Flow Chart on Surgical Approaches to Dry Eye

Mild to moderate symptoms and no signs

1 Episodic Mild to moderate conjunctival signs

Moderate to severe symptoms Tear film signs

2 Mild corneal punctate staining Chronic Conjunctival staining

Visual signs

Severe symptoms

3

Marked corneal punctate staining

Central corneal staining

Filamentary keratitis

Severe symptoms

4

Severe corneal staining

Erosions

Conjunctival scarring

Fig. 1. Management of dry eye as recently suggested by the ‘Dry Eye Workshop (DEWS)’.

such as lid margin malposition, lid retraction or exophthalmos are obvious. Although infrequent in this context, pre-existing occlusion of the lacrimal drainage system on the level of the nasolacrimal duct resulting in backwash of toxic cytokines should be excluded, since this can also induce surface disease.

The suggested sequence of treatment options is not obligatory, although it aims to use the less invasive procedures first while at the same time maximising efficacy and practicality (figs 1, 2). For example, punctal occlusion, especially if reversible, is more invasive than wearing scleral or limbal fit rigid contact lenses. However, it is also likely to be more practical for many patients.

Prior to any surgical attempt, inflammation of the ocular surface or adnexae should be controlled medically. Concomitant factors should also be excluded or – if present – treated first. Lid margin malposition (e.g. trichiasis, entropion, ectropion), lid retraction (e.g. due to thyroid disease or fornix shortening) and exophthalmos should be corrected. If the evaporative form of dry eye prevails, medical management including lid hygiene, topical anti-inflam- matory and systemic antibiotic treatment is common first-line treatment and tear substitutes should be used only as additive therapy. On the contrary, in aqueous deficiency, tear substitutes and subsequent occlusion of the lacrimal drainage are the obvious methods of first choice. If together with these measures contact lenses fail to relieve symptoms and signs of dry eye disease, then more invasive procedures such as minor salivary gland transplantation should be attempted. Only in the most severe cases, with severe visual impairment and discomfort recalcitrant to any other means should major salivary gland transplantation or implantation of a dacryoreservoir be considered.

Dry eye disease

(signs and symptoms present!)

Exclude and treat any exacerbating/concomitant disease

Lid margin malposition/lagophthalmos/exophthalmos

Exclude lacrimal drainage obstruction

Fig. 2. Flow chart on the surgical management of aqueous-deficient and evaporative dry eye.

Combinations of both forms of dry eye disease exist and if present require combined treatment. If the disease is mild to moderate with no threat of acute visual loss it is appropriate to take a stepwise approach and establish which means are and which are not effective. In more advanced disease with either severe discomfort or danger of loosing vision, several measures should be applied simultaneously.

Visual rehabilitation should only be attempted once all concomitant factors have been addressed appropriately and the above medical and surgical methods for substitution of the tear film have been successfully used. In the evaporative dry eye, limbal stem cell transplantation and/or corneal grafting, preferably as a

lamellar anterior keratoplasty to reduce the risk of endothelial rejection, are options. In persisting aqueous deficiency, osteoodontokeratoprosthesis remains the ultimate ratio to improve visual function.

Prof. Dr. Gerd Geerling

Klinik für Augenheilkunde, Julius-Maximilians-Universität Würzburg

Josef-Schneider-Str. 11, DE-97080 Würzburg (Germany)

Tel. 49 931 2012 0610, Fax 49 931 2012 0490

E-Mail g.geerling@augenklinik.uni-wuerzburg.de