In today's digital environment Dry Eyes and associated symptoms have become an epidemic. This presentation was recently delivered at a Pharmacy convention in Sydney Australia. It is applicable for anyone with dry eye problems.

1. Dry Eyes
“There Won’t Be a Dry Eye in the House”
Dr Jim Kokkinakis
BOptom FAAO FISCLS GCOT

2. Before We Start
Let’s Get It On The Table!

3. Outline
 What is it?
 How Common is it?
 Causes
 Current Treatments
 MUST DO’s&
 MUST NOT DO’s
 When to Refer

4. What are Dry Eyes?
 This might sound stupid
 But…
 The definition keeps evolving

5. DRY EYE DEFINED – DEWS REPORTS
1995
Dry eye is a disorder of the tear film
due to:
tear deficiency or
excessive evaporation,
which causes damage to the ocular
surface and is associated with
symptoms of ocular discomfort.”

6. 2007
“Dry eye is a multifactorial disease of:
The Tears and Ocular Surface that results in
symptoms of discomfort,
visual disturbance,
and tear film instability
with potential damage to the ocular
surface.”
“It is accompanied by increased
osmolarity&inflammation of the ocular surface.”

7. “MeibomianGland
Dysfunction
may be the leading cause of
dry eye syndrome.”
September 2008 statement
by prestigious
Tear Film & Ocular Surface Society
(TFOS)
following 2007 DEWS Report
A NEW PARADIGM FOR DRY EYE

8. Let’s Rewind – Back to Basics

9. The Tear Film is NOT Simple!
EVEN THIS IS SIMPLIFIED
THERE ARE NEARLY 1000
DIFFERENT COMPONENTS TO
THE TEAR FILM

10. What is a Tear Film?
 Basically
 3 layers
 Lipid
 Aqueous
 Mucin

11. How is it
Formed?
 Aqueous
◦ Lacrimal Gland
 Mucin
◦ Goblet cells
 Lipid
◦ Meibomian Glands

12. Tears are Hormonally Driven

13. The Lacrimal Gland - Aqueous

14. Goblet Cells – Mucin

15. Meibomian Glands - Lipid

16. Lid Eversion

17. Tear Film Irregularity

18. Lipids Stop Evaporation
 A reasonable quantity
of lipid inhibits:
 Aqueous evaporation
And
 Reduces Dry Eyes

19. Lipid Deficiency
Of all dry eyes presenting to an eye clinic:
86% had either lipid deficiency on its own
or in combination with aqueous deficiency
Distribution of aqueous-deficient and evaporative dry eye in a
clinic-based patient cohort: a retrospective study.
Lemp MA, et al. Cornea. 2012

20. Add The Oil!
MOST EYE
DROPS
ONLY DEAL
WITH
AQUEOUS
DEFICIENCY!

21. What Are the Symptoms?
 There are a multitude:
◦ grittiness,
◦ glare sensitivity
◦ burning,
◦ itchiness and ironically
◦ can then cause excessive tearing??

22. Causes of Dry Eyes
 Age
 Autoimmune disease
 Computer use
 Incomplete blink
 Environment
 Contact Lenses
 Preserved Eye drops
 Oral Medications
 Laser Eye Surgery
 Eyelid anomalies

24. Oral Medications & Dry Eyes
 Anti-Hypertensives
◦ Diuretics
 Antihistamines
 Decongestants
 Hormones
◦ Estrogens (increase)
◦ Androgens (decrease)
 Antidepressants
◦ Anticholinergic effects

25. Oral Medications & Dry Eyes
 Pain Relievers
 Dermatologic
◦ Roaccutane
 Gastrointestinal
◦ Proton Inhibitors
◦ H2 inhibitors
 Chemotherapy
 Antipsychotics

26. Causes & Associations
52%
10%
8%
18%
12%
Primary associations with dry eyes
Meds
Gender
Acute Inflammation
Age
Other

27. The Dry Eye Culprits
OPTOMETRISTS!
Pharmacists!
But How
Can That Be?
GP’s

28. The Dry Eye Culprits
Optometrists
Prescribe Preserved
Solutions…
to clean Contacts
Pharmacists
Prescribe Preserved
Decongestants
(Benzalkonium
chloride)
Do not realise that all
contact solutions are
NOT same

29. The Dry Eye Culprits
General
Practitioners
Poly-Pharmacy!

30. Treatments of Dry Eyes

31. Treatment Algorithm 1
 Level 1
◦ Education
 Blinking
◦ Modify Environment
◦ Control Systemic
medications
◦ Control Allergy
◦ Preserved Tears
◦ Mist Sprays

32. Treatment Algorithm 2
 Level 2
◦ Unpreserved Tears
◦ Lid heat & Massage
◦ Gels & Night-time
Ointments
◦ Nutritional Support
◦ Topical Steroids
◦ Topical Cyclosporine

33. Treatment Algorithm 3
 Level 3
◦ Oral Tetracyclines
◦ Punctal Plugs
 once inflammation is
controlled

34. Treatment Algorithm 4
 Level 4
◦ Systemic
immunosuppressants
◦ Moisture Goggles
◦ PunctalCautery
◦ Neuralgia Pain?
 Lyrica??

35. New Treatments
 LipiFlow
◦ MGD is part of most
dry eyes
◦ Concurrent massage
and heat
◦ Expensive
◦ Needs repeating
every 12 months

36. Before LipiFlow Treatment

37. After LipiFlow Treatment

38. Where Do I Start?
 Mainstay are tear
replacements
◦ Non-Viscous
◦ Viscous
◦ Mist Sprays
◦ Preserved
◦ Unpreserved

39. Non-Viscous Tear Replacements
 By far the most
commonly used
 Reasonable for very
mild occasional
symptoms
 Disadvantages
◦ Lose effect very quickly
 What about
preservatives?

40. Viscous Tear Replacements
 Better for moderate
symptoms
 Advantages:
◦ Last Longer
 Disadvantages
◦ Temporary Vision blur
 Preservatives?

41. Mist Sprays
 Perfect for mild to
moderate dry eyes
 Unique delivery
system
 Can be used with:
◦ Makeup
◦ Contact Lenses

42. Mist Sprays
 Remains sterile for 6
months
 NO Vision disturbance
 Effective up to 4 hours
 Restores Lipid layer

43. Mist sprays
 Spray directly onto
a closed eye
◦ This makes
instillation simple
 Elderly have
difficulty with drops
◦ This is also ideal for
them

44. Mist Spray
Actimist is slowly
released
This means it is long
lasting

45. When to refer
 Sometimes…
◦ LESS is MORE
 Try to NEVER use
DECONGESTANTS
◦ These are addictive
and a toxic cause of
dry eye
 Never use Chlorsig
if dry eye is present
 If minimal relief
occurs
 If drops are
required > QIDIF YOU SUFFER
FROM DRY EYE
MAKE AN
APPOINTMENT
TO SEE
DR JIM
KOKKINAKIS

46. Questions?