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The treatment of dry eye syndrome

dry eye syndrome or keratoconjunctivitis sicca (KCS) is an eye disease in which the quantity or quality, production tear down, or the evaporation of the tear film increases. The translation of "keratoconjunctivitis sicca" America is the "dry of the cornea and conjunctiva. "

Symptoms

The most common clinical findings of dry eye can be meibomitis, telangiectasias, blepharitis, superficial punctate keratopathy and hyperemia. Commonly described the typical symptoms of keratoconjunctivitis as dryness, burning [3] and eye irritation sand or, worse as the day progresses. [1] The symptoms can also be described as itching, [3] pike [4] stingy [3] or [3 tired eyes]. Other symptoms are pain, [5 redness], [5] a feeling of tension, [3] and the pressure behind the eye [3]. Many patients report a feeling that something, [3] such as a speck of dust, [5] is in the eye. The resulting damage to the cornea of the eye discomfort increases the surface and sensitivity to bright light. [3] Both eyes are usually affected [6]. There may also be a stringy discharge from the eyes. [5] Although it may seem contradictory, dry eye can lead the eyes to water. [5] This is because irrigation of the eyes become irritated. [5] One may experience excessive tearing the same way as a I would do if something is lodged in the eye. [5] The aqueous reflex tears will not reduce dry eye symptoms [5] because this type of tear is the type of water that occur in response to injury, irritation or emotion. [5] They have no lubrication and wound healing qualities necessary to prevent and cure dry eye. [5]

In those who suffer from dry eye, the flashing can have a negative impact, as well as a positive. On the one hand, causes the eyelid blinking to induce shear forces in the cornea as the top through the corneal surface. This force can be high and lead to corneal abrasion of the surface if normal tear film protection is in place to absorb the shear forces. Moreover, because in the normal eye blinking coats the surface of the cornea with tears, [5] The symptoms may be worsened by activities that blink rate is reduced due to prolonged use of the eyes [3]. These activities include prolonged reading, [1] the use of computers [1] [3] [5] driving, [3], or watching television [3] [5]. The severity of the symptoms of increased wind, [5] dusty [3] [5] or smoke (including cigarette smoke [5]) zones [1] [3] in dry environments [1] [3], high altitude, including airplanes, [6] on days with low humidity, [3] and in areas where an air conditioner [5] (especially in a car [3]), fan, [3 heater], [3] or hair dryer [5] is being used. The severity of symptoms was reduced during cooling, rain or fog and damp, as in the shower. [3]

Many people with dry eyes have a slight irritation, no long-term effects. [5] However, if the condition progresses, complications can be eye damage it causes, [5] that results in vision problems or infrequently in the loss of vision [3,5].

Symptom Evaluation is a key component of dry eye diagnosis, objective measurements are often not able to fully describe the disease. Several questionnaires have been developed to determine a score that allows diagnosis of dry eye. The McMonnies and Ho dry eye questionnaire is frequently used in clinical studies of dry eye. A version of the questionnaire can be accessed at: http://www.dipolarhosting.net/agingeye/dryeye.asp.

Epidemiology and Etiology

Over time, the dry eye condition can lead to tiny abrasions on the surface of the eye. [4] In advanced cases of dry eye, the epithelium undergoes pathologic changes as squamous metaplasia and goblet cell loss. [1] Severe cases may also result in thickening of the corneal surface, [3] corneal erosion, [1] punctate keratopathy, [1] epithelial defects, [1] corneal ulceration (sterile and infected), [1] corneal neovascularization [1] healing corneal, [1] [3] corneal thinning [1] and even corneal perforation [1].

Keratoconjunctivitis sicca is relatively common in the United States especially in elderly patients [1]. In particular, those most likely to be affected by dry eyes are the highest in 40 years or more [6].

Although people with autoimmune diseases have a high probability of having dry eyes, most people with dry eyes do not have an autoimmune disease. [6] The cases of Sjögren syndrome and keratoconjunctivitis sicca associated with it are present much more common in women, with a ratio of 9:1. [1] In addition, Milder forms of keratoconjunctivitis sicca are also more common in women. [1] This is partly because of hormonal changes, [6], such as those found in pregnancy, menstruation and menopause, [6] may decrease tear production. [5] Dry eye is a piece of lead in areas of the world where malnutrition is common and the diet is deficient in vitamin A. [23] There is no racial correlation to the disease [1].

