Alternative Treatments For Xerophthalmia

Dry Eye Handbook The Ultimate Dry Eye Treatment

The Dry Eye Handbook is based on extensive independent research over a 10 year period. The publication is ideally suited for everything from mild to severe cases of dry eye. The Dry Eye Handbook has helped hundreds of dry eye sufferers to date, and its appreciated by individuals, larger organisations as well as ophthalmologists. You will learn: #1. How to diagnose your specific case of dry eye most doctors actually have a hard time getting this correct. #2. How to start a proper dry eye treatment dont waste time doing the wrong things, get off to a correct start quickly. #3. The best diet for dry eyes learn what to eat and drink to create the biggest impact on your eye health. #4. The best eye drops for dry eyes find out what eye drops you should use for your specific case of dry eyes. #5. The best supplements for dry eyes find out all there is about anti-inflammatory supplements, oil supplements and much more. #6. The newest treatments find out the best and most innovative treatments for dry eye (constantly updated) #7. How to treat Meibomian Gland Dysfunction find out all there is about the best supplements, eye drops, eyelid scrubs, eyelid massages, heat compresses, removing chalazia and styes and much, much more. #8. How to treat Blepharitis get the details on how to reduce inflammation by using the best supplements, diets, artificial tears, eyelid scrubs and much more. #9. How to treat Aqueous Tear Deficiency if youre suffering from a lack of tears or a incorrect composition of your tears I will show you how to increase tear production, stabilise the tear film and several additional areas that will improve your eye comfort considerably.

Dry Eye Handbook The Ultimate Dry Eye Treatment Summary


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Ophthalmic Surgery And Dry Eyes

Chondroitin sulfate is used as a viscoelastic substance to protect and lubricate cells and tissues during ophthalmic surgery, as well as to preserve corneas before transplantation (Larson et al 1989, Liesegang 1990). In a double-blind crossover study of 20 subjects, 1 chondroitin sulfate was found to be equally as effective as polyvinyl alcohol artificial tear formulation and 0.1 hyaluronic acid in reducing itching, burning and foreign body sensation in people with keratoconjunctivitis sicca (Limberg etal 1987).

Present Understanding Of Dry Eye Disease And Implications For Therapy

Nomenclature Eye Picture

A recent international workshop designed to collate and critique in an evidence-based manner the accumulated knowledge concerning dry eye disease and its treatment published a comprehensive report in 2007.1 The Dry Eye Workshop provided guidance to clinicians and researchers regarding the definition, classification, epidemiology, and research findings, and treatment guidelines for dry eye disease. The consensus definition of dry eye disease was stated to be that dry eye is a multifactorial disease of the tears and ocular surface that results in symptoms of discomfort, visual disturbance, and tear film instability with potential damage to the ocular surface. It is accompanied by increased osmolarity of the tear film and inflammation of the ocular surface.2 This definition expands the scope of the disease to include effects on visual acuity and discomfort and damage to the ocular surface through both inflammation of the tissues and hyperosmolarity of the tear film.3 The classification...

Management Of Dry Eye Disease

An effective strategy for the management of dry eye disease includes attention to the patient's lifestyle and specific pharmacologic intervention. The aggravating factors to dry eye and predisposition to symptoms of irritation are well known. Smoking has been identified as a risk factor.35 Such activities as prolonged reading, prolonged staring at a video display terminal, airplane flight, and the use of antihistamines or anticholinergic medications all increase symptoms by worsening tear film stability and volume.36,37 Often simple modification of these behaviors or the use of room humidifiers to increase ambient humidity helps to reduce symptoms, but rarely do such adjustments completely control symptoms. Ensuring that there is no intercurrent blepharitis or inflammation of the anterior eyelid margin is essential. Nevertheless, topical or systemic medications are necessary adequately to treat the disease. The guidelines proposed by the Delphi Panel and the Dry Eye Workshop based on...

Plasma Retinol Binding Protein RBP

Protein-energy malnutrition results in functional vitamin A deficiency, with very low circulating levels of the vitamin and development of clinical signs of xerophthalmia (Section 2.4). The condition is unresponsive to the administration of vitamin A and often occurs despite adequate liver reserves of retinol. The problem is one of impaired synthesis of RBP in the liver and hence a

Hormonal Supplementation

A double-blind, placebo-controlled design was used. No significant differences were observed between the Deca-Durabolin and placebo groups in tear flow, parotid flow, labial salivary gland biopsy score, and subjective symptoms of dry eye and dry mouth. ESR did decline significantly over 6 months in the treatment group. Most commonly reported adverse effects were hirsutism and hoarseness. Patients who had SLE, RA, and SS have been noted to have low levels of serum dihydroe-piandrosterone (DHEA). Pillemer and colleagues32 performed a 24-week, randomized, double-blind, placebo-controlled trial of oral DHEA (200 mg per day) in 28 women who had SS who met AECC. Oral DHEA treatment did not result in a significant improvement in symptoms of dry mouth or dry eye, Schirmer's test scores, stimulated salivary flow rates, ESR, or IgG levels. These investigators did not recommend DHEA as oral therapy or as dietary supplementation for patients who had primary SS.

