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Penyakit Mata kering : Sebuah tinjauandari pendekatan diagnosis dan terapiHui Lin, MD, PhD; Samuel C. Yiu,MD, PhD
Journal of Ophthalmology(2014)28, 173-181
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Abstrak • penyakit mata yang umum yang
menyebabkan mata menjadi tidaknyaman, gangguan penglihatan dan berakibat pada kualitas hidup
Kata Kunci• mata kering, penyakit permukaan
okuli, gangguan penglihatan,
pendekatan diagnosis
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penyakit yangmultia!torial dari
air mata danpermukaan okuli
kisaran pre"alensi
berkisar darisekitar #$ sampailebih dari %#$ dikelompok usia yang
berbeda&beda
Pengantar
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Klasifikasi
'lasiikasi etiopatogenesis (modiikasi dari laporan )**+ D-S.
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Penilaian Diagnosis
ri/ayat danpemeriksaan
0ear break&uptime
pe/arnaanpermukaan
okuli denganloresin
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Evaluasi Subjektif
1ejala dan ri/ayat pasien mata kering ber"ariasi
ering kurangnya korelasi antarakeparahan gejala dan tanda&tanda matakering
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Evaluasi Objektif
0ear break&up time(2%$
pe/arnaankornea(3#$
penilaianilm airmata (+4$
pe/arnaankonjungti"a
(+5$
uji S!hirmer(#5$
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-"aluasidengan
0eknologi
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Osmolaritas air mata
• osmolaritas 6%*3 m7sms 8 lmerupakan indikator matakering ringan
• 6 %9) m7sms 8 l indikasi
mata kering sedang sampai berat
:ilaiindikator
• 0itik depresi pembekuan(PD
• 0ekanan uap• kondukti"itas listrik atau
impedans
Cara ukurosmolaritas
air mata
<<osmolaritas airmata tidak dapat
digunakan sebagai
satu&satunyaindikator penyakit
mata kering<<
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Penilaian stabilitas air mata
• dasar diagnosismata kering
• Tear Break-upTme
• non&in"asiTear Break-upTme (:=>?0
• :=>?0 dapatdiukur dengan
topograikornea,intererometri,aberrometry,penilaianungsional
ketajaman "isual, danmikroskop!onfo!al
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rpotensi digunakan
untuk e"aluasi yang tepat danobjekti ilm air
mata
untuk mengukurpenyebaran ilm air
mata ke atas danstabilitas
'e!epatan partikelilm air mata
diukur sebagaisebuah penilaian
hidrodinamika airmata dengan
mela!ak
pergerakanrelekti partikeldalam ilm air
mata
Sebuah program
menentukan
ke!epatan daripartikel saatmereka melintasike atas di ilm air
mata
dapat berpotensidigunakan untuk
e"aluasi klinis daristabilitas ilm airmata yang lebih
tepat dan objekti.
Penilaian partikel film air mata
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Sistem analisis topografi
Sistem topograi kornea
seperti 0MS&9 dan
"ideokeratos!opy
dengan ke!epatan tinggi
(HS@ menggantikan
keratometers untuk
menge"aluasi indeks
keteraturan permukaan(SA=, danindeks
asimetri permukaan
(SB=
pola topograi dapatdigunakan untukmenge"aluasiketeraturan permukaan
kornea dan stabilitasilm air mata
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Aberrometri"a#efront a$errometry memungkinkan penilaian non&in"asi dari gangguan "isual yang disebabkan oleh penyimpangan susunan yang lebih tinggi yang
timbul dari ketidakstabilan ilm air mata dan $reak-up
Perubahan pada "olume air mata dan
dinamikanya
pola
karakteristik dimata normal
dan mata kering
Pemberian perlahan&lahanair mata buatan telahterbukti mengurangi
penyimpangan dalam matakering ketika pengukurandiambil setelah beberapa
detik
untuk mendeteksi matakering dan untuk
memantau eekti"itaspengobatan
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Ketajaman fungsional visual
pasien denganmata kering
mungkin memilikimasalah mengaturpandangan yang
jelas ketikamenatap
@B adalahukuran
ketajaman "isual selama
mata terbukatanpa berkedip.
