researcher in fungal genetics, .rofessor 3ee &arter =<niversity of Syneys School of
/olec'lar Bioscience> took part in the discovery of ho% honey %ould )s'eetly but
effectively) kill infectious organisms. /t is a privilege to intervie% .rofessor &arter on this
subject, %hich has the potential to have a major impact on modern medicine#

.rofessor &arter, many thanks for participating in this intervie%, and of course please receive
our congratulations for this important health discovery#
6# *3*L The res'lts from the research #ere p'blishe in the E'ropean Ro'rnal of :linical
/icrobiolo%y an $nfectio's 9iseases almost a year a%o no# b't %hen exactly %as this discovery
of the curative properties of the *anuka honey made, .rofessorD
6# .$'0ESS'$L /ts been kno%n for many hundreds of years that honey can be used to
alleviate or cure a variety of ailments 2 %ell before is %as kno%n that these ailments are
caused by micro-organisms# )o%ever, the pioneering %ork on *anuka honey has really been
done in the past 9@ or so years, largely driven by our colleague .rofessor .eter *olan in (e%
Kealand, %here the *anuka bush is native# 9'rin% this time he an othersD incl'in% o'r %ro'pD
have trie to p't some soli science behin the observation that honey has c'rin% properties
9# he *anuka honey %as already being sold in health food shops as a natural
medicine but 'e to thereticence of the scientific community to consider some of these natural
products noboy ha teste the honey for its healin% properties. ;hat lead your research group
to consider that there could be an effective anti-bacterial component in this honey at the timeD
9# .$'0ESS'$L / had an undergraduate student, Shona 8lair, %ho had become very
interested in the initial %ork coming out of the *olan lab on the effect of honey on bacterial
*8
pathogens# At the time nothin% #as kno#n abo't #hat the Mspecial factorN present in the honey
mi%ht be that #as havin% this effect @ chemists like .rofessor *olan had been trying to isolate it
but %ithout success. As microbiolo%ists #e #ere intereste in eFplorin% the effects from the
microbial point of vie# to see if this mi%ht be able to tell 's more abo't the active components in
the honey. ;e tested many different bacterial strains, including those resistant to 6@ or more
different antibiotics, and found that these %ere all eEually susceptible to the killing effect of
honey# 0urthermore %e have not been able to get bacteria to develop resistance to honey, #hen
they #ill rapily become resistant to other antibiotics.
># *3*L Bhat #as the general reaction of the leading researchers from other scientific
groups on this discoveryD
># .$'0ESS'$L Some scientistsD partic'larly those #ith an interest in nat'ral pro'ctsD are very
interested in and excited about the %ork# 8ut it %ould be fair to say that there are some that
see it as a bit off-beat and not really Mserious scienceN. Bhich is c'rio's as #e 'se all of the same
techniH'es that one #o'l employ to test any 'ncharacterise antimicrobial s'bstance. $ think its
just the perception that honey belongs on toast that gives rise to this attitude#
-# *3*L 9o yo' think this discovery could prompt other research groups to test the
properties of common natural remedies that are being sold in health food shopsD
-# .$'0ESS'$L here is certainly a gro%ing interest in exploring natural products for their
health properties and in putting some solid science behind the %ays in %hich these %ork# 'ne
of the issues %ith natural products, ho%ever, is that they often have lo# levels of active
in%reients =#hich is #hy there are 's'ally fe# iss'es #ith sie effects> an these may vary since
they are iffic'lt to characteriJe. AlsoD ifferent people may respon ifferently to them.
So conducting a clinical trial and coming up %ith really robust data as is done for
conventional drugs, %here the active ingredient can be completely standardiCed, is often
difficult# /n addition, natural therapies often nee to be employe over a perio of time
an dont give the MEuick fixN that %e are used to, for example %ith antibiotics, leain% to the
perception that they ont #ork. The science is therefore H'ite iffic'ltD nonetheless its exciting to
see more of it being done, an it hols a %reat interest to the %eneral p'blic.
5# *3*L his honey is applied externally on bites and cuts as it acts on skin infections, hence
being a good replacement to antibiotic and antiseptic creams# The bees that pro'ce this honey
fee of tea trees an apparently microbiolo%ical testin% has confirme the effectiveness of tea tree
oil in fi%htin% infection. ;o#ever this type of oil only comes from the tea trees native to A'stralia.
&ould the components of the *anuka honey andBor those of the tea tree oil in itself be
genetically clonedD
5# .$'0ESS'$L / should start by saying that tea tree oil is derived from a completely
different tea tree species to *anuka and is not involved in the activity of *anuka or jelly bush
honey# Since my eFpertise is in honey $ can only really comment abo't this. Be no# kno# that at
least part of the activity of *anuka honey is due to a small molecule called methylglyoxyl, or
*4# &o' can p'rchase chemically synthesiJe /7 from fine chemical companies. $t #ill kill b'%s
b't its also toFic to h'man cells in the p're form. There is somethin% abo't it %hen in honey that
allo%s it to selectively kill pathogens %ithout harming the human cells 2 in fact honey as a
%hole product promotes %ound healing# Be have also trie spikin% some /7 into non-/an'ka
honey to see if #e can sim'late the antimicrobial an healin% effects of /an'kaD b't this really
oesnt #ork. ;e believe there are other compounds present in honey, not yet characteriCed,
that act %ith honey to produce the special antimicrobial and %ound healing properties that it
has# So no, / dont believe %e are yet able to make a simple derivative from a cloned !or
other%ise synthesiCed product" 2 although this might be possible in the future#
=# *3*L 9'e to yo'r o'tstanin% #ork for over the past .) years you have been established as
the leading researcher in cryptococcal genetics, #ith partic'lar foc's on molec'lar ecolo%y an
pop'lation %enetics that 'nerlie infection by ryptococcus gattii. ;ould you be as kind as to
*A
explain to our readers %hat diseases these type of organisms are responsible for and %here
can they be foundD
=# .$'0ESS'$L #ryptococcus gattii is a very interesting pathogenic yeast# ,easts are a type
of fungus that occur as single round cells rather than long threads, and fungal pathogens often
exist as a yeast form %hen infecting mammals# #. gattii is normally found in the environment
and in Australia appears to have a close relationship %ith certain species
of $ucalyptus trees, partic'larly Eucalyptus camaldulensis,also kno#n as the river re %'m. &o'
can fin . gattii on other trees b't is most reliably isolate from E. camaldulensis an close
relatives. This makes it interestin% to 's here in A'stralia as the re %'m is a native treeD b't its also
important %orld%ide as these trees have been extensively exported and are found in high
numbers throughout the Americas, Africa and Asia# 1nder circumstances that are not %ell
understood, #. gattii cells become aerosoliCed and can be inhaled by people and animals# Be
can 's'ally clear the infection very efficientlyD b't in a small number of people the fungus %ill
lodge in the lung and gro% to cause pneumonia# And in a small proportion of these cases it can
disseminate from the lung to other parts of the body, particularly the brain, to cause
meningitis# &ryptococcal meningitis is a fatal disease %ithout treatment, an treatment options
are limite since f'n%al cells arent so ifferent from h'man cells an antif'n%al a%ents can be toFic
to 's. ;e have been using molecular ecology techniEues to try to understand ho% #.
gattii spreads in the environment and contacts unlucky recipients# This interface bet#een the
ecolo%y of an or%anism in the environmentD an infection in a person or animalD are of %reat val'e in
'nerstanin% infectio's iseasesD partic'larly as the environment chan%es thro'%h climate chan%eD
eforestationD a%ric'lt're an other ecolo%ical isr'ptions.
?# *3*L ,ou have been invited to speak in scientific conventions partic'lar to yo'r area of
eFpertise in Australia, 1SA and have hosted visiting scientists from 0rance, 8ritain, Aietnam
and /ran, #ho have learnt molec'lar techniH'es an their application to f'n%i in yo'r lab. ;hat
specific projects of investigation !and other" are you currently %orking on and %hich %ould
you like to direct your efforts to%ards in the near futureD
?# .$'0ESS'$L / am very concerned about the lack of suitable treatments for so many
microbial infections, such as the drug-resistant bacteria and the fungi# Be are continuing our
studies of honey and are particularly interested in ho% it is able to prevent resistance from
developing @ maybe this information can be 'se in the rational esi%n of other r'% treatments.
5or f'n%al patho%ens my research has become foc'se on 'nerstanin% the infectio's process #ith
the lon%-term aim of evelopin% ne# therapies. /n our study of #ryptococcus %e are using a
techniEue kno%n as proteomics, %hich is able to characterise many expressed proteins at one
time# his allo%s us to see %hat proteins a pathogen makes during infection, and also %hat
proteins are made by a host to protect against infection. By characterisin% proteins that are
pro'ce by a f'n%'s that is able to pro'ce a serio's infection @ #hat #e call a vir'lent strain @
an comparin% this to the proteins pro'ce by a relate f'n%'s that cant pro'ce s'ch a serio's
infectionD #e can %et an iea of the proteins that are important in the infection processD #hich may
be 'se to inform the r'% evelopment process.
*3*L Thank yo' a%ain 0rofessor :arter for yo'r participation in this intervie#D it is a privile%e.
.$'0ESS'$L /y pleas're^

Addendum:
0aper: The Antibacterial Activity of ;oney 9erive from A'stralian 5lora by R'lie $rishD Shona
BlairD an 9ee A. :arter\ L5<44 A6T$:4E 4$,CE9M
Also:

)o% *anuka )oney Oills *$SA And )eals Staph /nfections
8y 0rank 8uonanotte
2)
Breakin% ne#s in the in'stry of avance #o'n care has le to the reco%nition of honey erive
from the /an'ka Tree =ini%eno's to ,e# Iealan> has eFtraorinary antibacterial properties that
are capable of estroyin% antibiotic-resistant strains of bacteria s'ch as /6SA.
As the name s'%%estsD /ethicillin-resistant Staphylococc's a'rea's =/6SA> is a bacteri'm that has
evelope a resistance to /ethicillin an other antibiotics. Bith the over'se of antibiotics in the
past ? ecaesD eFperts preict the emer%ence of more r'%-resistant bacteria in the f't're.
