Diagnosis and treatment of dry eye syndrome

Eun Chul Kim

doi:10.5124/jkma.2018.61.6.352

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Kim: Diagnosis and treatment of dry eye syndrome

Original Article

J Korean Med Assoc 2018;61(6):352-364.

Published online: 17 June 2018

DOI: https://doi.org/10.5124/jkma.2018.61.6.352

Diagnosis and treatment of dry eye syndrome

Eun Chul Kim, MD

Department of Ophthalmology, Bucheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Bucheon, Korea

Corresponding author: Eun Chul Kim E-mail: eunchol@hanmail.net

Received 9 May 2018 Accepted 23 May 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Dry eye syndrome is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms. Tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles. Symptom screening with the Five-item Dry Eye Questionnaire or Ocular Surface Disease Index can be used to identify the possibility that a patient might have DED dry eye syndrome and triggers. The results of these screening tools can lead to performing diagnostic tests of (ideally non-invasive) breakup time, osmolarity and ocular surface staining with fluorescein and lissamine green (observing the cornea, conjunctiva and eyelid margin). Meibomian gland dysfunction, lipid thickness/dynamics and assessments of the volume and severity of tear allow the subclassification of dry eye syndrome as predominantly evaporative or aqueous deficient, which informs the management of dry eye syndrome. A staged management algorithm was derived that presents a stepwise approach to implementing the various management and therapeutic options according to disease severity.

Keywords: Dry eye syndromes, Tear film instability, Meibomian gland dysfunction

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Figure 1.

Aqueous lacrimal secretion in upper fornix conjunctiva with slit lamp biomicroscopic exam.

Figure 2.

Noncontact infrared meibography (grade 1, 2, 3, 4, respectively).

Figure 3.

Lipid tear film interferometer with lipid thickness.

Figure 4.

Noninvasive tear breakup time with keratometer.

Figure 5.

Fluorescein stain (×16) of cornea in patient of dry eye syndrome.

Figure 6.

Rose Bengal stain (×16) of conjunctiva in patient of dry eye syndrome.

Table 1.

Korean Corneal Disease Study Group guidelines for the diagnosis of dry eye disease

Table 2.

Treatment recommendations according to the severity level of dry eye disease

Severity level	Treatment recommendation a)
Level I	Patient education, environmental control
	Check systemic medications (ex. anti-histamines, anti-depressants, or beta-blockers)
	Fluid intake, psychological support
	Artificial tears (preserved or non-preserved)
	4 Times a day, or incremental according to patients’ symptoms
	Allergy treatment, when necessary
Level II	Non-preserved artificial tears
	Anti-inflammatory therapy (ex. topical Cyclosporine A or topical corticosteroids)
	Oral supplements; essential fatty acid (ex. omega-3-fatty acid or gamma linoleic acid)
	Gels/ointment (may be used in level I patients, when necessary)
Level III	Autologous serum
	Oral tetracycline (may be used in level II patients)
	Punctual plug/occlusion
	Contact lenses, goggles
Level IV	Surgery
	Systemic anti-inflammatory medication

Reproduced from Hyon JY, et al. Korean J Ophthalmol 2014;28:197-206, according to the Creative Commons license [21].

^a )Accompanying ocular surface disease such as blepharitis or ocular allergies should be treated for any level.

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