> Table of Contents > Lacrimal Disorders (Dry Eye Syndrome)
Lacrimal Disorders (Dry Eye Syndrome)
Kinder K. Fayssoux, MD
Mark Minot, MD
image BASICS
DESCRIPTION
  • Diseases and abnormalities of tear production and maintenance of tear film
  • The most common lacrimal disorder is dry eye syndrome, which is often referred to as dysfunctional tear syndrome.
  • Lacrimal duct disorders usually result in overflow tearing.
  • System(s) affected: skin/exocrine
EPIDEMIOLOGY
Prevalence
Very common throughout the United States; more often seen in arid climates:
  • Predominant gender: female > male
  • Predominant age: Dry eye symptoms increase with age and are most often seen in the elderly.
ETIOLOGY AND PATHOPHYSIOLOGY
  • Tear film is composed of three layers:
    • Mucin layer: allows spread of aqueous tears
    • Thick aqueous layer: produced by lacrimal gland
    • Lipid layer: controls tear evaporation
  • Results from poor tear production, rapid tear evaporation, and/or an abnormal concentration of mucin or lipid in tear film
  • Most common cause of dry eye symptoms is aqueous tear deficiency.
  • Decreased androgens are thought to contribute to a decrease in tear production.
RISK FACTORS
  • Exposure to dry environments (e.g., high altitudes)
  • Contact lens wear
  • Female gender
  • Computer use
  • Hormonal diseases
  • History of collagen vascular disease such as rheumatoid arthritis, Sjögren syndrome, thyroid disease, rosacea, Bell palsy, eyelid abnormalities
  • Medications, including oral contraceptives, diuretics, &bgr;-blockers, anticholinergics, antihistamines, and antidepressants
  • Smoking
  • Vitamin A deficiency
  • Eye surgery: blepharoplasty, cataract, laser vision correction
  • Artificial tears (with preservatives)
GENERAL PREVENTION
  • Prevent exposure to eye irritants from pollution, cigarette smoke, and sun exposure.
  • Ensure adequate vitamin A intake through diet or as a supplement.
  • Patients with prior laser vision correction should wait at least 6 months before undergoing blepharoplasty because of the effects on corneal sensation, tear production, and tear film alteration (1)[C].
  • Increasing awareness of this condition among people residing in dry environments
  • Decrease or stop contact lens wear.
COMMONLY ASSOCIATED CONDITIONS
  • Sjögren syndrome
  • Rheumatoid arthritis
  • Thyroid disease
  • Rosacea
  • Pregnancy
  • Menopause
  • Malnutrition
image DIAGNOSIS
PHYSICAL EXAM
  • Slit-lamp exam reveals decreased tear film and may reveal punctate epithelial defects on cornea.
  • Schirmer test can be used to assess tear production.
  • Ocular staining may reveal epithelial defects.
DIFFERENTIAL DIAGNOSIS
  • Ocular: allergy, conjunctivitis, contact lens complication, exposure keratopathy
  • Other: ocular rosacea, thyroid ophthalmopathy, ocular manifestation of HIV, Bell palsy, vitamin A deficiency
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Tear production can be measured using a Schirmer filter strip after instillation of topical anesthetic. Wetting of <10 mm of the slip after 5 minutes is indicative of insufficient tear production.
Diagnostic Procedures/Other
  • Staining of the ocular surface with fluorescein will show areas of abnormal uptake and patches of drying. It allows the tear break-up time (TBUT) to be calculated. A TBUT of <10 seconds is abnormal.
  • Rose bengal will be taken up by dead or dying epithelial cells, and it may be a more sensitive test.
Test Interpretation
In Sjögren syndrome, infiltration of the lacrimal gland with inflammatory cells may be evident.
image TREATMENT
GENERAL MEASURES
  • Those with systemic illnesses predisposed to dry eye should be informed and instructed in the appropriate use of artificial tear supplements. Some artificial tear supplements with preservatives may exacerbate the condition.
  • Symptoms of dry eye may decrease with an increase in home humidification and hydration.
MEDICATION
First Line
  • Preservative-free artificial tears: 1 drop in each eye several times a day to prevent discomfort (2)[A],(3)[C]
  • Ophthalmic lubricating ointment may be used in each eye at bedtime (4)[B].
Second Line
  • Dry eye has been identified as having an inflammatory component that responds in refractory cases to topical immunosuppressives such as cyclosporine 0.05% (Restasis), 1 drop to each eye BID (5,6,7)[A].
  • Emerging therapies include topical androgens, secretagogues (e.g., oral pilocarpine), cytokine-blocking agents, and a P2Y2 receptor agonist (diquafosol).