$n aition to the fr'stration of /6SA bein% impervio's to antibioticsD its life-threatenin% nat're
has comm'nities affecte by Staph infections rattle. Since antibiotics ont #ork an some topical
a%ents ca'se tiss'e ama%eD /an'ka ;oney is bein% consiere a favorable healin% a%ent. Beca'se
/an'ka ;oney provies an osmotic effectD moist're is ra#n o't of bacteria #itho't ca'sin%
ama%e to the skin. Bacteria cannot s'rvive in the healin% environment create by /an'ka ;oneyD
makin% it an ieal #o'n ressin%.
,ot only has /an'ka ;oney been proven to heal all kins of bacterial infectionsD it has also been
fo'n to have no ne%ative sie effects. $n aition to its ability to estroy bacteria responsible for
infectin% #o'nsD /an'ka ;oneys healin% properties also have the ability to repair ama%e skin
an re%enerate ne# skin %ro#th. Even tho'%h /an'ka ;oney ra#s moist're a#ay from bacterial
cellsD it has a moist'riJin% effect on the skin.
;oneymarkD a man'fact'rer of /an'ka honey-base skin care pro'cts has evelope a 5irst Ai
Antiseptic 4otion containin% Active /an'ka ;oney that is bein% 'se to treat /6SA an Staph
infections. This pro'ct avois the sticky mess of applyin% honey irectly to the skin #hile havin%
other val'able in%reients that help clear infection. $n aition to Active /an'ka ;oneyD it contains
BenJalkoni'm :hlorie #hich is an 59A approve antisepticD proviin% a secon line of efense
a%ainst bacteria.
!Bhile the meical in'stry scrambles for an alternative to antibioticsD ;oneymark has offere
them a sol'tion to the /6SA epiemic on a silver platterD" says 5rank B'onanotteD :E1 of
;oneymark $nternational. !/an'ka ;oney has the ability to ra# #ater o't of bacterial cellsD
similar to the #ay salt makes a sl'% shrivel 'p an ie."
A;;%ND<=5 6 ctober 6>44 .%?<%3 F ;TM%T.@
S'1$&E
&onsistent Association %ith 3ry Eye is ;ell 3ocumented
$ncreasin% a%e
5emale %ener
;ormone replacement therapy
1me%a-? an 1me%a-+ fatty acis
Systemic antihistamine use
:onnective tiss'e isease
6efractive s'r%ery
(itamin A eficiency
Anro%en eficiency
6osacea
2.
+ong hours at computer
Association %ith 3ry Eye is Suggested by +iterature
Asian race
:ertain meications:
- Tricyclic antiepressants
- Selective serotonin re'ptake inhibitors
- 9i'retics
- Beta-blockers
9iabetes
;$(
:hemotherapy
0C or lar%e-incision corneal s'r%ery
$sotretinoin
4o# h'miity environments
Evidence for an Association %ith 3ry Eye is 1nclear
:i%arette smokin%
;ispanic ethnicity
Anti-choliner%ics: - AnFiolytics
Antipsychotics
Alcohol
/enopa'se
BotoF injection
Acnes
7o't
1ral contraceptives
0re%nancy
*anaging 3ry Eye Symptoms
The follo#in% simple environmental moifications can %reatly re'ce ry eye symptoms:
T'rn ceilin% fans off or to slo#er spee.
0osition comp'ter monitor at eye level or belo#.
Take 2- to .)-min'te break per ho'r from comp'ters an electronic evices.
6e-irect fans an A/: vents a#ay from the face.
:onsier intra-nasal steroid sprays as an alternative to systemic antihistamines for the treatment of
aller%ic sin'sitis.
$ncrease ambient h'miity at home or #ork #ith a h'miifier
<se 0anoptF =or other #rap-style s'n%lasses> o'toors.
2-
6e'ce contact lens #earin% time or s#itch to more freH'ent replacement.
7et eno'%h sleep.
;hen to .lug 0irst
$f there is a si%nificant inflammatory componentD that sho'l be aresse first before p'nctal occl'sion.
;o#everD in some cases of non-inflammatory ry eye s'ch as those liste belo#D patients respon very #ell
to p'nctal occl'sion as the initial intervention.
0ost-4AS$C ry eye
Any form of ne'rotrophic keratopathy
4a%ophthalmos
9ry eye seconary to anticholiner%ic or antim'scarinic meicationsD e.%.D 9etrol 4A =tolteroine tartrateD
0fiJer> for overactive blaer.
#linical Pearl
$f a patients ry eye symptoms seem to be #orse in the mornin%D ask #hether he or she s'ffers from sleep
apnea. ,ot only are sleep isorers themselves sometimes relate to ry eyeD b't the contin'o's positive
airflo# press're =:0A0> machines 'se to treat sleep apnea commonly in'ce ry eye.
-.
Artificial tears an
ni%httime ointments may help alleviate the ryin% effects of the machines. Also r'le o't floppy eyeli
synrome =5ES>D as it can mimic ry eye symptoms an is also hi%hly associate #ith sleep apnea.
#linical Pearl
0atients #ith SjT%rens synrome have a si%nificantly hi%her incience of several types of non-;o%kins
lymphoma compare to the %eneral pop'lation.
--
Bhile still fairly rareD one in .- SjT%rens patients #ill %et
this form of cancerD so a rhe'matolo%y referral can be life-savin%.
9ry eye is a compleFD m'ltifactorial isease affectin% the oc'lar s'rface an lacrimal %lans.
.
'ther than
mild, episodic cases, untreated dry eye is typically progressive in nature# The prevalence of ry eye has
been reporte as bet#een .*O an ??O of the pop'lation.
-
$t is closely associate #ith increasin% a%e an
female %ener. Base on ata from the Bomens ;ealth St'y an the 0hysicians ;ealth St'yD it is
estimate that ?.-? million #omen an ..+8 million menD for a total of nearly 2 million Americans over a%e
2)D s'ffer from ry eye.?D*
$n the Bl'e /o'ntains Eye St'y in A'straliaD 23.2O of participants a%e 2) an oler reporte at least one
ry eye symptomD an .+.+O reporte moerate to severe symptoms.
2
6e'ce levels of seF hormonesD partic'larly anro%enD are tho'%ht to be a major factor in the patho-
physiolo%y of ry eye.
+D3
9eclinin% hormone levels #ith a%e may be responsible for the !tippin% point" at
#hich #omen #ith normal oc'lar s'rfaces be%in to s'ffer from ry eye symptoms.
$n aition to a%e an %enerD a n'mber of other factors have been establishe as consistently associate #ith
or s'%%estive of ry eyeD #hile some conitions lon% consiere to be associate #ith ry eye have not been
establishe as s'ch in the literat're.
8
9ry eye is the sin%le most prevalent meically treatable eye isease seen in the typical clinical eye care
practice in the <nite States. 9ry eye is a leain% reason for ac'te eye care office visitsD an its symptoms
acco'nt for nearly half of all primary or seconary eye care complaints.
2?
3ry eye may be aEueous-deficient or evaporative in natureD an may be accompanie by anterior or
posterior li mar%in isease that also contrib'tes to symptomatolo%y. Amon% the most severe forms of
aH'eo's-eficient ry eye is SjT%rens synromeD commonly associate #ith rhe'matoi arthritis an other
connective tiss'e iseases.A ,on-SjT%rens aH'eo's eficiency may stem from lacrimal eficiencies or other
factors.
Evaporative dry eye may be intrinsicPcaused by meibomian oil deficiency or lid aperture problems,
for examplePor extrinsic and related to contact lens %ear or other factors#
Accorin% to the 9EBS report an other respecte so'rcesD a core mechanism in the initiation of ry eye is
tear hyperosmolarity.-D.) Tear hyperosmolarity activates a cascae of inflammatory events on the oc'lar
s'rface an the release of inflammatory meiators into the tears. /eibomian %lan ysf'nction =/79> likely
plays a si%nificant role in the etiolo%y of ry eyeD increasin% aH'eo's evaporationD hyperosmolarity an tear
film instability... Tear film instability can also be ca'se by other factors #itho't prior hyperosmolarity.
Allergy, the use of systemic drugs that decrease aEueous or oily secretions, chronic use of topical
medications %ith toxic preservatives, and reduced blink rates during computer usage are common
factors that can all contribute to an unhealthy ocular surface and reduced tear function#
ear dysfunction results in lacrimal gland inflammation# $ntercell'lar ahesion molec'le-. =$:A/-.>D
#hich has been sho#n to be 'pre%'late in ry eyesD promotes lymphocyte activation an mi%ration to the
oc'lar s'rfaceD #here the lymphocytes ca'se f'rther lacrimal %lan ama%eD as #ell as conj'nctival epithelial
cell apoptosis.
.-
The inflame lacrimal %lans secrete cytokinesD proteasesD an other inflammatory meiators
into the tearsD contin'in% the cycle of ecrease H'antity an H'ality of tear pro'ctionD
.?
increasin% lacrimal
%lan inflammation an oc'lar s'rface ama%eD an #orsenin% symptoms.
The nerves of the cornea are also important to corneal sensation an tear pro'ction. Abnormalities in these
ne'ronal path#aysD ca'se by inflammatory processes an/or oc'lar s'r%eryD may also ca'se inj'ry to the
lacrimal %lans an conj'nctival epitheli'm.
3
5'rther el'ciatin% the inflammatory cycleD SternD 0fl'%feler an others have s'%%este that the oc'lar
s'rface =corneaD conj'nctivaD accessory lacrimal %lansD an meibomian %lans>D alon% #ith the main
lacrimal %lan an the interconnectin% ne'ral refleF loopsD comprise a elicately balance f'nctional 'nit.
.?-
.2
Bhen any part of this oc'lar s'rface/lacrimal %lan refleF 'nit fails to #ork as it sho'lD the vol'me an
composition of tears become ins'fficient for normal homeostasis an repair.
/mpact of 3ry Eye
The tear film is the first refractive s'rface of the eye an therefore critical to %oo visionD as #ell as comfort
an protection from infection. 3isruption of the tear film via the processes described above causes
symptoms that can range from mild to Euite severe, even debilitating# $n 'tility assessmentsD patients
have rate severe ry eyes impact on their H'ality of life on par #ith hospital ialysis an severe an%ina an
hi%her than monoc'lar blinness..+D.3
As isease severity increasesD patients are increasin%ly likely to report bl'rryD fo%%y or fl'ct'atin% vision that
impairs vis'al f'nction. The abnormal oc'lar s'rface is also less capable of responin% to #inD lo#
h'miityD an aller%ensD so any environmental challen%e f'rther #orsens patient symptoms.
