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Dry eye Syndrome - Coggle Diagram
Dry eye Syndrome
Diagnosis: History
Exacerbating factors
Ocular history: topical medications, contact lens use, previous surgery, other conditions such as blepharitis
Symptom onset, duration and fluctuation over time
Ask about clinical features
Red flags
Past medical history
Associated features which may indicate undiagnosed underlying condition: eg dry mouth, dental cavities, oral ulcers, fatigue, joint or muscle pain
Systemic medication: retinoids, oral contraception, HRT, beta-blockers, anticholinergics, diuretics, antihistamines, antidepressants and isotrtinoin
Eye trauma
Social history: smoking, alcohol, occupation
Management
Lifestyle measures: warm compresses, lid hygiene and massage, modification of contact lens use, environmental modification, avoid alcohol and cigarette smoke.
If needed consider alternative medications if current may exacerbate dry eye syndrome.
Provide education and information on the chronic nature of the the condition and explain long term treatment.
Optimise management of other associated ocular/systemic condition such as allergic conjunctivitis, blepharitis, rosacea or sleep apnoea.
Obtain advise if diagnosis uncertain
Recommend use of tear supplements (drops better for day time and gels reserved for night) if lifestyle adjustments alone do not improve symptoms
Arrange referral (urgency dependent on clinical judgement) if underlying systemic condition suspected, persistent symptoms which do not respond to treatment, abnormal lid anatomy or function.
Provide information on dry eye syndrome
Arrange same day assessment if serious eye condition is suspected. For children urgent opthalmology referral is required with any corneal change
Arrange follow up within 4-6 weeks of initiating treatment to review response and adjust to different formulation if required. If fail to respond after 12-16 weeks refer to secondary care.
Causes
Meibomian gland dysfunction
Blepharitis
Age-related lacrimal gland deficiency
Low blink rate
Vitamin A deficiency
Malposition of the eyelids
Environmental causes
Latrogenic factors: contact lens wearer, medications, ocular surgery, post-radiation fibrosis.
Underlying conditions: primary or secondary Sjogren's syndrome, HIV, allergic conjunctivitis, dermatological disorders, endocrine disorders etc.
Clinical Features
Itching
Photosensitivity
Redness of the eyelids or conjunctiva
Mucous discharge
Intermittent blurring of vision
Ocular fatigue
Dryness
Irritation or discomfort
Differential Diagnosis
Exposure to keratopathy
Nocturnal lagophthalmos (failure to close eyes at night)
Keratoconjunctivitis
Ocular pemphigoid
Blepharitis
Sjogren's syndrome
Allergic, infective or giant papillary conjunctivitis
Diagnosis: Examination
The pupils - abnormalities may indicate serious cause
Inspect the eyelids and lashes
Clinical signs
The cornea and conjunctiva - abnormalities may indicate serious alternative cause
Visual acuity - should not be severely impaired with dry eye syndrome
Signs of associated conditions such as rosacea, acne, seborrhoeic dermatitis, rheumatoid arthritis, Sjogren’s syndrome, systemic lupus erythematosus, Raynaud’s phenomenon, thyroid eye disease, Bell’s palsy or Parkinson’s disease.
Red flags
Persistent or profound visual loss
Associated diplopia
Acute history
Systemic features such as weight loss or fever
Investigations:
Slit lamp examination of the cornea and tear film and investigations such as Schirmer's test are required for diagnosis. Usually a referral for Optometrist or opthalmologist is required for this.
Definition: Dry eye syndrome is a chronic condition which is characterised by inflammation of the ocular surface and reduction in the quality and/or quantity of tears. Tear film covers the cornea and exposed conjunctiva, it is made up of three layers: inner mucin layer secreted by goblet cells in the eyeball and eyelids: a middle aqueous layer secreted by lacrimal and accessory glands on the upper eyelid: outer lipid layer secreted by Meibomian glands in the upper and lower eyelids. The tear film helps keep the cornea and conjunctiva healthy. Dry eye syndrome is into categories: aqueous or evaporative tear deficiency, both can overlap and co-exist.