Examples of Food Fortification Programs in Developing Countries

Addition of vitamin A to margarine and other vegetable fats started in 1918 in Denmark, when cases of xerophthalmia were associated with the replacement of butter by margarine. Then, the practice of nutritional equivalence, that is emulating the nutritional composition of butter, was adopted by the industry. Thus, vitamin A and D started to be added to margarine and other vegetable fats. Despite the fact that the bioavailability and utilization of vitamin A has been confirmed experimentally in the Philippines and other countries, the compliance and effectiveness of this practice at the national level has not been documented. Similarly, the addition of vitamin A in oil has been proven to be efficacious in

Head and Neck Manifestations

Painless enlargement of the salivary glands occurs in 4 to 6 of patients with sarcoidosis. The parotid glands are most commonly enlarged, but any of the salivary glands can be affected. Sarcoidosis may mimic Sjogren's syndrome by causing symptoms and signs of dry eyes and mouth. The constellation of parotid enlargement with facial palsy, fever, and anterior uveitis is called Heerfordt's syndrome (30,33). Ocular involvement occurs in 20 to 30 of patients with sarcoidosis and can affect any part of the eye or orbit this is the presenting problem in about 5 of patients with this disease. Uveitis is the most frequent and early ocular feature of sarcoidosis (40). Common ocular findings include anterior uveitis, posterior uveitis, retinal vasculitis, intermediate uveitis, vitritis, and keratoconjunctivitis sicca. Other ocular manifestations are conjunctival nodules (Fig. 2A), iris nodules (Fig. 1F), lacrimal gland enlargement, dacryocystitis, scleritis, and orbital muscle involvement...

Fulfillment of the Sjogrens Syndrome Classification Criteria

There is a considerable overlap between European diagnostic criteria for SS and some extrahepatic features of HCV infection.39 Extrapolating from the main studies with large series of HCV patients,6 xerostomia was observed in 158 (18 ) of 859 patients xerophthalmia in 129 (17 ) of 769 positive ocular tests in 83 (38 ) of 216 positive salivary gland biopsy (grades 3-4 of Chisholm-Mason classification) in 64 (25 ) of 251 positive ANA in 481 (18 ) of 2641 and positive RF in 357 (40 ) of 1117 HCV patients. In contrast, positive anti-Ro SS-A antibodies were described in only 30 (4 ) of 765 HCV patients and anti-La SS-B in 27 (3 ) of 765 (Table 4).10 These percentages suggest that a diagnosis of SS could be easily made in HCV patients presenting with sicca syndrome, positive ANA, or RF. The SS diagnosed in these HCV patients may be considered as one of the extrahepatic manifestations of chronic HCV infection.

Toxicity of Vitamin A

Vitamin A is both acutely and chronically toxic. Acutely, large doses of vitamin A (in excess of 300 mg in a single dose to adults) cause nausea, vomiting, and headache, with increased pressure in the cerebrospinal fluid - signs that disappear within a few days. After a very large dose, there may also be drowsiness and malaise, with itching and exfoliation of the skin extremely high doses can prove fatal. Single doses of 60 mg of retinol are given to children in developing countries as a prophylactic against vitamin A deficiency -an amount adequate to meet the child's needs for 4 to 6 months. About 1 of children so treated show transient signs of toxicity, but this is considered to be an acceptable adverse effect in view of the considerable benefit of preventing xerophthalmia.

Oral Immunosuppressive Agents

Methotrexate (MTX) has been used successfully for the treatment of RAfor 25 years. Little is known regarding the effect of MTX on secondary SS in patients who have RA. Skopouli and colleagues14 evaluated the safety and efficacy of MTX for primary SS in a 1-year, open-label pilot trial involving 18 patients one dropped out after 1 month. All patients met European Community criteria and had a positive minor salivary gland biopsy. Patients received 0.2 mg kg (10-15 mg) of MTX weekly. Significant improvement in subjective signs of dry mouth and dry eyes was observed, whereas objective improvement as measured by Schirmer's test, rose bengal staining, tear break-up time (BUT), and unstimulated salivary flow (USF) was not seen. Parotid gland enlargement was significantly improved as was dry cough. ESR decreased in three patients at 1 year. Seven (41 ) required reductions in MTX dosing secondary to transaminase elevations. MTX seems to deserve further study in a large randomized controlled...