.A$ 9< 3/A4('S/S
9espite #hat is no# kno#n abo't the role of inflammation in ry eyeD it is not al%ays easy to identify
lacrimal inflammation clinically# 9ia%nosis an treatment is therefore more typically base on a
combination of symptoms an objective clinical si%nsD #hich are not al#ays #ell correlate.
Several protocols for classifyin% an treatin% ry eye have recently been propose .
-D8
The clinician may also
simply consier classifyin% patients H'alitatively as havin% milD moerateD or severe ry eyeD #ith or
#itho't accompanyin% li isease.
Altho'%h an 'nerstanin% of etiolo%y is certainly helpf'lD one need not identify evaporative dry eye
versus aEueous deficient dry eye in the patient chart, nor does exact etiology necessarily change treat-
ment recommendations#
2*
Symptoms
Symptoms of ry eye incl'e ryD scratchyD %rittyD sanyD stin%in%D b'rnin%D an/or fati%'e eyesD an
occasionally refleF #aterin%. 1ftenD these symptoms are the primary complaint rivin% the patient to seek an
appointment #ith the eye care provier.
;o#everD it behooves the clinician #ith an oler or pre/posts'r%ical patient pop'lation to ro'tinely ask abo't
ry eye symptoms. $n these important pop'lationsD %la'comaD cataractsD refractive s'r%ery stat'sD an other
iss'es may take center sta%eD leain% both patient an clinician to i%nore treatable ry eye.
A%e-relate ry eye may tri%%er seconary conitions s'ch as internal or eFternal horeolaD or lo#-%rae
blepharitis. :linicians sho'l reco%niJe an aress the root ca'se of these conitionsD the ry eye.
A formal H'estionnaire may be helpf'l in elicitin% symptomsD b't it is not necessary for the ia%nosis an
care of ry eye. A key Euestion to ask is the timing of symptoms, as research has sho%n that patients
%ith dry eye almost al%ays have %orse symptoms later in the day#
.8
;o#everD those %ith meibomian gland dysfunction may have %orse symptoms in the morningD #ith
moerate ry eyesD it is common for patients to have a scant ropey or m'co's ischar%e or to complain of
their eyelids being stuck together in the morning. The key to istin%'ishin% s'ch symptoms from those of
an early bacterial infection is the lack of conj'nctival hyperemia in the ry eye.
6opy ischar%e seen in a patient #ith moerate ry eye that stains #ith lissamine %reen
1ther ry eye symptoms can also mimic vario's other conitions. $tchin%D for eFampleD is very commonly
#ithin the constellation of symptoms associate #ith ry eye iseaseD b't the mention of this symptom can
erroneo'sly lea practitioners to a ia%nosis of aller%y.
9ry eye patients #ill often complain of !eye pain". 1n f'rther H'estionin%D the ry eye patient #ill likely say
that the pain is H'ick b't very sharpD like a pin-prick. SharpD transient eye pain is often reporte in patients
#ith ry eye.
The patient may also eFperience epiphora. /f tears are rolling do%n the cheek or if the symptom is uni-
lateral, it is likely due to a stenotic or blocked nasolacrimal system# 4aFity in the lo#er li in oler
patients may also lea to epiphora. B't a feelin% of #etness or a #atery characteristic to the tear film can be
the res'lt of compensatory activity of the accessory or main lacrimal %lans. This makes the tears #etterD
ca'sin% co'nterint'itive eFcess #aterin% in a ry eye.
5inallyD blurred or intermittent vision is a very important symptom that patientsEan many cliniciansE
fail to associate #ith ry eye.
)istory
A thorough history is essential in differentiating dry eye from other conditions that affect the ocular
surface and in assessing the impact of topical or oral medications and other ocular or systemic
conditions#
0artic'larly importantD of co'rseD is to 'nerstan #hether the patient has any a'to-imm'ne or connective
tiss'e isorers s'ch as SjT%rens synromeD rhe'matoi arthritisD iabetesD thyroi isease or l'p's. 0atients
may not connect these isorers to oc'lar symptoms 'nless specifically aske.
$n the case of some systemic iseasesD s'ch as rosacea or iabetesD the isease itself m'st be #ell controlle
in orer for ry eye therapy to be effective in resolvin% oc'lar s'rface problems.
.A
/n a large study in /srael,
patients %ith diabetes not only had a higher incidence of dry eye, but also needed to use artificial tears
22
more often %hen glycemic control %as poor.
-)
$n other systemic isorersD the meication 'se to control
the isease may itself be responsible for the ry eye.
Telan%iectasia of the li mar%in in a patient #ith avance ry eye. Also note absence of inferior lacrimal
lake hei%ht classic in avance ry eye states.
The clinician nees to kno# abo't c'rrent or prior contact lens #ear an any eye rops the patient is 'sin%.
Askin% for specific etails abo't eye rops can provie insi%ht to the preservative loa on the eyeD as #ell as
inappropriate 'se of vasoconstrictors or other topical a%ents.
.hysical Exam
The physical eFam sho'l be%in #ith careful observation of the facial and peri-orbital skin. 1ne often
sees oc'lar manifestations of rosacea before or alon% #ith very mil ermatolo%ic si%nsK in other casesD the
ermatolo%ic evience is clearD b't the patient has never been ia%nose #ith rosacea..A $n s'ch casesD
e'cation an referral to another clinician for treatment of the skin iss'es is very important.
At the slit lamp, one should look at the tear meniscus# A scant tear lake can be a confirming
observation in the diagnosis of dry eye#
+id assessment %ith manual expression of the meibomian glands is a critical component of the dry eye
exam#
1ne sho'l look for a consistentD 'niformly smooth li mar%in. $n avance li iseaseD the meibomian
%lans start to isplace an the li mar%in is markely irre%'larD a clear si%n of moerate to avance
lon%term isease that reH'ires more a%%ressive therapy. The presence of telan%iectasia on the li mar%in is
also an inicator of a more chronic conition. B't it is important to note that in the early stages, the lid
margin may appear perfectly normal until the glands are expressed#
/eibomian %lan eFpression can be performe #ith a %love fin%er presse firmly across the li mar%in
from the nasal to the central eyeli fo'r to siF times. The secretions sho'l be fairly clearK #hen the %lans
are not f'nctionin% properlyD the secretions can ran%e from milly t'rbi to frothy or soapy to #hitish-yello#
an very thickD almost the consistency of toothpasteD or even no secretions at all#
3ry Eye esting
To confirm a potential ia%nosis of ry eyeD objective clinical testin% may be helpf'l. 'ne of the more
reliable tests is tear film break-up time !081"#
To perform T5B<T testin% correctlyD #et a fl'orescein strip li%htly #ith one rop of non-preserve saline
an to'ch it to the s'perior b'lbar conj'nctiva. ;ave the patient blink several timesD close the eye f'llyD an
then open. Bhen the eye is openD observe the time reH'ire 'ntil the tear film breaks 'p. A break-up time of
Q6@ seconds is a sign of dry eye# An eFa%%erate reaction of iscomfort to the fl'orescein in the eye can
also be inicative of ry eye.
T5B<T testin% performe immeiately after contact lens removal or instillation of a topical anesthetic #ill
not be acc'rate. $eallyD T5B<T testin% sho'l be performe at least several min'tes after removin% lensesD
b't before ilation or instillation of other rops or topical anesthetic. $f the practice flo# oes not allo# for
T5B<T to be performe firstD then it sho'l be one lastD at least -) min'tes after anesthetic rops have
#orn off.
$t is also important to notice ho# the tear film breaks 'p. $f it keeps breakin% 'p in the eFact same spot on the
corneaD that can be an early inication of map-ot ystrophy in that location.
2+
Schirmers testing, %hile sometimes reEuested by a referral or for insurance coverage, has little value
in the clinical diagnosis of dry eye because repeatability, sensitivity, and specificity of Schirmers
testing are all Euite poor.
&orneal or conjunctival staining, preferably %ith lissamine green dye, is typically indicative of more
advanced dry eye that should be managed aggressively# 6ose ben%al is certainly an appropriate an
acceptable ia%nostic a%entD b't is m'ch more 'ncomfortable for patientsD #itho't any aitional benefits
over lissamine %reen. A ne% drop, 0luramene !EyeSupply", combines fluorescein and lissamine green in
a single drop for easier diagnosis#
Staining is particularly helpful in Euantifying the severity andBor progression of dry eye# AitionallyD
takin% photo%raphs of the lissamine %reen stainin% to emonstrate to the patient #hat is happenin% #ith the
eye can facilitate patient e'cation an treatment compliance.
Even #ith treatmentD T5B<T oes not al#ays improve to #hat one #o'l consier a normal baseline levelD
b't oc'lar s'rface stainin% may iminish over time as therapy re'ces the inflammation an s'rface ama%e.
A ne#D .)-min'teD in-office test for matriF-metalloproteinase A =//0-A> has j'st become available =60S
$nflamma9ry 9etectorD 60SD $nc.>. **.-G, an inflammatory cytokine, is a
marker of ocular surface inflammation that is not present in a normal eye, so this test could be Euite
useful in identifying inflammation and predicting response to anti-inflammatories#
ear hyperosmolarity is a %ell-established predictor of dry eye disease that may be useful as a
diagnostic marker# 0revio'sly only performe in research laboratoriesD osmolarity testin% may no# be
practical in the clinic #ith a ne# osmometer =Tear4ab 1smolarity SystemD Tear4ab :orporation> that
reH'ires only a tiny tear sample for testin%. $n one prospective m'lticenter st'y, it has been sho%n to have
high levels of sensitivity and specificity for dry eye.
-?
$f this proves to be tr'eD s'ch tests #o'l be a nice
complement to other tools in the ia%nostic eval'ation of ry eye.
.A$ >< *A(A4E*E( '0 3$, E,E
As isc'sse aboveD clinicians can 'se a simple contin''m to %'ie treatment ecisions in ry eye. 0atients
can be H'alitatively classifie has havin% milD moerateD or severe ry eyeD #ith or #itho't concomitant li
isease. The severity of the si%ns an symptoms sho'l %'ie ones ecisions on ho# a%%ressively to treat
the conition.