P.587

ISSUES FOR REFERRAL
Rheumatology referral if systemic collagen vascular disease is suspected
ADDITIONAL THERAPIES
Lid massage and warm compresses several times a day
Pediatric Considerations
For most babies born with nasolacrimal duct obstructions, the obstructions will clear spontaneously during the 1st year of life. On occasion, surgical probing is necessary.
SURGERY/OTHER PROCEDURES
Punctal occlusion, with either punctal plugs or laser, is used in moderate to severe dry eye if medical therapy fails.
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • Fatty acid (omega-3), linoleic acid, and &ggr;-linoleic acid supplements (8)[B]
  • Acupuncture has been studied with inconclusive results (9)[A].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
  • Monitor early to assess efficacy of treatment.
  • The viscosity of artificial tears and frequency of use can be increased for symptom relief.
DIET
  • Diet rich in omega-3 fatty acids and/or linoleic acids may benefit some patients.
  • Adequate vitamin A intake
PATIENT EDUCATION
All individuals with systemic illnesses predisposed to dry eye, postmenopausal women, residing in arid climates, or those >60 years of age should be instructed in the use of artificial tear supplements to combat dry eye symptoms.
PROGNOSIS
  • Lacrimal disorders can be adequately managed with artificial tear supplements.
  • Blocked tear ducts can be managed with probing and punctal dilation and/or dacryocystorhinostomy procedures in more severe cases.
REFERENCES
1. Lee WB, McCord CD Jr, Somia N, et al. Optimizing blepharoplasty outcomes in patients with previous laser vision correction. Plast Reconstr Surg. 2008;122(2):587-594.
2. Ousler GW, Michaelson C, Christensen MT. An evaluation of tear film breakup time extension and ocular protection index scores among three marketed lubricant eye drops. Cornea. 2007;26(8):949-952.
3. Karadayi K, Ciftci F, Akin T, et al. Increase in central corneal thickness in dry and normal eyes with application of artificial tears: a new diagnostic and follow-up criterion for dry eye. Ophthalmic Physiol Opt. 2005;25(6):485-491.
4. Tauber J. Efficacy, tolerability and comfort of a 0.3% hypromellose gel ophthalmic lubricant in the treatment of patients with moderate to severe dry eye syndrome. Curr Med Res Opin. 2007;23(11):2629-2636.
5. Hardten DR, Brown MJ, Pham-Vang S. Evaluation of an isotonic tear in combination with topical cyclosporine for the treatment of ocular surface disease. Curr Med Res Opin. 2007;23(9):2083-2091.
6. Roberts CW, Carniglia PE, Brazzo BG. Comparison of topical cyclosporine, punctal occlusion, and a combination for the treatment of dry eye. Cornea. 2007;26(7):805-809.
7. Sall K, Stevenson OD, Mundorf TK, et al. Two multicenter, randomized studies of the efficacy and safety of cyclosporine ophthalmic emulsion in moderate to severe dry eye disease. CsA Phase 3 Study Group. Ophthalmology. 2000;107(4):631-639.
8. Barabino S, Rolando M, Camicione P, et al. Systemic linoleic and gamma-linoleic acid therapy in dry eye syndrome with an inflammatory component. Cornea. 2003;22(2):97-101.
9. Lee MS, Shin BC, Choi TY, et al. Acupuncture for treating dry eye: a systematic review. Acta Ophthalmol. 2011;89(2):101-106.
Additional Reading
&NA;
  • Dogru M, Nakamura M, Shimazakie J, et al. Changing the trends in the treatment of dry-eye disease. Expert Opin Investig Drugs. 2013;22(12):1581-1601.
  • Galor A, Feuer W, Lee DJ, et al. Prevalence and risk factors of dry eye syndrome in a United States veterans affairs population. Am J Ophthalmol. 2011;152(3):377.e2-384.e2.
  • Gilbard J. The diagnosis and management of dry eyes. Otolaryngol Clin North Am. 2005;38(5):871-885.
  • Tong L, Petznick A, Lee S, et al. Choice of artificial tear formulation for patients with dry eye; where do we start? Cornea. 2012;31(Suppl 1):S32-S36.
See Also
&NA;
Sjögren Syndrome
Codes
&NA;
ICD10
  • H04.129 Dry eye syndrome of unspecified lacrimal gland
  • H04.9 Disorder of lacrimal system, unspecified
  • H04.122 Dry eye syndrome of left lacrimal gland
Clinical Pearls
&NA;
  • Dry eye syndrome is common in the United States, affecting postmenopausal women more than any other population.
  • Symptoms are usually adequately managed with preservative-free artificial tears and humidified environments.
  • Dry eye symptoms that are refractory to medical treatment and/or punctal plugs should raise suspicion of an underlying systemic condition, and a rheumatology consult should be considered.