Sections

Dry Eye Disease (Keratoconjunctivitis Sicca)

Sections Dry Eye Disease (Keratoconjunctivitis Sicca)
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Tables
References

Presentation

History

Depending on the severity of dry eye disease (DED), or keratoconjunctivitis sicca (KCS), the following are the most common patient complaints:

Foreign-body, burning, gritty, or itching sensation.
Redness
Mucoid discharge
Ocular irritation
Ocular dryness
Excessive tearing (secondary to reflex secretion)
Photophobia
Itching
Fluctuating or blurry vision that may improve with blinking

These symptoms often are exacerbated in smoky or dry environments, by indoor heating, by fans, or by excessive reading or computer use. Often, the symptoms worsen as the day goes on.

These symptoms are quantified objectively in the Ocular Surface Disease Index (OSDI) questionnaire, which lists 12 symptoms and grades each on a scale of 1 to 4.

Patients with meibomian gland dysfunction (MGD) may complain of redness of the eyelids and conjunctiva, but in these patients, the symptoms are often worse upon awakening in the morning.

Paradoxically, some patients with dry eye disease complain of too much tearing. When evidence of dry eye disease exists, this symptom often is explained by excessive reflex tearing due to severe corneal surface disease from the dryness. Epiphora also may accompany conjunctivochalasis, which demands consideration of surgical intervention.

The patient’s medical history may be significant for coexisting connective tissue disease (CTD), rheumatoid arthritis (RA), or thyroid abnormalities. A thorough review of systems should be obtained, focusing specifically on dry mouth, arthritis, cutaneous changes, malaise, weight loss, and lymphadenopathy. Within the veteran population, a study found an increased incidence of dry eye disease in both men and women that was also strongly connected to cases of posttraumatic stress disorder and depression.^[31]

Differential Diagnoses

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Media Gallery

Eye tear system anatomy: a. tear gland / lacrimal gland, b. superior lacrimal punctum, c. superior lacrimal canal, d. tear sac / lacrimal sac, e. inferior lacrimal punctum, f. inferior lacrimal canal, g. nasolacrimal canal.

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Table. Dry Eye Severity Levels

Table. Dry Eye Severity Levels

Variable	Dry Eye Severity Level
Variable	1	2	3	4 (must have signs and symptoms)
Discomfort (severity and frequency)	Mild, episodic; occurs under environmental stress	Moderate, episodic or chronic; occurs with or without stress	Severe, frequent, or constant; occurs without stress	Severe or disabling, constant
Visual symptoms	None or episodic mild fatigue	Annoying or activity-limiting, episodic	Annoying, chronic, or constant; activity-limiting	Constant and possibly disabling
Conjunctival injection	None to mild	None to mild	+/–	+/++
Conjunctival staining	None to mild	Variable	Moderate to marked	Marked
Corneal staining (severity and location)	None to mild	Variable	Marked central	Severe punctate erosions
Corneal and tear signs	None to mild	Mild debris, decreased meniscus	Filamentary keratitis, mucus clumping, increased tear debris	Filamentary keratitis, mucus clumping, increased tear debris, ulceration
Lid and meibomian glands	MGD variably present	MGD variably present	MGD frequent	Trichiasis, keratinization, symblepharon
Tear breakup time	Variable	≤ 10 s	≤ 5 s	Immediate
Schirmer score	Variable	≤ 10 mm/5 min	≤ 5 mm/5 min	≤ 2 mm/5 min
MGD=meibomian gland dysfunction.