/iler cases may benefit from artificial tears an environmental moifications alone. Si%nificant corneal
breako#n an/or li irre%'larityD ho#everD #o'l inicate a more moerate to severe case that #arrants
more a%%ressive intervention.
*43
4i isease is often concomitant #ith ry eyeD an the t#o conitions may affect one anotherD so in most
cases they sho'l be treate at the same time.
A three-part re%imen of li hy%iene is essentialD an may be all that is neee in miler cases.
9ry spots seen on the corneal s'rface associate #ith a re'ce tear break-'p time.
0atients sho'l be instr'cte in proper techniH'e an the orer of the steps:
23
.. Barm compresses heat the meibomian oils an make them easier to eFpress man'ally. A cleanD #et
#ashclothD as hot as is comfortableD sho'l be applie to the close eyelis for .) to .2 min'tesD stoppin%
half#ay thro'%h to #arm the cloth a%ain. This sho'l be one t#o to three times aily at first.
-. /assa%e the lis for several min'tes.
?. 5inallyD cleanse a#ay any eFpresse ebris from the lis an lashes #ith li scr'bs. :ommercial li
scr'bs promote patient acceptance an complianceD b't il'te baby shampoo is also effective if cost is a
barrier.
!/ilkin%" the %lans #ith cotton-tip applicators rolle from the c'l-e-sac to the li mar%in or #ith a
*astrota meibomian paddle !'cuSoft" inserte behin the lo#er li can be very helpf'l in hi%hly
symptomatic patients #ith clearly obstr'cte meibomian %lans.
A ne# thermal p'lsation evice =4ipi5lo#D TearScience> esi%ne by 9onal CorbD 1.9.D a'tomates an
stanariJes both the #armin% of the meibomian oils an the li massa%e. $t heats the palpebral s'rface of
the 'pper an lo#er eyelis #hile sim'ltaneo'sly applyin% %rae p'lsatile press're to the o'ter li for .-
min'tes. he treatment has been sho%n to significantly improve meibomian gland secretions and
081 compared to standardiCed %arm compresses, and the effect on dry eye symptoms may last up
to 69 months
.-*D-2
$t is b'nle #ith an oc'lar s'rface interferometer that may also help clinicians ia%nose
/79 by objectively H'antifyin% lipi layer thickness.
-+
5or moerate to severe cases of /79D or if li hy%iene meas'res o not relieve symptomsD oral doxycycline
for t%o to three months is recommended. 9osa%e may be bet#een -) an 2) m% once or t#ice aily.
9oFycycline may be taken #itho't re%ar to meals. Altho'%h esopha%eal erosion is a potential sie effectD it
can be avoie simply by not lyin% o#n after takin% the meication. Another #ay to minimiJe 7$ an
esopha%eal problems is by takin% the pills #ith #aterD rather than aciic bevera%es.
5or patients #ho cannot 'se the tetracycline r'% class 'e to aller%yD stomach iss'esD or pre%nancyD another
treatment option is oral erythromycinD -3 altho'%h it is not as effective as the tetracyclines.
$n patients #ith blepharitisD /79 an an inflammatory ry eyeD loteprenol etabonate ).2O/ tobramycin
).?O =IyletD Ba'sch _ 4omb>D is the ieal #ay to %et the inflammatory components of both the oc'lar
s'rface an li isease 'ner control. Iylet has a lo#er risk of $10 elevation compare #ith ketone
corticosterois 'e to its rapi e-esterification to inactive metabolites. $t also lacks the ability to form Schiff
base intermeiates #ith lens proteinsD a common first step in cataracto%enesis .-8
Topical aJithromycin =AJaSiteD $nSite (ision $ncorporate/ /erck> has also been sho#n to be 'sef'l in the
treatment of li isease.-A@?. $n yo'n% chilrenD or if cost is a barrierD bacitracin or 0olysporin ointment at
betime may be consiere.
1n%oin% 'se of #arm compresses an appropriate artificial tears over the lon% term #ill be necessary. Any
time there is meibomian %lan involvement or ysf'nctionD one can eFpect to see a ecrease lipi layer that
benefits from replacement #ith a lipi-enhancin% artificial tear s'ch as Soothe W0 =Ba'sch _ 4omb> or
Systane Balance =Alcon>.?-
3ry Eye
Z Artificial tears. Artificial tears remain the first line of efense a%ainst ry eye. The H'ality of
artificial tear pro'cts has improve markely in recent yearsD to the point that most clinicians no#
specifically recommen lipi-base or other avance tear technolo%ies for their patientsD rather than j'st
hanin% the patient a selection of tear samples.
According to 0oulks, there is a strong correlation among dry eye symptoms, tear film osmolarity, and
the state of the lipid layer of the tear film .?? The active in%reient in Soothe W0 has been sho#n to more
than o'ble lipi layer thicknessD helpin% to stabiliJe both the lipi an aH'eo's layers of the tear filmD as
#ell as the interface bet#een those t#o layers.?-D?*
A typical re%imen for mil ry eye sho'l be%in #ith artificial tears H.i.. Soothe W0D an ineeD most
artificial tearsD can be 'se as neee 'rin% contact lens #earD espite the labels ca'tionin% a%ainst 'se #ith
contact lenses. <se of these rops #ith contact lenses has not been eval'ate in clinical trialsD b't in o'r
28
eFperienceD they are not etrimental to the lenses an are eFcellent re#ettin% rops. $n factD an artificial tear
#ill be m'ch more effective than contact lens re-#ettin% rops in relievin% symptoms.
;avin% a !tear of choice" simplifies ones approach to ry eyeD b't it is al#ays necessary to have
alternativesD as every patient is ifferent. Tears #ith milD transient preservatives are ieal for most ry eye
patients beca'se they are convenientD yet still nontoFic to the oc'lar s'rface. $n more severe cases #ith oc'lar
s'rface breako#nD one sho'l certainly avoi toFic preservativesD an consier s#itchin% to non-preserve
tears.
,i%httime ointments are helpf'l for those #ith la%ophthalmos or incomplete li clos'reD as #ell as those #ith
very avance ry eye.
4acrisert =Aton 0harmaD $nc.> is another effective therapy for avance cases. This slo#-release artificial tear
is a ry pellet of hyroFypropyl cell'lose. $t is esi%ne to be place eep in the c'l-e-sacD #here it imbibes
resi'al fl'i an then releases the polymer over -* ho'rs. /ost pharmacists are 'nfamiliar #ith this
pro'ctD so it is best to obtain samples from the man'fact'rer an teach the patient in the office ho# to insert
it.
Even high-Euality and long-lasting tears have a primarily palliative effect and do not address the
underlying inflammation# $f patients start o't #ith more avance isease or contin'e to be symptomatic
after a month of artificial tear 'seD one sho'l move to more tar%ete anti-inflammatory therapy.
Z Anti*inflammatory therapy. $n recent yearsD the parai%m shift in ry eye treatment has been to#ar earlier
an more a%%ressive mana%ement of ry eye inflammation. The inflammatory component of ry eye may be
treate #ith topical anti-inflammatory rops.
?2
&orticosteroids are the only therapeutic class that Euickly
and thoroughly suppresses ocular surface inflammation#
St'ies have sho#n that the 'se of the topical ester steroiD loteprenol etabonate ).2O =4otemaFD Ba'sch _
4omb>D may be beneficial in patients #ho have ry eye #ith at least a moerate inflammatory component.
?+

9ose H.i.. for t#o to fo'r #eeksD then b.i.. for another fo'r to siF #eeksD alon% #ith tearsD loteprenol
aresses inflammation immeiately to provie rapi relief of symptoms.
$n factD any topical corticosteroi can be effective in treatin% ry eyeD b't there are si%nificant ifferences in
the safety profiles of ifferent steroi classes. Bith lon%term 'se of fo'r #eeks or lon%erD loteprenol has far
less propensity to ca'se clinically si%nificant elevation of $10 than most ketone steroisD s'ch as
prenisolone an eFamethasone. $n terms of safetyD loteprenol is essentially comparable to
vehicle/placebo.
?3
/any %la'coma patients have concomitant ry eyeD attrib'table to a%e an the 'se of topical preserve
meicationsD an these patients are more likely to be steroi responers. As a preca'tionD one sho'l #atch
$10 caref'lly in %la'coma/ry eye patientsD especially 'rin% the first fe# #eeks.
B't even in kno#n steroi responersD the $10 response to loteprenol etabonate ).2O is neither clinically
nor statistically si%nificant.
?8
AitionallyD there have been no cases of cataract in patients 'sin% this
meication reporte in the literat're. he safety of loteprednol makes it much easier to consider long-
term corticosteroid therapy for patients suffering from chronic dry eye# Even in the mil to moerate
ry eyeD if the patient is symptomatic eno'%h to have mae an appointmentD a short co'rse of topical steroi
therapy for fo'r to ei%ht #eeks can %reatly re'ce the symptoms.
Altho'%h it is preferre to avoi 'sin% corticosterois #hile #earin% contact lensesD st'ies have sho#n that
contact lens #earers can safely 'se topical sterois even #hile #earin% their contact lenses. $n st'ies of
treatment for %iant papillary conj'nctivitis =70:>D one st'y protocol calle for H.i.. loteprenol instillation
on top of the contact lensesD for fo'r #eeks. $n this st'y of ..) patientsD there #ere no infections or corneal
complications 'sin% this protocol .
?A
;o#everD one mi%ht #ant to #atch $10 a bit more closely beca'se the
contact lens co'l act as a steroi epot.
AlternativelyD steroi rops can be instille abo't .) min'tes before p'ttin% contact lenses on in the mornin%
an a%ain in the evenin% after lens removal. 9aily isposable or at least more freH'ent replacement lenses
an/or re'ce #ear time can also alleviate ry eye symptoms.
