Lacrimal System/ Tears
Function




Optical
o This is the first refracting surface of the eye. The tears smooth the optical surface so that
vision is clear. This smoothing occurs with blinking.
Protective
o Tears contain a variety of antimicrobial proteins, antibodies, complements and
immunoglobulins which decrease bacteria.
 Lysozyme degrades bacterial cell walls.
 B- Lysin disrupts the bacterial plasma membrane.
 Mucin, the first layer next to cornea, attaches pathogens, moving them away
from the eye.
o Reflex tears flush away particles.
Lubrication
o Tears allow the lid to easily glide over the globe.
Nutrition
o Tears contain oxygen and metabolic end products of the cornea, including CO2 and lactic
acid. It also contains necessary electrolytes to control the physiological pH and
osmolarity, as well as protein factors for growth and wound healing.
Anatomy
Lid Structures
 Upper System
o Puncta
 0.5mm in diameter, on average
o Canaliculi
 2mm vertical
 8mm horizontal
o Common Canaliculus
o Lacrimal Sac
 5x12mm
 Lower System
o Nasolacrimal Duct
 Extends 15-20mm to drain into the inferior nasal meatus
o Valve of Hasner
o Inferior Nasal meatus
Lacrimal Functional Unit
 Structures
o Lacrimal glands
 These glands promote the ocular surface health by producing aqueous tears,
growth factors and other proteins.
 They are regulated by the constant input from the neural network, as well as sex
hormones and other serum factors.
o Ocular surface
 This contributes vital components to the tear film, including lipids and mucins. It
is richly innervated with sensory nerve endings that connect to the neural
network.
o Neural network
 This connects the lacrimal glands to the ocular surface.
 It provides a feedback pathway between the ocular surface and the lacirmal
glands via the brainstem. Signals transmitted over the network regulate tear
production supporting basal tearing and promoting reflexive tearing as needed
to meet environmental challenges.
Tear Layers
 Oil (Lipid)
o This is the most superficial layer of the tear film, roughly 0.1 micron thick.
o It is made up of waxy esters, sterols, cholesterol and lipids, being produced by the
meibomian glands, sebaceous glands of Zeiss, and sweat glands of Moll.
o Its main purpose is to provide a smooth refracting surface and retard the evaporation of
the aqueous component, up to 5-10%. This stabilizes and thickens the tear film.
o It is released upon irritation, release of parasympathetics, during blinks, upon exposure
to histamine.


Aqueous
o The aqueous layer compromises 90% of the tear film, providing the bulk of the liquid
volume of the tears. It is about 7 microns thick.
o This layer is a complex mixture of proteins, mucins, and electrolytes.
 Water, inorganic salts, glucose, urea, trace elements, proteins and glycoproteins
and immunoglobulins.
 It is an isotonic solution.
o It is produced by the acinary secretory cells of the lacrimal gland and accessory glands of
Wolfring and Krause
 The secretions from the acinar cells converge into excretory ducts, then onto
the ocular surface.
o The aqueous provides the bulk of the tear film and acts as a flushing and buffering
system when contamination occurs. It prevents dessication (dehydration) of the
epithelium and transports the principle tear components, e.g. oxygen, bacteriolytic
enzymes, proteins, etc. There is some bacteriostatic function.
Mucous (Mucin)
o This is the innermost layer of the tear film and is 0.02-0.05 microns thick. If deficient,
this causes a more serious dry eye.
o The mucin is produced by the conjunctival goblet cells, crypts of Henle and glands of
Manz
 5-20% of conjunctival epithelial cells are mucin-producing goblet cells. These are
located on the superficial layer of the bulbar conjunctiva.
o Mucin is a layer of hydrated glycoproteins. The soluble mucins are essential for viscosity
and stability of the normal tear film. This helps restrict thin spots and tear break-up
time.
o The purpose of this layer is to provide viscosity and stability during the blink cycle. It
attaches to the epithelium to make the surface hydrophilic, thus reducing the surface
tension. Also, mucous is helpful in trapping debris and bacteria so they can be flushed
away by the lid action
o It can be divided into two sublayers.
 Inner layer- glycocalyx
 Produced by underlying epithelial cells
 Outer layer- mucous
The mucin gel decreases in density toward the tear film surface.
Tear Composition

Composition
o A complex mixture of proteins, mucins and electrolytes.
o Antimicrobial proteins
o Growth factors and suppressors of inflammation
 EGF, cytokines
o Soluble mucin 5AC secreted by goblet cells provides viscosity
 Membrane-bound mucins 1 and 4 help stabilize tear film
o Electrolytes for proper osmolarity
Tear Proteins
 The collection method will affect the protein composition of tears.
o Capillary tubes are atraumatic and mildly stimulatory, giving mainly lacrimal gland
proteins. This is the best method.
o Sponges or filter paper give lacrimal gland fluid, mucous, and epithelial cells. Proteins
may be absorbed to paper. This leads to contamination.
o Stimulation of tears dilutes protein concentration, yet ion concentration is relatively
constant.
 Protein secretion
o Constitutive
 These are the proteins that require something else for their production.
 IgA is a good example. It is dependent on the availability of plasma cells in the
interstitial space.
o Regulated
 Regulated secretion is controlled by intracellular second messengers, via neural
stimulation.

Major proteins
o Albumin
 Major component
 Function unknown
 Control osmolarity?
 Decreased hormonal degradation via transportation
o Lysozyme
 This is a bacteriostatic hydrolytic enzyme, reduced in Sjogrens syndrome.
 Albumin and lysozyme accounts for about 40% of tear proteins
o Lactoferrin
 Very effective chelator (remover) of Fe3+, bacteriostatic
o IgA and Secretory Component (SC)
 Synthesized by interstitial plasma cells, taken up by lacrimal acinar cells and
secreted into the lumen
 Label bacteria to be destroyed or destroy it themselves
 IgA is the most common immunoglobulin.
o IgG is found in very low concentration
o Glycoproteins, i.e. mucous
o Antiproteinases
 These are found in very low concentrations, but levels are increased during
infection.
 They may function to block hydrolytic enzymes produced by bacteria.
o Tissue plasminogen activator
 This activates plasmin, which is needed during epithelial wound healing.
o Epithelial Growth Factor
 Secretion stimulated in response to a cornea wound
Tear Film Thickness and Volume
 Tears are thickest at the lid margins. This is called the tear meniscus.
 The physics of tears has not been sufficiently worked out in order to understand why tears form
at this thickness (7-8um). Clearly, if they were thinner, they may form holes more often,
necessitating more frequent blinking. If they were thicker, gravity could overcome the surface
tension forces and lead to a non-uniform thickness.
 Thickness can be estimated by placing fine glass fibers in the tears and observing the thickness
of fiber needed to peek out of the tear film.
 Thickness can also be estimated by fluorophotometry.
Physical Properties
Tears
Plasma
Osmotic Pressure
0.9% NaCl (300 mOsm/L)
6.62atm
pH
7.4 (7.3  7.7)
7.39
Refractive Index
1.357
1.35
Volume
0.5-0.67g/16hr (Waking)
 Osmolarity increases with KCS and CL wear due to water evaporation (about 320-330 mOsm/L)
Physiology
Formation of Lacrimal Fluid
 The acinus-intercalated duct region secretes a fluid resembling an isotonic ultrafiltrate of
plasma, while the later ductal segments secrete additional potassium and chloride. The ionic
concentration/composition remains constant over a wide range of flow rates, indicating
coordinate control between acini and ductal segments. Secretions from acinar cells converge
into excretory ducts, then moves onto the ocular surface.
 Androgens are important for glandular homeostasis.
 Isolated glands secrete fluid, and can thus be studied experimentally. Secretion is inhibited by
sodium free or chloride free bathing solutions. Fluid secretion is also inhibited by furosemide
(Lasix), a kidney loop diuretic that blocks NaCl cotransport.
 Carbachol, a parasympathomimetic agent, has been shown to increase intracellular calcium
which leads to an increase in potassium permeability causing membrane hyperpolarization, i.e.,
an increase in the driving force for chloride exit. The high calcium also increases chloride
channel permeability. Together all these changes will enhance chloride secretion into the duct.
Sodium must diffuse paracellularly in order to preserve electroneutrality. It has been recently
shown that carbachol will also recruit additional Na/K pumps from the intracellular pool
(endoplasmic reticulum and Golgi) and insert these molecules into the plasma membrane. This
will ensure that the sodium and potassium gradients will not run down during stimulated fluid
secretion.
Lacrimal Flow
 Tears are produced at a rate of 1.2 ul/min. 95% of aqueous comes from the lacrimal gland, while
the remainder comes from the accessory glands (K&W).
o This rate can go up to 70ul/min with irritation.
o The rate can also be decreased with procedures such as LASIK, which cut the nerves.
 Measurement of tear flow
o Clinical
 Schirmer Tear Strip
 Coated threads
 Sponge
 Measure tear meniscus
o Research
 Fluorophotometry
o These are all discussed in depth in the Evaluation portion of this chapter.
Tear Secretion
 Neural control
o Tear secretion in under control of the autonomic nervous system (ANS).
o The main control is the parasympathetic branch.
 This controls the balance and production of electrolytes, water, and proteins.
 Pathway
 Stimulatory messages from the pons  sphenopalatine ganglion leads
to tear secretion.
 Messages are then sent to the zygomatic nerve  lacrimal nerve 
lacrimal gland.
 This is the reason that parasympathomimetic drugs cause tear secretion.
Sympathetic
 Sympathetic stimulation should inhibit tear secretion produced by
parasympathomimetic, possibly due to blood vessel constriction at the same
time as parasympathetic stimulation. Yet, the actions of parasympathetic and
sympathetic systems are not really antagonistic. Not a lot of information is yet
known regarding this.
 Stimulation of the superior cervical ganglion actually can lead to tear secretion.
Sympathomimetics also cause some tear secretion by affecting blood flow to
the gland, which may have secondary effects on secretion.
 Multiple postsynaptic receptors include
 Alpha and beta adrenergic
o Alpha- increases protein concentration
o Beta- no protein effects
 Therefore, different effects with occur with different circumstances
Reflex tearing
o Reflex tearing is usually produced by the main lacrimal and palpebral lacrimal glands. It
is controlled by the ANS, with the parasympathetic system responsible for the afferent
pathway stimulating lacrimal gland secretion.
o Reflex tearing produced by afferent pathways may originate from trigeminal nerve
stimulation associated with corneal irritation, optic nerve stimulation from bright light,
or CNS stimulation from emotional trauma.
o

