ARTIFICIAL_TEARS presentation dhir .pptx

ARTIFICIAL_TEARS presentation dhir .pptx

1. Dry Eye And Artificial Tear PRESENTER - Dr Nikhil Agrawal ( 1 st year resident ) MODERATOR – Dr Parikshit Dhir DHIR HOSPITAL & POST GRADUATE INSTITUTE OF OPHTHALMOLOGY

2. Tear Film 0.02-0.04microns 6-8microns 0.1-0.2microns

3. Secretion of Tears Afferent pathway of this secretion is formed by fifth nerve and efferent by parasympathetic (secretomotor) supply of lacrimal gland.

4. Dry Eye Dry eye disease is a disorder of the tear film due to reduced tear production or excessive tear evaporation, which causes damage to the interpalpebral ocular surface. Symptoms of discomfort, visual disturbance. Tear film instability Increased Osmolarity Increased cytokines & T-cells , IL-17 , MMP-9 Decreased Viscosity Increased Friction between eyelids and ocular surface

5. Etiology

6. Slit Lamp Examination Increased debris/mucin strands in tear film Inspection of tear meniscus at lid margin. Normal thickness – 1mm, convex. < 0.5mm – tear deficiency. In severe cases – Marginal tear meniscus is concave, small & absent.

7. Questionnaires Ocular Surface Disease Index (OSDI) : S cores 0 to 12 : normal, 13 to 22 : mild dry eye disease 23 to 32 : moderate dry eye disease > 33 : severe dry eye disease. DEQ5: >6 non-SS DE , >12 suspect SS

8. OSDI

9. DEQ-5

10. NIBUT Provides noninvasive and objective evaluation of meibomian glands, tear film, meniscus height and ocular surface. T he software asses the different segments and distortion in the reflected mires. Any placido based device can be used to see break up of the rings . Clarion OSA

11. Osmometery Collects 50nl of tear fluid . Gold plated microchip measures the electrical impedance , this provides the osmolarity . Variability >8mOsmol/L between both eyes indicative od dry eye. >316mOsmol/L - Dry eye 290-316mOsmol/L – Borderline <290mOsmol/L - Normal

12. Vital stains of the ocular surface SICCA Ocular Staining Score T he National Eye Institute grading system T he Oxford scale1 T he van Bijsterfeld scale.

13. Meibography Phoenix Meibography Workstation It uses a slit-lamp biomicroscope with IR filter and an IR charge-coupled device video camera to image a digitally everted eyelid.

14. Tear Film Breakup Time Tear film breakup time of less than 10 sec represent unstable tear film . Sensitivity -82-84% Specificity -76-94% Development of dry spot always in the same location may indicate a local corneal surface abnormality.

15. Schirmer test Whatman Filter Paper no.41 Schirmer 1: Basic + Reflex secretion Without anaesthesia <10mm in 5 min Schirmer 2 : Basic secretion With anaesthesia <6mm in 5 min

16. Treatment First-line -Over the counter artificial tear drops, gels, ointments, or lubricants . Environmental interventions- Increase air moisture and reduce particles in the air, and nutritional supplements . Anti-inflammatory agents- Corticosteroids, cyclosporine A , NSAIDS, and tetracycline derivatives . Extreme measures- Application of autologous serum , punctal plugs.

17. http://clinicalestablishments.gov.in/WriteReadData/6411.pdf

18. Artificial Tears Lubricants are the first-line treatment for many causes of ocular irritation, in particular for dry eye. There are a multitude of artificial tear choices available. Goal of this presentation is to provide information about T he components that make up artificial tears T o discuss the functions of these components

19. How Do These Work Decrease dryness. Humectants: Compounds which promote hydration and feel good upon application. L ubricant: T hey decrease friction on the ocular surface . I ncrease tear retention by : Increasing tear viscosity, increasing the adherence of the tears to the ocular surface, decreasing tear evaporation, and decreasing tear clearance. Osmoprotection : To counteract the effects of hyperosmolarity. Eg : Erythritol , L – carnitine , Glycerol

20. Components of Artificial Tears Active Ingredients: - Demulcents - Emollients Inactive Ingredients Preservatives

21. Active Components of Artificial Tears Ophthalmic Demulcent : A water soluble polymer, helps to protect and lubricate mucous membrane . Cellulose derivatives Carboxymethcellulose sodium (CMC) Hydroxypropyl methylcellulose (HPMC) 2.Dextran 70. 3.Gelatin 4. Polyols, liquid Glycerin 0.2 to 1% Polyethylene glycol Polyvinyl alcohol

22. Types of Artificial Tears Ophthalmic emollients : It is usually a fat or oil which is applied locally to eyelids to protect or soften tissues and to prevent drying and cracking. Lanolin preparations Oleaginous ingredients Light mineral oil up to 50% in combination with other emollient agents Mineral oil up to 50% in combination with other emollient agents Paraffin up to 5% in combination with other emollient agents . Petrolatum up to 100%. White ointment up to 100%. White petrolatum up to 100%. White wax up to 5% in combination with other emollient agents . Yellow wax up to 5% in combination with other emollient agents.