2A
:yclosporine ophthalmic em'lsion ).)2O =6estasisD Aller%an> may be consiere in the treatment of ry eye
as #ellD epenin% on severity an clinician preferences. 6estasis inhibits activation of inflammatory T-
lymphocytes an in'ces imm'ne cell apoptosisD stim'latin% lacrimal %lan tear pro'ction.*)D*. $t has also
been sho#n to re'ce the levels of interle'kin-+D an inflammatory cytokineD in moerate to severe ry eye
patients treate for siF months.*- $n pivotal clinical trialsD 2AO of patients achieve improvement from
baseline Schirmer scores at siF months. *? :ompare to vehicleD the cyclosporine eye rops also
si%nificantly re'ce epenence on artificial tears at siF months. 0atients typically have a b'rnin% sensation
'rin% the first fe# #eeks #hen p'ttin% cyclosporine rops on an inflame eye. 5or this reasonD many
clinicians prefer to 'se it in conj'nction #ith loteprenol etabonateD #hich can achieve more immeiate
inflammatory relief an re'ce the b'rnin% sensation.**
1n an on%oin% basisD an artificial tear that preserves and protects the tear film can protect against re-
initiation of the inflammatory process# Short p'lsin% =t#ice aily for a fe# ays to a #eek> #ith
corticosterois can aress any inflammatory breakthro'%h to keep symptoms f'lly 'ner control. 1ther
effective lon%term meications incl'e cyclosporine AD #hich has been st'ie o't to three years of 'seD an
n'tritional s'pplements.*2
Z Nutritional supplements. The Bomens ;ealth St'y s'%%ests that increase ietary intake of fish oils may
re'ce ry eyeD *+ #hile other st'ies have s'%%este that n'tritional s'pplementation #ith essential ome%a-
? fatty acis is helpf'l. *3 1me%a-? an ome%a-+ fatty acisD from fishD flaFseeD or other so'rces are %oo
for the hairD skinD heartD an %eneral h'man healthD so takin% a s'pplement or increasin% fish cons'mption is a
positive step that patients can take that #ill complement any systemic or topical therapies for ry eye. This
can be recommene very early in the isease co'rseD for mil ry eye an thro'%ho't the entire contin''m
of the isease.
There is no consens's on the best form of fatty acis. The typical recommene s'pplement ose is -)))
m%/ay. ;i%her-H'ality s'pplements may be p'rerD #ith less chance of sie effectsD b't there is no stron%
evience favorin% one partic'lar form'lation over any other. $n factD the lo#est cost form may be better than
not takin% the s'pplements at all.
Z Punctal occlusion. $n the pastD p'nctal pl'%s #ere typically 'se immeiately if artificial tears faile
to resolve symptoms. $n recent yearsD they have move o#n on the therapy laer an may act'ally be
'ner'tiliJe c'rrently.
.unctal occlusion can be very effective, provided that any ocular surface inflammation is suppressed
first.*8D*A There are also still some circ'mstances #here pl'%s are the best first-line option for the treatment
of ry eye. 0'nctal occl'sion is one of the fe# ry eye interventions #e have that is not epenent on patient
complianceD an pl'%s may re'ce epenency on topical therapy. 6ecent st'ies have sho#n that even
#hen the pl'% is spontaneo'sly lostD it ca'ses some canalic'lar stenosis that contin'es to be mechanically
therape'tic for several years.2)
$f the patient remains symptomatic after an initial co'rse of topical anti-inflammatory meicationsD one
sho'l consier p'nctal occl'sion. 0ractitioners typically pl'% both lo#er p'ncta #ith silicone pl'%s. 1ther
approaches incl'e pl'%%in% the lo#er p'nct'm on the more symptomatic eye an eterminin% the
effectiveness at a one-month follo#-'p visitK or insertin% re%'lar silicone pl'%s in both lo#er p'nctaD alon%
#ith flo#-controller pl'%s in the 'pper p'nctaD in a step-#ise manner.
Temporary occl'sion #ith issolvable colla%en pl'%s may be an option for the clinician 'ns're of their
effectiveness or #hen consierin% a%%ressive occl'sion of all fo'r p'ncta. Some have fo'n siF-month
colla%en pl'%s to be partic'larly helpf'l post-4AS$C.
$ntracanalic'lar pl'%s are not recommene. These have been associate #ith rareD b't serio's
complicationsD incl'in% canalic'litis an the potential nee for s'r%ical removal.2.@2?
Z Antibiotic therapy. 1ral oFycycline is appropriate for /79D as isc'sse previo'slyD an for ry
eye in a patient #ith rosacea. 1ther#iseD oc'lar s'rface symptoms are better controlle #ith topical
therapies.
.atients %ith blepharitis have in the past been treated %ith antibiotic ointments %ithout great efficacy#
Typically these eyes have ecrease T5B<T an ecrease inferior lacrimal lake vol'meD an they 's'ally
+)
lack s'fficient tears to #ash a#ay the ointmentD so the patient ens 'p #ith chronically bl'rre vision. A
combination antibiotic-steroi eye ropD s'ch as IyletD or an antibioticD s'ch as AJaSiteD may be more
appropriate.
Z 1ther consierations. 1ral pilocarpine =Sala%enD /7$ 0harmaD $nc.>D 's'ally ose 2 m% t.i.. or
H.i.. may be effective for some patients. Sie effects s'ch as scalp s#eats have been reporte at hi%her
oses. A better alternative #ith fe#er sie effects for patients #ith ry eye =or ry mo'th> is oral cevimeline
=EvoFacD 9aiichi SankyoD $nc.> ?) m% t.i..2*
A'tolo%o's ser'm eye rops have been sho#n to have some benefits. 22 The patients response may be
relate to the e%ree of inflammation present in the bloo #hen it is ra#n. There is a risk of infectionD so
a'tolo%o's ser'm is rarely 'se eFcept as a last resort for eFtremely symptomatic patients .2+ A lo#er-risk
alternative may be rops containin% 2O alb'minD the key protein in ser'm.
5or the most severe casesD one mi%ht also consier ?O testosterone cream that can be mae 'p in the
pharmacy an applie to the 'pper lis t#ice aily. There is some rationale for estro%en or anro%en-base
eye rops an even for topical ome%a-? an ome%a-+ fatty aci rops. 23D28
&onclusions
/ana%ement m'st be%in #ith environmental moifications an hi%h-H'ality artificial tears. Aitional
therapies m'st aress the inflammation responsible for symptoms.
Be propose a treatment parai%m that incorporates artificial tearsD topical anti-inflammatory meications
s'ch as corticosterois an/or cyclosporineD p'nctal occl'sion an n'tritional s'pplementationD base on the
severity of si%ns an symptoms.
$n s'mmaryD ry eye is a compleF conition that is typically inflammatory in nat're an may also involve
concomitant li or skin iseaseD aller%yD or other systemic or oc'lar s'rface conitions.
7iven that symptoms o not al#ays correlate #ith clinical si%nsD clinicians m'st 'se the severity of patient
symptomsD alon% #ith a thoro'%h history an eFamD to ia%nose ry eye an %'ie treatment ecisions.
0roactive treatment of ry eye can si%nificantly improve visionD H'ality of lifeD an s'r%ical o'tcomesD an
represents a si%nificant opport'nity for increasin% patient loyalty an practice reven'es
$eferences
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-. -))3 6eport of the $nternational 9ry Eye BorkShop =9EBS>. The 1c'lar S'rface -))3K2=->.
?. Scha'mber% 9AD S'llivan 9AD B'rin% RED 9ana /6. 0revalence of ry eye synrome amon% <.S.
#omen. Am R 1phthalmol -))?K.?+=->:?.8--+.
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+. Stern /ED Be'erman 6BD 5oF 6$D et al. A 'nifie theory of the role of the oc'lar s'rface in ry eye.
Av EFp /e Biol .AA8K*?8:+*?-+2..
3. Ba'o'in :. The patholo%y of ry eye. S'rv 1phthalmol -)).K*2 S'ppl -KS-..---).
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A. 5oF 6$. Systemic iseases associate #ith ry eye. $nt 1phthalmol :lin .AA*K ?*:3.-83.
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inflammation in ry eye patients an Sjo%rens synrome-like /64/lpr mice. EFp Eye 6es
-))*K38=*>:8-?-8?2.
.?. Stern /ED 7ao RD Siemasko C5D et al. The role of the lacrimal f'nctional 'nit in the pathophysiolo%y
of ry eye. EFp Eye 6es -))*K38=?>:*)A-*.+.
.*. Stern /ED Be'erman 6BD 5oF 6$D et al. The patholo%y of ry eye: The interaction bet#een the
oc'lar s'rface an lacrimal %lans. :ornea .AA8K.3=+>:28*-28A.
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year revie#. :ornea -)))K.A=2>:+**-+*A.
.+. Schiffman 6/D Balt R7D Racobsen 7D et al. <tility assessment amon% patients #ith ry eye isease.
1phthalmolo%y -))? R'lK..)=3>:.*.--.*.A.
.3. B'chholJ 0D Stees :SD Stern 4SD et al. <tility assessment to meas're the impact of ry eye isease.
1c'l S'rf -))+ R'lK*=?>:.22-.+..
.8. Be%ley :7D :halmers 64D AlbetJ 4D et al. The relationship bet#een habit'al patient-reporte
symptoms an clinical si%ns amon% patients #ith ry eye of varyin% severity. $nvest 1phthalmol (is
Sci -))?K**=..>:*32?-*3+..
.A. 1ltJ /D :heck R. 6osacea an its oc'lar manifestations. 1ptometry. -)..K8-:A-@.)?.
-). Caiserman $D Caiserman ,D ,akar SD (inker S. 9ry eye in iabetic patients. Am R 1phthalmol
-))2K.?A=?>:*A8-2)?.
-.. ;arrison BD 0ence ,D Covacich S. Anterior se%ment complications seconary to contin'o's positive
air#ay press're machine treatment in patients #ith obstr'ctive sleep apnea. 1ptometry.
-))3K38=3>:?2-@?22.
--. EkstrTm Smeby CD (ajic :/D 5alster /D et al. A'toimm'ne isorers an risk of non-;o%kin
lymphoma s'btypes: a poole analysis #ithin the $nter4ymph :onsorti'm Bloo. -))8 Apr
.2K...=8>:*)-A-*)?8.
-?. 4emp /AD Bron ARD Ba'o'in :D et al. Tear osmolarity in the ia%nosis an mana%ement of ry eye
isease. Am R 1phthalmol -)..K.2.:3A-@8.
-*. 5rielan B6D 5lemin% :0D Blackie :AD Corb 96. A novel thermoynamic treatment for meibomian
%lan ysf'nction. :'rr Eye 6es. -)..K?+:3A@83.
