1. NALIN NAYAN
B.OPTM 006
NSHM KNOWLEDGE CAMPUS .
DURGAPUR

2. PREFACE
• The main aspect of this project is to show the
different tear function test to show any abnormality
in the tear film or tear film dysfunction.
• This give us a brief idea about the abnormality and
proper care to be taken in ocular surface disorders.
This project has been explained in simple and
illustrative manner about the different condition of
tear film dysfunction.
This project has explained about the different test that
has to be done to assess the tear film dysfunction.

3. ACKNOWLEDGEMENT
• THIS PROJECT HAS BEEN COMPLETED IN SUPPORT
OF MANY PEOPLE, OTHERWISE IT WAS NOT
POSSIBLE FOR ME TO PREPARE THIS PROJECT . I
WANT TO GIVE MY SINCERE THANKS TO
DR.AGRAWALS’ EYE HOSPITAL FOR ALLOWING ME
TO COMPLETE MY INTERNSHIP HERE.
• I WOULD LIKE TO THANK NSHM KNOWLEDGE
CAMPUS, DURGAPUR FOR GIVING ME SUPPORT.
• LAST BUT NOT THE LEAST I WOULD LIKE TO THANKS
MY FACULTIES, MY SENIORS , FRIENDS AND MY
COLLEAGUES FOR THEIR SUPPORT.

4. Tear Film- introduction
It covers the exposed part of
the globe i.e., the cornea
and the bulbar conjunctiva
It remains most directly in
contact with the
environment
Imp for protecting the eye
from external influences
aqueous

5. Function of Tear Film
For maintaining health of the underlying
structures
To maintain the optical stability
Antibacterial Function
Provides Corneal Nutrition
Mechanical function by flushing cellular debris, FB
from cornea & conjunctival sac & by lubricating the
surface

6. Structural components of Tear film:
Outer lipid layer
Middle aqueous layer
Inner mucin layer
To retard the evaporation of the aqueous
To lower the surface tension of the tear film
To lubricate the eyelids
To supply atmospheric O2 to the
avascular corneal epithelium
Antibacterial function
To wash away debris and allow the
passage of leucocytes after injury
Lubrication
Protection by covering FB with a
slippery coating
Converts hydrophobic into Hydrophilic
surface

8. Physical properties of Tear film
98.2% H2O
1.8% solids
pH 7.3-7.7
310-334 mOsm
RI 1.37

9. Bio-chemical components
Solutes( Protiens
-Na120-160
-Cl 118-135
-HCO3 20-25
-K 20-42
-Mg 0.7-0.9
-Ca 0.5-1.1
-Glucose 0.5-1.1
-Retinol
-Urea
-Lysozyme
-Lactoferrin
-lipocalin
-IgA, IgG
-Albumin
•Enzymes
-Glycolytic enz
-Amylase
-Plasminogen
activator
-Latent
proteanases
-Latent
Collegenase

10. Healthy Tear film Tear film in dry eye

11. Deficit aq.
production Evaporative
Sjogren’s
syndrome
Non Sjogren’s
syndrome
Meibomian
Gland Disease
Exposure
Keratopathy
CL
AbnormalityPrimary 2ndary
Lac. Gland
Disease
Lac. Gland
Obstruction
Loss of Reflex
Tearing
Ocular irritation
Tear film instability
Ocular surface
dysfunction
s
Age
Related

12. Lac glands
Brain
Neuronal feedback loop for tear production
Ocular surf
produces neural
stimulation
Secretomotor
nerve impulses
Ocular surfaceTear supports and
maintains ocular
surface

13. Change in the neuro-secretory arc/
Changes in immunomodulation of
the lac gland
Disruption of the
feedback loop
Diminution of neural tear
stimulus
Sensory nerves will adapt
to prolonged sureface
irritation
Decrease the
stimulus for
reflex tearing
Ocular surface
dessication

