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Dry Eye Syndrome

ROUTINE — Adnexa

Symptoms

burning, dryness, and foreign body sensation

mildly to moderately decreased vision

paradoxical excess tearing (reflex tearing)

exacerbation by smoke, wind, heat, low humidity, or prolonged visual tasks

Clinical Findings

Ocular surface staining

  • punctate corneal or conjunctival staining (fluorescein, rose bengal, or lissamine green)
  • distribution usually inferior or in the interpalpebral zone

Tear film

  • excess mucus or debris in the tear film
  • corneal filaments in severe cases

Etiology

Classification (dews II)

  • aqueous-deficient and evaporative subtypes; pure forms are rare and usually coexist

Aqueous-deficient

  • sjögren-associated: primary or secondary (ra, sle, systemic sclerosis)
  • non-sjögren: age-related (most common), lacrimal gland obstruction, or infiltration (sarcoidosis, igg4)
  • reflex block: post-refractive surgery (lasik/prk/smile) or cataract surgery
  • systemic drugs: antihistamines, anticholinergics, tcas, ssris, isotretinoin, beta-blockers, diuretics

Evaporative

  • meibomian gland dysfunction (mgd): major cause due to lipid-layer deficiency
  • blink abnormalities: reduced rate (screens) or parkinson disease
  • lid malposition: ectropion, lagophthalmos, proptosis, or cn vii palsy
  • vitamin a deficiency: mucin deficiency due to goblet cell loss

Temporal patterns

  • aqueous-deficient: worse as the day progresses
  • evaporative/mgd: worse on awakening; clears with blinking

Red Flags

filamentary keratitis or persistent epithelial defects

systemic features (dry mouth, parotid swelling, arthritis) suggesting sjögren syndrome

severe dry eye with lagophthalmos or cn vii palsy

severe neurotrophic dry eye post-lasik

Investigations

Slit lamp

  • assess tear meniscus height before instilling drops
  • fluorescein staining for punctate erosions and tear break-up time (tbut <10 s abnormal)
  • rose bengal or lissamine green for conjunctival staining

Diagnostic battery

  • schirmer i (unanesthetized): normal ≥15 mm; borderline 10–15 mm; abnormal ≤10 mm
  • schirmer (anesthetized): measures basal tearing; abnormal ≤5 mm
  • tear osmolarity: abnormal >308 mosm/l or asymmetry >8 mosm/l
  • mmp-9 (inflammadry): indicates ocular surface inflammation (≥40 ng/ml)

Systemic screening

  • screen for sjögren syndrome (ss-a/ro, ss-b/la, ana, rf) if systemic symptoms are present

Treatment

Mild to moderate

  • artificial tears (preferably preservative-free) up to q1–2h
  • lubricating gel or ointment at bedtime
  • lifestyle: humidifiers and smoking cessation

Anti-inflammatory

  • cyclosporine (0.05% or 0.09%): for chronic inflammation; takes 1–3 months for effect
  • lifitegrast (5%): improvement often within 2 weeks
  • mild topical steroids: short-term bridge to reduce initial burning and inflammation

Procedural

  • punctal occlusion: collagen (temporary) or silicone (permanent) plugs
  • thermal cautery: for permanent occlusion if plugs repeatedly fail

Severe or adjunctive

  • autologous serum tears and oral omega-3 fatty acids
  • filament management: manual removal and 10% acetylcysteine q.i.d.
  • bandage lenses or scleral lenses; moisture chamber goggles at night
  • lateral tarsorrhaphy for refractory exposure-related dry eye

Differential Diagnosis

  • allergic conjunctivitis
  • superior limbic keratoconjunctivitis
  • preservative toxicity (medicamentosa)
  • blepharitis with meibomian gland dysfunction
  • sjögren syndrome

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