Dry eye is a chronic symptomatic condition which, if not addressed promptly and appropriately, can lead to ocular surface disease. It is estimated that approximately 100,000,000 people suffer from it worldwide. Often, it is underdiagnosed and remains untreated, while in other cases it is underestimated and treated only symptomatically with tear substitutes and\/or corticosteroids, depending on the case.<\/p>\n
The disease is multifactorial, and the loss of integrity of the tear film initially affects visual function to a limited extent, while in severe cases it may even lead to vision loss.<\/p>\n
<\/p>\n
Dry eye is a multifactorial disease of the ocular surface characterized by the loss of homeostasis of the tear film and accompanied by ocular symptoms. Etiological factors include tear film instability and hyperosmolarity, inflammation, ocular surface damage, as well as various neurosensory abnormalities.<\/p>\n
The new definition allows the inclusion of subclinical conditions that involve ocular surface changes without the presence of symptoms.<\/p>\n
The complex and sensitive system of ocular surface homeostasis is affected by various environmental and habitual factors, hormonal changes, age, multiple local ocular and systemic diseases, as well as the use of both topical and systemic medications.<\/p>\n
Symptoms vary in intensity and type and are not easily distinguishable between the different categories of dry eye, making diagnosis challenging.<\/p>\n
Chronically affected patients are not easily diagnosed and often use various formulations without significant or long-term effect.<\/p>\n
Today, a decisive step in management is recognizing the specific dysfunctions of the components responsible for maintaining ocular surface homeostasis.<\/p>\n
These components include:<\/p>\n
a) Eyelids \u2013 their position, functionality, blink quality and frequency, and the glands producing the lipid layer of the tears
\nb) Conjunctiva \u2013 with goblet cells that produce mucin
\nc) Limbal region (sclero-corneal border) \u2013 responsible for epithelial renewal of the cornea with its specific microenvironment
\nd) Cornea \u2013 with its rich neural network
\ne) Lacrimal apparatus \u2013 including the secretory glands of the aqueous layer and the lacrimal drainage system
\nf) Sensory and motor innervation of the above structures<\/p>\n
Based on the cause and resulting dysfunction, a stepwise approach to management is determined, aiming ultimately to improve the patient\u2019s quality of life.<\/p>\n
The approach to correct diagnosis includes a complete history (habits and occupation), a questionnaire, a stepwise and organized examination of the structures maintaining ocular surface health, a summary of results, and management based on the cause, resulting dysfunction, and severity of findings.<\/p>\n
It is important for ophthalmologists to acquire both theoretical knowledge and practical skills because there is no single diagnostic test to confirm the presence of dry eye and ocular surface disease (OSD).<\/p>\n
Combining various diagnostic tests increases the accuracy of diagnosis, leading to better management.<\/p>\n
Understanding the pathophysiological mechanisms, knowledge of different examination methods, and integrated presentation of results will lead to diagnosis and initial proper management.<\/p>\n
The following analysis outlines the steps for diagnosis and management as a guide to improving the approach and treatment of these patients.<\/p>\n
INSTRUCTIONS:<\/p>\n
Diagnosis and Management of Ocular Surface Disorders Defined as Dry Eye and Blepharitis<\/p>\n
aims to<\/p>\n
Identify patients suspected of developing ocular surface disorders (OSD)
\nSafely diagnose patients with OSD
\nDetermine the causes of OSD