23. Demulcents Demulsants Properties Carboxymethylcellulose sodium Increase Viscosity (thickener) Stabilize emulsions Hydroxypropyl- Methylcellulose Cross links upon contact with tear film due to pH difference to increase viscosity. Too viscous to instill easily alone Polyethylene glycol Increases viscosity Forms protective layer over mucous membrane to relieve irritation Propylene glycol Forms a protective layer over mucous membranes relieving inflammation. Increases viscosity Holds up to 3x own weight in water

24. Demulsants Demulcents Properties Dextran 70 Increase mechanical strength of tear film. Requires thickener due to low viscosity of compound Glycerine Blunts the damaging effects of high osmolarity on the ocular surface. Lubricant, humectant Promote epithelial cell growth Gelatin Gelling agent Polyvinyl alcohol Lowers tear viscosity Povidone Lubricating and soothing Lipid that integrates with existing oil layer, thickening it and reducing evaporation

25. Emollients Emollients Properties Lanolin Lubrication and soothing Contributes to oil layer Light mineral oil Mineral oil Replace or thicken lipid layer .  Non-moisturizing, but does seal in existing moisture. Paraffin Waxy consistency Seal in moisture  White Wax  Yellow Wax Contributes to oil layer

26. Inactive Ingredients-The Difference Makers Inactive Ingredients Properties Sorbitol Lowers the viscosity of gelling agents Dissipates quickly, optimizing viscosity. Main addition to the solution Systane to produce Systane Ultra Hyaluronic Acid Binds multiples of its weight in water to lower tear osmolarity. Adheres to ocular surface. Highly viscous until blink thins it out. Improves cell-cell adhesion. Sodium Hyaluronate Protects and promotes healing of corneal epithelium It  is a humectant, lubricant, and hypo-osmotic. Helps control localized inflammation. Reduces mucous strands. Highly viscous until blink thins it out. L-carnitine Erythritol Osmoprotectants : blunt the damaging effects of high osmolarity on the ocular surface by . Gets absorbed by dehydrated cells where they promote hydration and prevent cell shrinkage and inflammation.

27. Inactive Ingredients Inactive Ingredients Properties Hydroxypropyl Guar (HP Guar) Increasing viscosity. Mimics the mucin layer of the eye . Binds to cornea and aqueous layer . Actively cross links/gels at pH above pH 7/. Boric acid Borate Buffer Sodium-citrate Phosphate Phosphate-citrate Phosphate-citrate-bicarbonate Sodium hydroxide Buffer systems used to obtain a pH for the artificial tear that is healthy and comfortable for the eye. Calcium chloride Magnesium chloride Potassium chloride Zinc chloride Sodium chloride Sodium citrate Sodium bicarbonate Electrolytes are added to maintain or lower tear osmolarity as high osmolarity products pull water from epithelial cells, interfering with metabolism. Some of the added electrolytes are also important for corneal epithelial metabolism. Some electrolytes are part of buffer system T hese ingredients function as buffers, electrolytes, emulsifiers, osmoprotectants or viscosity-enhancers. These ingredients set individual drops apart from one another. Trehalose, an osmoprotectant found in Refresh Optive Mega-3 stabilizes cell membrane lipids and proteins and can protect corneal epithelial cells from death .

28. Preservatives They prevent bacterial growth and subsequent infection. EDTA-Chelating Agent

29. References https://www.reviewofcontactlenses.com/article/artificial-tears-looking-beneath-the-surface http://webeye.ophth.uiowa.edu/eyeforum/tutorials/artificial-tears.htm https://www.researchgate.net/publication/323579529_Combination_of_hyaluronic_acid_carmellose_and_osmoprotectants_for_the_treatment_of_dry_eye_disease/fulltext/5a9e960b0f7e9b80dfb4e452/Combination-of-hyaluronic-acid-carmellose-and-osmoprotectants-for-the-treatment-of-dry-eye-disease.pdf?origin=publication_detail https://www.reviewofoptometry.com/article/master-the-maze-of-artificial-tears Google Images

30. THANK YOU FOR YOUR KIND ATTENTION

31. TYPES Keratoconjunctivitis sicca Riley-Day syndrome Congenital Alacrima Paralytic hyposecretion Idiopathic Hypo- vitaminosis A, Ocular pemphigoid, Stevens-Johnson syndrome Drug induced Chemical burns. Chronic blepharitis. Exposure keratitis Symblepharon Pterygium Eyelid trauma Others : Alteration in microvillous morphology of corneal epithelium. Anaesthetic cornea after damage to the trigeminal nerve .

32. Dry Eye and Inflammation White Inflammation Due to -neurogenic inflammation -Hyperosmolarity -Chronic irritation ( contact lens ) -Auto immune disease Mediated by T-cells , IL-17 , MMP-9 Cyclosporine and tacrolimus might help in mild cases .