An anomaly of any of the three layers of tears produce an unstable or inadequate tear film composition, resulting in symptoms of keratitis sicca. [1] To help keep your eyes and feel comfortable in the optical components of the surface of the cornea in optimal conditions, a normal film, thin layers of tears your eyes. Three main layers make up this tear film:

The innermost layer is thinner and is composed of mucin (or mucus). This thin layer of mucus is produced by cells in the conjunctiva (Light skin covering the eye). The mucus has multiple functions and helps the aqueous top layer to spread evenly over the eye.

The middle layer is aqueous and more. This layer is essentially a very dilute solution of salt water that contains many proteins important for protection and healing. Lacrimal glands in the upper eyelids and tear accessory glands produce the aqueous layer. This layer function is to keep the eye moist and comfortable, remove dust, debris or foreign objects may enter the eye, and wound healing and provide protection. Defects of the aqueous layer are the most common cause of the syndrome of dry eye.

The outer layer of the tear film is a very thin layer of lipids (fats or oils). These lipids contain fatty acids omega-3 fatty acids are produced by the meibomian glands and glands of Zeis (oil glands in the eyelids). The main function of this layer lipid is to help decrease evaporation of the water layer below it.

Deficient tear production

Keratoconjunctivitis sicca is usually due to insufficient tear production. [1] [3] The aqueous tear film is affected, leading to deficiency aqueous tear (ATD) or lacrimal hyposecretion. [1] The lacrimal gland does not produce enough tears to keep the entire conjunctiva and cornea covered by a complete layer. [3] This usually occurs in people who are healthy. Increasing age is associated with reduced watering. [1] This is the most common type found in postmenopausal women. [3] [7]

Alacrimia Causes include idiopathic, congenital, xerophthalmia, the lacrimal gland ablation and sensory denervation. [1] In rare cases, can be a symptom of collagen vascular diseases such as rheumatoid arthritis [3], Wegener's granulomatosis and systemic lupus erythematosus [1]. Sjögren's syndrome [3] and autoimmune diseases associated with Sjögren's syndrome are also conditions attached with aqueous tear deficiency. [1] Drugs such as isotretinoin, [3] sedatives, [3] [6] diuretics [3] tricyclic antidepressants [6] antihypertensive, [3] oral contraceptives, [1] [3] antihistamines [1] [3] [5] nasal decongestants, [5] beta-blockers, [a] phenothiazines [1 atropine] [1], and to relieve pain opioids such as morphine [6] can cause or worsen this condition. The infiltration of the lacrimal glands by sarcoidosis or tumors, or fibrosis after radiation of the lacrimal glands can also cause this condition. [1]

Abnormal composition tears

Keratoconjunctivitis sicca can also be caused by abnormal tear composition resulting from the rapid evaporation [3] or premature destruction of tears. [1] When it is caused by rapid evaporation, evaporation is called dry eyes. [3] In this regard, despite lacrimal gland produce enough tears, the evaporation rate of tears is too fast. [3] There is a loss of water of tears which results in tears that are too "salty" or hypertonic. As a result, the entire conjunctiva and cornea can not be kept covered with a full coat of tears during certain activities or in certain environments. [3] Dry eye disease is accompanied by an increase in the proinflammatory forms of IL-1 (IL-1 alpha and beta mature IL-1) and a decrease in the biologically inactive precursor IL-1 beta in tear fluid. Increased protease activity on the ocular surface may be a mechanism by which splits the IL-1 beta precursor to mature biologically active form. The conjunctival epithelium appears to be a source of increased concentrations of IL-1 in the tear fluid of patients with dry eye disease. These results suggest that IL-1 may play a key role in the pathogenesis of keratoconjunctivitis sicca. Other factors identified in the tear film that can be modified in dry eye include epidermal growth factor (EGF), monocyte chemotactic protein (MCP) -1, IL-8, tissue inhibitor of metalloproteinases (TIMP) -1 and -2, and many previously undetected tear components, such as angiogenin (ANG), VEGF, CXC and CC chemokines and IFN-gamma inducible protein (IP) -10, growth-related oncogene (GRO), epithelial neutrophil activating protein (ENA) -78, and the inflammatory protein macrophage (MIP)-3alpha.