-2. 7reiner R(. Effect of a sin%le thermal p'lsation treatment on clinical si%ns an symptoms of
meibomian %lan ysf'nction an ry eye over .- months. 0aper presentationD -).. American
Society of :ataract an 6efractive S'r%eryD San 9ie%oD :alif.
-+. ;amilton 96. A novelD H'antitative metho for eval'atin% lipi layer thickness. 0aper presentationD
-).. American Society of :ataract an 6efractive S'r%eryD San 9ie%oD :alif.
-3. ;ammersmith C/D :ohen ERD Blake T9D et al. Blepharoconj'nctivitis in chilren. Arch 1phthalmol
-))2K.-?=.->:.++3-.+3).
-8. :omstock T4D ;ollan ER. 4oteprenol an tobramycin in combination: a revie# of their impact on
c'rrent treatment re%imens. EFpert 1pin 0harmacother -).)K ..=2>:8*?-2-.
-A. 4'chs R. Efficacy of topical aJithromycin ophthalmic sol'tion .O in the treatment of posterior
blepharitis. Av Ther -))8K-2=A>:828-83).
?). 5o'lks 7,D Borchman 9D &appert /D et al. Topical aJithromycin therapy for meibomian %lan
ysf'nction: clinical response an lipi alterations. :ornea. -).)K-A=3>:38.@8.
+-
?.. ;aH'e 6/D Torkilsen 74D Br'baker CD et al. /'lticenter open-label st'y eval'atin% the efficacy
of aJithromycin ophthalmic sol'tion .O on the si%ns an symptoms of s'bjects #ith blepharitis.
:ornea. -).)K-A=8>:83.@3.
?-. Corb 96D Scaffii 6:D 7reiner R(D et al. The effect of t#o novel l'bricant eye rops on tear film
lipi layer thickness in s'bjects #ith ry eye symptoms. 1ptom (isSci -))2K8-=3>:2A*-+)..
??. 5o'lks 7,. The correlation bet#een the tear film lipi layer an ry eye isease. S'rv 1phthalmol
-))3K2-=*>:?+A-?3*.
?*. Scaffii 6:D Corb 96. :omparison of the efficacy of t#o lipi em'lsion eye rops in increasin% tear
film lipi layer thickness. Eye :ontact 4ens -))3K??=.>:?8-**.
?2. 0fl'%feler S:. Anti-inflammatory therapy for ry eye. Am R 1phthalmol -))*K.?3=->:??3-?*-.
?+. 0fl'%feler S:D /askin S4D Anerson BD et al. A ranomiJeD o'ble-maskeD placebo-controlleD
m'lticenter comparison of loteprenol etabonate ophthalmic s'spensionD ).2OD an placebo for
treatment of keratoconj'nctivitis sicca in patients #ith elaye tear clearance. Am R 1phthalmol
-))*K.?8=?>:***-*23.
?3. ,ovack 79D ;o#es RD :rockett 6SD Sher#oo /B. :han%e in intraoc'lar press're 'rin% lon%-term
'se of loteprenol etabonate. R 7la'coma .AA8K3:-++--+A.
?8. Bartlett R9D ;or#itJ BD 4aibovitJ 6D ;o#es R5. $ntraoc'lar press're response to loteprenol
etabonate in kno#n steroi responers. R 1c'l 0harmacol .AA?KA:.23-.+2.
?A. Bartlett R9D ;o#es R5D 7hormley ,6D et al. Safety an efficacy of loteprenol etabonate for
treatment of papillae in contact lens-associate %iant papillary conj'nctivitis. :'rr Eye 6es .AA?K .-:
?.?-?-..
*). C'nert CSD Tisale ASD Stern /ED et al. Analysis of topical cyclosporine treatment of patients #ith
ry eye synrome: effect on conj'nctival lymphocytes. Arch 1phthalmol -)))K..8=..>:.*8A-.*A+.
*.. Stern /ED 7ao RD Sch#alb TAD et al. :onj'nctival T-cell s'bpop'lations in Sjo%rens an non-
Sjo%rens patients #ith ry eye. $nvest 1phthalmol (is Sci. -))-K*?=8>:-+)A--+.*.
*-. T'rner CD 0fl'%feler S:D Ri ID et al. $nterle'kin-+ levels in the conj'nctival epitheli'm of patients
#ith ry eye isease treate #ith cyclosporine ophthalmic em'lsion. :ornea -)))K.A=*>:*A--*A+.
*?. Sall CD Stevenson 19D /'norf TCD 6eis B4. T#o m'lticenterD ranomiJe st'ies of the efficacy
an safety of cyclosporine ophthalmic em'lsion in moerate to severe ry eye isease.
1phthalmolo%y -)))K.)3=*>:+?.- +?A.
**. Sheppar R9D Scoper S(D Sam're S. Topical loteprenol pretreatment re'ces cyclosporine stin%in%
in chronic ry eye isease. R 1c'l 0harmacol Ther. -)..K-3=.>:-?@3.
*2. Barber 49D 0fl'%feler S:D Ta'ber RD 5o'lks 7,. 0hase $$$ safety eval'ation of cyclosporine )..O
ophthalmic em'lsion aministere t#ice aily to ry eye isease patients for 'p to ? years.
1phthalmolo%y -))2K..-=.)>:.3A)-.3A*.
*+. /iljanovi` BD Trivei CAD 9ana /6D et al. 6elation bet#een ietary n-? an n-+ fatty acis an
clinically ia%nose ry eye synrome in #omen. Am R :lin ,'tr -))2K8-=*>:883-8A?.
*3. :akiner-E%ilmeJ T. 1me%a ? fatty acis an the eye. $nsi%ht. -))8K??=*>:-)--2.
*8. Tai /:D :osar :BD :ohen ERD et al. The clinical efficacy of silicone p'nctal pl'% therapy. :ornea
-))-K-.=->:.?2-.?A.
*A. BaFter SAD 4aibson 06. 0'nctal pl'%s in the mana%ement of ry eyes. 1c'l S'rf -))*K-=*>:-22--+2.
2). Bolin $D Clein AD ;aller-Schober E/D ;or#athBinter R. 4on%-term follo#-'p of p'nctal an
proFimal canalic'lar stenoses after silicone p'nctal pl'% treatment in ry eye patients. Am R
1phthalmol -))8K.*+=+>:A+8-A3-.
+?
2.. 5o#ler A/D 9'tton RRD 5o#ler B:D 7illi%an 0. /ycobacteri'm chelonae canalic'litis associate
#ith Smart0l'% 'se. 1phthal 0last 6econstr S'r% -))8K-*=?>:-*.--*?.
2-. /aJo# /4D /c:all TD 0ra%er T:. 4o%e intracanalic'lar pl'%s as a ca'se of lacrimal obstr'ction.
1phthal 0last 6econstr S'r% -))3K-?=->:.?8-.*-
2?. 4ee RD 5lana%an R:. :omplications associate #ith intracanalic'lar pl'%s. 1phthal 0last 6econstr
S'r% -)).K.3=+>:*+2-*+A.
2*. 1no /D Takam'ra ED ShinoJaki CD et al. Therape'tic effect of cevimeline on ry eye in patients #ith
Sjo%rens synrome: a ranomiJeD o'ble-blin clinical st'y. Am R 1phthalmol -))*K.?8=.>:+-.3.
22. Cojima TD ;i%'chi AD 7oto ED et al. A'tolo%o's ser'm eye rops for the treatment of ry eye
iseases. :ornea -))8K-3 S'ppl . :S-2-?).
2+. Beisbach (D 9ietrich TD Cr'se 5ED et al. ;$( an hepatitis B/: infections in patients onatin% bloo
for 'se as a'tolo%o's ser'm eye rops. Br R 1phthalmol -))3KA.=.->:.3-*-.3-2.
23. (ers'ra 0D :ampos E:. /enopa'se an ry eye. A possible relationship. 7ynecol Enocrinol
-))2K-)=2>:-8A--A8.
28. 6ashi SD Rin &D Ecoiffier TD et al. Topical ome%a-? an ome%a-+ fatty acis for treatment of ry eye.
Arch 1phthalmol -))8K.-+=->:-.A---2.
+*
4etting to the $oot of .atientsR 3ry Eye
)o% to use signs, symptoms and tests to diagnose the cause of a case of dry eye#
+alter Bethke" ,anaging $ditor
--./.01--
Symptomatic complaints associate #ith ry eye can be ca'se by a n'mber of thin%sD from somethin% as
compleF as a systemic isease to somethin% as
simple as starin% at the comp'ter too lon%.
Beca'se of the variety of ca'sesD %ettin% to the
bottom of a patients complaints isnt al#ays
easy. ;o#everD #ith a systematic approach an
an eye for certain telltale si%nsD physicians say
yo' can fi%'re it o't. $n this articleD several
oc'lar-s'rface isease eFperts share their tips
on s'ssin% o't the ca'se of a patients ry eye.
;hat the .atient Says
0hysicians say that tho'%h symptoms ont tell
yo' everythin% yo' nee to kno# abo't a
patients conitionD theyre important beca'se
symptoms are #hat bro'%ht the patient in to see
yo' in the first place. 1phthalmolo%ists say a
%oo history #ill also help to shape yo'r ia%nosis.
!7et a history of patients symptoms an elve into other thin%sD s'ch as elements of their environment that
mi%ht be ca'sin% their symptomsD" says R. 9aniel ,elsonD /9D a professor of ophthalmolo%y at the
<niversity of /innesota /eical School. !Bhat #ork o they oQ 9o they have any pets at homeQ 9o they
en%a%e in any hobbies that involve chemicalsD s'ch as paintin%Q 9o they have aller%ies that mi%ht ca'se the
symptomsQ /aybe they have a contact sensitivity to make'pD or theyre p'ttin% on their make'p too close to
their eyes. $s there maybe a sensitivity to somethin% in their ietQ Bhat topical rops are they 'sin% an #hat
preservatives mi%ht those containQ 5or all of these reasonsD its important not to j'mp ri%ht into the eFam.
5or someone #ith aller%iesD for eFampleD relief may be as simple as #ashin% his face an hans #hen he
comes in from the #in an the 'st o'tsie.