14. Mechanism of Tear Film Break up

15. Condition in Dry Eye vs. Normal Eye

16. Chief C/O the patients with Tear Film
dysfunction
 Burning or Itching
 Fluctuating Vision
 Foreign Body Sensation
 Grittiness or irritation
 Watering or excessive tearing
 Sore or tired eyes
 History of Styes
 Ocular Discharge
 Light sensitivity
 Contact Lens Discomfort

17. History taking for a Dry Eye(DE) patient…..
Duration of reading or computer use
Whether using contact lens
Living in arid condition
Living in air conditioned environment
Frequent air traveling
Addiction to cigarettes
Exposure to environmental allergans or systemic
allergies
Any recent diagnosed hormonal change
Autoimmune diseases
CRx (sply oral antihistaminic, antidepressants,
hormone replacement therapy,etc.)

19. External Evaluation
 Palpebral Aperture Size
 Blink Patterns
 Lid Closure
 Lid Margin Evaluation
 Lid/punctal Apposition
Tear Volume
 Subjective Tear Meniscus
 Schirmer
 Phenol Red Thread
 Meibomian Gland
Evaluation
 Gland Observation
 Lipid Expression
Ocular Surface Evaluation
 Temporal Bulbar
Conjunctiva
 Cornea
 Nasal Bulbar Conjunctiva
 Inferior Palpebral
Conjunctiva
 Staining with Sodium
Fluorescein
 Tear Break Up Time
(TBUT)/Tear Stability
 Rose Bengal Staining
Drainage Mechanism
6-sector examination
1
2
3 4
5 6

20. Diseases related to dysfunction in tear
film
Evaporative Dry Eye
Oil deficiency- secondary to
obstructive meibomian
gland dysfunction
Defective resurfacing of the
eye by the tear film (result
of poor blinking or
abnormal lid-globe
congruity)

21. Dry Eye: Multifactorial nature
Elderly woman
Contact lens
user
Post
menopausal
Taking
glaucoma
medications
Working for long
hours in front of
computer
Air-conditioned
environment

22. Diseases related to dysfunction in tear film
Lacrimation from
excess tearing
Obstructive
epiphoria as a
result of failure of
tear drainage
( Schirmer’s
value)

24. Early Signs of Tear Dysfunction
Precorneal Tear Film
Presence of an increased amount of mucin strands and debris
In Chronic Dry Eye(CDE) lipid contaminated mucin
accumulates
Marginal Tear Strip
MTS is reduced in height (0.3mm)
Attains concave shape
In CDE it can be absent

25. Tear Film Break-up Time(BUT)
It is the difference b/w the
last blink and the first
randomly appearing dry
spots
Assessed with fluorescein
and cobalt blue filter in
broad beam
Avg of three reading is
taken
Suspect Dry Eye when
BUT<10secs

26. Causes of Tear Film Destability
Tear Film rupture occurs when hydrophobic lipid
diffuses from the superficial layer and contaminates
the underlying hydrophilic mucin layer
Epithelial change (like poor secretion of glycocalyx)
can cause poor adherence of tearfilm

27. Schirmer’s Test
 Rate of tear formation is
estimated
 Whatman filter paper no 41 is
used
 Dimension 5mm X 35mm
 5mm tab is folded at one end
 The bent end is placed at the
junction of the lateral 1/3rd
and
medial 2/3rd
of the lower
conjunctival sac
 The test is performed in dim
light with fans and ACs
switched off

28. Schirmer test
 Without Anesthesia
Measures Reflex Tear
Secretion (dry eye = <
6mm wetting)
 With Anesthesia
Measures Basal Tear
Secretion (dry eye =< 3mm
wetting)

29. Rose Bengal
staining
 Rose Bengal solution 1%
placed into the conjunctival sac.
 After a wait of 2 mins, degree of rose bengal staining on bulbar
conjunctiva and cornea is quantitated by microscopic exam.
 Stains devitalized cells.
 Also stains mucous strands (very often present in KCS)
J Am Optom Assoc 1991, 62:187-199

