Dry eye is a group of diseases in which the tear film is unstable and the ocular surface is damaged due to abnormalities in the quantity or quality of tears, resulting in ocular discomfort symptoms. It includes corneoconjunctival dryness.
Dry eye includes not only dry eyes caused by lack of tears, but also signs and symptoms caused by tear film instability due to normal amount of tears and other abnormal factors.
Epidemiology: The prevalence is 14.6% among 65~84 people in the United States. Germany: >40 years old, prevalence 23%. Sweden: 55-72 years old, prevalence 15%. Japan: patient screening, 17%. China: recently reported (Liu Ying et al.) ophthalmology outpatients, prevalence 32.1%, male:female 1:4.
With the aging of society, air pollution, “air-conditioned environment”, the popularity of corneal contact lenses and terminal vision screens, the incidence of dry eye disease should be increasing year by year.
Common symptoms: dryness, foreign body sensation, burning sensation, itching, photophobia, eye redness, blurred vision, fluctuating visual acuity, visual fatigue, etc.
Causes of dry eye.
Under normal conditions, the surface of the conjunctiva and cornea is covered with a layer of oil secreted by the lid glands, under which is a layer of aqueous humor secreted by the lacrimal glands, and the innermost layer is a layer of mucus secreted by the cupula cells, all three of which together form a film that protects the cornea and conjunctiva – the tear film, which distributes tears evenly over the surface of the cornea and conjunctiva through transients.
The function of the tear film: the oil layer slows down the evaporation of tears, the aqueous and mucus layers have the function of moistening and protecting the epithelium of the cornea conjunctiva, lubricating the eye surface and inhibiting the growth of microorganisms, while flushing foreign bodies from the conjunctival sac and providing essential nutrients to the cornea. A stable tear film is the basis for maintaining the health of the ocular surface, and any abnormality of the tear film on the ocular surface caused by any reason will cause dry eye.
When the tear secretion function is impaired, it can cause insufficient secretion of aqueous humor and produce dry eye; in addition, if the aqueous humor production is sufficient, but the evaporation loss of the eye surface is too fast also causes dry eye.
A. Poor tear film formation
1, aqueous layer changes.
①Decrease in secretion: disease, trauma.
② Excessive evaporation: lack of lipid layer.
2. Lack of lipid layer: lid gland dysfunction disease.
3. Lack of mucus layer: cupular cell damage, Vit A deficiency disease, preservatives.
II. Excessive evaporation of tear film and abnormal cell distribution
1, poor formation and distribution of lipid layer.
2, lid entropion, lid margin abnormalities, hyperthyroidism, corneal disease, etc.
Third, dry eye and corneal limbal stem cells
Corneal limbal stem cells are an important component in maintaining the health of the ocular surface epithelium. History of injury: chemical injury, thermal burns, corneal rim surgery and condensation, long-term contact lens wear, previous severe infectious inflammation.
IV. Systemic medications
Thiazides, antidepressants, beta-blockers, anticholinergics, phenylsulfonamides, antiparkinsonians, antihistamines and antihypertensives.
V. Dry eye and ocular surface inflammatory diseases
1, Sj?gren syndrome: inflammatory infiltration of exocrine glands, resulting in destruction of the lacrimal gland.
2.Dry eye with allergy: destruction of cupular cells.
3.Dry eye and conjunctivitis: destruction of cupular cells, long-term application of antimicrobials and hormones.
4, dry eye and blepharitis: destruction of the lid and sebaceous glands, change in tear composition, and excessive evaporation.
5. Dry eye and eye medication: preservatives lead to toxic effects.
VI. Systemic diseases
1.Collagenous diseases: rheumatoid arthritis, scleroderma, lupus erythematosus, Sjögren’s syndrome
2, other diseases: allergic diseases, chronic conjunctivitis, skin mucous membrane syndrome, Stevens-Johnson syndrome, etc.
Seven, dry eye disease and the working life environment
Long-term work in the open air conditioning, air circulation “building disease syndrome”; often engaged in focused work such as: the use of computers “terminal syndrome”, dark rooms to watch movies, driving cars, etc. cause transient interval exposure to the eye surface area increased and reduced frequency of transients; intolerance to smoky, irritating environments.