@B menurunse!ara signiikanpada pasien mata
kering sindromnon&Sjgren (:SS
dan Sjgrensyndrome (SS
sistem terbaru pengukuran terus menerus @B (@BM, :=D-', 1amagori,
epang telah dikembangkan, yang memungkinkan ketajaman "isusmonokuli terus menerus selama %* detik tanpa kedipan.
berguna untuk menge"aluasi pasien dengan ketidakstabilanair mata dan telah dilaporkan bah/a penilaian berkorelasi dengan 0>?0
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Tomografi
koherensi optik
• Segmen anteriortomograi koherensi
optik (7C0 dapatmengukurketebalan lapisanair mata danparameter menis!usair mata yangmenunjukkan total "olume air mata
Microskopconfocal non-
kontak
• Sebuah non&kontak,tan%em&&!annng mikroskop !ono!almenunjukkangambar real-tme telah digunakanoleh beberapapeneliti mengamatiilm air mata
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Evaluasi permukaanmata dan peradangan
Mikroskop !ono!al
Mi!rokop kornea!ono!al in "i"o(=@CM adalahsebuah no"el,
nonin"asi, alat&resolusi tinggi yang
memungkinkanpen!itraan kornea
pada tingkat sel danmemberikan gambar
yang sebandingdengan metode
histokimia.
-"aluasi kelenjar
meibomM1D adalah
penyebab palingumum dari mata
kering karenae"aporasi
Meiboskopi
Meibograi
Meibometri
Pe/arnaan kornea
dan konjungti"amerupakan prosedur
in"asi yangmemungkinkan
penilaian kerusakanpermukaan okuli
dengan
menanamkanpe/arna sepertinatrium luores!ein,
ro&e $engal , ataul&&amne hijau.
'esan sitologikonjungti"a atau
sikat sitologiPenelitian telah
menunjukkan bah/asitokin =L&9a, =L&9bmatang, dan =L&9Aa
ditemukan dalampersentase yang lebih
tinggi dari spesimensitologi konjungti"adari mata dengan SS,
daripada yang berasal dari mata
normal
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Testes lain
• m e n g u k u r p e n y e r a p a n l u o r e s ! e i n d i p u s a t k o r n e a d a n d i a n g g a p s e n s i t i
m e n g u k u r i n t e g r i t a s e p i t e l
luorophotometri
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Pengobatan
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Perawatan anti-inflamasi
Siklosporin B
bereek imunosupresi dan anti&inlamasimelalui beberapa jalur
Steroid
Sering di kombinasidengan CSB
Steroid topikal jugadigunakan untuk
meredam peradanganpada permukaan okuli
pada mata kering,
rekuensi dosis tinggi
dapat meningkatkaneisiensi pengobatan,
beberapa pasienmengalami eek tidak
nyaman
memblokadesiklooksigenase,
produksi prostaglandindari asam arakidonat
dan stimulasiapoptosis dari limosit
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Aeseptor untuk androgen,estrogen, progesteron,dan prolaktin telahdiidentiikasi dalam beberapa jaringan mata,termasuk kelenjarlakrimal dan kelenjarmeibom
pengolesan androgentopikal dan hormonsteroid estrogen selama%&5 bulan juga telahditemukan untukmenunjukkan perbaikanklinis
0erapihormonal
antibioti! makrolid(aEitromisin danturunannya tetrasiklin(tetrasiklin,doFy!y!line,danmino!y!line memiliki bahan imunomodulator
untuk mengurangiperadangan permukaanmata dan menormalkanproduksi lemak olehkelenjar meibom
sangat berguna dalammata kering sekunderkarena rosa!ea okuli dan blepharitis
Bntibiotik
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Perawatan tambahan
Bsam Lemak-sensial (-Bs
• 7mega&% (asamala&linolenatdan omega&4(asam linoleat
• sebagian besar buktimenunjukkanomega&%, dapat
mengurangikeparahan matakering
aktorpertumbuhansara (:1
• untukmeningkatkansensiti"itaspermukaan mata,menghambatreaksi inlamasidan mengaturproduksi lapisanair mata
• penggunaan :1eksogen mungkin bermanaatdalammemulihkan
kerusakanpermukaan okuli
Serum autologus
• Butologus danserum tali pusarmengandungEat&Eat yangmendukungprolierasi,dierensiasi, danpematangan dari
epitelpermukaan mata
yang normal
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Perawatan tambahan
• P e n g g u n a a n a k u p u n k t u r s e b a g a i p e n g o b a t a n u n t u k p e n y a k i t m a t a d i d a s a r k a n
p a d a k l a i m b a h / a a k u p u n k t u r m e m o d u l a s i s i s t e m s a r a o t o n o m d a n s i s t e m k e k e b a l a n t u b u h
akupuntur
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Pembedahan
S u m b a t a n p u n ! t a l
• S u m b a t a n p u n ! t a l m e n g u r a n g i d r a i n a s e , m e n j a g a a i r m a t a d a n m e m p e r p a n j a n g e e k p e l u m a s
P r o s e d u r k e l e n j a r l u d a h
• k e l e n j a r l u d a h s u b m a n d i b u l a r k e d a e r a h t e m p o r a l d a n i m p l a n d a r i d u k t u s " h a r t o n k e o r n i k s a t a s
• P a r a p a s i e n m e l a p o r k a n r a s a s u b j e k t i l e g a d a r i g e j a l a m a t a k e r i n g s e g e r a s e t e l a h o p e r a s i .