Vitamin A Deficiency Disorders

Corneal Scar Detetction

And intake adequacy of breast-fed infants, stable isotopic dilution to assess the total body vitamin A pool, impression cytology that detects early or mild metaplasia on the bulbar conjunctiva, and clinical stages of xerophthalmia. Xerophthalmia Conjunctival and corneal epithelium deprived of vitamin A undergoes keratinizing metaplasia. Columnar epithelial cells become squamous and mucus-producing goblet cells disappear, providing the histopathologic mechanisms for deficiency-induced xerotic (drying) changes to the ocular surfaces. VA deficiency is also required for rod vision in dim light. VA deficiency-induced night blindness often occurs with histopathologic changes on the ocular surface. Thus, night blindness and clinical eye signs are both listed under one xerophthalmia classification scheme (Table 1). Table 1 WHO and IVACG classification and minimum prevalence criteria for xerophthalmia and vitamin A deficiency as a public health problem perceptive threshold is reached that...

Impact of Interventions

Xerophthalmia Practically any intervention that delivers adequate amounts of VA will control VA deficiency. High-potency vitamin A delivered to preschool children every 4-6 months is 90 efficacious in preventing both corneal and noncorneal xerophthalmia. Prophylactic failure ( 10 ) may reflect inadequacy of dosage for some children who are severely VA deficient or become ill. Xerophthalmia, on the other hand, virtually disappears in child populations consuming adequate amounts of vitamin A-fortified foods. There is less experience with regard to preventing night blindness in women, other than in large trials that suggest supplementation at recommended dietary levels may be insufficient to prevent all xerophthalmia, depending on background severity. Supervised dietary treatment has been reported to cure or improve noncorneal xerophthalmia however, population trials to assess the impact of dietary change in preventing xerophthalmia have yet to be carried out.

Rheumatoid Arthritis

Rheumatoid arthritis is frequently associated with both sicca symptoms and true secondary Sjogren's syndrome.9 The association between the two disorders has already been observed by Henrik Sjogren himself.43 Symptoms of dryness and objective signs of gland dysfunction are only weakly correlated,44,45 similar to the situation in normal populations.46,47 Sjogren's syndrome is usually included among extra-articular manifestations of rheumatoid arthritis. The prevalence varies considerably, depending on the definition of secondary Sjogren's syndrome, disease duration, and geographic region.48 In Spain, the cumulative prevalence of secondary Sjogren's syndrome in rheumatoid arthritis was 17 at 10 years' disease duration and as much as 25 after 30 years when actively looked for and diagnosed by presence of objective and subjective sicca manifestations in the eyes or mouth.49 This relationship to disease duration was not confirmed in the Norwegian study by Uhlig and colleagues,45 but was...


Vitamin A is involved in ocular health and function in two distinct ways. First, in the form retinaldehyde, it is an essential component of rhodopsin and is necessary for maintaining vision (Wahlqvist et al 1997). Deficiency states initially cause a reversible night-blindness that can progress to complete blindness due to photoreceptor degeneration (McCaffery & Drager 1993). Second, as retinoic acid it maintains normal differentiation of cells in the conjunctiva, cornea and other ocular structures, with deficiency resulting in xerophthalmia (dry eye) and corneal ulceration. In xerophthalmia, the cells lining the cornea lose their ability to produce mucus, and therefore lubrication of the eye becomes compromised. Dirt particles that eventually enter the eye are more easily able to scratch the surface, increasing the risk of infection and, ultimately, blindness.

Vitamin A

Diagram Xerophthalmia

Deficient A lack ofvilA (for which about one-third of lite world population is at risk initially causes reversible night blindness, later increasingly severe and irreversible loss of vision due to changes of the eye structure (xerophthalmia with drying of the conjunctiva and increasing opacity of the corneal. Hyperkeratosis and other skin lesions are further typical effects of inadequate intake. Another concern with even mild deficiency is impaired immune function, especially in children. Excessive intake Retinol intake above I000p.g d increases bone fracture risk in older people. Moderately high intakes of retinol (3000p.g d). but not of provitamin A earotenoids. during early pregnancy increase the risk of birth defects. Daily ingestion of 15000 pg retinol initially may lead to itching, scaling of skin, malaise, and loss of appetite. Cerebrospinal pressure may increase causing nausea, vomiting, headaches, and eventually seizures, coma, respiratory failure, and death.

Indications Melon

Photophobia (1 FNF) PMS (1 FNF) Polyp (f BIB) Porphyria (1 FNF) Prostatosis (f FAC) Psoriasis (1 FNF) Rhinosis (f BIB) Sore (f BIB) Sore Throat (f KAB) Stomatosis (f BIB) Stress (1 FNF) Sunburn (f BIB) Sunstroke (f BIB) Thirst (f KAB) Tumor (f BIB) Tympanites (f DEP) Ulcer (1 FNF) Uterosis (f JLH) Venereal Disease (f BIB) Xerophthalmia (1 FNF).