One of the reasons for aging is associated with dry eye because tear production decreases with age. [5] Dry eye can also be caused by thermal or chemical burns, or (in epidemic cases) by adenovirus. Diabetics are at increased risk for the disease. [8] [9]

An eye injury or other problem in the eyes or eyelids, such as bulging eyes or a drooping eyelid can cause keratoconjunctivitis sicca. [4] Disorders of the eyelid can impair the complex blinking motion required to spread the tears. [6]

About half of all people Contact lens wearers complain of dry eyes. [5] This is because soft contact lenses, which float in the tear film covering the cornea, absorb the liquid tears. [5] Dry eye also occurs or gets worse after LASIK and other refractive surgeries, in which nerves are cut during creation cornea of a corneal flap. [5] The corneal nerves stimulate tear secretion. [5] Dry eyes caused by these procedures, often but not always, resolve after several months. [6] Those who are considering refractive surgery should consider this possible side effect. [5]

Lipid abnormalities tear film caused by blepharitis and rosacea, and abnormalities of the mucin tear caused by vitamin A deficiency, trachoma, keratoconjunctivitis Diphtheria mucocutaneous disorders and certain topical medications are the causes of keratoconjunctivitis sicca. [1]

People with keratoconjunctivitis sicca have elevated levels tear of nerve growth factor (NGF). [1] It is possible that ocular surface NGF plays an important role in the inflammation associated with ocular surface dryness of the eyes [1].

Rosacea is a chronic skin disorder that affects the face and chest, and takes place mainly in the third to sixth decades of life. It is characterized by erythema, telangiectasia and recurrent hot flashes. During the time of this chronic inflammation of the skin usually develops papules, pustules, and swelling. Ocular involvement occurs in 3-58% of patients with skin changes. Common ocular findings include blepharitis, meibomitis, and dry eyes. The rosacea keratitis, when present, however, has a poor prognosis and can lead to blindness. Among the skin diseases, infection with Helicobacter pylori is sometimes associated with rosacea. A higher prevalence of indigestion and Helicobacter pylori infection in rosacea patients than in healthy controls described in limited studies. However, no causal relationship has been identified. On the other hand, oral treatment with metronidazole is beneficial in all three events mentioned of rosacea (skin, eyes, indigestion). Further research is needed to explore this possible relationship.

Diagnosis

Dry eye usually can be diagnosed by symptoms only. [3] tests can determine both the quantity and quality of tears. [6] A slit lamp examination may be performed to diagnose dry eye and to document the damage to the corneal surface. [1] [3]

A Schirmer test was used to measure the amount of moisture bathing the eye. [3] This test is useful in determining the severity of the condition. [5] A five-minute test Schirmer with anesthesia and without using a filter paper Whatman # 41-5 mm wide and 35 mm in length takes place [1]. For this test, wetting in children under 5 mm with or without anesthesia is considered to diagnose of dry eye. [1]

If the results for the Schirmer test are abnormal, a type II Schirmer test may be performed to measure reflex secretion. [1] This test, the nasal mucosa is irritated with a cotton swab, after which tear production is measured with a Whatman # 41 filter paper. [1] For this test, wetting in less than 15 mm after five minutes is considered abnormal. [1]

Tear breakup time (TRL) test measures the time it takes for tears to break eyes. [5] The breakup time is determined after placing a drop of fluorescein in the cul de sac (at the corner of the lower eyelid) [1].

A tear test measures analysis of protein lysozyme contained in tears. [1] In tears, lysozyme is part of the immune system and represents surface more than 20 percent protein content. [1] A lactoferrin (an anti-microbial) test analysis provides a good correlation with other tests. [1]

The presence of recently described molecules, the diadenosine polyphosphates, naturally in tears, are abnormally high in the different states of dry eye. A molecule, Ap4A, which is important in healing ocular (Mediero et al, 2006), can be quantified biochemically simply by acquiring a tear of the sample with a simple test Schirmer. Using this technique it is possible to determine concentrations of Ap4A in tears of patients and diagnostic so objective dry eye [10].