Tear Removal
 Evaporation
o Evaporation accounts for 25% of tear removal.
 The rate is the same with males and females, and it does not change with age.
o When there is an increase in osmolarity, water is pulled out of the cornea, increasing
the rate of evaporation.
o This rate is measured with a closed system measuring humidity.
o Basically, everything disrupts and increases evaporation, including saline, proparacaine,
and contact lens wear.
 Drainage
o 60% of tears drain through the inferior puncta. Some drain through the superior puncta,
but this is only utilized with increased tear production.
o Mechanism
 The orbicularis oculi contracts and closes lateral to medial, forcing tears to the
lacus lacrimalis. This pulls on the lacrimal sac wall. It also shortens the caniculi,
and the punctum dips into the lacus lacrimalis, sucking up tears. This can also be
aided by gravity and inhalation during respiration.
 This is demonstrated when carbon particles are placed in the eye. The
lid action will bring the particles to the margin, and particles can be seen
to move toward the puncta after each blink.
 The movement is due to Marangoni’s Law, which says that tears flow to
areas of higher temperature and higher surfactant concentration.
 As the lid begins to open after a blink, the tear fluid is drawn into each
canaliculus by capillary forces, and the lacrimal sac collapses. During the blink,
the canaliculi shift medially and become compressed and shortened.
Compression forces fluid into the now opened lacrimal sac. This is known as the
Jones Lacrimal Pump Theory.
 The fluid pressure within the lacrimal sac can be measured by placing a
very thin canula connected to a pressure transducer into the upper
puncta. Pressure in the canaliculi and lacrimal sac shows a brief positive
spike at a blink, followed by a slower negative transient, which
presumably can suck tears into the canaliculi.

Absorption
o Tears flow through the membrane into the lymphatics. The rate is up to 2ml/min. This is
what occurs during sleep.
o Technetium tracer studies show tracer remaining in the lacrimal sac when a head is on
its side, running down the nasolacrimal duct only after holding the head upright. Since
tears did not spill out of the eye, they must have been absorbed across the conjunctiva
and lacrimal sac epithelium.
With eye closure
 Increased temperature and respiratory quotient
 Decreased tear osmolarity
 Decreased pH
 Decreased pO2
 Increased cellular debris
 Decreased metabolic waste removal (lactic acid)
Evaluation
Patient Questionnaire
 Dry Eye Questionnaire (DEQ)
 National Eye Institute Visual Function Questionnaire (NEI VFQ-25)
 Ocular Surface Disease Index, OSDI
Vital Stains
 Sodium Fluorescein
o Purpose
 Penetrates cornea through an epithelial defect
 Evaluates integrity of the cornea
 Evaluates CL, HSV, abrasions, erosions, TBUT
 This is one of the most effective means of evaluating the integrity of the cornea.
o Procedure
 Wet fluorescein strip with solution
 Fixate patient’s eyes upward, gently grasp and control the eyelids, apply strip
inside lower lid
 Use two different strips if the infectious anterior segment disease is
suspected.
 Have patient blink several times to distribute dye
 Evaluate the anterior segment with cobalt blue filter (slit lamp or burton lamp)
 High illumination, moderate magnification, narrow beam
o Appearance
 Areas of highly fluoresced areas indicate defects or depressions
 Areas of darkness or non-fluoresced areas indicate uneven distribution of tears
or elevations (negative staining)
 Only seen on conjunctiva with very large defects
 Will be seen darker at the area of application.
o Diagnosis
 In inferior two thirds, at palpebral aperature
 Toxic
 Incomplete blinker
 Diffuse
 Allergic
 Conjunctivitis
 Toxicity
 Rose Bengal
o Purpose
 Stains devitalized tissue and mucous
 Good for dry eye, filamentary keratitis, and HSV.
 Stains early damage to limbal conjunctival tissues
 Seen easier on conjunctiva than NaFl
 Useful in patients with dry eyes
 May demonstrate protective effect on the precorneal tear film
 Increased RB with decreased protection
 Reduced tear volume causes a degeneration of corneal and conjunctival
epithelium especially in the exposed interpalpebral aperture.
o Procedure
 Stings and stains!
 Available in strip form
 Apply strip same as fluorescein strip- need a lot!
 Red-free light enhances the appearance.
 Staining looks purple.

White light can also be used.
o


Appearance
 Defects indicate a reddish appearance indicating the collection of the stain by
the devitalized cells. The more damaged the cell, the brighter the intensity of
this stain.
 Van Bijstervald Criteria
 Grade on a 0-3+ scale for 6 areas of the eye
 6 areas of the eye are evaluated for staining
 Interpretation
 3.5 or greater total for one eye is diagnostic for KCS
 The diagnosis of KCS is positive when a characteristic triangular stippled staining
of the temporal and nasal bulbar conjunctiva (base towards limbus) in the
interpalpebral area and punctuate staining of the inferior two-thirds of the
cornea is observed.
Lissamine Green
o Purpose
 Stains dead/devitalized cells in a similar manner to Rose Bengal. Mucous is not
stained.
 Mainly stains conjunctiva
 Does not sting as much as RB
 Currently sold in strip form
 Useful for early KCS
o Procedure
 Apply into the eye in a similar manner as RB
 Use white light.
o Appearance
 Stains both corneal and conjunctival devitalized cells
Summary
Stains healthy cells
Stains devitalized cells
Stains mucous
Irritation
Light Source
Toxicity
Sodium Fluorescein
No
No
No
Minimal
Cobalt Blue
No
Rose Bengal
Yes
Yes
Yes
Stinging
White or Red-Free
Yes
Lissamine Green
No
Yes
No
Minimal
White Light
Yes
Biomicroscopy
 Lid Margins
 Corneal epithelial abnormalities
o Dry spots
o Punctuate epithelial keratopathy
o Mucous adherent to degenerated corneal epithelial cells (filaments or plaques)Filamentary keratopathy
o Corneal thinning and perforation can complicate KCS.
Evaluation of the Tear Meniscus
 In the normal eye it is 0.3-0.4mm.
Evaluation of Blinks
 Look at the blink rate and completeness of blink.
Tear Break-Up Time (TBUT)
 Tear quality is assessed clinically using the tear break-up time test (TBUT). A small amount of
fluorescein is instilled in the eye and the patient is asked to blink a few times and then hold the
lids open. In 10-30 seconds, dark spots will appear on the corneal surface (breakup), indicating a
local thinning of the tears. A very thin tear layer (aqueous insufficiency), mucin insufficiency, a
damaged epithelial surface or a poor lipid covering could all lead to a faster than normal
breakup time.
o Fluorescein breaks lipid, so decreased TBUT
o Non-invasive techniques found. Use slit lamp and grid. Look for distortion in grid. Has
>TBUT.
o Tear scopes.
 Purpose
o Measure mucin layer stability
 For patients with “burning” eyes, unstable refractions, etc.
 Procedure
o Apply several drops of an unpreserved solution to a fluorescein strip.
 Preserved solutions destabilize the tear film.
 Use fluorescein, not fluress
 Less is better. Micro-quantities of fluorescein (<5 ul) yield more precise, reliable
TBUT measurements
o Gently touch the strip to the inferior tear meniscus
o Have the patient blink several times and wait 30-60 seconds.
o Position the patient at the slit lamp
o Adjust the slit lamp to diffuse beam with cobalt blue filter
o Instruct the patient to refrain from blinking and look straight ahead
o Scan the cornea and count time until black spots or lines appear in tear film
 Focus on the bottom of the tear film
o Test also stops when the patient blinks their eye
o Calculate the mean time in seconds for three trials
 Interpretation
o Classic
 <10 seconds considered abnormal
 10-15 borderline (equivocal)
 >15 seconds- normal
o Today’s


 <5 seconds considered abnormal
 5-10 seconds borderline (equivocal)
 >10 seconds- normal
Non-Invasive TBUT
o Use a keratometer to look for appearance of distortion
 No dye required
o Normal is 20 seconds or greater
Factors affecting TBUT
o Decreased by
 Topical ointments
 Preservatives
 Topical anesthetics
 Estrogen phase of menstrual cycle
o Increased by artificial tears
o Temperature and humidity have little effect on test results
Tsaboto Dry Eye Testing
 Have the patient blink and close one eye. Hold the lid up. How long does it take to lose the
20/20 line?
 >15 seconds is normal.
Tear Secretion Tests
Schirmer Test I (Without Anesthetic)
 Purpose
o Measures reflex and basal secretions
o Determines the maximum amount of basal secretion
o Moderate to severe KCS
 You want to know absolutely how much tears they can produce
 Procedure
o Do this pre-tonometry
o A 5cm paper strip (Schirmer strip) is folded at the notch and placed within the lower culde-sac near the outer one-third of the lid (nearest the outer canthus)
o Do not touch the part that is placed in the eye. It could cause bacterial infections. The oil
could also stop the tear flow.
o Once in place, the patient remains sitting with their eyes either open or closed.
o After 5 minutes, remove the strips and measure the amount of wetting with a
millimeter rule from notch.
 Interpretation
o 5mm or less of wetting is considered abnormal
o 5-10mm is mild to moderate dry eye
o >10mm is considered normal
o This is an irritating procedure. Tears can evaporate, and the result can be affected by
the basal tear volume.
 Graph
o Has a basal tear volume effect

 Due to excess aqueous.
o Tear production rate
Influenced by
o Anesthetic
o Temperature, humidity, evaporation
Jones Basal Secretion Test (With anesthetic)
 Purpose
o Measurement of basal tear secretion produced by the accessory lacrimal glands (Kraus
and Wolfring)
 Anesthetic decreases the reflex response
o Evaluation of minimal amount of tear secretion
o Suspected mild KCS or CL related dry eye
o Note that this test lacks statistical support.
 False positives (values less than 10mm) or negatives (values greater than 10mm)
occur in approximately 15% of Schirmer tests.
 Procedure
o Prior to placement of Schirmer strips, one drop of topical anesthetic is placed in the eye.
o Wait approximately 1-2 minutes and blot the inferior cul-de-sac with their a cotton-tip
applicator or Kleenex to remove excessive anesthetic and reflex tears
o Keep room illumination low so as to not cause reflux tearing due to bright lights.
o Continue as in the Schirmer I test
 Interpretation
o 5mm or more is considered normal
Short Basal Secretion Test
 Identical to that of the basal secretion test, however, strips are removed after one minutes
 Results are multiplied by a factor of three to extrapolate to a five minute value. Interpretation of
these results are the same as Schirmer and Basic Secretion Test
Schirmer II Test
 Purpose
o Measures reflex secretions.
 Procedure
o Instill topical anesthetic in each eye
o Wait 30 seconds to 1 minutes and remove excess tears from inferior cul-de-sac
o Place strips in both eyes
o Using a cotton-tip applicator, irritate the nasal mucosa for approximately 10-15 seconds
on one side.
 Interpretation
o <10mm of wetting strip after 2 minutes suggests impaired reflex tearing
Sno Strips
 Purpose
o Same function as Schirmer Strips
 Procedure
o