Cranial Irradiation

The eyes and their surrounding structures can receive radiation in the course of brain irradiation or total body irradiation. This commonly results in dry eyes (xerophthalmia) which can lead in turn to corneal abrasions. Artificial tears can palliate this symptom. Patients whose eyes have been radiated are also at increased risk of developing cataracts. Radiation involving the ear can damage the acoustic structures, and this occurs more commonly than damage to the auditory nerve. Consequently, bone conducting hearing aids can yield effective amplification.


Systemic rheumatic disease may present with a variety of manifestations in the head and neck regions. Especially important among these are the dermatologic findings of SLE, DM, and scleroderma. Rashes characteristic of these disorders may also arise later in the course of the diseases. Some of the more frequently reported manifestations to be aware of are autoimmune hearing loss, especially in SLE esophageal dysmotility in scleroderma oropharyngeal and esophageal involvement in DM PM and keratoconjunctivitis sicca and cervical spine involvement in RA.


The ocular component of SS is termed keratoconjunctivitis sicca (KCS). The Schirmer I test is used to test tear production. Standardized Schirmer strips 35 mm long and 5 mm wide, composed of sterilized filter paper, are folded at the notched ends and placed over the lateral lid margin of both lower lids and allowed to remain for five minutes, or until the strips are saturated, if sooner. The Schirmer I is preferred because it tests the ability of the lacrimal gland to produce tears under normal conditions of relatively mild stimulation. Application of a topical anesthetic (Schirmer II) creates an artificial situation in which test values are abnormally low, even in some patients without KCS. In most circumstances, less than 5 mm of wetting in five minutes is considered abnormal. Low Schirmer values are also caused by other ocular conditions not associated with SS.


Hydroxychloroquine (HCQ) is used widely in the management of primary SS by rheu-matologists despite a lack of evidence for sustained objective improvement in glandular function. A 2-year, double-blind, crossover trial reported by Kruize and colleagues6 enrolled 19 patients who were randomized to HCQ for 1 year followed by placebo for 1 year or placebo for 1 year followed by 12 months of HCQ. All patients met criteria proposed by Daniels and Talal.7 Data from 14 patients who completed the study were eligible for analysis. Patients expressed no clear preference for treatment with HCQ or placebo with respect to symptoms of dry eye, ocular inflammation, or dry mouth. In addition, patients did not prefer either treatment with regard to fatigue, parotid swelling, myalgia, or arthralgia. A significant reduction in levels of IgM and IgG and a trend toward a decrease in ESR were noted. Lacrimal gland function, as measured by Schirmer's test, rose bengal test, tear lysozyme, and tear...

B cells Biomarkers

Sjogren's syndrome (SS) is a chronic autoimmune disease affecting mainly the exocrine glands. Nearly all patients complain of a persistent feeling of dry mouth (xerostomia) and dry eyes (keratoconjunctivitis sicca).1,2 The subjective symptoms can be confirmed by objective tests, showing significant functional impairment in saliva secretion capacity and tear production. Histologic evaluation of the salivary and lacrimal glands show large and persistent infiltrates of mononuclear cells within the glandular tissue. Beside lymphocytic infiltration, acinar epithelial cell atrophy and progressing fibrosis can be observed within glands from patients who have SS. Traditionally, loss of secretory capacity, degree of lymphoid infiltration and production of specific autoantibodies were anticipated to correlate with each other and indicate disease state and disease severity.1,2 The correctness of this assumption is, however, difficult to prove and may not apply to all patients. Processes...

Management Treatment

Children with xerophthalmia and measles should be treated immediately with oral, high-potency vitamin A (200,000 IU) according to WHO and IVACG guidelines (Table 5) and provided other supportive nutritional and medical therapy as indicated. Corneal lesions should be topically treated with a suitable antibiotic (e.g., tetracycline or chloramphenicol) to prevent bacterial infection. Corneal xerophthalmia typically improves with VA treatment within Treat all cases of xerophthalmia and measles on days 1 and 2 give an additional dose for xerophthalmia on day 14. For severe malnutrition give one dose on day 1. bFor women of reproductive age, give 200,000 IU only for corneal xerophthalmia on days 1, 2 and 14 for night blindness or Bitot's spots, give 10,000 IU perday or 25,000 IU per week for 3 months. Treat all cases of xerophthalmia and measles on days 1 and 2 give an additional dose for xerophthalmia on day 14. For severe malnutrition give one dose on day 1. bFor women of reproductive...