VIII. Other related factors.
The influence of age factors: the higher prevalence of dry eye disease in patients older than 40 years old may be related to the gradual weakening of tear secretion function with age; patients under 40 years old may suffer from frequent computer use, television viewing, contact lens wear, and lid gland dysfunction resulting in
abnormal tear quality and quantity function.
Influence of gender factors: the prevalence of women is significantly higher than that of men because sex hormones have an important influence on lacrimal secretion, and low androgen levels are an important factor in women’s disease.
Diabetic dry eye is due to peripheral nerve paralysis and insufficient reflex tear secretion.
Nine, dry eye due to allergic conjunctivitis in children
Spring keratoconjunctivitis (VKC) dry eye is associated with damage to conjunctival epidermal cells and cupped cells. The disease is characterized by itchy, dry eyes and increased number of transients, accompanied by burning sensation, tearing, photophobia and mucous filiform discharge. Most dry eyes are relieved when allergic conjunctivitis is relieved.
Common in modern young people: computers, air conditioning, contact lenses.
Classification.
1, evaporation-overpowered dry eye: this type of dry eye is mainly caused by abnormalities in the lipid layer (qualitative or quantitative abnormalities), such as lid gland dysfunction, blepharitis, blepharitis, etc. Defects or abnormalities in the eyelids cause increased evaporation.
2, aqueous deficiency type dry eye: caused by insufficient aqueous tear production, such as sjogren’s syndrome, many systemic factors cause this type of dry eye. Aqueous tear quality abnormalities also lead to tear film instability, causing dry eye.
TCM classification.
It is mostly divided into two types: lung yin deficiency (Nourishing Yin and Clearing Lung Soup, Baihe Gujin Tang) and liver and kidney yin deficiency (Great Tonic Yin Pill, Siwu Wu Zi Tang, Qiju Dihuang Wan).
Other subtypes include evil heat retention (Sang Bai Pi Tang), damp heat in the spleen and stomach (San Ren Tang combined with Si Jun Zi Tang), yin deficiency and damp heat (Nourishing Yin and Clearing Lung Tang combined with San Ren Tang), spleen deficiency and qi weakness (Gui Spleen Tang), and deficiency fire floating over (Plus and Minus Jin Kui Ren Qi Wan).
Pathogenesis
1, deficiency of lung yin: white eyes belong to the lung. It mostly occurs in younger patients, mostly due to long-term fatigue and excessive use of eyes; or lack of sleep and mood, qi depression and fire injury to fluid, resulting in loss of moistening of the eyes, hence dry eyes. Treatment is to clear the dryness and save the lung soup.
2, liver and kidney yin deficiency: liver collects blood and opens the orifice in the eyes, liver blood is most important for the purpose of moistening. Tears are liver fluid and the liver is the master of drainage. Deficiency of Yin and Blood in the liver, the drainage is not normal, the source of tears is not enough, the lack of tears, the eyes are not moistened, the eyes are dry. The kidney is the main reservoir of essence, the kidney is the master of water and fluid, and plays an important role in the metabolism and distribution of water in the body. Deficiency of kidney qi and kidney essence will prevent fluid from moistening the eyes, and if the eyes are not moistened, the eyes will be dry. Clinical manifestations are: dry eyes, foreign body sensation, photophobia and shyness, white eyes faintly light red, prolonged vision symptoms aggravated, may be accompanied by dry mouth, waist and knee weakness, dizziness and tinnitus, dreamy and easy to wake.
3, post-operative dry eyes: LASIK surgery patients are mostly young people, the pathogenesis to the deficiency of both Qi and Yin, mostly due to eye surgery caused by exhaustion of Qi can not spread the essence, filling the five organs, the upper glory of the eye to the eye loss of moistening and dry eyes. The treatment is to moisten the lung and benefit the qi, so that the fluid can be spread normally to moisten the eyes, benefit the qi and nourish the yin, so that the fluid can fill the organs and moisten the orifices. The treatment is to add the flavor of Sha Shen Mai Dong Tang.
Other treatment methods.
Thunder fire moxibustion medicine stick eye moxibustion therapy.