Perform same as Schirmer test except place strip in each eye and wait until 10mm are
wet with tears
o Measure time period from insertion of strip to achieved 10mm wetting
Interpretation
o 3-5 min- sufficient secretion
o 5-10min- borderline
o >10 minutes- insufficient
Phenol Red Thread Test
 Indications
o Measures the basal tear secretion
 This is because it is smaller, there is decreased reflex tearing due to decreased
irritation
 Procedure
o Take crimped end of thread out of the packet
o Place quickly in the lateral canthi of both eyes
o Leave in the eye for 15 seconds
o Thread turns red with tears
o Remove and measure
 Interpretation
o 9-18 mm is considered normal
Summary
Test
Schirmer I
Basal Secretion
Short Basal
Sno-Strips
Phenol Red
Schirmer II
Tearing
Reflex/ Basal
Basal
Basal
Reflex/ Basal
Basal
Reflex
Time
5 min
5 min
1 min
10 min wet
15 sec
2 min
Abnormal
<5mm
<5mm
<5mm
>10 min
<9mm
<10mm
Sponge
 In this process, tears are collected with a sponge, which is then weighed. The process is not very
convenient, and it gives low values (0.5ul/min), probably due to some evaporation. It can also
block drainage. Since the sponge is not specific, mucous, oil, etc, are also collected.
Lactoferrin Test (Lactoplate)
 Designed to measure levels of lactoferrin, a tear protein. The lactoferrin level is an indicator of
lacrimal gland secretory activity.
 Procedure
o Using forceps, place the filter paper disc in the inferior fornix and allow time for
sufficient wetting (approximately 5 min)
o Remove the disc and place on the Lactoplate reagent pad
o After 2-3 days, measure the size of the precipitate ring with the template provided and
convert to mg/ml


Interpretation
o Average lactoferrin level = 1.4 mg/ml
o Levels <0.0 mg/ml are considered to be abnormal and suggestive of insufficient lacrimal
secretory activity.
Touch Tear Microassay Test (Touch Scientific, Inc)
o 2 microliter capillary tube is placed into the inferior tear meniscus
o Transferred to a card with rabbit antibody to lactoferrin
o Apply conjugate, wash, and substrate solutions
o Placed into a reflectance spectrophotometer
o Results within 10-15 minutes
o Comparable accuracy to Lactoplate test
Diagnostic Punctal Occlussion
 Punctual occlusion with a collagen, intracanalicular iplant is used to increase the time that tears
remain in contact with the eye by decreasing tear drainage
o Temporary occlusion with collagen plugs is a diagnostic procedure used to determine
how a patient would respond to long-term punctual occlusion therapy.
o This is more diagnostic and not treatment, because the plugs dissolve.
 Procedure
o Anesthetize the punctum with proparacaine (optional)
o Evaluate the size of the puncta to use the appropriate size implant.
o Gently roll the lid from the eye and direct the patient’s fixation superior temporally.
Visualize the puncta.
o Grasp the collagen implant and insert vertically into the punctum
o Quickly push the plug below the surface of the puncta.
 The plug will quickly swell so there are only a couple of seconds to complete the
procedure.
o The implant may be inserted behind the biomicroscope or in free space with the aid of a
magnifying loupe.
o The patient should be instructed to avoid rubbing their eyes.
o The patient returns in 7-10 days for follow-up.
 Interpretation
o Re-evaluate the patient in approximately one week (the inserts dissolve within 7 days)
o If significantly improvement in signs and symptoms, consider more long-term occulssion
therapy such as silicone plugs or punctual cautery.
Other Tests
 Fluorophotometry
o With this procedure, a known volume and concentration of fluorescein dye is applied
and the dilution is measured with time. Special instrumentation (fluorophotometer) and
complicated data analysis is required. Using this technique, it was shown that tear
production decreases about 20% in 40-63 age group.
o Although with this procedure there is decreased irritation, it is very expensive and
difficult to perform.
o Graph
 Decreases quickly, because the dye is an irritant and increases tears to wash it
away.
 The second slope is the true rate.
This is affected by many drugs, such as antihypertensives, beta blockers, decongestants,
antihistamines, tranquilizers, and BCP.
Tear Osmolarity
Tear Evaporation
o


Tear Drainage Tests
Fluorescein Dye Disappearance Test
 NaFl is instilled into the patient’s eyes (2 strips). Apply an equal amount to both eyes.
 After 5 minutes, the inferior cul-de-sacs are examined to determine the amount of dye retention
in the lacrimal lake
 Dye retention is graded on a 1-4+ scale
o 1+ is little or no dye retention
o 4+ is maximum retention, which can be problematic
 Asymmetry or prolonged presence suggests poor drainage.
Jones No. 1 Dye Test (Primary Dye Test)- Fluorescein Dye Appearance Test
 NaFl is instilled to the eye
 After 5 minutes, dye should appear under the inferior turbinate as it is explored with cottontipped applicator
o 10 minutes if the patient is older. Can see up to 60 minutes, depending on the amount
of dye.
o The applicator must be placed 1-2cm up and then laterally inside the nose
 The results may be enhanced by having the patient blow their nose into a tissue. A burton lamp
will allow visualization of the dye. Must do one eye at a time.
o Also look at the back of the throat
 If dye is detected, it is considered a positive finding
 If no dye is detected, then perform Jones No 2 Test
o Jones I test is falsely negative (no dye discovered) in 22% of tests.
Jones No. 2 Dye Test (Secondary Dye Test)- Lacrimal Dilation and Irrigation
 The lacrimal drainage system is dilated and irrigated
 Wait 5 minutes after Jones No 1.
 If dye does not appear with Jones No 1, but is detected with the Jones No 2, then there is a
functional block. The block is in the sac/duct.
 If only saline appears in the nose, blockage is in the canaliculi or puncta. Fluorescein does not
reach the sac.
 If no dye appears with Jones No 1 or No 2, there is an anatomical block/ complete obstruction.
 Procedure
o Punctual Dilation
 Purpose
 Mechanical enlargement of the lacrimal puncta
 Procedure usually involved the lower puncta
 The upper puncta may also be dilated
 Procedure

o
Topical anesthesia is instilled, usually 1-2 drops per eye. Deeper
anesthesia achieved by soaking a cotton-tipped applicator with
anesthetic and placing it over the lacrimal puncta for 1-2 minutes.
 A lacrimal dilator of the correct size is placed vertically into the puncta
and gently rolled between the thumb and index finger. Downward
pressure is required to expand the punctual ring.
o After 2mm of downward insertion, the dilator is reoriented
horizontally (nasally) and the forward motion is continued while
applying temporal tension on the lid.
 Using larder dilators or those with a faster taper can be used to insure
adequate dilation. After approximately 30 minutes, the puncta will
return to its original diameter.
Lacrimal Irrigation
 Purpose
 Irrigating solution (usually saline) is flushed through the lacrimal
excretory system to evaluate its integrity
 Irrigation of the nasolacrimal system following an infectious process
 Procedure
 Dilation usually precedes irrigation to ease insertion of the irrigating
cannula
 A 23 gauge cannula is inserted vertically for 2mm, then is tipped 15
degrees below the horizontal plane.
 Stretch the lower lid temporally. The cannula may then be inserted until
it meets the wall of the lacrimal sac, approximately 8mm nasally.
 Gently apply pressure to the syringe to release saline.
 Interpretation
 The drainage system is open if the patient coughs or tastes salt in their
throat.
o Alternative: can used a saccharine based solution so the patient
can taste something “sweet.”
 If the drainage is blocked, resistance will be felt when pressure is
applied to the plunger. Do not force it!
o If fluid expressed through the opposite puncta blockage is distal
to common canaliculus.
o If plunger does not move and no fluid expressed through
opposite puncta or is regurgitated through same puncta, then
blockage is proximal to common canaliculus.
Lacrimal Probing
 Purpose
o Probing of lacrimal drainage system indicated when irrigation reveals blockage
 Procedure
o Repeat topical anesthesia
o A lacrimal probe is inserted into puncta and canaliculus (Bowman probe commonly
used)
o If resistance to the probe felt approximate the blockage site by measuring length of
probe which is inserted.

Interpretation
o A “hard stop” noticed when the probe contacts the medial wall of the lacrimal fossa
(normal).
o A “soft stop” is noticed when probe hits an obstruction or collapses the lacrimal sac
against the lacrimal fossa (abnormal)
Pathology
Dry Eye (aka Dysfunctional Tear Syndrome)
 Definition
o This is a mutlifactorial disease of the tears and ocular surface, resulting in symptoms of
discomfort and visual disturbances. It is accompanied by increased osmolarity of the
tear film and inflammation of ocular surface.
o It is progressive, with increasing severity marked by a cumulative sequence of events,
including loss of goblet cells, epithelial desquamation, and destabilization of the corneatear interface.
o The average dry eye patient suffers with symptoms related to his or her disease for 6.5
years before seeking care from an eye-care practitioner. Patients have rated dry eye
similar to moderate angina in terms of it affecting their daily lives. Many individuals selfmedicate with OTC products.
 Epidemiology
o Multiples studies estimate the prevalence of dry eye from 3.5-14.4%, depending on the
population involved and the definition of dry eye.
o In the US, about 3.2 million women and 1.7 million men over the age of 50 are reported
to have dry eye.