\nManage dysfunctions and improve patients\u2019 quality of life<\/p>\n
Educate and inform both patients and other healthcare providers involved in ocular surface dysfunctions to achieve comprehensive management
\n1.\u00a0 \u00a0 \u00a0 When surface damage is primary and tear production is very low, diagnosis is made using the Schirmer test and the Oxford scale is used to grade severity. In this case, aqueous tear deficiency from the lacrimal gland is investigated for Sj\u00f6gren syndrome and non-Sj\u00f6gren syndrome.<\/p>\n
2.\u00a0 \u00a0 \u00a0 Tear film instability disorders, along with findings from Meibomian glands and eyelashes, indicate increased evaporation.<\/p>\n
3.\u00a0 \u00a0 \u00a0 Exogenous factors such as contact lens use, eye drops, ocular surface disease, and environmental factors are investigated regarding the cause and type of disorder.<\/p>\n
History<\/p>\n
Patient demographics<\/p>\n
History of symptom onset, duration, exacerbations and remissions, previous treatments, and symptom progression over time<\/p>\n
Investigation of habits, occupation, environmental factors, and their effect on symptoms<\/p>\n
Complete ophthalmic history including surgeries, use of eye drops, and contact lenses<\/p>\n
Complete medical history and history of systemic medications<\/p>\n
Questionnaire: OSDI (Ocular Surface Disease Index) \u2013 the most widely used. Helps with initial symptom assessment and is used during management to monitor treatment response.<\/p>\n
Evaluation of Symptoms\/Findings<\/p>\n
The primary diagnostic symptom of dry eye is intermittent blurred vision.<\/p>\n
There may be a discrepancy between symptoms and findings, either in early stages (many symptoms with few findings) or in advanced stages (many findings with few symptoms).<\/p>\n
Ophthalmic examination is targeted to diagnose tear and ocular surface disorders.
\nTear film and ocular surface evaluation via slit-lamp examination
\nTear quantity assessment: Schirmer test (<5 mm reliable) or phenol red thread test<\/p>\n
Fluorescein Assessment:
\nStaining with Lissamine Green\/Rose Bengal
\nFluorescein\/Rose Bengal\/Lissamine Green characteristics<\/p>\n
Stains healthy cells | No | Yes | No |
\nStains dead\/degenerating cells | No | Yes | Yes |
\nStaining blocked by mucin layer | No | Yes | No |
\nToxicity | No | Yes | Yes |
\nReal diffusion rate through collagen | Very fast | Very slow | Fast |
\nColoring through cell junction breakdown
\nTear film protection insufficient, dead\/degenerating cells, cell junction breakdown
\nOxford scale: Corneal and conjunctival staining grading
\nTear meniscus height assessment (TMH)
\nFluorescein clearance test: Tear drainage assessment
\nTear film stability: TBUT (tear breakup time)
\nTear film dynamics (TF-dynamics): thinning\/movement time
\nConjunctival folds\/looseness (LIPCOF \u2013 CCH)
\nTarsal and bulbar conjunctiva assessment and redness grading, including limbal evaluation
\nOther diagnostic tests:
\nTear osmolarity measurement
\nTear interferometry
\nMMP-9 (metalloproteinase 9) \u2013 ocular surface inflammation marker
\nInflammatory Tear Marker: Measurement of MMP-9 in tears is an objective indicator of inflammation on the ocular surface. The test has 92% specificity and 87% sensitivity for diagnosing the presence of dry eye. In a positive test, the patient is likely to respond to anti-inflammatory therapy. It is also used to monitor the effectiveness of treatment.<\/p>\n
Impression cytology
\nMucin assessment (tear ferning test)
\nTear protein analysis
\nEyelid and Meibomian gland examination
\nEyelid and Lid Margin Assessment:
\nObservation of eyelid position, shape, skin texture, facial appearance, and potential rosacea (cheek telangiectasia, rhinophyma, etc.)