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Author

Trent Tsun-Kang Chiang, MD, MS Resident Physician, Department of Ophthalmology, Case Western Reserve University School of Medicine, University Hospitals

Trent Tsun-Kang Chiang, MD, MS is a member of the following medical societies: American Medical Association, American Medical Student Association/Foundation, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Coauthor(s)

Ahmed Farghaly Abdelhameed Omar, MD, PhD Assistant Professor of Ophthalmology, Department of Ophthalmology and Visual Sciences, Case Western Reserve University School of Medicine; Ophthalmologist/Cornea Specialist, University Hospitals Eye Institute, University Hospitals Cleveland Medical Center

Ahmed Farghaly Abdelhameed Omar, MD, PhD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Egyptian Medical Syndicate, Egyptian Ophthalmological Society, European Society of Cataract and Refractive Surgery, International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Additional Contributors

C Stephen Foster, MD, FACS, FACR, FAAO, FARVO Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary; Founder and President, Ocular Immunology and Uveitis Foundation, Massachusetts Eye Research and Surgery Institution

C Stephen Foster, MD, FACS, FACR, FAAO, FARVO is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Association of Immunologists, American College of Rheumatology, American College of Surgeons, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, American Uveitis Society, Association for Research in Vision and Ophthalmology, Massachusetts Medical Society, Royal Society of Medicine, Sigma Xi, The Scientific Research Honor Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Aldeyra Therapeutics (Lexington, MA); Bausch & Lomb Surgical, Inc (Rancho Cucamonga, CA); Eyegate Pharma (Waltham, MA); Novartis (Cambridge, MA); pSivida (Watertown, MA); Xoma (Berkeley, CA); Allakos (Redwood City, CA)<br/>Serve(d) as a speaker or a member of a speakers bureau for: Alcon (Geneva, Switzerland); Allergan (Dublin, Ireland); Mallinckrodt (Staines-upon-Thames, United Kingdom)<br/>Received research grant from: Alcon; Aldeyra Therapeutics; Allakos Pharmaceuticals; Allergan; Bausch & Lomb; Clearside Biomedical; Dompé pharmaceutical; Eyegate Pharma; Mallinckrodt pharmaceuticals; Novartis; pSivida; Santen; Aciont<br/>Stock for: Eyegate Pharma.

Anthony S Ekong, MD Consulting Staff, Department of Ophthalmology, Marshfield Clinic

Anthony S Ekong, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association

Disclosure: Nothing to disclose.

Fahd Anzaar, MD Fellow, Massachusetts Eye Research and Surgery Institute; Clinical Research and Education Coordinator, Ocular Immunology and Uveitis Foundation

Disclosure: Nothing to disclose.

Erdem Yuksel, MD Fellow, Department of Ophthalmology, Massachusetts Eye Research and Surgery Institute, Medical School of Gazi University

Disclosure: Nothing to disclose.

Acknowledgements

Marc R Bloomenstein, OD, FAAO Director of Optometric Services, Schwartz Laser Eye Center; Adjunct Assistant Professor, Arizona College of Optometry; Adjunct Assistant Professor, Southern California College of Optometry

Marc R Bloomenstein, OD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association, Arizona Optometric Association, and International Society of Cataract and Refractive Surgeons

Disclosure: Nothing to disclose.

Jacqueline Freudenthal, MD Co-Investigator, Ophthalmic Consultants Centre, Toronto

Jacqueline Freudenthal, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, and Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Simon K Law, MD, PharmD Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Fernando H Murillo-Lopez, MD Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Institute

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark Ventocilla, OD, FAAO Clinical Professor, Michigan College of Optometry; Editor, American Optometric Association Ocular Surface Society Newsletter; Chief Executive Officer, Elder Eye Care Group, PLC; President, Lakeshore Professional Eyecare, PC

Mark Ventocilla, OD, FAAO is a member of the following medical societies: American Academy of Optometry and American Optometric Association

Disclosure: Nothing to disclose.

Jack L Wilson, PhD Distinguished Professor, Department of Anatomy and Neurobiology, University of Tennessee Health Science Center College of Medicine

Jack L Wilson, PhD is a member of the following medical societies: American Association of Anatomists, American Association of Clinical Anatomists, and American Heart Association

Disclosure: Nothing to disclose.