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How to Manage your Patients' Tear Film Quality

TearFilmQuality.jpg

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

Grade 0: Amorphous/ Marble
Grade 1: Polluted tear film
Grade 2: Lipid
Grade 3: Excessive lipid, foam in tears
Grade 4: No lipid layer

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
(D) Blepharitis
(E) Reduced Wettability

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)

Reference 

Adapted from a handbook of Contact Lens Management (3rd Edition)