Good Hope, Heartlands, and Solihull Eye Clinics

Sore dry eyes & eyelids signs etc for professionals

David Kinshuck

Treatment copy and paste

treatment for dry eye

  • Hyloforte       hourly
  • VitApos  night
  • get more from GP if help, reduce if eyes comfortable, increase if sore
  • read page http://www.goodhopeeyeclinic.org.uk/sore%20dry%20eye.htm
  • healthy diet, with vegetables, fish, and possibly Vitamin D
  • reduce doses of omeprazole and lansoprazole
  • very dry: there are many alternative drops, but thophthalmic eye outpatient clinic

 

Molluscum

molluscum

 

 

 

Fluorescein test

  • 1 drop of (1-) 2% fluorescein in medial canthus
  • wait 3 minutes
  • look at tear film for dry eye
  • wait 13 minutes (10 more), dye should have cleared (no sac washout needed...patent)
  • if eye sticky..cotton bud over lacrimal sac after fluorescein and look for seidels from canaliculus

Examination

  • Symptoms. Gritty, dry,  (Ache) sore, discharge, itch
  • History..muco-cutaneous disease and other problems
    • Symptoms questionnaire
    • Pain , vision, how long, burning, what triggers the problem,
    • sensitive to wind...hypoalgesia, light hurts..alodynia to light: bBoth are markers of neuropathic pain
    • epression, anxiety, people with backache and other pains feel more eye pain
    • orparicaine..rate pain when instilled..if reduded, indicates a corneal problem, if not,central pain mechanism
    • In some persistent cases, think nerve dysfunction 
    • After lasik
      • Nerve problem..patients need explanation
    • Pain specialsit treatment pregabelin etc, tricyclic, tens..did help,
    • nerve.... inject with steroid and anaesthetic..if peripheral nerve injury (eg lots of nasty surgery)
    • Botulinum toxin: use migraine protocol forehead injections
    • Emotional response to pain more in some people...cortical pathways difference, cbt, relaxation, etc
  • pressure: Icare best, no anaesthetic , lights on,
  • For lids
    • schirmers before anaesthetic
    • papillae..look under lid
    • press on lid for secretions,
    • fluorescein
    • if fluorescein negative lissamine green
    • Culture all ulcers even tiny 
    • Canaliculitis causes recurrent conjunctivitis
    • Deep set etc eyes giant fornix
    • Lissamine green best conjunctival stain
    • none invasive break up time, staining
  • Interstitial keratits, infective and none infective
  • the lipid layer is the anterior tear film
  • look for parallel conjunctival folds in dry eye, common in dry eyes
  • Meibomianitis is present in most dry eye patients 
  • osmolality
  • Vitamin a deficiency?
  • Ocular surface disease index questionnaire..ask patient to complete
  • Blink rate
  • Lid margin staining
  • lagophthalmos
  • folds of conjunctiva (can surgicaly take a strip off)
  • Shirmers no anaesthetic.tear break up time,
  • floppy lids
  • sleep apnea or  still sore cover eyes at night with cling film or shield
  • Symblepharon?
  • Mucous fishing syndrome: Lubricants steroids no fishing
  • Optimal environment: no baby shampoo, use blepharaclean wipes, or plain water,
    Hot bathing ,
  • types: evaporative, aqueous deficient, or mixed 2019

 

Ptosis

  • test for dry eye...no ptosis surgery if dry
  • ice test..put ice on closed eyelid, for 2 minutes, in myasthenia (MG)the ptosis recovers
  • if reduced eye movements..CPEO?
  • Cogans twitch..look down for 20 secons...if ou look down for 20 seconds andt hen look up, lid overshoots for a second = MG

Hints

  • test for dry eye...no ptosis surgery if dry
  • tetracaine ...local anaesthetic for sac washout (SWO)
  • inject tetracaine first as part of SWO
  • any loss of sensation...?SOL
  • 7th and 5th ? SOL
  • loss of lashes ?BCC
  • cannot look up..one of the first signs TED

Floppy eyelid

  • ? giant papillary conjunctivitislook down, see palpebral lacrimal gland
  • concretions
  • obese/snore/sleep apnoea
  • see

Ocular Neuropathic pain

Severe pain in dry eye >signs

Dysfunctional pain 'pain without stain' ..there are two groups (Rauz OSM16)

  • First group: there may be maladaptive pain, with treatment including counselling  
  • Second Group:
    • the cornea shows sensory amplification due to aberrant nerve regeneration, collateral sprouting, branching tortuosity neuronal formation, beading, and this is seen on confocal micorsopy.
    • treat as ocular surface pain
    • treat the neuropathic element
    • Therapeutic hard scleral lens does help
    • Counselling, what's happening at home
    • Drugs amitrytyline, duloxetine, gabapentin, pregablin
    • Pain without stain
    • Serum eye drops

Extremely severe dry eyes

This is a more serious condition, and an ophthalmologist should give you specific advice. The eye is prone to develop ulcers and infections.

  • Punctal occlusion is essential, but scarring may cause this naturally.
  • Some patients with severe filamentary keratitis need plugs and special contact lenses, see.   
  • Serum drops for severe cases. This should be considered in patients with severe ocular pemphigoid or alkali burns etc. Contact jean.harrison at nbs.nhs.uk. 
  • Blood orained from a finger prick with a lancet (as used to test blood sugar) can be very helpful (Eye17)
  • Serum free eye drops Eye 18 College Guidelines
  • Pilocarpine 5 mg once day increasing to 4-6 times a day may help.
  • Spectacles increase humidity.
  • Moisture googles will help: sealed chambersteam.
  • Check Vitamin A:
    • Night blind... can you see stars, cinema, more prolonged.
    • Poor countries supplement e.g. vit A in sugar has reduced corneal melting and ulcers lot.
    • In developed world malnutrition, anorexia, autism, or malabsorption cirrhosis, cystic fibrosis, bariatric surgery, depression may cause or contribute to Dry eyes, and bilateral corneal melt.

DEWS 2

 

DEWS 2

Epidemiology

  • classified etiologically 35.5%, 20.6% and 39.9% of patients had evaporative, aqueous deficient and mixed type of DED, respectively.  see 19