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Dry Eye and Clinical Disease of Tear Film, Diagnosis and Management

US Ophthalmic Review, 2014;7(2):109–15 DOI: http://doi.org/10.17925/USOR.2014.07.02.109

Abstract:

Dry eye disease (DED) is a clinically significant multifactorial disorder of the ocular surface and tear film as it results in ocular discomfort and visual impairment and predisposes the cornea to infections. It is important for the quality of life and tends to be a chronic disease. It is also common, as the prevalence is estimated between 5 % to 30 % and this increases with age. Therefore, it is recognised as a growing public health problem that requires correct diagnosis and appropriate treatment. There are two main categories of DED: the deficiency of tear production (hyposecretive), which includes Sjögren syndrome, idiopathic or secondary to connective tissue diseases (e.g. rheumatoid arthritis), and non-Sjögren syndrome (e.g. age-related); and the tear evaporation category, where tears evaporate from the ocular surface too rapidly due to intrinsic causes (e.g. meibomian gland disease or eyelid aperture disorders) or extrinsic causes (e.g. vitamin A deficiency, contact lenses wear, ocular allergies). Management of the disease aims to enhance the corneal healing and reduce patient’s discomfort. This is based on improving the balance of tear production and evaporation by increasing the tear film volume (lubrication drops) and improving quality of tear film (ex omega-3 supplements, lid hygiene, tetracyclines), reducing the tear film evaporation (paraffin ointments, therapeutic contact lenses), reducing tear’s drainage (punctal plugs, cautery) and finally by settling down the ocular surface inflammation (steroids, cyclosporine, autologous serous), as appropriate. In this article we will review the clinical presentation, differential diagnosis and treatment options for DED.

Keywords: Dry eye disease, tear film, Sjögren, ocular inflammation.
Disclosure: Vasilis Achtsidis, Eleftheria Kozanidou, Panos Bournas, Nicholas Tentolouris and Panos G Theodossiadis have no conflicts of interest to declare. No funding was received in the publication of this article.
Received: February 27, 2014 Accepted March 31, 2014
Correspondence: Vasilis Achtsidis, MD, FEBO, Consultant Ophthalmologist, Department of Ophthalmology, Worthing Hospital, Lyndhurst Road, Worthing, West Sussex BN11 2DH, UK. E: billachtsidis@yahoo.gr

There is now an increased recognition by clinicians that dry eye disease (DED) is a common disorder characterised by dryness and damage of the ocular surface. It affects quality of life, including aspects of physical, social and psychological functioning, because it induces ocular discomfort, burning sensation, light sensitivity, visual disturbances or even corneal erosions and infections. DED is also known as keratoconjunctivitis sicca, dry eye syndrome and dysfunctional tear syndrome.

DED prevalence has been reported to range from 5 % to 30 %, this being a likely result from differing study populations and DED definitions. In a large population study, Moss et al. reported the prevalence of dry eye to be 14.4 % in 3,722 subjects aged 48 to 91 years and noted that the prevalence of the condition doubled after the age of 59. As a consequence, DED prevalence is expected to increase in ageing populations, which will eventually make this health problem more prominent.1–4

In order to address the problem, the International Dry Eye Workshop (DEWS) defines dry eye as a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.3–5

Indeed, DEWS has recognised dry eye as a disturbance of the lacrimal functional unit, an integrated system comprising the lacrimal glands, ocular surface (cornea, conjunctiva and meibomian glands) and lids, and the sensory and motor nerves that innervate them.3,4 Dysfunction of any component of the lacrimal functional unit may lead to ocular surface disease, related to inflammation and increased tear film osmolarity.

This multifactorial aetiopathogenesis explains why the clinical diagnosis of dry eye remains a challenge, not only due to the wide spectrum of alterations of the ocular surface with different aetiology and pathophysiology,5 but also due to the lack of well standardised diagnostic tests,6 and the fact that corneal surface is sensitive to external stimuli and, while the most diagnostic tests are overly invasive, the non-invasive tests are still considered expensive for everyday practice. Therefore, a holistic approach and a careful examination of tear film, cornea, eyelids, anatomically and functionally, as well as a thorough clinical history is needed to diagnose DED.3,5–8

Early diagnosis of DED and identification of the underlying cause is essential not only for the management of the ocular surface disease, but also for the diagnosis and management of the systematic disease,which might be occult, and may serve as a common link between ophthalmologists and physicians.9,10

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Keywords: Dry eye disease, tear film, Sjögren, ocular inflammation.