Treatment

A variety of approaches can be taken for treatment. These can be summarized as follows: avoid aggravating factors, tear stimulation and supplementation, wound healing and prevention, increasing the retention of tear, cleaning eyelids, and treatment of eye inflammation [11].

General measures

Dry eyes can be exacerbated by environments smoke, dust and air conditioning and our natural tendency to reduce our blink rate when you concentrate. Speaking of blinking, especially during the use of the computer and rest your tired eyes are the basic steps you can take to minimize discomfort. [11] rubbing the eyes can cause further irritation, should therefore be avoided [6]. Conditions such as blepharitis can often coexist [11], paying particular attention to cleaning of the eyelids in the morning and night with gentle shampoo and warm compresses may improve both conditions.

Environmental control

Seco, drafty and environments with smoke and dust should be avoided. [3] This includes avoiding hair dryers, heaters, air conditioners or fans, especially when these devices are directed toward the eyes. [6] The use of glasses or cast my eyes down, for example, by reducing the computer screen can be used to protect the eyes when factors aggravating the environment can not be avoided [6]. Using a humidifier, [3] [4], especially in the winter, [4] can help to add moisture to dry indoor air [6]. [11]. For mild and moderate cases, additional lubrication is an important part of treatment. [1] The application of artificial tears every few hours [3] may provide temporary relief.

Autologous serum eye drops

None of the commercially available preparations of tears Artificial essential tear components such as epidermal growth factor, hepatocyte growth factor, fibronectin, neurotrophic growth factor and vitamin A, all of which have been shown to play an important role in maintaining a healthy ocular surface epithelial environment. Autologous serum drops containing these essential. However, there is some controversy regarding the efficacy of this treatment. At least one study (PubMed) has shown that this method is more effective than tears artificial in a randomized control study.

Additional Options

Tears Lubricant ointments can be used for the day, but generally are used at bedtime due to poor vision after application. [1] contain petrolatum, mineral oil and similar lubricants. [1] serve as a lubricant and emollient. [1] Application requires pulling down the eyelid and apply a small amount (0.25 inches) inside. [1] Depending on the severity of the condition, can be applied from every hour to just at bedtime. [1] Do not use with contact lenses. [1] Especially designed glasses that form a moisture chamber around the eye can be used to create additional moisture. [6]

Medication

Inflammation occurs in response to tears film hypertonicity can be suppressed by mild topical steroids or topical immunosuppressants such as cyclosporine. [12] [13] For example, elevated levels of tear NGF has been shown to decrease with prednisolone 0.1% [1].

Fish consumption and acid-3 omega

The consumption of omega-3 fatty acids is associated with a lower incidence of dry eye syndrome in women. [14] The mechanism underlying may be a reduction in pro-inflammatory proteins in the tear film. [14]. The first experimental work in omega-3 fatty acids has shown promising results when used in a topical application [15] or by mouth. [16]. We recommend using the omega-3 fatty acids in both directions, for oral and topical (alpha-linolenic acid was used in the study of topics).

Restasis

Topical cyclosporin A (TCSA) 0.05% ophthalmic emulsion is an immunosuppressant marketed in the United States by Allergan under the trade name Restasis [1]. Approved as a prescription drug by the Food and Drug Administration U.S. [5] in 2002, falling from the eyes is reported to reduce surface inflammation [6]. Restasis is thought to works by inhibiting [17] of transcription factors necessary for cytokine production and maturation of T lymphocytes [18]. A review of the a summary of the approval of the FDA's website is displayed in a trial involving 1,200 people, Restasis demonstrated a small positive effect: increasing production tears in 15% of patients, compared to 5% with placebo [5]. Thus, only 10% of patients with dry eye benefit from Restasis.

The recipe Typical Restasis is one drop instilled in each eye twice a day, 12 hours [1]. Do not use Restasis while wearing contact lenses, [1] during infections eye [5] or with a history of herpes virus infections [6]. Side effects include burning sensation (common) [5], redness, drainage, tearing, eye pain, foreign body sensation, itching, stinging and blurred vision. [1] [5] The long-term use of cyclosporine in high doses is associated with increased cancer risk [19] [20].