Pathogenesis
o
o
o

In the lacrimal glands, degenerative processes (such as a decrease in androgen levels or
neural stimulation) may cause inflammation. The inflammation causes cytokine
production and activation of T cells, leading to increased levels of inflammatory
mediators in the tear film and possibly apoptosis of acinar cells of the lacrimal glands.
On the ocular surface, inflammatory mediators in the tear film cause inflammation. This
can disrupt epithelial cell function and interfere with mucin production.
Constant stimulation from the neural network is essential to maintaining the function of
the lacrimal glands. Several factors can disrupt this stimulation. Inflammatory cytokines
in the lacrimal glands inhibit the activity of secretomotor nerve endings in the glands
and inflammation on the ocular surface decreases corneal sensitivity by both promoting
degeneration of afferent corneal neurons and by thickening the ocular surface epithelia.
In addition, mechanical damages to the neural network such as that produced by LASIK
surgery, reduces signaling via the neural network.
With insufficient tear production or excessive evaporation, the tear film becomes
hypertonic with excessively high concentration of salts. As a result, the ocular surface is
insufficiently hydrated, and the increased salt concentration results in protein
degradation. Ocular surface cells flatten and become apoptotic, losing their ability to
maintain moisture levels adequate for proper functioning, thus further increasing
osmolarity.
Etiology
o Mucin Deficiency: Destruction/ Impairment of Conjunctival Goblet Cells
 Vitamin A deficiency (Avitamintosis A)
 (keratinized conjunctiva  dermal tissue)
 Ocular pemphigoid
 >60 years old, females, with decreased inferior fornix
 Stevens-Johnson syndrome (Erythema Multiforme major)
 <30 years old
 + Sulfonamides, HSV
 Chronic conjunctivitis (i.e. trachoma)
 Due to meds, drugs, etc.
 Chemical burns
 KCS
 Older females >60 years old
 Connective tissue disorder (RA, SLE)
 Horner’s Syndrome

o
o
o
o
o
Congenital Disorders
 Most difficult cases
Aqueous Deficiency
 Largest category
 Aging
 Location, especially So Cali
 Inflammation of gland ducts
 Trauma
 Tumors
 Drugs, medications (antihistamines, anticholinergics, beta adrenergics)
 Neurological conditions (Bell’s palsy)
 Congenital disorders (lack of glands)
 Congenital alacrima (without lacrimal glands)
 KCS
 Sjorgren’s syndrome
 Riley-Day syndrome
 Sarcoidosis
 Leukemia, lymphoma
 Amyloidosis
 Hemochromatosis
 Infections (trachoma, mumps)
Lipid Deficiency
 Congenital disorders
 Meibomian keratoconjunctivitis
 Gland blockage
 Inflammation of glands (acne, rosacea, etc)
 Rarer
Lid Resurfacing Problems
 Eyelid abnormality (coloboma, etc)
 Ectropion, entropion, trichiasis, distichiasis
 Notches, elevations (papillomas, verruvae)
 Incomplete blinking
 Corneal and Conjunctival abnormality (pterygium, etc)
 Dellen
 Nocturnal lagophthalmos (lid does not close with sleep), exophthalmus,
proptosis
 Bell’s palsy (CN VII paralysis)
 CL wear (at edge, etc)
 3 and 9 o’clock staining
Tear resurfacing problems
Corneal Epithelial disorders
 Corneal epithelial dystrophies (Map-Dot)
 Negative staining
 Green swirl
 Scars
 Punctuate keratopathy
 Filamentary keratopathy
o


Neurological disorders
 Neurotrophic keratitis- lack of CN VII innervations
 Decreased corneal sensitivity leads to decreased blink rate and poor corneal
wetting.
o Environmental dessication
 Especially in So Cal.
o DM
 Tend to have altered corneal innervations
Signs and Symptoms
o Burning, dry, or FBS
o Occasional watery eyes
o Mild conjunctival infection
o Frequent blinking
o Photosensitivity
Evaluation
o There is no single test available to correctly diagnose the various forms of dry eye.
o Through case history including
 Signs and symptoms
 Burning, foreign body, sandy, dry sensation
 Too many tears (epiphora)
 Frequent blinking
 Photosensitivity
 History of medications (Both OTC and Rx)
 Antihistamines, sedatives, diuretics, parasympatholytics, beta blockers,
acne medications
 Patient and family systemic health history
 Certain autoimmune disorders associated with dry eye including
o RA, SLE, scleroderma
 Sjogren’s syndrome
o Classic triad of RA, dry eyes, dry mouth
 Environmental conditions
 Smog, smoke, fumes, dust, other particulates
 Wind, drafts, air conditioners, hot air vents
 Low humidity
 Reading habits
 Blink rate decreases during prolonged reading
 History of CL wear
 Interest in contact lens
 Previously unsuccessful wearer
o Acuities
o Slit lamp exam
 Lids
 Entropion or ectropion
 May look for position of lids to determine if patient is incomplete
blinking
 Nocturnal lagophthalmus
 Thyroid eye disease


Conjunctiva
 Look for areas of dessication (staining)
 Cornea
 Look for areas of dessication (staining)
 Tear film
 Check for fullness and stability
 Average tear meniscus is 0.2-1mm
 Blink rate
 Is the patient blinking?
o Not as important because this is done in vitro.
o Specific lacrimal system tests
 Vital stains
 NaFl
 RB
 TBUT
 Schirmer tests and variations
 Diagnostic Punctal Plugs
Tear Composition in the dry eye
o Lesser concentrations of many proteins
 E.g., antimicrobial proteins
o Growth factor concentrations decreased
o Cytokine balance shifted, promotes inflammation
 Increases
 Interleukin (IL)-1α, IL-1β, IL-6, and tumor necrosis factor α, chemokines, matrix
metalloproteinases, and adhesion molecules.
 These proinflammatory factors recruit CD4 T cells to the ocular surface, which
then produce IL-17 and interferon (IFN)-γ.
 These factors affect the function of multiple structures on the ocular surface,
including superficial epithelial cells, corneal nerves and goblet cells.
 IL-17 and (IFN)-γ on the ocular surface affect epithelial cell differentiation,
leading to accelerated loss of superficial epithelial cells and impaired barrier
function. The loss of epithelial cells increases the vulnerability of the ocular
surface to infection and exposes corneal nerve endings to environmental stimuli.
 Goblet cell density decreases in dry eye, resulting in decreased levels of
protective factors secreted by the goblet cells, such as mucins (MUC5AC) and
transforming growth factor-β2.
o Loss of goblet cells decreases mucin
 Soluble mucin 5AC greatly decreased
 Due to loss of goblet cells
 Imoacts viscosity of tear film
o Activated proteases
 Degrade extracellular matrix and tight junctions (risk of infections)
o Increased tear osmolarity
 This causes ocular inflammation
o Increased electrolytes
o Altered environment for ocular surface tissues
 Increased osmolarity



Imbalanced growth factors and cytokines fail to promote normal epithelial
growth
 Poor viscosity can cause thin spots in tear film and tear break-up
 Blurred vision
 Lubrication compromised
o Ocular surface damage
 Cellular damage with loss of corneal epithelial integrity and squamous
metaplasia of conjunctival epithelium
o Misc
 Increased HLA class II, increased CD4/ TCells, increased MMP-p act, increased IL1/ cytokines, decreased lacrimal proteins
International Task Force (ITF) on Dry Eye
o Also referred to as the Delphi Panel, a group of 17 ophthalmologists and 2 optometrists
whose purpose was to come to a consensus on dry eye diagnosis and treatment.
o Listed their top 4 clinical tests used to diagnose dry eye
 TBUT
 NaFl staining
 RB vital dye
 Schirmer’s Testing
Dry Eye Workshop Report (DEWS)
o This was an international workshop convened to review critically the classification,
epidemiology, diagnostic, basic and clinical research, management and therapy, and
clinical trial methodology of dry eye syndromes. It took three years.
o Published in April 2007 in the Ocular Surface Journal.
o Definition
 “Dry eye is a multifactorial disease of the tears and ocular surface that results in
symptoms of discomfort, visual disturbances and tear film instability with
potential damage to the ocular surface. Its accompanied by increased
osmolarity of the tear film and inflammation of the ocular surface.
 It moved the role of inflammation to a prominent position and pused aside the
debate of aqueous deficiency vs. evaporation.
o Etiology Classification
 Aqueous Deficient
 Sjogren’s Syndrome
o Primary
o secondary
 Non-Sjogren’s Syndrome
o Lacrimal deficiency
o Lacrimal gland duct obstruction
o Reflex blockage
o Systemic drugs
 Evaporative
 Intrinsic
o Meibomian oil deficiency
o Lid disease
o Decreased blink rate
o Drug reactions

o
o
DES Diagnosis
 Level 1


 Level 2




 Level 3



 Level 4





Treatment
 Level 1




 Level 2






 Level 3



 Level 4



Extrinsic
o Vitamin A deficiency
o Topical drug preservatives
o CL
 CLIDE- Contact Lens Induced Dry Eye
o Ocular surface disease
Mild to moderate symptoms, no signs
Mild to moderate conjunctival signs
Moderate to severe symptoms
Tear film signs, visual signs
Mild corneal punctuate staining
Conjunctival staining
Severe symptoms
Marked corneal punctuate staining
Filamentary keratitis
Extremely severe symptoms
Lifestyle affected
Severe corneal staining
Erosions
Conjunctival scarring
Patient education
Environmental changes
Medication review
Preserved tears
Unpreserved tears
Gels, ointments
Cyclosporine A
Topical steroids
Secretagogues
Omega 3 fatty acids
Tetracyclines
Punctual plugs
Autologous serum drops
Systemic anti-inflammatory agents
Moisture spectacle/ goggles
Surgery

Treatment
o Note that it is not just the lacrimal system that needs attention, but the entire apparatus
from gland to ocular surface.
o Try to determine the etiology of the dry eye and vary treatment accordingly.
 Environmental counseling
 Decreasing caffeine intake, smoking cessation plans, overall diet
adjustments (including increasing water intake and/or fish oil
consumption or supplements)
 Medication counseling
 Drying meds and hormone meds
 Blink training
 Lipid deficiencies
 Treat meibomian gland dysfunctions
 Warm compresses
 Lid scrubs
 Gland expression and massage
 Topical antibiotics (eg Bacitracin, Polysporin for secondary infections)
 Systemic antibiotics (tetracycline)
 Artificial tears with lipid component (Teargard)
 Aqueous Deficiencies
 Artificial tears (all have aqueous like component)
 Mucin Deficiencies
 Treat with artificial tears with mucomimetic components
 Tropical vitamin A may help reverse process of epithelial keratinized (Vit
A Drops)
o Retinyl palmitate
 If etiology is unknown treat symptoms
 Tear supplements (artificial tears)
o Be aware of components of artificial tears
 Saline
o Tonicity varies- hypotonic solutions such as in Hypotears may
work a little better in KCS.
 Buffers
 Agents to increase viscosity and/or vary surface tension
o Hydroxypropylmethyl cellulose (thick)
o Hydroxyethylcellulose
o Polyvinyl alcohol (thin)
o Povidone
o Lipiden
o Liquifilm
 Lipopheric (lipid bearing) agents
o Ultrabase
 Note
o Selection of tear supplement often trial and error. Some
individuals respond better to a particular drop than others.
o Prescribe a recommended dosage of drops (e.g., 5-6 times/day)
rather than on prn regimen
o