30. Rose Bengal staining in
Early, Moderate and Late KCS
EARLY MODERATE LATE

31. Phenol Red Thread test
A sterile cotton thread is draped
over the non-anesthetized lid
margin
It changes color upon aqueous
contact and the length of
colored thread is measured
This test is used to evaluate the
tear secretion quantity without
inducing significant reflex
tearing
The normative value is 13±4 mm
of wetting over a fifteen second
period

32. Impression cytology
 Removal of superficial layers of conjunctival epithelium
 Application of circular discs of cellulose acetate filter paper
for a certain period of time.
 Obtained specimen observed under microscope for signs
and symptoms of squamous metaplasia or presence of
inflammatory cells.
 In CDE conditions the cells appear fewer, irregular in size &
shape and takes up stain less uniformly
J Am Optom Assoc 1991, 62: 187-99

33. Impression Cytology Mapping
Healthy Mild
Moderate Severe

34. Lysozyme Assay
Hyposecretion of tears may be due to the reduction in the
concentration of lysozyme
Wetted filter strip is placed into an agar plate containing
specific bacteria
The plate is incubated for 24 hrs and the zone of lysis is
measured
The zone will be reduced if the concn of lysozyme in tears
is decreased

35. Tear Globulin Assay
Decreased tear formation may be due to dec
IgA
Performed on spl tripartigan immunodiffusion
plates containing specific agar gel in wells
Twenty microliters of tear samples is put into
these wells and the plates are incubated for 48
hrs
The diffusion of rings around wells are
measured to nearest 0.1mm with partigen ruler
The ring will be reduced if the concn of Iga in
tears is decreased

36. To check the outflow mechanism
Jones test

37. Jones-I (primary) test
Differentiates excessive watering due to blockage in lacrimal passage
with primary hypersecretion of tears
1 drop of 2% fluorescein in instilled in the conjunctival sac
After 5mins a cotton tipped bud (moistened with 4%proparacaine) is
inserted under the inferior turbanate
Fluorescein if recovered from the nose then the excretory system is
patent
Otherwise should go for Jones-II test

38. Jones-II (Secondary) Test
 Helps to identify the probable site of partial obstruction
 4% xylocaine in instilled in the conjunctival sac
 Any residual fuorescein is washed out
 NLD is irrigated with normal saline
 The patient is positioned his/her down by 45deg
 +ve –fluorescein stained saline recovered from the nose showing
functional patency of upper lac passage
 -ve- unstained saline recovered from the nose shows block in the
upper lac passage or defective lacrimal pump mechanism

39. Jones Dye-I
Jones Dye-II

40. Tearscope
Assess patient's tear film quantity, quality and
stability
Non invasive method
Tear quantity is assessed with one full-length view
along the tear meniscus
Tear quality is assessed by matching the patient's
tear film with the equivalent pattern in the Guillon-
Keeler Tear Film Grading System, and by viewing the
tear film flow dynamics.
Tear stability is assessed by directly viewing the tear
film on the contact lens or corneal surface and
measuring the non invasive break up time

41. Cold cathode illumination
Timer
Star/stop button
On/off
High/low
Lap time reset button
Tearscope -the instrument itself…

42. a) normal smooth tear film that is the most representative case, b) post-blink roughness
that usually lasts no longer than two seconds, c) bubbles, d) ridges produced by the
eyelids, e) unusually rough tear surface, f) tear break-up, g) and h) are typical rough tear
surface typical of contact lenses.
Tearscope- it
depends on the
principle of
INTERFERENC
E

44. Take Home Messages…
Ocular surface disorders related to tear film
dysfunction is a complex condition
It requires careful observation, knowledge about
various diseases and their etiologies, and a
thorough ocular and systemic history
It is crucial to diagnose the correct disease
mechanism prior to considering management of
any kind
 In many situations there may be multiple causes
and only careful assessment over multiple visits
will lead to the correct diagnosis and proper
treatment plan

45. THANK YOU