How to Manage your Patients' Tear Film Quality

What You Need to Know

Slit Lamp Viewing

1. Low light intensity
2. High magnification (25-40x)
3. Direct focal illumination

Use flourescein to measure tear break-up time (TBUT)

Grading

Assessment of Tear Film

Questionnaires - such as:

• Standardized Patient Evaluation of Eye Dryness Questionnaire (SPEED)
• Ocular Surface Disease Index (OSDI)
• Contact Lens Dry Eye Questionnaire (CLDEQ)
• CLDEQ-8
• McMonnies Dry Eye Index
• Dry Eye Questionnaire (DEQ)
• Invasive, using flourescein and non-invasive break up time (NIBUT) 
• Other instrumentation - Tearscope, Keratometer, LipiView® 

Etiology

• Variation in individual tear chemistry (blinking pattern, tear film, ocular physiology, medication, age, diet)
• Reduction in lipid layer leads to marginal dry eye problems and lens contamination
• Lid margin disease
• Contact lens (material, design, wearing schedule, care regimen)
• Cosmetics, soap contamination 
• Environment

Symptoms

• Dryness symptoms including discomfort, grittiness and irritation
• Blurred or variable vision

Patient Recommendations

Signs

• Low pre-ocular tear break-uptime (TBUT), poor tear mixing
• Thin (or absent) tear film lipid layer or excess lipid (debris in tear film)
• Meibomian gland dysfunction, blepharitis (refer to image D below)
• Bulbar conjunctival hyperemia
• Superficial punctate epithelial erosions
• Bulbar conjunctival staining
• Reduced wettability, deposited CL (refer to image E below)
• High tear osmolarity (>316 mOsmol/L)
• Reduced tear ferning

Recommendations

• Manage all grades if signs or symptoms exist - improve tear film quality
• Treat any lid margin disease - lid hygiene, warm compresses, LipiView®
• Consider lens type (design, material, modality, replacement frequency and care system)
• Maintain good lens cleaning including rub and rinse step
• Use of lipid containing drops or sprays, visco-elastic agents or overnight lubricants
• Alter diet, alter environment, change cosmetics, blink training
• Recommend Omega-3 supplements

Prognosis

Good, unless fundamental imbalance of tear film (keratoconjunctivitis sicca)