Have patient instill drops before irritation indicating epithelial
damage
o Superficial punctuate keratitis- a sign of medicamentosa from
the preservatives. Unit dose unpreserved saline good
alternative for sensitive patients as well as unpreserved tears.
 Lubricating ointments
o Qhs only with severe dry eyes/ nocturnal lagophthalmus
o Bland petroleum and/or mineral oil based ointments
o May be used alone or with tear supplements
o Apply ¼ - ½” in inferior cul-de-sac
o Ointments tend to blur vision so bedtime application may be
preferable.
 Time released insert (Lacrisert)
o Hydroxypropylcellulose rod inserted into inferior cul-de-sac
usually once a day
o Moisture from existing tears causes the rod to dissolve. Thus,
may need tear supplement.
o May be slightly uncomfortable or blur vision
o Patient needs good manual dexterity and nearpoint vision
 Bandage Soft CL
o Use in combination with lubricating drops
o These patients often have decreased levels of tear lysozyme and
other immunoglobins, thus becoming more prone to ocular
infections.
Management of Filaments (Filamentary Keratitis)
 Treat underlying condition
 Removal of filaments with forceps after topical anesthesia
 Bandage SCL
 Application of 10% acetylcysteine (Mucomyst) qid, a mucolytic agent
(not FDA approved)
 Preservation of existing tears
 Artificial tears 4-8x/ day
 Sodium chloride 5% drops qid, ointment qhs
Preservation of Existing Tears (Punctal Plugs)
 Taping lids at bedtime
 Saran wrap shields- at bed time
o Held with petroleum jelly
 Commercially available moisture chambers- expensive
 Swimming goggles- not that practical
 Moisture chamber spectacle shields
 Punctual occlusion
o Collagen plugs (dissolve in 7-10days)
o Silicone plugs- permanent
o Cyanoacrylate adhesives- permanent
o Electrocautery- permanent (best)
o YAG laser occlusion- permanent (worst)
 Tarsrraphy- surgical decrease of interpalpebral area

o
o
o
o
Hormone Supplements
 Consult with female patient’s gynecologist or internist
 Drugs not FDA approved yet
 Bromohexidine (stimulates tear production)
 Sodium Hyaluronate 1%
 Oral pilocarpine
 Topical steroids qid x 1 month
 Cyclosporine 2% ointment- qhs
Based on the DEWS report, we may need to consider implementing anti-inflammatory
therapy earlier in our management of the condition, including prescribing steroids and
other topical or oral agents.
Drop Usage
 Get the drops in the eyes before dryness occurs.
 With dry eye, close and wet.
 Month 1: 5x/ day
 Month 2: qid
 Month 3: tid, etc until in therapeutic range
Oral supplements that improve lipid and mucin layer production
Artificial Tears
 This is still the mainstay in the initial management of dry eye.
 Used by 20 million Americans
 Contain electrolytes
 But they lack the complex mixture of proteins, mucins and other factors
found in normal healthy tears
 Provide temporary, palliative relief
 There is no single brand of artificial tears that works well for every form of dry
eye.
 Brands
 Moisture Eyes
o Eye drops, Protect, PM
 Bion Tears
 HypoTears Lubricant EyeDrops
 Visine Tears
 Akwa Tears
 Celluvisc
 Murine Tears Lubricant Eye Drops
 All Clear
 Theratears
 Genteal Eye Drops (and Gel)
 Tears Naturale (Forte, Free)
 Systane
 Refresh Tears (PM, Plus, Liquigel, Endura)
 Soothe XP Emollient
o Active ingredients
 Light mineral Oil (1%)
 Mineral oil (4.5%)
 FreshKote (Focus Laboratories)
o
o
o
o
o
o
Ingredients
 2% polynivyl pyrrolidone
 0.9% polyvinyl alcohol (87% hydrolyzed)
 1.8% polyvinyl alcohol (99% hydrolyzed)
 Phospholipid Amisol clear
 By mixing the two types of polyvinyl alcohol, it is
possible to lower the surface tension of the solution
while forming a completely wettable adsorbed layer
over a hydrophobic surface.
By prescription only
Designed to lubricate the ocular surface and replace tear
volume.
High oncotic pressure of 65mmHg assists in removing excess
water from damaged epithelium compacting the cells and
enhancing adhesiveness.
Antiinflammatories
 Topical corticosteroids
 Tetracycylines
 Low-dose doxycycline 20mg, bid.
o Potential side effects
 GI upset
 Offer strategies to minimize these side effects.
 Avoid antacids or dairy products, as they can
render the medication ineffective.
 Omega-e fatty acids
 Topical cyclosprorine A
Topical Steroids
 Limits production of inflammatory precursor proteins at a nuclear level and
control the increase of mast cells and lymphocytes at the cellular level.
Biochemical actions include curbing the synthesis of histamine and encouraging
its breakdown, as well as blocking phosphlipase A2 to prevent production of
arachidonic acid.
 Improves signs, symptoms, and tear clearance
 Normalize mucous production
 Often have sustained benefit after a 2 week pulse.
 Anti-inflammatories
 Targest inflammation of various contributory structures (e.g., lacrimal
gland)
 Reduce the inflammatory response of the ocular surface
 Dry eye disease is not a stable condition
 Many factors influence dry eye
o Hormonal
o Medications
o Environmental
 Recommend use of topical corticosteroids when patients experience a
transient increase in dry eye symptoms while on restasis
 Drops

o
o
o
o
o
o
o
Lotemax (loteprednol etabonate ophthalmic suspension, 0.5%)
o Qid x3 wk, bid x 3 week. Stop at week 6.
o One of the advantages of loteprednol is that it treats all ocular
surface inflammation associated with dry eye. Its highly
lipophilic nature penetrates cells better than other
corticosteroids. The glycerin in the drug penetrates cells
neutrally. Specifically targets T-lymphocytes.
Restasis
Loteprednol-cyclosporine combination
 Loteprednol targets T cells whereas cyclosporine prevents T cell recruitment, so
fewer cytokines come to the ocular surface. Loteprednol works quickly, while
cyclosporine may take 3 to 4 weeks to begin.
 Prescribe loteprednol qid x2 weeks, then lower the dosage to bid, during which
time add cyclosporine bid.
Lacrisert
Secretagogues
 Stimulate the production of essential tear components
 Types
 15 (S)- HETE
o Stimulates mucin production (Muc 1)
 INS- 365 (P2Y2 agonist)
o Stimulates aqueous, mucin and lipid production (Muc 5AC)
 Others: IFN – EGF, Garfornate
Anti-Evaporatives
 Stimulate lipid secretion
 Optimize/ enhance barrier function of the lipid layer
 Types
 Topical androgens
o Androgens help regulate quality and/or quantity of lipid
secretions
 Lipid component replacement
o Lipocalin, phosphatidylcholine, caster oil
Mucomimetics
 Mucomimetics are designed to mimic the functions of naturally occurring
mucins.
 Stabilizing the tear film, resulting in a healthier ocular surface
 On the horizon- Milcin
Omega 3s and 6s
 Decrease inflammation by inhibiting the production of inflammatory cytokines
 Sjogren’s patients have a lower dietary intake of Omega 3s, including EPA and
DHA, than matched controls.
 Omega 3s augment the oil layer. Essential fatty acids provide the raw material
for the production of meibum.
 Omega 3s control the lipid profiles of meibomian gland secretions in Sjogren’s
patients.
 Clinical reports have observed clearer and thinner oils with omega-3 treatment.
 Dosage


o
o
o
o
o
o
12,000 mg po bid
3-6 mo before it works.
o Consider 6 month temporary punctual plugs
 Keep bottle of Lotemax prn for really bad days.
Punctal Occlussion
 Punctual plugs in inflamed eyes means that inflamed cells stay on the eye.
 Punctual plug options provided temporary, semi-permanent and permanent
designs.
Delphi Panel Suggestions
 A DED severity grading scheme was developed, using grade 1 for mold or
episodic dry eye to grade 4 for severe or disabling and constant DED.
 The treatment should be according with the diagnosis level.
 When a patient does not respond to any of the above treatments, the ITF
guidelines recommend oral tetracyclines or punctual plugs as further steps in
treatment.
 Doxycycline 0.025% gtt have demonstrated improvement in dry eye
signs and symptoms.
Treatment Costs as a Barrier to Both Patient and Doctor
 It may ultimately cost the patient more in the long-run via complication costs,
utilization costs and other indirect costs by not aggressively treating their ocular
surface disease at the earliest opportunity.
Non-adherence or Compliance
 Adherence is better when patients are symptomatic
 Major predictors of poor medication adherence
 The treatment of a chornic disease
 The treatment of an asymptomatic disease
 Inadequate follow-up or discharge planning
 Medication side effects
 Patients’ lack of insight into the illness
 Poor provider-patient relationship and communication
 Missed appointments
 Complexity of treatment
 Cost of treatment
Failure to Establish Realistic Expectations
 Educate your patients from the beginning that there are extrinsic and intrinsic
variables that, at any time, can lead to a worsening of symptoms, including
 Environmental conditiona
 Systemic conditions, which require medications that may be a drying
effect
 Concomitant ocular disease
There are three times when a targeted medication might be warranted
 A patient on an advanced artificial tear product who still uses the product 4 or
more times per day or does not experience at least 1 hour of relief after
instilling a drop
 A patient on an advanced artificial tear who manifests lissamine staining



A patient on an advanced artificial tear who complains of symptoms such as
burning, stinging, redness, ocular discomfort, photophobia, blurred vision or
other symptoms more inflammatory in nature.
LASIK and Dry Eye
o A number of the subbasal and superficial stromal nerves is decreased by 90% after LASIK
surgery.
o Effect of denervation
 Decreased corneal sensitivity
 Decreased blink rate
 Increased inter-blink interval
 Decreased aqueous (reflex tearing)
 Decreased mucin
 Decreased lipid
 Decreased mitosis
 Unhealthy ocular surface
 Increased symptoms
 Increased keratitis
 Increased oncjunctival staining
 Decreased TBUT
 Increased vulnerability
Misc Information
o www.theocularsurface.com
Keratoconjunctivitis Sicca (KCS)
 Definition
o Most common cause of dry eye
 Pathophysiology
o Significant decrease in tear production and decreased parotid production
o Infiltration of lymphocytes into the lacrimal gland tissue
o May lead to atrophy of the gland
 Patient Profile
o Older postmenopausal women
 Signs and Symptoms
o Dryness of mucous membranes
 Oral, vaginal and respiratory
o Enlargement/ infiltration of the salivary gland
 Xerostomia
o Decreased aqueous production
 Reduced tear prism
 Schirmer’s test abnormal
o Tears
 Debris and frothy appearance
o Cornea
 Band-pattern SPK in interpalpebral area
 Filamentary keratitis
 Associated Conditions
o Sjogren’s Syndrome
o
o
o
o

