• Inflammation around meibomian gland orifices,  pouting of gland orifices, solidification of meibomian secrections.
• Causes significant disruption of tear film stability
• Low TBUT seen

Measures aqueous secretion.

Time its done = 5min

Normal= > 15mm.

Mild to moderate KCS = 5-10mm of wetting in 5mins

Severe KCS= <5mm of wetting

No Anesthetics

Reflex and Basal

WITH anesthesia

measures basal rate of tears on a regular basis

Most important test of aqueous layer!

Without anesthetic- measures maximal reflex tearing

Stimulate nasal mucosa with a cotton tip

Stimul

thread with dye in inf conj with NO anesthesia : 15sec

Normal: 10-20mm color change

Dry Eye sx: <10mm color change from yellow to red

Elevated with aqueous deficient Keratoconjunctiva Sicca

Will be high even after artificial tears

Farily accurate and sensitive to dry eye

Evaluates decrease in lacrimal gland output. Measures tear protein lactoferrin,

meaures TEAR VOLUME

Measures tear volum

Abnormal < 1mg/ml

Detect LIPID and MUCIN deficiency (tear quality)

Normal = 15-45 sec

Borderline =10-15 sec

Abnormal < 10 sec

Lowest on awakening

rises 2 hrs later

constant throughout day

• Stains dead and devitalized cells (mucus & corneal filaments)

• Early Dry eye + stains exposed bulbar conj and cornea

• See better w/ lids spread widely apart

• Seen in lower 1/3 of the cornea

Stains dead and devitalized cells

Less discomfort

Cells easier to see

Examine Bulbar and palberal conj well

Discolors skin!

This ocular surface test penetrates broken epithelial surfaces and diffuses through intercellular space WITHOUT staining the cells

does NOT stain dead cells pr mucin.

• Will show when the integrity of the epithelial surface is disrupted

• Will reveal punctuate epithelial keratopathy in the interpalpebral region

lacrimal irrigating needle inserted into caniculi and saline is irrigated through the lacrimal system.

if Fluorescein dye passed = open system but some functional blockage

mild to moderate sx; no signs

mild to moderate conj signs

Px counseling, preserved tear's use hypoallerginic, environmental

management

Unpreserved tears, gels, ointment,

cyclosporine A,

topical steroids, nutritional support (flax-seed Oil)

systemic anti imflammatory therapy,

acetylosteine, punctual cautery & surgery

Severe Sx, marked corneal punctuate staining, central corneal staining,

filamentary keratitis

Tetracylcines

PUNCTUAL PLUGS

Stabilze tear film

increase lubricity

increase aqueous production

decrease inflammation

create normal tear film environment for epithelial healing

customize mgment

Refresh Tears, Refresh liquid gel.

Tears Naturale, genteal

advanced eye relief (glycerin)
Tears Naturale Forte, Visine tears.

Optive

1. Articial Tears function as lubricants, short relief( many time a day)
2. Tears again liposome spray: lubricant
3. Restasis: for dry eye caused by ocular inflammation; incr schirmer wettin, improves conj rose bengal staining and SPK
4. Sustained-release artifical tear inserts (continous in inf cul-de-sac)
5. Ointments (b4 bed, refresh PM)
6. punctual plugs (improves tear qualittiative, stops drainage of natural and artificial tears: increased aqueous components of test,
7. Blink therapy
8.  If artificial tears and punctual occlusion don't do the job, Goggles and shield (slow tear evaporation
9. Flaxseed oil and nutritional supplements
10. if severe: bandage CLS (incr risk of infxn)

Replenish moisture/ delay evaporation of px natural tears.

insill ophthalmic lubricant every hour or more as needed then taper

little relief or no compliance, do Punctual Occlusion

Strands of mucous attached to the epithelial surface, Remove the strands and prescribe lots of articial tears and ointments.

Px with extremely dry eyes

Frequent complication that is subacute (mild to moderate tenderness on palpation) and chronic (painless) for wks/mos

both eyes or 1

Acute onset with moderate to severe pain,

Unilateral

Tenderness at inferior canthus,

diffuse pain around eye and orbit,

HA

Moderate swelling of sac

EPIPHORA!

edema and erythema throughout inf nasal region (mild to moderate)

Ocassionally hardened distention of sac (mucocele) will make focal enlargement in the swollen area,

Purulent discharge

secondary conjunctivitis

Severe cases = secondary preseptal cellulitis

Less severe, more common congenital presentation.

Purulent discharge when you massage of lacrimal sac,

9-12mos in congenital with spontaneous remission

Ask previous episodes, concomitant ear,nose, throat infxn?

Evaluation: Compress lacrimal sac near the puncta w/cotton swapb to express discharge from punctum. Yes discharge = bacterial or fungal

Check EOM motility

Check for proptosis

• Gram's stain and blood agar culture of discharge

• CT scan of orbit and paranasal sinuses in atypical/severe cases or those which do not respond to or get worse on antibiotics.

NEVER dilate and irrigate during the acute stage of this INFXN cos it would force the infxn further in!

Typical antibiotic drugs,

Warm compresses,

gentle massage QID,

Pain Med acetaminopehn) prn (pro re nata= as circumstances arise),

Consider surgical correction = dacryocystorhinostomy

Follow up daily

most common congenital abnormality of system-- 30% of newborns secondary to delayed opening of hasner (open spontanously in we/mo)

Ask Epihora? (if yes then acute dacryocystitis)

Evaluation: Observation of punctual integrity and position

Do Drainage test (Jones test)

Do Dilation & Irrigation

in serious or suspicious cases do Dacryocystorhinogram

(x-ray) definitive usually

Treat cause of obstructions, frequent heat and firm massage,

follow up in 3-6mos

from chronic, untreated  dacryocystitis has inflamed the lacrimal sac to the point of perforation

"abnormal connection"

Infxn or inflammation of the canaliculi uaually caused by fungal infxns secondary to a blockage.

dificult to treat because fungi have slow metabolism

Yellow, putty-like deposits that block the drainage system and are secondary to fungal infxns

"limb/ tip of finger point"

occur in secretory or drainage system

very rare.