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`All rights reserved.
`
`Dry Eye Syndrome
`• What Is Dry Eye Syndrome?
`• What Are Causes of Dry Eye Syndrome?
`• What Are Signs and Symptoms of Dry Eye Syndrome?
`• When Should Someone Seek Medical Care for Dry Eye Syndrome?
`• What Questions Should People Ask Their Doctor About Dry Eye Syndrome?
`• What Exams and Tests Diagnose Dry Eye Syndrome?
`• Are There Home Remedies for Dry Eye Syndrome?
`• What Are Medical Treatment Options for Dry Eye Syndrome?
`• What Medications Treat Dry Eyes?
`• When Is Surgery Appropriate for Dry Eye Syndrome?
`• Other Therapy
`• Follow-up
`• Is It Possible to Prevent Dry Eyes?
`• What Is the Prognosis for Dry Eye Syndrome?
`• Dry Eye Syndrome Support Groups and Counseling
`• Where Can People Get More Information About Dry Eye Syndrome?
`• Dry Eye Syndrome Picture
`• Read more on Dry Eye Syndrome from Healthwise
`
`What Is Dry Eye Syndrome?
`
`To help keep your eyes comfortable and your vision optimal, a normal, thin film of
`tears coats your eyes. Three main layers make up this tear film:
`
`• The innermost layer is the thinnest. It is a layer of mucin (or mucus). This
`very thin layer of mucus is produced by the cells in the conjunctiva (the clear
`skin that lines the eye). The mucus helps the overlying watery layer to
`spread evenly over the eye.
`• The middle (or aqueous) layer is the largest and the thickest. This layer is
`essentially a very dilute saltwater solution. The lacrimal glands under the
`upper lids and the accessory tear glands produce this watery layer. This
`layer's function is to keep the eye moist and comfortable, as well as to help
`flush out any dust, debris, or foreign objects that may get into the eye.
`Defects of the aqueous layer are the most common cause of dry eye
`syndrome, also referred to as keratoconjunctivitis sicca (KCS).
`• The most superficial layer is a very thin layer of lipids (fats or oils). These
`lipids are produced by the meibomian glands and the glands of Zeis (oil
`glands in the eyelids). The main function of this lipid layer is to help decrease
`evaporation of the watery layer beneath it.
`
`Dry eye syndrome (DES) is a common condition of the tear film, affecting a
`significant percentage of the population, especially those older than 40 years of
`age. DES can affect any race and is more common in women than in men.
`
`What Are Causes of Dry Eye Syndrome?
`
`Dry eye syndrome is a common disorder of the normal tear film that results from
`one of the following:
`
`• Decreased tear production
`• Excessive tear evaporation
`• An abnormality in the production of mucus or lipids normally found in the tear
`layer
`
`Aqueous (watery) tear deficiency is caused by either poor production of watery
`tears or excessive evaporation of the watery tear layer.
`
`• Poor production of tears by the tear glands may be a result of age, hormonal
`changes, or various health conditions like autoimmune diseases such as
`primary Sjogren syndrome, rheumatoid arthritis, or lupus.
`• Evaporative loss of the watery tear layer is usually a result of an insufficient
`overlying lipid layer.
`• Some medications, such as antihistamines, antidepressants, beta-blockers,
`and oral contraceptives, may decrease tear production.
`
`If blinking is decreased or if the eyelids cannot be closed, the eyes may dry out
`because of tear evaporation.
`
`• When you read, watch TV, or perform a task that requires close attention
`with your eyes, you may not blink as often. This decreased blinking allows
`excessive evaporation of the tears.
`• Certain health conditions, such as stroke or Bell's palsy, make it difficult to
`close your eyes on your own. As a result, your eyes may become dry from
`tear evaporation.
`
`Abnormal production of mucin by the conjunctiva may occur.
`
`http://www.emedicinehealth.com/dry_eye_syndrome/article_em.htm?pf=2
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`MYLAN - EXHIBIT 1095
`Mylan Pharmaceuticals Inc. et al. v. Allergan, Inc.
`IPR2016-01127, -01128, -01129, -01130, -01131, & -01132
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`• This can result from chemical (alkali) burns to the eye or as a result of
`different health conditions, such as Stevens-Johnson syndrome and
`cicatricial pemphigoid.