Chemical burns
Pemphigoid/ Stevens Johnson
Trachoma
Lacrimal gland infiltration (neoplasia)
 “S shaped lid”
 Eye displaced down and in.
Evaluation
o Vital dyes: NaFl, Rose Bengal
o Schirmer Test
Sjogren’s Syndrome
 Definition
o KCS in association with connective tissue disorder
o An autoimmune condition that affects multiple systems and has a wide range of
possible organ-specific and systemic manifestastions including arthritis, fever and
fatigue.
o Affects about 0.6% of the population.
o 10-20 times higher among women.
 Associated Conditions: Autoimmune disorders
o Rheumatoid arthritis (most common)
o SLE
o Polyarteritis nodosa
o Hashimoto’s thyroiditis
Wet Eye
 Etiology
o Epiphora suggests ocular abnormalities.
 Acute epiphora tends to be more easily diagnosable and attributable to an
underlying cause than chronic epiphora. In acute cases, foreign bodies, trichiasis
or new onset allergic reactions provoke the patient to seek immediate care.
Acute epiphora usually resolves following removal of the irritant.
 Chornic epiphora, however often does not resolve. Symptoms may be
exacerbated.
o Increased tear production due to
 Bright light
 Pain
 Emotion
 Corneal irritation
 Abrasion, foreign body, sutures, trichiasis
 Dry eye
 Infections, especially viral
 Smoke, smog, other irritants
 Yawning, sneezing, etc
 Allergy, sinus inflammation, etc.
 Congenital glaucoma (rare)
 Primary hypersecretion due to lacrimal gland tumors or inflammation (rare)
Decreased tear drainage due to
 Congenitally closed nasolacrimal duct
 2-4% of all infants
 Takes 6 months to open.
 See water/ discharge
 Improper contact between punctum and globe
 Ectropion
 Loose conjunctiva/ edema
 The lower eyelid puncta should not be visible unless the eyelid is
manually everted.
 Conjunctivochalasis
o May also be observed on biomicroscopy
 Blocked or stenosed punctum, canaliculus or lacrimal sac caused by
 Infection
 Inflammation
o Inflammatory canaliculitis
 Most common organism Actinomyces Israelii
(streptothrix) (G+) oozing out of puncta
 Sulfur granules produced
 Tetracycline 250mg qid or penicillin
 Surgical excision of granules/ dacryolithes
o Dacrocystitis (acute or chronic)
 Dacryoliths or casts (epithelial cells, calcium and/or
lipids), may cause blockage.
 From strep/ haemophilus in kids and staph in adults.
 Extremely painful
 Do not probe. Can cause orbital cellulitis
 Medications
o Idoxuridine, phospholine iodine, serine, epinephrine
 Trauma/ Injury- causes scarring
 Tumors / Neoplasms
o Lacrimal sac tumors
o Blood comes out of puncta
 Treat with ampulotomy- place scalpel in to split muscle.
 Treatment
 In cases of chronically flaccid or stenotic puncta, laser punctoplasty or
ampullotomy can enlarge the outflow orifice.
 Dacryocystorhinostomy (DCR) creates a surgical bypass of the common
canaliculus directly into the nasal mucosa.
Evaluation
o Case history. Wet all day.
 Ask the patient if eye rubbing improves or worsens the feeling. Patients who
feel worse typically suffer from allergies, while those who feel better with
increased tearing after eye rubbing are suffering from dry eye and/or
blepharitis.
o Visual acuities- usually alright. Pinhole if needed
o

o
o

Gross observation of lids and tissues surrounding the nose
Slit lamp examination
 Puncta, lids, inflammation/debris
o Punctual regurgitation
 Press firmly on lid directly beneath the inferior punctum
 Obsere punctual orifice for bubbles or expression of discharge
o Tear drainage tests
Management
o Congenital Nasolacrimal Obstruction
 Caused by late canalization due to membrane covering valve of Hasner, and
spontaneously resolve 4-6 weeks after birth.
 Conservative treatment/ management
 Topical antibiotics (erythromycin)
 Massage and nasal decongestants if child is less than 6 months. Rotate
motion than push down several times.
 If condition does not resolve after several weeks of treatment, irrigation and/or
probing should be considered.
 Cure rate >90% if probing done before 8 months of age.
 If child is >6 months, general anesthesia usually needed for this
procedure.
o Punctual Stenosis- from topical drugs
 Punctual dilation
 Ampullotomy (snip procedure)
 Breaking muscle with mouse scissors
 Silicone intubation
 Run silicone tube through upper/ lower punctum and rebuild canaliculli.
o Bacterial Canaliculitis
 Warm compresses/ expression
 Systemic antibiotic therapy
 Penicillin G solution 100,000 units/ml or iodine 1% solution
(canaliculitis)
 Amoxicillin/ clavulanate (Augmentin) 20-40 mg/kg/day in children and
500 mg po q8h in adults
o Check with pediatricians
 Curettage with canaliculotomy to remove liths
o Chronic Obstruction of the Lacrimal Drainage System
 Silicone intubation
 Dacryocystorhinostomy- rebuild lacrimal system with silicone
o Dacryoadenitis (Lacrimal Gland)
 Definition/ etiologies
 Infection or inflammation of the lacrimal gland
o 50-75% are inflammatory
 Acute vs. chronic
o Chronic is more common
 Primary vs. Secondary
o Secondary acute more common than primary
 Most common in women (third to fourth decade)

o
Pathophysiology
 Infectious
o Mumps
o Gonorrhea
o Staphylococcus aureus
o Mononucleosis
o Herpes zonster
o Tuberculosis (chornic)
o Syphilis (chornic)
o HSV
 Inflammatory
o Sarcoidosis
o Sjogren’s
o Grave’s Disease
o Pseudotumor
 Presentation
 Acute
o Swelling of upper lid or orbit
o Ipsilateral pre-auricular node
o Pain and tearing
o Proptosis and globe displacement (down and in)
o Primary: unilateral
o Secondary: bilateral and due to systemic infection
 Chronic
o Usually bilateral
o Hard, palpebral mass under the orbital rim
o Usually no pain (unlike malignancy)
o Most often inflammatory
 Treatment
 Acute
o Identify causative agent
o Oral antibiotic therapy
 Adults: 250-500mg Augmentin tid x7 day
 Children: 20-40mg/kg/day in 3 divided doses
 Chronic
o Rule out lacrimal gland tumor via CAT scan/ MRI
o Treatment of underlying cause
o Treatment of dry eye
Dacryocystitis (Lacrimal Sac)
 Definition
 Infection or inflammation of the lacrimal sac
 Secondary to obstruction
 Acute vs. chronic
 Congenital vs. acquired
 Acute: Staph aureus, Streptococcus, Actinomyces in adults. Strep, H. flu,
Actinomyces in kids.
 Pathophysiology



Congenital
o Due to congenital dacryostenosis (2-4%)
o Unilateral or bilateral
o Reflux of mucopurulent discharge from puncta upon
compressing the nasolacrimal sac
 Acquired
o Usually unilateral
o Due to infectious organism
o Staph aureus in adults
o Haemophilus in children
Presentation
 Acute/ acquired type
o Occurs most often in women over 40 years old
o Tearing (epiphora) and pain
o Pain may radiate to teeth or ear
o Moderate swelling of sac
o Tenderness of inner canthus
o Purulent discharge (regurgitation)
o Secondary preseptal cellulitis
 Chronic/ congenital type
o Unilateral tearing
o Intermittent milky discharge
o Non-tender mass in medial canthus
o Chronic discharge
o History of acute dacryocystitis
Treatment
 Congenital
o Children
 Can have spontaneous opening- 90%
 Can persist for 9-12 months
 Nasolacrimal sac massage
 Acquired
o Children
 Oral antibiotics
 Augmentin 20-40 mg/kg/day in 3 divided doses
 Cefclor 20-40 mg/kg/day in 3 divided doses
o Adults
 Rule out tumor (blood in tears)
 Never dilate and irrigate, if inflammed
 This is painful!
 Topical antibiotics qid, if infection is present
 Oral antibiotics, if tear sac is infected
 If staph
o Dicloxacillin or Cloxacillin (250mg po
qid)
o Keflex (500mg po qid)
o Augmentin (500 mg tid 10-14 days)


Analgesics for pain
 Aspirin, vicodin, codeine, NSAIDs (Ultram)
Warm compresses

Chronic
o Lacrimal dilation and irrigation
o Warm compress therapy
o Dacryocystorhinostomy
Tumors of the Lacrimal System
Epidermoid Carcinoma
 Most common
Lacrimal Sac Tumors
 Rare (0.01%) but can be a potentially life-threatening situation which can be easily overlooked
 Presents as a triad of
o Mass above medial canthal region
o Chronic dacryocystitis that irrigates freely
o Bloody reflex on irrigation
 Treatment
o Complete excision followed by irradiation
Lacrimal Gland Tumors
 Approximately 50% are benign and 50% are malignant
 Most common cause of lacrimal gland enlargement
 Occur in adults ages 40-50
 Diagnosis
o Acquired unilateral ptosis
o Lump outer upper eyelid- S-shaped
o Pain (50%)
o Exophthalmos- eye displaced down and in
o Diplopia if large enough
 Prognosis
o Poor to fair, depending on when caught
o Difficult to remove completely and recurrence rate high
 Follow up every year
 Can occur again in 10-12 years
Hypersecretion Syndrome
 Looks like epiphora, but not constant, more sporadic
 Extremem dry eye causes hige flush of tears and cant drain.
 Treat with AT.
Pharmacology
Lubricants
 Uses
o
o
o
o
o
Decreased mechanical lid trauma
Wash out toxins
Increase tear volume
Increase corneal wetting
Environmental barrier
Artificial Tears
 Demulcents are compounds intended to both lubricate and soothe epithelial surfaces,
particularly mucosal membranes.
 General formulation
o Inorganic electrolytes
o Preservatives
o Polymers
 To increase wettability of corneal surface
 To extend adhesion
 To increase conjunctival sac retention time
o Viscoelastic agents
o Electrolytes- Ca, Na, O, Mg, etc.
o No single artificial tear solution will work for all dry eye patients.
 Cellulose Ethers ( a polymer)
o Agents
 Methylcellulose (MC)
 Hydroxyethylcellulose (HEC)
 Hydroxypropylcellulose (HPC)
 Hydroxypropylmethylcellulose (HPMC)
 Carboxymethylcellulose (CMC)
o These are polysaccharides known as mucilages.
o They increase the residence time of tears as well as increase the viscosity of tears.
o Also used to moisten contact lenses and to proling contact time of ophthalmic solutions
with the eye.
o May be indicated in patients who demonstrate ocular surface staining with vital dyes.
o Essentially inert chemically and pharmacologically.
 No action, therefore no side effects
o Examples
 Refresh (Allergan)- CMC
 Both preserved and non-preserved, as well as liquigel.
 TheraTears(Advanced Vision Research)- CMC
 This is a hypotonic solution that may provide comfort in dry eye
patients.
 Tears Naturale- HPMC
 With or without preservatives
 Bion Tears (Alcon)- HPMC
 Preservative free. Good for severe dry eye
 GenTeal (Novartis)- HPMC