Generic Alternative

The less costly generic alternatives are available Restasis in some countries. In India, the generic is marketed as Cyclomune Sun Pharma [20].

Conserving tears

There are methods that allow natural and artificial tears to stay longer but have a limited benefit [6]

The blocking of drainage tear

In each eye, there are two puncta [22], which are small openings that drain tears into the tear ducts [5]. There methods for partially or completely close the tear ducts. [6] This blocks the flow of tears into the nose, and therefore are available more tears eyes [3].

Buffers plugs

Socket Buffers

punctal plugs are inserted into points tear to block tear drainage. [5] For those who have not found dry eye relief with drugs, punctal plugs may provide limited benefit. [5] Plugs are reserved for people with moderate or severe dry eye when other medical treatment has been inadequate. [5]

Cauterization

If punctal plugs are effective, thermal [6] or electrical [1] punctio cauterization can be performed.

In thermal cautery, Local anesthesia is used, then applies a hot wire. [6] This reduces the drainage area of tissue and cause scarring, which closes the tear duct. [6]

custom contact lenses

People with severe dry eyes may benefit from the Boston Ocular Surface Prosthesis, which is a custom contact lens. [6] at rest on the sclera, the prosthesis creates a fluid-filled layer over the cornea, thus preventing dryness of the cornea. [6]

Surgery

In severe cases of keratoconjunctivitis sicca, tarsorrhaphy may be performed when the eyelids are partially sewn. This reduces the palpebral fissure (eye separation), ideally leading to a reduction of evaporation of tears. [3]

Experimental growth factors present

Eye drops containing the factors present in normal tissue, healthy cornea, which are applied topically on the corneal surface are currently in clinical trials of moderate to severe dry eye. These eye drops are currently developing A & G Therapeutics, Inc. of Irvine, California in the U.S..

Prognosis

keratoconjunctivitis dry usually is a chronic problem [6]. The prognosis of the disease shows considerable variation, depending on the severity of the disease. [1] Many patients have mild to moderate cases, and can be treated symptomatically with lubricants [1] provide adequate relief of symptoms [1].

When symptoms are severe dry eye, vision and quality of living is lower. [5] People sometimes feel that their vision becomes blurred with the use, irritation [3] or severe [3] to the point that they have trouble keeping your eyes open [5] or may not be able to work or drive [5]. Those who use a CRT monitor or computer screen all day at work will likely experience extreme discomfort, sometimes to the point of being visually impaired.

Prevention

Experimental Procedures to prevent dry eye are being studied. These methods include topical application of stem cells derived from protein and other nutrients to revitalize the natural protein and nutrient content of the aqueous portion of the tear film.