`• This abnormal production of mucin leads to poor spreading of the tears over
`the surface of the eye. The surface of the eye can dry out and even become
`damaged, even though more than enough watery tears may be present.
`
`Insufficient lipid layers are the result of meibomian gland dysfunction, as with
`rosacea or as a result of taking oral isotretinoin medication.
`
`• Meibomian glands are the oil glands in the eyelids that produce the lipid
`layer.
`• If the oil glands become blocked or if the oil is too thick, there may not be
`enough oil to cover the watery tear layer to prevent its evaporation.
`• Also, if an infection is present along the eyelids or the eyelashes, called
`blepharitis, the bacteria may breakdown the oil so there may not be enough
`oil.
`
`What Are Signs and Symptoms of Dry Eye Syndrome?
`
`If you have DES, you may also experience the following symptoms:
`
`• Dry, gritty/scratchy, or filmy feeling in the eyes
`• Burning or itching in the eyes
`• Redness of the eyes
`• Blurred vision
`• A sensation of having a foreign body in the eyes
`• Light sensitivity
`
`Symptoms seem to worsen in dry climates, in windy conditions, with higher
`temperatures, with lower humidity, with prolonged use of your eyes (for example,
`reading, watching TV), and toward the end of the day.
`
`Sometimes a symptom of DES may actually be intermittent excessive tearing with
`DES. When your eye becomes slightly dry and irritated, it may initiate reflex
`tearing with production of a large amount of tears all at once to try to get moist
`and comfortable again. Unfortunately, your eye can only handle so many tears at
`any one time; the rest pour over your eyelids and down your cheeks. Those tears
`that pour down your cheeks do not help your eyes and are wasted. A short time
`later, your eyes will become slightly dry and irritated again, and the whole process
`may repeat itself.
`
`When Should Someone Seek Medical Care for Dry Eye Syndrome?
`
`If you routinely experience any of the following symptoms, you should probably
`see your ophthalmologist (a medical doctor who specializes in eye care and
`surgery):
`
`• eye pain,
`• excessive tearing,
`• dry, gritty/scratchy, or filmy feeling in the eyes,
`• burning or itching of the eyes,
`• redness of the eyes,
`• blurred vision,
`• a sensation of having a foreign body in the eyes, or
`• light sensitivity.
`
`What Questions Should People Ask Their Doctor About Dry Eye Syndrome?
`
`• Is there a specific cause for my dry eyes?
`• What is the most effective treatment for my dry eyes?
`• Is there anything I can do to decrease the need for eyedrops or artificial
`tears?
`
`What Exams and Tests Diagnose Dry Eye Syndrome?
`
`During your eye examination, your health care professional will most likely be
`able to diagnose dry eye syndrome just from hearing your complaints regarding
`your eyes. As part of your eye examination, the doctor may also perform the
`following tests.
`
`• The front of your eyes are examined using a special microscope, called a slit
`lamp microscope.
`◦ The amount and thickness of the tear film are inspected.
`◦ The stability of the tear film is assessed by checking the tear break-up
`time.
`◦ The conjunctiva is examined to determine if it is too dry.
`◦ The cornea is checked to see if it has dried out or become damaged.
`• Different dyes may be used during your eye examination.
`
`http://www.emedicinehealth.com/dry_eye_syndrome/article_em.htm?pf=2
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`◦ Fluorescein is a yellow dye that stains the cornea where the epithelial
`(surface) cells have been worn away because of the lack of an
`adequate protective tear film.
`◦ Rose Bengal is a red dye that stains the cornea and the conjunctiva
`where the cells are dead or dying as well as where healthy cells are
`inadequately protected by the tear film.
`◦ Lissamon Green is a green dye which likewise can help differentiate
`between normal and abnormal surface cells of the cornea and
`conjunctiva.
`• Schirmer tests measure the amount of tears produced by your eyes. Your
`ophthalmologist places the end of a thin strip of filter paper just inside the
`lower eyelid. After a minute, the filter paper is removed and the amount of
`wetting is measured. Less wetting of the filter paper is more indicative of
`DES.
`• The osmolarity (salt content) of the tears may be measured. This is a newer
`test which has been developed to aid in the diagnosis of DES.
`• If autoimmune diseases are suspected as a cause of DES, blood tests may
`be performed. These blood tests check for the presence of different
`autoantibodies that may be associated with DES.