Available in 3 different formulations: one each for mild, moderate and
severe dry eyes.
 Visine Tears (Pfizer)- HPMC
 With or without preservatives
 Lubricating the ocular surface in order to promite the integrity of the
surface.
Polyvinyl Alcohol (PVA)
o Seen more in contact lens solutions
o Enhances contact time of ophthalmic solutions
o Much less viscous than MC
o Thickened or gelled by sodium bicarbonate, sodium borate, sodium sulfate, potassium
sulfate and zinc sulfate
o Purpose
 Principle of lubricating the ocular surface
o Drops
 Murine Tears (Murine Eye Care)
 Provided the drop volume closest to the volume of the volume of the
natural tear fluid and was also the least expensive per year.
 Tears Again (Cynacon/ Ocusoft)
 Eyedrop as well as the gel formulation
 HypoTears (Novartis)
 Hypotonic solution with or without preservatives
HP-Guar Based Artificial Tears
o Systane (Alcon)
 Gel-forming
 Improves the recovery of the ocular surface due to possible increased retention
time of the AT drop. Also increases the TBUT times.
 Helpful in patients with conditions causing evaporative dry eye as well as
patients demonstrating ocular surface staining.
Other Polymeric Systems
o Polyvinylpyrrolidone (PVP, Povidone)
 Forms a hydrophilic, mucomimetic layer that adsorbs to the epithelial surface
 Makes a smooth curtain to decrease irritation with blinking.
o Polycarbophil
 Longer retention time than PVA or CMC
Other ingredients of artificial tear preparations may affect surface activity
Sodium Hyaluronate (SH)- Based ATs
o Purpose
 Useful in improving subjective symptoms.
 Helps protective effects on the corneal epithelium
 Great for post-LASIK or cataract surgery.
o Blink tears and Blink contacts (Abbott Medical Optics)
 Has a unique “OcuPure” preservative that dissipates upon exposure to light.
 Preservative free upon instillation.
o AQuify comfort drops (CIBA Vision)
 Sh aids in a gradual release of water molecules, which increases the duration of
wettability as well as relieves lens-related dryness.



Oil-Based Tears
o Good to improve tear stability and aid in the treatment of meibomian gland disease.
o Refresh Endura (Allergan)
 Preservative-free cator oil based formulation
 Aids in the reformation of the lipid layer of the tear film and prevents
evaporation of the existing tear film.
 Discontinued as of Dec 2008
o Soothe XP Emollient (Bausch and Lomb)
 Mineral oil based
 Increased the thickness of the lipid layer of the tear film.
Optive (Allergan)
o First tear to work on the surface and cellular level. This dual approach treats dry eye by
providing both osmoprotection at the cellular level and lubrication of the ocular surface.
o Contains compatible solutes (specifically glycerine, L-carnitine and erythritol) that
provide osmoprotection. Compatible solutes are small organic molecules that have
osmotic action but without the detrimental effects that high concentrations of salts
have in deactivating cell proteins and compromising cell function. Other examples of
compatible solutes include various amino acids, polyols, sugars ad methylamines.
o Compatible solutes can migrate into the corneal epithelium and be absorbed by
individual cells, helping them hold onto water and reach osmotic balance.
o Contains CM, a cellulose polymer used to lubricate the ocular surface.
o 0.5% CMC
o CMC binds to human corneal epithelial cells, and stimulates cell migration to scratch
wounds by attracting to glucose-biding sites.
Rx Drops
o FreshKote eyedrops (Focus Laboratories)
 Includes PVA as well as poluvinyl pyrrollidone
 “Amisol Clear” which is intended to stabilize the lipid layer of the tear film and
prevent evaporation of the tear film.
 It is a phospholipid, somewhat akin to the oil-based tears.
 Has a high oncontic pressure, which helps in increasing ocular surface integrity.
 Used daily as an “as needed” frequency
Vitamin A Derivatives (Vita A Drops)
 Ocular manifestations or deficiency can be alleviated by systemic or topical administration
o Epidermal keratinization
o Squamous metaplasia of mucous membranes
o More testing needed for other disorders
 Forms that are of therapeutic value
o Tretinoin (all-trans retinoic acid)
o Retinol
o Retinoic acid analogs
 Preparations
o Ointments
o Solutions
o Capsules and tablets for systemic use

o Included in some artificial tears preparations
o Gels- thinner than ung and thicker than MC. In tubes.
Adverse effects (ointment)
o Transient hyperemia
o Transient irritation
o Transient burning
o Decreased VA
o Entrapment
Viscoelastic Agents
 Sodium hyaluronate
o A polysaccharide polymer
o Very high viscosity
o Uses
 Dry eye
 Intraocular surgical procedures
o Preparations: 0.1% buffered solutions
 Chondroiton sulfate
o A polysaccharide polymer
o Very high viscosity
o Use: treat KCS and anterior segment diseases
o Preparation: Viscoat (also contains sodium hyaluronate)
Mucolytic Agent: Acetylcysteine
 Breaks disulfide bonds of mucin
 Preparation: Mucomyst
o 10% solution
o 20% solution
 Use: treat KCS
 Dilute to 2-5% prior to instillation
 Smells, keep refrigerated
Cyclosporine (Restasis)
 This is the dominant therapy for long-term treatment of dry eye.
 Ophthalmic cyclosporine 0.05% emulsion
 Contains the immunomodulator cyclosporine
 Cyclosporine inhibits T-cell activation leading to increased natural tear
production
 Increased tear production
 Reduced corneal staining
 Increased goblet cell density
 Reduced reliance on ATs.
 Cyclosporine is an immunomodulator that suppresses T cells, inhibits their
activation and down regulates T cell mediated cytokines.
 Restasis ophthalmic emulsion increases tear production in patients whose tear
production is presumed to be suppressed due to ocular inflammation associated
with KCS.







Increased tear production was not seen in patients who were currently
using topical anti-inflammatory drugs or in patients who use punctual
plugs.
How does Restasis work?
 Restasis has clinically shown an increase in production of natural tears
 Chronic dry eye patients show a decrease in tear production and altered
tear composition
o Activated T-cells may disrupt lacrimal glands and cause ocular
surface tissue damage.
o Loss of mucin-producing goblet cells from the conjunctival
epithelium impacts tear composition.
Patient profile
 Frequent chronic symptoms
 Frequent tear user, more than qid.
 Functioning lacrimal gland
Increased tear production
 Schirmer scores increased from baseline for 59% of CDE patients
treated with restasis.
o Maximum improvement was 16mm.
 Significantly more Restasis treated patients improved by >10mm vs.
vehicle (15% vs. 5%)
 Increased goblet cell density after t6 months of treatment.
 Cyclosporine reduced meibomian gland inclusions.
Good for ocular rosacea as well.
 After 6 months
o 18% complete resolution
o 31% significant improvement
o 31% moderate improvement
o 20% poor response
Dosing
 Bid. 1 gt OU q12h
o Inform patients to not use them “as needed” like traditional
drops.
 Concomitant aqueous tears
o Nonpreserved tears.
o Allow 15 minutes interval between installations.
 Cannot be used with CL.
 Can use concomitantly with a steroid.
o Improves patient compliance and restasis efficacy
o Decreases irritation associated with Restasis by 75%
o Dose
 Loeprednol qid x2 week, then bid x 2 week.
 Significant improvement with 6 months. Starts 1-2 months.
 Use without contact lenses
Adverse ocular effects
 Burning and stinging are the most important reasons that patients
discontinue use of Restasis (17%)
o
o







Cost

Patients with dry eyes are more sensitive to ocular insults.
Patients with return of tear function have a return of corneal
sensation, burning and stinging.
o Patients with dry eyes are accustomed to treatment failure and
are not willing to continue therapy which may make them feel
temporarily worse.
Use with LASIK
o Stop 3-4 days prior to LASIK due to glycerin (slippery)
o Can continue one day post-op.
$100/month
An immunosuppressant
Applied topically
0.05% emulsion, qid
Very expensive
>16 year old
Non-preserved Tear Preparations
 To avoid epithelial damage and disruption of tear film stability
 Preservatives tend to increase epithelial permeability
 Uses
o KCS
o Application of gonioscopic lenses
 Disadvantages
o Higher cost than preparation containing a preservative
 Example
o Genteal
 Preserved with sodium perborate which turns to sodium borate and inactive
hydrogen peroxide in the eye
Ointments
 Contain petroleum (petroleum jelly), mineral oil and/or lanolin
 Most contain no preservatives
o Inert, so bacteria cannot grow
 Apply to inferior cul-de-sac
 Usually instilled at bedtime as they cause blurring of vision
Lacrisert (Alton Pharmacy)