S u b k u t a n e u s a b d o m i n a l
p o m p a & / a d u k a i r m a t a b u a t a n • P o m p a / a d u k a i r m a t a b u a t a n d i s a r a n k a n o l e h ' u r u $ e u n t u k p e n g o b a t a n m a t a k e r i n g y a n g p a r a h
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Kesimpulan
Pada kesimpulan, pemahaman patogenesis dan responseluler tertentu yang terlibat dalam berbagai bentukmata kering dapat mengakibatkan pengembangan
strategi pengobatan lainnya untuk manajemen yanglebih baik dan hasil jangka panjang. >ukti peradangan yang berimplikasi pada patogenesis mata kering telah
membuka jalan baru untuk pengobatan gangguankompleks ini. Pengembangan pilihan pengobatan
tambahan dalam bentuk senya/a menargetkankomponen tertentu seperti penghalang epitel, sarakornea, konjungti"a sel goblet, atau sel&sel imun dan
sitokin yang terlibat dalam reaksi inlamasi okular akanmemberikan harapan bagi jutaan orang yang setiap hari
mengalami kondisi merugikan ini.
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Referensi9. Aesear!h in dry eyeG report o the Aesear!h Sub!ommittee o the =nternational Dry -ye orkShop ()**+. 7!ul Sur )**+;#()G9+22%.
). 0he epidemiology o dry eye diseaseG report o the -pidemiology Sub!ommittee o the =nternational Dry -ye orkShop ()**+. 7!ul Sur )**+;#()G2%9*+.
%. >ehrens B, Doyle , Stern L, et al. Dysun!tional tear syndromeG a Delphi approa!h to treatment re!ommendations. Cornea )**4;)#(3G 2**+.
5. M!1innigle S, :aroo SB, -perjesi . -"aluation o dry eye. Sur" 7phthalmol )*9);#+(5G)2%%94.
#. Serin D, 'arsloglu S, 'yan B, BlagoE 1. B simple approa!h to the repeatability o the S!hirmer test /ithout anesthesiaG eyes open or !losedI Cornea )**+;)4(3G2*%4.4. Lemp MB, >ron B, >audouin C, et al. 0ear osmolarity in the diagnosis and management o dry eye disease. Bm 7phthalmol )*99;9#9(#G+2)3, e9.
+. 1ilbard P. 0ear ilm osmolarity and kerato!onjun!ti"itis si!!a. CLB7 923#;99(%G)5%#*.
3. Pensyl CD, >enjamin . @apor pressure osmometryG minimum sample mi!ro"olumes. B!ta 7phthalmol S!and 9222;++(9G)+%*.
2. 7gasa/ara ', Mitsubayashi ', 0suru 0, 'arube =. -le!tri!al !ondu!ti"ity o tear luid in healthy persons and kerato!onjun!ti"itis si!!a patients measured by a leFible!ondu!timetri! sensor. 1raees Br!h Clin -Fp 7phthalmol 9224;)%5(2G#5)4.
9*. @ersura P, ProaEio @, Campos -C. Perorman!e o tear osmolarity !ompared to pre"ious diagnosti! tests or dry eye diseases. Curr -ye Aes )*9*;%#(+G##%45.