`• Rarely a biopsy of the salivary glands may be performed. Certain disease
`processes affect both the salivary glands, which produce saliva in your
`mouth, and the lacrimal glands, which produce tears.
`
`Are There Home Remedies for Dry Eye Syndrome?
`
`To help alleviate your symptoms from DES, you may want to try these self-help
`tips at home.
`
`• A humidifier puts more moisture in the air. With more moisture in the air, your
`tears evaporate more slowly, keeping your eyes more comfortable. Both
`furnaces in the winter and air conditioning in the summer decrease the
`humidity in the air.
`• Excessive air movement dries out your eyes. Avoid having excessive air
`movement by decreasing the speed of ceiling fans and/or oscillating fans.
`• Large amounts of dust or other particulate matter in the air may worsen the
`symptoms of dry eye. In those situations, an air filter may be helpful.
`• Hot compresses and eyelid scrubs/massage with baby shampoo help by
`providing a thicker, more stable lipid layer. This is especially helpful if you
`have meibomian gland dysfunction, rosacea, or blepharitis. The heat warms
`up the oil in the oil glands, making it flow more easily; the massaging action
`helps get the oil out of the glands. The cleansing action decreases the
`number of bacteria that break down the oil.
`• Artificial tears and lubricating eye drops and gels (available over the counter)
`help provide more moisture and lubrication for the surface of your eye. They
`are typically used about four times a day, but they can be used as often as
`needed. Preservative-free solutions are recommended if you wish to use
`artificial tears more than six times a day. There is no single over-the-counter
`drop that is best for everyone. Each individual will determine which drop
`provides the most relief from symptoms. Some drops may have a longer
`effect than others.
`• Lubricating eye ointments are much thicker than eye drops and gels.
`Because ointments are so thick, they last much longer than eye drops and
`gels. However, because of their thickness, ointments may blur your vision if
`used during the day. Therefore, they are typically used to lubricate the eyes
`overnight while you are asleep.
`• If you notice your eyes are dry mainly while you are reading or watching TV,
`taking frequent breaks to allow your eyes to rest and become moist and
`comfortable again is helpful. Closing your eyes for 10 seconds every five to
`10 minutes will increase your comfort, as will blinking more frequently.
`
`What Are Medical Treatment Options for Dry Eye Syndrome?
`
`Although no cure exists for DES, many types of treatment are available.
`Treatment is dependent on the severity of DES; you may only require a humidifier
`or occasional eyedrops, or you may require surgery to help treat DES.
`
`Over-the-counter lubricating eyedrops, commonly referred to as artificial tears,
`may help relieve your dry eyes. Some examples of these products include 20/20
`Tears, Celluvisc, Comfort Tears, Dry Eyes, Murine, Refresh, and Tears Naturale.
`Your ophthalmologist may also prescribe medications to help with DES.
`
`What Medications Treat Dry Eyes?
`
`Certain types of prescription medications may help with DES.
`
`• Eye lubricants may be prescribed, including eye inserts. Cellulose is
`contained in the insert and acts to stabilize and thicken the film of tears over
`the eyes and to prolong the time the tear film works. The artificial tear insert
`must be properly inserted, otherwise corneal abrasion may occur.
`• Cyclosporine A 0.5% (Restasis) helps decrease any inflammation on the
`surface of your eye. This inflammation is thought to decrease the ability of
`
`http://www.emedicinehealth.com/dry_eye_syndrome/article_em.htm?pf=2
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`your eyes to maintain a healthy tear film. Used twice a day, cyclosporine
`0.5% helps you make healthier tears on your own.
`• Corticosteroid drops (Lotemax, Alrex, FML, Vexol), either alone or used in
`conjunction with Cyclosporine, reduce signs and symptoms of dry eye.
`Although the FDA has not yet approved this group of drops for the treatment
`of DES, they are being successfully used by many ophthalmologists.
`Corticosteroid drops, if used in excess, may have some health side effects,
`but new formulations with fewer side effects have become available. Like all
`medications, these should only be used under your doctor's supervision and
`according to her or his instructions.
`• Nonsteroidal anti-inflammatory drops (Voltaren, Acular, Nevanac, Xibrom)
`likewise reduce the inflammation associated with DES.
`• Antibiotics are used if you have blepharitis or meibomian gland dysfunction.
`◦ Antibiotic ophthalmic ointments, such as erythromycin and bacitracin,
`among others, are used at night for about seven to 10 days to decrease
`the number of bacteria that break down the lipid layer of your tear film.