5mg Hydroxypropyl cellulose ophthalmic insert
o Preservative free
o 1.27 x 3.5mm
o 60 unit doses per box
o Two applicators come with it.
o Costs $175-200
This is a single daily dose artificial tear, sustained release, dry rod shaped ocular insert. Slowly
dissolves through the course of the day to retain moisture, stabilize and thicken the porecorneal
tear film and prolong TBUT.
For who
o Patients who have corneal exposure conditions such as Bell’s palsy, lid trauma/surgery
or abnormal blinks with incomplete closure benefit from the sustained protection
provided by the insert.
o Ocular surface disease, Sjogren’s syndrome, RA, SLK and limbal stem cell disease
Directions
o Placed in the inferior cul-de-sac with a plastic applicator. Immediately absorbs fluid and
dissolves slowly over the course of the day.
o It dissolves (over 6-8 hours) in fluid form from the conjunctival circulation
 Difficult to dissolve in a dry eye.
For moderate to severe dry eye patients using drops >4 times a day.
Can also use steroids and artificial tears
Can use a second dosage
Can use with contact lenses
o Patients should apply the CL first and then place the Lacrisert.
Contraindications
o No known drug interactions
o Those hypersensitive to ingredients
o Includes blurring of vision, eye discomfort or irritation, matting or stickiness of
eyelashes and red eyes.
o If improperly placed, can cause corneal abrasions.
Adverse effects
o Blurring
o FBS
Lacrimal Occlussive Devices
 Prevent drainage.
o Good if problem is due to decreased aqueous


o Very effective way to treat DES with little or low inflammation.
o Punctual occlusion is best used in cases of aqueous deficient dry eye.
Evaluation
o Look for lid taughtness to the globe and the presence of posterior lid disease.
o No necessarily the first line treatment.
o There are a number of conditions that worsen when occluded, such as allergies,
meibomianitis and highly inflamed dry eye. Consider punctual plugs after these
conditions are treated.
o Consider punctual occlusion after about 3 months of treatment with topical if the
condition has only marginally improved. Topical treatment is 2 months of loteprednol
and 3 months of restasis.
o Post-LASIK patients respond well to plugs. With patients who suffer from mechanical dry
eyes occlusion can be first line therapy.
Two types
o Surface
 Design
 Surface plugs are typically made of silicone and are positioned with the
shaft of the plug inside the punctum and the head of the plug on the
surface. They come in a variety of shapes, sizes and angles of insertions.
 Easy to insert and easy to take out.
 Tendency to fall out, FBS, risk of pyogenic granuloma
 Ready-Set Punctum Plug (FCI Ophthalmics Inc.)
 A slanted, ultra-thin collarette designed to conform to the natural
anatomy of the eyelid for maximum comfort.
 Made of silicone and packaged individually, 2 per box.
 Seven sizes, ranging from 0.4-1.0mm.
 2 designs
o Slim mini and slim petite plugs
o Micro and large plugs
 The punctum is premeasured with FCI’s punctum gauge
 One of the downfalls of the slanted collarette is positioning. If the plug
changes orientation and the edge of the colarette lifts slightly, the
patient may experience foreign body sensation
 Eagle Vision
 Designs
o SuperFlex Punctum Plug (Eagle Vision)
 9 sizes, ranging from 0.4-1.1mm and 1.1-2.0m, in length
o Super Eagle
 This design is intended to decrease the fall-out rate and
increase patient comfort.
 3 sizes: small (0.4-0.65mm), medium (0.6-0.85mm) and
large (0.8mm and larger)
o Flow Controller
 Ability to create a vector forcem which is intended to
keep the plug in better position and partially occlude
the punctum.
 4 sizes, ranging from 0.4-0.8mm

 Corneo Gauge/ Dilator system
 Oasis Silicone Punctum Plug
 Preloaded and nonleaded
 5 sizes, ranging from 0.4-0.8mm
 Parasol Occluder System (Odyssey)
 Small (o.3-0.6mm(, Medium (0.6-0.8mm) and extra-small and large for
unusually sized puncta.
 Hollow nose collapses, usually eliminating the need for punctual
dilation.
 UltraPlug (Surgical Specialties)
 Profile cap designed to decrease or eliminate FBS.
 Individually packaged, preloaded
 5 sizes from 0.4-0.8mm
 Three-instrument punctum gauge kit
o Intracanalicular
 Lacrimedics
 VisiPlug- a nondisolvable intracanalicular plug made of silicone. New
blue color helps identify the golf tee-shaped plug upon retroillumination
of the eyelid using patented Transillumination technology
 Occlude the upper puntua first, and then if dryness persists, occlude the
lower.
 Lasts about 6 months
 Removal can be challenging. Sterile saline is drawn into a syringe with
an irrigation tool, and the saline is used to push the plug throughout the
system. A strong force is necessary.
 Medennium
 SmartPlug. 6x0.4mm held by specially designed forceps
 After the plug is inserted into the punctum, it is rotated horizontally ito
follow the architecture of the canaliculis and driven in, leaving about
2mm exposed. As the patient’s body temperature heats the plug, the
plug will shrink in length and expand in diameter, conforming to the
punctum size and shape. One size fits most.
 A: Comfort and ease of removal.
 Removed in the same fashion as the VisiPlug.
 Disadvantage: upon insertion, the plug breaks easily. Has a learning
curve.
 Oasis
 Form Fit intracanilicular plug made of a polyvinylpyrrolidone-based
hydrogel material
 3x3mm
 Plug remains in the canaliculis. Over the next 10 minutes, it expands to
20 times its original size. It can be removed easily in the same manner
as the other intracanalicular plugs.
Collagen rods
o Preparations
 Collagen implant
 Temporary intracannalicular collagen implant





o Dissolves in 4-7 days. Used for a short-term trial.
Silicone-based plugs
o Preparations
 Freeman punctum plug
 Herrick lacrimal plug
o Longer-lasting than collagen rods
o Topical anesthetic may be required for insertion
o Only 1 in 20 patients can feel them .
Temporary Intracanalicular Plugs
o “Hidden”
o Lasts 90-180 days
o Used for patients pre-and post-op LASIK and premium IOLs post-operatively.
Smart Plug
o Put ½ in. it takes 3 seconds to become soft 15-30 sec to completely shrink.
o Canaliculitis with insertion too far in
o You can tell its in because when NaFl is placed in, and press the puncta, NaFl will come
out.
o Dilate 20% of the time.
o Cannot be rubbed out. Need irrigation.
Placement Technique
o Apply topical anesthetic generously for full anesthesia.
o Stretch the lid gently by pulling with index finger to straighten the cannaliculi.
o Insert the punctum dilator to gently stretch the terminal ring of the punctum
o Insert the plug with forceps or the plug injector
Complications
o These can be minimized by selecting the appropriate patients and choosing specific plug
configurations
o Eiphora
 This usually constitutes the second most frequent complication.
 Plugs are put in for the wrong reason. Treating the wrong type of dry eye, which
will result in complications.
 It is not uncommon for the patient to experience epiphora for the first day or
so. However, it should not last long term. The best solution is probably to
remove the plug.
o Foreign body sensation
 This represents 60% of all complications. It is caused by the plug not being
seated correctly. An edge is showing, which rubs on the surface of the eye.
o Infection
 For treating infections related to a punctum plug, antibiotics are recommended.
4th generation fluoroquinolones.
o Pyogenic granuloma
 This mad lead to extrusion of the plug in 4.2% of patients over a 141-day period.
 This is often treated by removing the plug. If the tissue is not inflamed, no
further treatment is needed.
o Dislodgement
 If this occurs within 48 hours of plug placement, it usually means that the
punctum was overdilated. After 48 hours, the wrong size plug was used. Simply
o
o
o
o
o
insert the next larger size plug. Proper size selection of a plug is important. You
want the plug to be snug, but not too tight.
Washout
 This occurs when the plug lodges further down the drainage system. A punctual
dye test will tell you if you have drainage. This is not a very specific test.
 Irrigation is the preferred method to determine flow. Patients with washout, but
without epiphora or infection , can have their plug remain.
Punctual canalicular erosion
 The final step in the treatment of punctual canalicular erosion is removal of the
existing plug. Use of a topical steroid or 4th generation fluoroquinolone is
advised. In most instances, the erosion will heal on its own. In rare instances,
sutures may be required and recannulization issues must be reviewed.
Dacryocystitis
Increased allergy symptoms
Lodged plugs
 If irrigation/ probing fails, the only solution is a DCR, whereby a plastic surgeon
slits through the canaliculus and finds the plug.
 This is very difficult. Plugs are not radio-opaque, so they do not show up on an
X-ray.
 Once the plug is removed, a piece of silicone tubing is placed in the tear duct
during the healing process, so the tear duct will not close or scar down.
Ocular Physiology Lab- The Lacrimal System
Quality or Stability of the Tear Layer
Lab Procedure
1. Evaluate the TBUT of your lab partner
TBUT: OD 3 sec, OS 4 sec
2. Instill a local anesthetic in one eye, wait 5 minutes and repeat the TBUT on that eye.
Eye used: OD, TBUT 9 sec
3. Several samples of artificial tears will be available in the lab. Apply one or two drops of the
artificial tears to one eye, wait 5 minutes and repeat the TBUT on that eye. Use two different
types of artificial tears.
AT #1: Refresh Tears (Allergan), Eye used: OS, TBUT: 5 sec
AT #2: Viva Drops, Eye used: OD, TBUT: 5 sec
Explain any difference obtained for the TBUT with the different artificial tears.
There was not a major change, therefore the drops are not mixing well with the tear
chemistry.
Tell the patient to use a variety and choose one that works best for them.
Drainage of Tears
Lab Procedure
1. Perform Jones I on your partner
Results: Negative
Schirmer I Test
Lab procedure
1. Perform a Schirmer I Tear Test on one eye of your partner. Measure the extent of the filter
paper soaked with lacrimal fluid after five minutes and record the results below.
22mm
Basic Secretion Test
Lab Procedure
1. After performing the Schirmer I Tear Test, instill one drop of anesthetic and perform Basic
Secretion Test on the same eye. Compare your results.
Basic Secretion: 17mm
Schirmer II Test
Rose Bengal Dye Test
Lab Procedure
1. Instill one drop of 1% rose Bengal solution into the conjunctival sac of the eye used in the
Schirmer testing. After 30 seconds have elapsed, examine the eyes for red punctuate staining of
the conjunctiva and cornea as previously described. The added magnificat5ion provided by a slip
lamp aids in this evaluation. Describe and sketch your observation below.
Discussion Questions
1. What other clinical signs may accompany symptoms of tear deficiency when the Schirmer I test
is normal?
Reduced visual acuity, red eye
2. A normal TBUT is more dependent on what anatomic and physiologic ocular considerations?
Anatomic
If the epithelial surface is damaged or the lipid layer of the tear film is abnormal.
Physiological
Mucin and/or aqueous insufficiency
3. Briefly discuss the relationship of the BUT to the Schirmer Tear Test.
The TBUT measures the quality of the tear layer while the Schirmer Test measures the
quantity.
4. Why is the clinician urged to avoid irritating the conjunctiva or the cornea during the Schirmer I
test?
Irritation of the conjunctiva produces a reflex tearing to rid the eye of the stimulus. This
increased tear flow does not provide an accurate measurement of normal tear flow.
5. Discuss the suggested therapy(ies) for patients with abnormal Schirmer test results.
Occlude the puncta (usually just lower)
Use OTC artificial tears during the day and lubricating oiuntment at night
Massage lids and use a hot compress