Fishy grass injection (antipyretic, anti-dampness, anti-inflammatory, anti-pathogenic effects), Chaihu injection (antipyretic, anti-inflammatory, anti-pathogenic effects, plus the spray plays a role in cleaning the eye) fog treatment; Chinese herbal formula decoction and external fumigation.
Acupuncture: eye-mind, Zanzhu, Sizhukong, pupil s, Sibai, Yingxiang, Taixi, Foot Sanli, Liver Yu, Kidney Yu, Fenglong, Neiguan, Fengchi, Sanyinjiao, Yinlingquan, Sun, Hegu, etc.
Prevention
1, maintain a regular life, get enough sleep, do not stay up late, and eat a reasonable diet.
2, do not work in air-conditioned rooms all year round and do not drive for long periods of time.
3, do not use the computer continuously for a long time, maintain a most appropriate posture, avoid reflections or unclear fluorescent screen, make both eyes look flat or lightly downward at the fluorescent screen, should blink more, let the eyes rest at least once every hour, with a suitable pair of glasses.
4, do not work in smoky and windy environments, increase indoor humidity, and increase the number of transient eyes.
5. avoid eye make-up as much as possible, and increase estrogen in moderation for women in menopause.
6.Avoid wearing contact lenses for a long time.
7, do eyelid cleaning and hot compresses.
8, with eye redness, eye dryness symptoms do not buy their own medicine point eye, to the regular hospital ophthalmology consultation.
9, use eye gel, point artificial tears as needed, point artificial tears (nutrient solution) should be careful not to be too frequent, preferably no more than 6 times a day.
Dietary modifications.
1, long-term computer operators, to eat more fresh vegetables and fruits, while increasing the intake of vitamin A, B1, C, E. To prevent dry cornea, dry eyes, vision loss, and even night blindness, you should eat more foods rich in vitamin A, such as soy products, fish, milk, walnuts, green vegetables, cabbage, hollow vegetables, tomatoes and fresh fruits. Vitamin C can effectively inhibit cell oxidation. Vitamin E is mainly used to: lower cholesterol, remove waste from the body and prevent cataracts (walnuts and peanuts are rich in vitamin E). Vitamin B1 can nourish nerves (green leafy vegetables contain a large amount of vitamin B1). You can drink green tea and chrysanthemum tea properly every day, because the lipopolysaccharide in tea can improve the body’s hematopoietic function, and tea also has the function of preventing radiation damage.
2, food therapy: 1, lily red dates porridge: lily 10 grams, 15 grams of yam, 20 grams of barley, red dates (remove the core) 10. Wash the above materials, together cook porridge to eat. This porridge is not only effective in preventing dry eyes, but also used to improve eyesight.
2, chrysanthemum and wolfberry tea: chrysanthemum tea with wolfberry infusion. Efficacy: “Compendium of Materia Medica” recorded that chrysanthemum “sweet, cold, has the effect of dispersing wind-heat, calm the liver and brighten the eyes”. Modern pharmacological analysis shows that chrysanthemum is rich in vitamin A, which is an important substance for maintaining eye health. Chrysanthemum tea can clear the mind and brighten the eyes, especially for dry eyes caused by liver fire and excessive use of eyes. It should be noted that chrysanthemum is cold, cold body, usually afraid of cold, easy to cold hands and feet should not often drink
3, walnuts: chew two every night, can relieve symptoms. Efficacy: walnut kernel is rich in fatty oil, vitamin A, vitamin B1, vitamin B2, vitamin C, vitamin E and other nutrients, has the effect of tonifying the kidney and fixing the essence, nourishing the liver.
4, Chinese wolfberry: 15 grams per day, washed and chewed or boiled in water. Efficacy: wolfberry nourishes yin and bright eyes, can promote the repair of diseased cornea, improve the body’s ability to resist disease.
5, chrysanthemum, maitake, xuan ginseng, sand ginseng bubble water to drink on behalf of.
Common misconceptions.
1, many patients and clinicians misdiagnose dry eye as conjunctivitis, and prolonged use of antibacterial drugs for treatment, and antibacterial drugs in the preservative and antimicrobial agents have a destructive effect on the eye surface cells, aggravating the patient’s condition, dry eye symptoms shall not be relieved.