`These ointments also lubricate your eyes overnight.
`◦ Oral antibiotics, particularly tetracycline and doxycycline, not only help
`to decrease the number of bacteria but also help to make the oil more
`fluid so it flows out of the oil glands more easily. This is often used if
`you have rosacea. There are many people who have rosacea of the
`eyelids and do not have the typical changes of rosacea on the rest of
`the face.
`
`When Is Surgery Appropriate for Dry Eye Syndrome?
`
`Different minor surgical procedures may help in the medical treatment of DES.
`
`• Near the inner corner of each eyelid are small openings, called punctae, that
`are the beginning of the normal tear drainage system. A procedure known as
`punctal occlusion can help by decreasing the normal drainage of your tears
`off the eye and down the tear drainage system, into the back of your nose,
`and down your throat. This occlusion is usually a very simple office
`procedure and only takes a few minutes.
`◦ Different punctal plugs or lacrimal canalicular plugs can be placed at or
`just inside these openings to block the normal drainage of tears down
`the tear drainage system. Just like a stopper that you put in the drain of
`a sink to keep the water from flowing down the drain, these plugs keep
`the tears that you have from flowing down the tear drainage system.
`Therefore, your eyes stay more moist and comfortable, even if you have
`fewer tears. These plugs can usually be removed very easily, if
`necessary.
`◦ Sometimes, in severe cases of DES, these openings are permanently
`closed, usually by cautery (burning) or laser. This accomplishes the
`same thing as the plugs, but it is very difficult, if not impossible, to
`reverse.
`• If you have difficulty closing your eyes for any reason, your eye may dry out
`because of tear evaporation.
`◦ Lateral tarsorrhaphy is a procedure during which the lateral (outside)
`one-third of your eyelids are sewn together to decrease the ability of
`your eye to open widely and to help your eye close more easily.
`◦ If stroke or nerve damage keeps your eyelids from closing properly, a
`small gold weight may be implanted into your upper eyelid to help it
`close.
`
`Other Therapy
`
`Sometimes, people sleep with their eyes slightly open. If you do sleep this way,
`you might want to actually tape your eyes shut at night.
`
`Moisture chambers are plastic shields (similar to swim goggles) that help keep the
`eyes from drying out by decreasing the evaporation of tears off the eye. The
`moisture chambers may be used just at night if you sleep with your eyes slightly
`open, or they may be used all day, if necessary.
`
`Follow-up
`
`If you have mild DES, you may only need annual follow-up examinations with
`your ophthalmologist.
`
`If you have more serious DES, more frequent follow-up appointments are
`required, based on the severity of your disease.
`
`Is It Possible to Prevent Dry Eyes?
`
`DES cannot be prevented. If you develop DES, you can help decrease its effects
`through some of the self-care suggestions listed above.
`
`What Is the Prognosis for Dry Eye Syndrome?
`
`http://www.emedicinehealth.com/dry_eye_syndrome/article_em.htm?pf=2
`
`

`

`Most people with DES have nothing to worry about more than an annoying
`inconvenience. Although your symptoms might make activities of daily living (for
`example, reading, watching TV, driving) difficult for you, no long-term vision loss
`is to be expected. Sever DES may cause more serious complications.
`
`Dry Eye Syndrome Support Groups and Counseling
`
`Support groups and counseling for people with DES are available through various
`organizations specializing in eye care.
`
`Where Can People Get More Information About Dry Eye Syndrome?
`
`American Academy of Ophthalmology
`655 Beach Street
`Box 7424
`San Francisco, CA 94120
`415-561-8500
`
`Dry Eye Syndrome Picture
`
`Dry eye syndrome is a common disorder of the tear film, which is made up of
`three layers, consisting of mucus, a very dilute saltwater solution, and fats or oils.
`
`Medically reviewed by William Baer, MD; Board Certified Ophthalmology
`
`REFERENCE:
`
`"Dry eyes"
`UpToDate.com
`
`Medically Reviewed by a Doctor on 8/31/2015
`
`© 2017 WebMD, LLC.
`All rights reserved.
`eMedicineHealth does not provide medical advice, diagnosis or treatment. See Additional Information.
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`http://www.emedicinehealth.com/dry_eye_syndrome/article_em.htm?pf=2
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