!AlsoD tho'%h this is a simplistic #ay of lookin% at itD $ listen to ho# they characteriJe their symptomsD" as
9r. ,elson. !$f they have an irritation of the oc'lar s'rfaceD theyll complain of a b'rnin% like yo' feel
from soap or shampooD irritation like feelin% san or %ravelD or itchin% like from a mosH'ito bite. $f $ ont
hear any of these types of symptom escriptionsD for me that p'ts the patient in a separateD non-oc'lar-
s'rface cate%ory of isease." ;e says also to look for 'ncorrecte hyperopia or presbyopia in patients #ho
have symptoms of irritation b't no obvio's si%ns: !Bith 'ncorrecte hyperopia or presbyopiaD as patients a%e
they have to foc's so m'ch it can ca'se a ecrease blink rate an eye fati%'e that mimic ry-eye
symptoms."
0hysicians also make it a point to look for histories of iseasesD both systemic an ophthalmicD that incl'e
ry eye as a si%n an/or symptom. !Ask abo't iseases s'ch as SjT%rensD iabetesD thyroiD a'toimm'ne
isorersD li iseases or rosaceaD" says 1tta#as Br'ce RacksonD /9. !Those are key thin%s yo' #ant to
make s're yo' look for."
9r. ,elson offers some tips for tryin% to #ee o't systemic illnesses. !0atients #ith primary SjT%rens
synrome #ill often sho# 'p in the ophthalmolo%ists office firstD" he saysD !#hile patients #ith rhe'matoi
arthritis or l'p's #ill often present in the rhe'matolo%ists office first. SoD if someone comes from the
rhe'matolo%ists office #ith complaints of ry eye an he has been ia%nose #ith systemic iseaseD yo'r
s'spicion of the systemic illness as the ca'se sho'l rise. To meD epenin% on the classification system yo'
<sef'l V'estions for 9ry-Eye S'spects
;ave yo' eFperience any of the follo#in% symptoms
'rin% the last #eekQ
Sensitivity to li%ht
7ritty or scratchin% sensation
B'rnin% or stin%in%
(ision that improves #ith artificial tears
;ave yo' eFperience eye irritation #hile performin% any of
these activitiesQ
6eain% or rivin% a car for lon% periosD 'rin% the
last #eek
Batchin% T(/#orkin% on a comp'ter for an
eFtene perioD 'rin% the last #eek
=5reH'ency is %rae as none of the timeD some of the timeD half of the timeD most of the timeD or all of
the time.>.
+2
'seD yo' nee evience of an a'toimm'ne isease from bloo testin% Lisc'sse belo#M." 0hysicians say to
s'spect SjT%rens if yo' elicit complaints of ry mo'th an/or va%inal ryness.
:ertain meicationsD iscovere in the patients historyD can also contrib'te to ry eyeD say physicians.
!Antihistamines are a common contrib'torD" says 4o'isvilleD Cy.D ophthalmolo%ist 7ary 5o'lks. !AlsoD
anFiolyticsD often taken at ni%htD an other tranH'iliJers can ecrease tear pro'ction. $f yo' fin the ca'se of
the ry eye is a meicationD talk to the patients primary-care octor an let him kno# that the ry eye isEat
the very leastEbein% a%%ravate by the meicationD an inH'ire abo't the possibility of 'sin% alternative
r'%s. AnFiolytics are 's'ally 'se by a psychiatrist or %eriatricianD an he can 's'ally recommen
somethin% that oesnt have s'ch an anti-choliner%ic effect. 1ral Ac'tane has also been associate #ith
meibomian %lan ysf'nction an ry-eye problems. $f a patient has a history of m'cosal inflammatory
isease s'ch as cicatricial pemphi%oi or a reaction to a r'% s'ch as ac'te toFic epiermal necrolysisD these
are severe problems that can be a systemic basis for ry-eye isease."
9r. ,elson says its also important to fin o't #hat the patient has been 'sin% for treatment of his ry eyes
an #hether its #orkin% or not. !$f he tr'ly has oc'lar s'rface isease an ry eyeD artificial tears sho'l
helpD" he says. !/f the artificial tears arent helping, then something else is going on# ,ou have to ask
yourself< /s it really dry eyeD"
!A n'mber of other thin%s can come into playD" as /ichael 4empD /9D a clinical professor of
ophthalmolo%y at 7eor%eto#n <niversity. !These incl'e #earin% contact lenses. :ontact lens #ear can be a
problem if the patient has borerline tear pro'ction. The contact lens stresses the system an ca'ses
evaporative tear lossD p'shin% the person into bein% symptomatic. There are also iatro%enic ca'ses like
refractive s'r%eryD #hich can sever the corneal nerves." ;e says %raft vs. host isease m'st also be r'le o't
in transplant patients.
1ne thin% that 9r. Rackson says has really helpe his ia%nostic process is a moifie H'estionnaire he
evelopeD the :anaian 9ry Eye AssessmentD #hich is basically a conense version of the the pop'lar
1c'lar S'rface 9isease $neF H'estionnaire. The b'lk of it consists of H'estions abo't the freH'ency of
partic'lar symptoms or the circ'mstances 'rin% #hich the symptoms 's'ally occ'r. 4For a list of several of
t-e #EA 'uestions, refer to @9seful Auestions for #ry$Eye ,uspectsB on p. .8.5
!<sin% the H'estionnaire is somethin% #e hant one in the pastD" says 9r. Rackson. !Back thenD #e #o'l
's'ally j'st listen to the patient talk abo't his b'rnin%D irritate eyes. ;o#everD #eve fo'n that yo' have to
be able to H'antify their s'bjective complaints beca'se other#ise patients #ill %o on an on. $ think the
patient H'estionnaire has mae a ifference at o'r practice."
;hat the .hysician 0inds
Tho'%h symptoms brin% the patient to yo'r officeD the si%ns of isease #ill be the most helpf'l in makin% a
ia%nosis an %a'%in% the severity of the ry eyeD ophthalmolo%ists say. 5ollo#in% is a isc'ssion of key
si%ns an #hat they mi%ht meanD as #ell as ho# to employ certain tests.

C Facial and lid exam. 0hysicians say its helpf'l to look for %eneral si%ns of rosacea before yo' %et closer to
the eye #ith the slit-lamp eFam. !Assess the blink rate an the li clos'reD" says 9r. Rackson. !$f theres any
abnormality of the lisD yo' m'st treat that. &o'
#ont be s'ccessf'l in treatin% ry eye 'ntil yo'
foc's on that."
At the slit lampD the clinician can thoro'%hly
eFamine the li mar%in for evience of meibomian
%lan ysf'nction# *43 is a major contributor
to dry eyeD specifically in its ability to initiate an
evaporative ry-eye processD as oppose to the
other major ca'se of ry eye: eficiency in aH'eo's
pro'ction. The main feat'res physicians look for
The appearance of obstr'ctive meibomian %lan ysf'nction: po'tin% of orificeK loss of efinition
of c'ssK an pl'%%in%.?

4?mage courtesy Dary Foul2s, M#/T-e %cular ,urface5
++
in eterminin% /79 are obstr'ction of the meibomian %lans an/or chan%es in the H'ality an amo'nt of
meib'm eFpresse from them. $n the eFamD eFperts say to first try to eFpress fl'i from the %lans. $n some
cases of severe /79D no %lans #ill be eFpressable 'e to hyperkeratiniJation. $f some of the %lans are
eFpressableD the $nternational Borkshop on /eibomian 7lan 9ysf'nction p'blishe a report in /arch of
-).. that provie a system for ratin% the H'ality of the secretion in orer of increasin% /79 severity:
clear meib'mK
clo'y meib'mK
clo'y #ith ebris =%ran'lar>K or
thickD like toothpaste.
-
9r. 5o'lks hi%hli%hts other li feat'res to eFamine. !4ook for any erythema of the li mar%inD" he says. !The
presence of abnormal telan%iectatic vessels can inicate chronicity. AlsoD look for evience of p'ckerin% of
the meibomian %lan orifice or even notchin% of the liD #hich are other hallmarks of a chronic case of
meibomian %lan ysf'nction. $n terms of systemic isease associate #ith meibomian %lan ysf'nction
an evaporative ry eyeD the more common presentation is a rosacea patient #ho presents #ith a rosy
compleFion an prominent sebaceo's %lans an telan%iectasia of the skin."
9r. 5o'lks says blepharitis is separate from /79. !0osterior blepharitis implies inflammationD an it can be
a component of meibomian %lan ysf'nctionD" he says. !B't theyre separate iss'es. SoD meibomian %lan
ysf'nction can occ'r even #hen there isnt a lot of inflammationD an posterior blepharitis is inflammation
that sometimes occ'rs as a component of meibomian %lan ysf'nction."
9r. 4emp says thatD tho'%h /79 is a freH'ent ca'se of evaporative ry eyeD its not the only ca'se. !&o'
have to r'le o't li problems like improper blinkin%D #hich can occ'r in patients #ith thyroi eye isease in
#hom the palpebral fiss're is very #ieD" he says. !$n themD the s'rface is more eFpose an theres more
evaporative tear loss. 1ne thin% #eve fo'n is that people %ho use computers more than three hours per
day %ill have a decreased blink rate from staring at the screen, and %ill freEuently report symptoms of
dry eye# They may even have evience of meibomian %lan ysf'nction beca'se the muscles of the lids
actually pump the oil glands, but %hen theyre not used as freEuently they get lax and arent as
effective at pumping out the oil#N
9r. 4emp says the key to keep in min #hen eval'atin% a patient an event'ally evelopin% a treatment plan
is that the -))3 9ry Eye Borkshop reporte aH'eo's eficiency an evaporative ry eye as the t#o major
s'b-types of the isease. !$n oneD aH'eo's eficiencyD the lacrimal %lan oesnt perform #ellD an in the
otherD evaporative lossD the meibomian %lan 's'ally isnt performin% #ellD" 9r. 4emp says. 1ne caveat
tho'%hD say physiciansD is that it can be iffic'lt to say efinitively that a patient has only evaporative or
aH'eo's-eficient ry eye beca'se the t#o forms often co-eFistD especially in severe cases.
C orneal and con3unctival exam. !The other conition to look for is conj'nctival chalasisD" says 9r. 5o'lks.