References

1. "Keratoconjunctivitis Sicca". Emedicine. WebMD, Inc.. 2006-04-21. http://www.emedicine.com/oph/topic695.htm. Retrieved on 11/12/2006.
2. "Keratoconjunctivitis Sicca". The Merck Veterinary Manual. Merck & Co., Inc.. http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/30107.htm. Retrieved on 2006-11-18. "Keratoconjunctivitis sicca." The Merck Manual, Home Edition. Merck & Co., Inc.. 02/01/2003. http://www.merck.com/mmhe/sec20/ch230/ch230d.html. Retrieved on 11/12/2006.
3. "The eyes dry." MedlinePlus Medical Encyclopedia. U.S. National Library of Medicine. 04/10/2006. http://www.nlm.nih.gov/medlineplus/ency/article/003087.htm. Retrieved on 2006-11-16.
4. Michelle (May-June 2005). "Dealing with dry eye." FDA Consumer Magazine. U.S. Administration Food and Drugs. http://www.fda.gov/fdac/features/2005/305_eye.html. Retrieved 2006-11-16.
5. "Dry eyes". Mayo Clinic. Free Mayo Medical Education and Research. 2006-06-14. http://www.mayoclinic.com/health/dry-eyes/DS00463/DSECTION=1. Retrieved on 2006-11-17.
6. M Sendecka, Baryluk A, Polz-Dacewicz M (2004). "Prevalence and risk factors of dry eye syndrome." Przeglad Epidemiol 58 (1): 227-33. PMID 15218664.
7. Kaiserman I, Kaiserman N, Nakar S, S Vink (2005). "Dry eye in diabetic patients. Am J Ophthalmol 139 (3): 498-503. doi: 10.1016/j.ajo.2004.10.022. PMID 15767060.
8. Li H, Pang G, Xu Z (2004). "Tear film function of patients with type 2. "Zhongguo Yi Xue Ke Xue Yuan Xue Bao 26 (6): 682-6. PMID 15663232.
9. A. Peral, G. Carracedo, MC Acosta, J. Gallar, J. Painter. "Increasing levels of Diadenosine Polyphosphates in Dry Eye" (2006) Invest. Ophthalmol. Vis. Sci.47 (9) :4053-4058 [1]
10. Lemp MA. (2008). Management of dry eye. "American Journal of Managed Care 14 (4): S88-S101. PMID 18452372.
11. Tatlipinar S, Akpek E (2005). "Topical Cyclosporin in the treatment of ocular surface disorders." Br J Ophthalmol 89 (10) 1363-7. doi: 10.1136/bjo.2005.070888. PMID 16170133.
12. L Barber, S Pflugfelder, J Tauber, G Foulkes (2005). "Phase III safety evaluation of cyclosporine 0.1% ophthalmic emulsion administered twice a day to dry the disease of patients with eye for a maximum of three years. "Ophthalmology 112 (10): 1790-4. doi: 10.1016/j.ophtha.2005.05.013. PMID 16102833.
13. MiljanoviÄ B ‡, Trivedi K, Dana M, J Gilbard, Burying J, Schaumberg D (2005). "Relationship between dietary n-3 and omega 6 fatty acids and clinically diagnosed dry eye syndrome in women." Am J Clin Nutr 82 (4): 887-93. PMID 16210721.
14. Rashid S, Y Jin, T Ecoiffier, Barabino S, M Schaumberg, Dana MR (2008). "Topics Omega-3-6 and omega fatty acids to treat dry eye. "Arch Ophthalmol 126 (2): 219-225. Doi: 10.1001/archophthalmol.2007.61. PMID 18268213.
15. C Creuzot, M PASSEMARD, Viau S, Joffre C, Pouliquen P, Elena PP, Bron A, Brignole F (2008). "Improvement of dry eye symptoms with acid polyunsaturated fatty acids. J Fr Ophtalmol 29 (8): 868-73. doi: JFO-10-2006-29-8-0181-5512-101019-200606358. PMID 17075501.
16. Micromedex Health Series (electronic version). Thomson Micromedex, Greenwood Village, Colorado, USA. Available at: http://0-www.thomsonhc.com.library.uchsc.edu:80 (Cited: 09/05/2006).
17. Barber LD, Pflugfelder SC, Tauber J, Foulks GN. Phase III safety evaluation of cyclosporine ophthalmic emulsion 0.1% administered twice daily patients with dry eye disease for up to three years. Ophthalmology. October 2005, 112 (10) :1790-4.
18. "Restasis (PDF). Allergan. January 2008. http://www.allergan.com/assets/pdf/restasis_pi.pdf. Retrieved on 07/23/2008.
19. Dantal J, M Hourmant, Cantarovich D, Giral M, Blanch G, B Drain, Soulillou JP. (1998). "Effect of long-term immunosuppression in kidney-graft recipients on the incidence cancer: randomized comparison of two cyclosporine regimens. "Lancet 351 (9103): 623-628. doi: 10.1016/S0140-6736 (97) 08496-1. PMID 9500317.
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About the Author

Drs. Al-Qahtani and Maguire are Co-Founders of A & G Skin Solutions, Inc. of Irvine, California, USA(www.agskinsolutions.com). Both Al-Qahtani and Maguire are NIH-supported research scientists, professors at medical schools, with numerous peer-reviewed publications. Maguire was awarded the NIH’s prestigious Fogarty Fellowship for his work in studying the nervous system, and Al-Qahtani has received numerous international awards for his work in immunology and medicine. Both professors have been working on stem cells dating back to 1997

Karl Steudel, Boston Celtics, New England Eye Center, Lasik

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