\nAssessment of eyelid functionality: mobility, closure pattern
\nHorizontal lid laxity evaluation (medial-lateral canthal ligaments), lower lid retractors, floppy eyelid check
\nBlink assessment: frequency (increased e.g., dry eye, decreased e.g., Parkinson\u2019s), quality; incomplete blinking reduces Meibomian gland expression and lipid layer distribution, increasing tear evaporation
\nEyelid Margin Examination via Slit-Lamp:
\nEvaluation of eyelash quality, quantity, and position; check for Demodex at base of lashes
\nLid margin shape and position relative to globe; normal: smooth trapezoid in contact with globe; puncta internally positioned without eversion on closure
\nInflammation signs: hyperemia, telangiectasia
\nMeibomian gland orifices: visible, smooth, without secretion, or with abnormal secretion\/atrophy
\nMeibomian Gland Evaluation:
\nMeiboscopy: assesses gland presence, dilation, or atrophy
\nMeibography (Keratograph 5M): records gland morphology, classifies pre-existing damage
\nFunction evaluation: MGEvaluator or manual expression to assess quality\/quantity of meibum: clear, cloudy, granular\/paste-like
\nPressure applied: mild, moderate, or firm; MGEvaluator ensures consistent pressure
\nCount of functional glands per lower lid segment
\nDiagnostic and staging devices for follow-up and treatment efficacy<\/p>\n
Eyelid hygiene: foams, gels, or impregnated pads; selection based on treatment goals
\nTopical therapy:
\nTear substitutes (artificial tears), tailored to type, severity, and patient response
\nSuppression of ocular surface inflammation:
\nCyclosporine 0.5\u20131% eye drops, 2\u20134 times daily
\nAutologous serum 20%
\nMild corticosteroids (fluorometholone or hydrocortisone), varying dose and duration, careful for side effects
\nAntimicrobials (tobramycin, gentamicin, chloramphenicol) for active blepharitis
\nImproving Meibomian Gland Secretion Quality:
\nAzithromycin
\nTetracycline\/doxycycline systemic
\nOmega-3 supplementation
\nTTO (tea tree oil) or impregnated wipes for coexisting Demodex
\nWarm compresses and gland expression
\nBlinking exercises
\nSurgical interventions:
\nConjunctival laxity correction
\nPunctal eversion
\nEntropion\/ectropion\/floppy eyelid correction
\nTarsorrhaphy for exposure
\nCorrective eyelid\/conjunctiva\/lacrimal surgeries
\nAmniotic membrane or limbal stem cell transplant for ocular surface disease
\nPunctal plugs
\nAlternative therapies:
\nHydrophilic contact lenses as a bandage
\nSpecialized glasses to create a high-humidity ocular chamber
\nEnvironmental and systemic factors:
\nIdentify and regulate environmental triggers
\nAddress systemic issues (thyroid, hormone replacement, autoimmune diseases)
\nPatient education:
\nChronicity explanation and treatment rationale encourage compliance
\nTreatment selection is based on findings and patient cooperation
\nRealistic patient expectations
\nOngoing discussion with patient regarding symptom evolution
\nFollow-ups: Regular follow-up visits aim to assess the effect of treatment on both symptoms and ocular surface findings. Any lesions and changes resulting from the therapy are re-evaluated, and appropriate questions are used to investigate the treatment\u2019s impact on the patient\u2019s quality of life. The intervals between follow-up visits are adjusted according to the patient\u2019s response to the proposed therapy. Follow-ups may be frequent initially (e.g., every few days) and gradually become less frequent (once or twice a year) after the condition stabilizes.<\/p>\n
<\/p>\n
Dalianis, A. Karidis, V. Liolios
\nEdited by: Ch. Terzidou<\/p>\n","protected":false},"excerpt":{"rendered":"
Dry eye is a chronic symptomatic condition which, if not addressed promptly and appropriately, can lead to ocular surface disease. It is estimated that approximately 100,000,000 people suffer from it worldwide. Often, it is underdiagnosed and remains untreated, while in other cases it is underestimated and treated only symptomatically with tear substitutes and\/or corticosteroids, depending […]<\/p>\n","protected":false},"author":3,"featured_media":2597,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_mbp_gutenberg_autopost":false,"footnotes":""},"categories":[23],"tags":[],"class_list":["post-2761","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-blog"],"_links":{"self":[{"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/posts\/2761","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/comments?post=2761"}],"version-history":[{"count":4,"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/posts\/2761\/revisions"}],"predecessor-version":[{"id":2825,"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/posts\/2761\/revisions\/2825"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/media\/2597"}],"wp:attachment":[{"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/media?parent=2761"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/categories?post=2761"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/eye-center.gr\/en\/wp-json\/wp\/v2\/tags?post=2761"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}