2. Patients with conjunctivitis and blepharitis should be actively treated for the original disease and use artificial tears on this basis.
3. Patients with severe or persistent symptoms that cannot be alleviated should seek timely medical attention from an ophthalmologist and be prepared for long-term medication.
Dry eye examination
Slit lamp examination.
1.The width of tear river line: greater than or equal to 0.3
2, corneal changes: keratosis, blistering, degeneration, ulceration, white spots, vascular opacity, corneal neovascularization
3, debris on the corneal surface and lacrimal lake
4, eyelid bulb adhesions
5, Conjunctiva: congestion, papillary hyperplasia, conjunctival folds of the conjunctival sac
6. Eyelid examination: lid margin congestion, irregularity, thickening, blunting, ectropion, glandular opening obstructed by yellow mucous secretions, blurring, etc. Compression of the gland reveals either no lipid secretion discharge or excessive discharge of abnormal morphology of lipids
Shirmer1 and 2 tests: 1 reflects the basal secretion of tears; 2 reflects the reflex secretion of tears
Tear film rupture time: reflecting the stability of tear film
Ocular surface staining in vivo: corneal fluorescein staining and tiger red staining
Tear clearance, tear osmolarity
Other 1 tear lactoferrin content measurement 2 tear fern-like change test 3 dry eye meter 4 conjunctival blot cytology 5 corneal topography examination 6 serological examination (to understand autoantibodies SS: anti-nuclear antibody, anti-DNA antibody, anti-ENA antibody, rheumatoid factor, etc. positive)
Dry eye treatment
I. Aqueous tear deficiency dry eye
1.Tear component replacement therapy, medication and surgery
2, preservation of tears: 1. silicone eye shields and wet room mirror: provide an airtight environment, reduce the air flow on the eye surface, reduce the evaporation of tears on the eye surface. Long-term wearing silicone in the skin allergy prone people are not easy to tolerate. 2. bandage corneal contact lens: mild better efficacy, especially office filiform keratitis. Severe dry eye is not suitable. 3. tear dots embolism and tear dots closure. Complications embolus displacement, dacryocystitis
3, to increase tear secretion: 1 must couch flat, efficacy varies. 2 pilocarpine: promote glandular secretion
4.Anti-inflammatory and immunosuppressant: cyclosporine A
5.Sex hormones: androgens
6.Treatment of diseases related to Sjogren’s syndrome
II. Evaporative overactive dry eye
Abnormal lid gland function: insufficient secretion and impaired discharge
1. Eyelid cleansing: hot compresses, massage, scrubbing
2. Oral antibiotics
3. Local drug application: antibiotics, hormones, artificial tears, treatment of seborrheic dermatitis
4.Lipid replacement therapy
5.Androgen
Our ophthalmology department has achieved good results in the treatment of dry eye and related ocular surface diseases in young and middle-aged patients by applying traditional Chinese medicine internal medicine, acupuncture, thunder fire moxibustion, traditional Chinese medicine nebulization and traditional Chinese medicine cold compress.
The application of Mulberry Bai Pi Tang is based on supporting the righteousness, nourishing Yin and increasing fluid, applying bitter-cold and heat-clearing herbs, as well as bright-eye and meridian-attracting herbs to clear the floating fires in the upper jiao, draining the depressed evil qi, and at the same time, strengthening the Wei and supporting the righteousness, realizing the righteousness and driving away the evil.
Acupuncture treatment and moxibustion treatment can achieve the effect of unblocking the meridians, regulating qi and blood, improving blood circulation, and consolidating the surface to remove evil.
Chinese medicine nebulization and Chinese medicine cold compress apply Chinese medicine to clear heat and dispel dampness, brighten the eyes and remove opacities, which can quickly and obviously reduce the local inflammatory reaction of the eyes and improve the patient’s discomfort.
Applying the comprehensive treatment of internal and external treatment, complemented by the patient’s cooperation in changing bad habits and seeking the root cause of the disease, fundamentally, improving the imbalance of yin and yang of the internal organs and Qi and blood, relieving the patient’s pain.