!;ereD the symptoms the patient complains of #ill be
a bit ifferent from ry eye. ;ell complain of painD
an si%nificant forei%n boy sensation or of #atery
eyesD even tho'%h his eye is ry. This is beca'se
#hen anythin% rests on the lo#er liD as the
conj'nctiva may be oin% in this caseD it #ill %ive the
feelin% of #ater in the eye." 0hysicians say keratitis
also may be present.
C Tear 'ualities and sta!ility. 9r. 5o'lks %ives a lot of
#ei%ht to tear stability. !Tear stability or lack thereof
is one of the hallmark feat'res of both evaporative
an aH'eo's-eficient ry eyeD" he says. !A tear-film
break'p time of less than .) secons is a si%n of tear
instability. This tells yo' theres a problem #ith tear
f'nction b't oesnt tell yo' #hat the 'nerlyin%

At the #orst en of the meibomian eFpression spectr'mD the secretion comes o't thickD like a
paste.?
4?mage courtesy Dary Foul2s, M#/T-e %cular ,urface5
+3
ca'se is. ;o#everD it can be important for establishin% the level of severity of the ry eyeD beca'se the
recommene treatment al%orithms are base on the level of severity.
!The other step yo' can take #hen tryin% to etermine if theres a eficiency in aH'eo's pro'ction is look at
the tear menisc's at the slit lampD" 9r. 5o'lks as. !TypicallyD in an aH'eo's eficiency caseD there #ill be a
re'ction in tear menisc's hei%htD 's'ally at the inferior li mar%in. $n evaporative ry eyeD ho#everD thats
not al#ays soD since the tear vol'me #ill be s'fficient 'e to the refleF tearin% maintainin% it. SoD if yo' %et a
si%nificant loss of tear menisc'sD thats a %oo inicator yo're ealin% #ith aH'eo's-eficient ry eye."
AlsoD ebris in the tear menisc's can also point to aH'eo's eficiencyD says 9r. Rackson. !1r there may be a
soapy appearance inicative of meibomian %lan ysf'nction."
0hysicians say Schirmers testin%D aime at eterminin% the rate that the eye can pro'ce tearsD can help
contrib'te to yo'r ia%nosisD b't that it has limitations. !Be try to stay a#ay from relyin% on Schirmers test
res'lts eFcept on the severe level of ry-eye iseaseD" says 9r. Rackson. !1ftenD someone in a clinic #ill %et a
Schirmers of .2 anD even tho'%h the patient has ry eyeD the person #ill still sayD The Schirmers is %ooD
no problem here. A%ainD it may be a ry eye 'e to a lipi eficiency or meibomian %lan iseaseD or aller%y
may be playin% a role. These are some reasons #hy Schirmers tests can thro# people off."
C ,taining. Even for the b'sy clinicianD physicians say performin% some simple stains can be #orth#hile.
!The pattern of oc'lar s'rface stainin% or lack thereof #ith instillation of fl'orescein or lissamine %reen #ill
confirm that theres s'rface ama%e consistent #ith one of the types of ry eyeD" says 9r. 5o'lksD !b't it #ill
also help %ive the level of severity of the isease.
!$n aH'eo's-eficient ry eye the nasal stainin% is %reater than temporal stainin% of the conj'nctiva #ith
lissamine %reenD" says 9r. 5o'lks. !An theres some evience that si%nificant stainin% of the temporal
conj'nctiva is an inication of ry eye associate #ith SjT%rens. 5l'oresceinD on the other hanD is 'se for
corneal stains. :lassicallyD #ith aH'eo's-eficient ry eyeD it appears as interpalpebral or inferior stainin%
#ith fl'orescein. B't #ith meibomian %lan ysf'nctionD the stainin% tens to be in the lo#er half of the
cornea. 6arely o yo' see stainin% in the 'pper thir of the cornea #ith ry eye 'nless its very severe
isease." Several other physicians a%ree that flori conj'nctival stainin% can be a very stron% inicator of a
systemic a'toimm'ne iseaseD an yo' sho'l be%in H'estionin% the patient abo't symptoms s'ch as joint
painD constipation an iarrhea. !&o'll be%in to pick 'p hints abo't #hats %oin% onD" says 9r. ,elson.
!$f theres no stainin% in %eneralD it tells yo' that the patient probably oesnt have a systemic isease
involvin% the lacrimal %lans s'ch as SjT%rensD" as 9r. ,elson. !AlsoD corneal stainin% often correlates
#ith symptoms. 5or eFampleD someone #ith a b'rnin% or forei%n boy sensation #ill often sho# stainin%D as
#ell. AlsoD if someone comes in #ith conj'nctival lissamine %reen stainin%D this can sometimes be the res'lt
of a toFic reactionD s'ch as from a r'% #ith a certain preservative. This #ill 's'ally %o a#ay if yo' stop the
r'%. Bhereas in SjT%rens patientsD lissamine %reen stainin% is there almost forever. AlsoD it oesnt
correlate #ith painK thats not the so'rce of pain in patients #ith SjT%rens synrome ry eye."
C %t-er testing. Some s'r%eons have be%'n 'sin% tear osmolarity testin% to eval'ate patients. 1smolarity
testin% involves takin% a sample of a patients tears an meas'rin% its milliosmoles per liter. !$t tells yo'
#hether someone has ry eye or notD an #hether its milD moerate or severeD" says 9r. 4empD #ho has a
financial interest in the evice. !$t can also sho# ho# a patient is responin% to treatment for his ry eye.
Bhat it oesnt tell yo' is the s'btype of ry eye thats presentK in other #orsD #hether its aH'eo's-
eficient or evaporative.
!The osmolarity meas'rement has ifferent levelsD tho'%h its not absol'te like $10 can be in %la'comaD" 9r.
4emp contin'es. !$t 'ses ?)8 m1sm/liter as the c'toff bet#een normals an ry eye. Be then 'se ?.+ m1sm
to ifferentiate bet#een mil an moerate ry eyeD an someone #ith ?-8 m1sm is more in the
moerate/severe to severe cate%ories."
+8
Another eviceD recently approveD is the 4ipi(ie# $nterferometer by TearScience. Bith 4ipi(ie#D the
clinician positions the patients eye in front of an ill'mination so'rce thats aime at the tear film. 6ays from
the li%ht so'rce pass thro'%h the tear film an reflect into a cameraD formin% an interference pattern that can
be compare to an interferometry scale to help meas're the thickness of the oil layer of the tear film an
catch a patient #ith evaporative ry eye. 0hysicians noteD ho#everD that even #ith a lipi layer analysisD
yo'll still have to look to see if the patient has aH'eo's eficiencyD as #ell. !Another eviceD the Ceeler
TearscopeD looks at H'alitative patterns of the tear filmD" says 9r. 5o'lks. !B'tD a%ainD it tells yo' if there are
problems #ith the lipi layer of the tear film b't oesnt eFcl'e
aH'eo's-eficient ry eye."
To help %rae the severity of a patients ry eyeD some physicians
#ill meas're corneal sensationD since s'rface ama%e from ry
eye #ill event'ally lea to nerve s'ppression an lack of
sensation. This lack of sensitivity can make a patients reports of
symptoms 'nreliable as the ry eye #orsensD since he act'ally
#ill be feelin% less iscomfort. !Be meas're corneal sensation
#ith a :ochet-Bonnet corneal aesthesiometerD" eFplains 9r.
5o'lks. !This involves applyin% a nylon filament of varyin%
len%th to the cornea. The shorter the nylonD the %reater the
press're thats place on the cornea. The shorter the piece of
filament neee to stim'late the corneaD the more the nerves are s'ppresse. $f yo' ont have a :ochet-
Bonnet aesthesiometerD yo' can take a cotton-tippe applicator an strin% o't the cotton to a fine point an
'se that to to'ch the cornea an see if the patient reacts. ;o#everD its not as precise as the aesthesiometer."
$f yo' s'spect a systemic ca'se for the ry eyeD f'rther testin% may be necessary. These incl'e SjT%rens
SSA/SSB antiboy tests an a rhe'matoi factor. &o' mi%ht also consier havin% the patient see a
rhe'matolo%istD say physicians. 5or a efinitive ia%nosis of ry mo'th in a SjT%rens s'spectD yo' may have
to sen the patient to a entist or oral s'r%eon. 5ailin% thatD 9r. ,elson says !$ often 'se a simple screenin%
test: $ ask the patient if he can che# a soa cracker an s#allo# it #itho't #aterD then $ have him stick o't
his ton%'e to see if it looks moist or ry."
9r. ,elson says that the %oo ne#s is that after yo' ia%nose the patient an initiate a treatment for his ry-
eye iseaseD it %ets easier to monitor his pro%ress #ith the treatment re%imen. !A patient comin% in #ith ry-
eye symptoms is analo%o's to a compresse accorionEj'st like the accorion can only be compresse so
farD the patient can only feel so m'ch painD" he says. !SoD he j'st feels ba all the time. ;e cant tell #hat
eFactly is botherin% him. B't as yo' start clearin% 'p the inflammationD %ettin% the meibomian %lans
#orkin% a%ain an so onD all of a s'en the accorion eFpans an he can feel thin%s more specificallyD an
can tell yo' #hat bothers him more. ;e starts to be able to tell the ifference bet#een a %oo ay an a
ba ayD an can tell #hen thin%s are startin% to %et #orseD 'ltimately allo#in% yo' to intervene sooner #ith
treatment."
.. Rackson BB. /ana%ement of ysf'nctional tear synrome: A :anaian consens's. :an R 1phthalmol -))AK**:?82-A*.
-. Celly C. ,ichols. The $nternational Borkshop on /eibomian 7lan 9ysf'nction: $ntro'ction. $nvest 1phthalmol (is Sci -)..K2-:*:.A.3-.A-..
?. 5o'lks 7D Bron A. /eibomian %lan ysf'nction: A clinical scheme for ia%nosis an classification. The 1c'lar S'rface -))?K.:.)3-.-+.

Bhen a patient presentsD physicians say to look for si%ns of oc'lar rosacea
in eterminin% a ca'se of ry eye.
4?mage courtesy )ruce Eac2son, M#.5
+A

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Eye strain, computer vision syndrome, dry eyes, ocular surface disorders, eye allergy: some explorations.

A free book by Sanjeev Sabhlok

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