99. SuEuki M, Massingale ML, Ye , et al. 0ear osmolarity as a biomarker or dry eye disease se"erity. =n"est 7phthalmol @is S!i )*9*;#9(2G5##+49.
9). S/eeney D, Millar 0, Aaju SA. 0ear ilm stabilityG a re"ie/. -Fp -ye Aes )*9%;99+G)3%3.
9%. :orn MS. Desi!!ation o the pre!orneal ilm. =. Corneal /etting& time. B!ta 7phthalmol (Copenh 9242;5+(5G34#3*.
95. Smith , :i!hols '', >ald/in -'. Current patterns in the use o diagnosti! tests in dry eye e"aluation. Cornea )**3;)+(4G4#44).
9#. @arikooty , 'eir :, Simpson 0. -stimating tear ilm spread and stability through tear hydrodynami!s. 7ptometry @ision S!i )*9);32(3G -9992)5.94. Liu J, Plugelder SC. Corneal sura!e regularity and the ee!t o artii!ial tears in aKueous tear dei!ien!y. 7phthalmology 9222;9*4(#G 2%25%.
9+. SE!Eesna DH, Blonso&Caneiro D, =skander DA, et al. Predi!ting dry eye using nonin"asi"e te!hniKues o tear ilm sura!e assessment. =n"est 7phthalmol @is S!i )*99;#)()G+#94.
93. Montes&Mi!o A, CaliE B, Blio L. a"eront analysis o higher order aberrations in dry eye patients. Aera!t Surg )**5;)*(%G)5%+.
92. M!Donald -. Sura!e phenomena o tear ilms. 0rans Bm 7phthalmol So! 9243;44G2*#%2.
)*. inis D, Pis!hel :, S!hrader S, 1eerling 1. -"aluation o lipid layer thi!kness measurement o the tear ilm as a diagnosti! tool or meibomian gland dysun!tion. Cornea)*9%;%)(9)G9#52#%.
)9. Yokoi :, 'omuro B. :on&in"asi"e methods o assessing the tear ilm. -Fp -ye Aes )**5;+3(%G%225*+.
)). 1ar!ia&Aesua C, ernandeE M1, Penedo M1, et al. :e/ sot/are appli!ation or !lariying tear ilm lipid layer patterns. Cornea )*9%;%)(5G#%354.
)%. 'oh S, Maeda :, Hirohara Y, et al. Serial measurements o higher& order aberrations ater blinking in normal subje!ts. =n"est 7phthalmol @is S!i )**4;5+(3G%%93)5.
)5. Lin YY, Carrel H, ang =, et al. -e!t o tear ilm break&up on higher order aberrations o the anterior !ornea in normal, dry, and post& LBS=' eyes. Aera!t Surg
)**#;)9(#GS#)#2.)#. 'oh S, Maeda :, Hirohara Y, et al. Serial measurements o higher& order aberrations ater blinking in patients /ith dry eye. =n"est 7phthalmol @is S!i )**3;52(9G9%%3.
)4. Montes&Mi!o A, Blio L, Charman :. Postblink !hanges in the o!ular modulation transer un!tion measured by a double&pass method. =n"est 7phthalmol @is S!i)**#;54(9)G5543+%.
)+. Aidder H, LaMotte , Hall , et al. Contrast sensiti"ity and tear layer aberrometry in dry eye patients. 7ptometry @ision S!i )**2;34(2G 9*#243.
)3. Die!ko/ . 4th =nternational Coneren!e on the 0ear ilm 7!ular Sura!eG basi! s!ien!e and !lini!al rele"an!e (loren!e, =taly, September )*9*. 7!ul Sur )*99;2(9G%9).
)2. 'aido M, Dogru M, =shida A, 0subota '. Con!ept o un!tional "isual a!uity and its appli!ations. Cornea )**+;)4(2 Suppl. 9GS)2%#.
%*. 1oto -, Yagi Y, Matsumoto Y, 0subota '. =mpaired un!tional "isual a!uity o dry eye patients. Bm 7phthalmol )**);9%%()G9394.
%9. =shida A, 'ojima 0, Dogru M, et al. 0he appli!ation o a ne/ !ontinuous un!tional "isual a!uity measurement system in dry eye syndromes. Bm 7phthalmol )**#;9%2()G)#%3.
%). 'aido M, =shida A, Dogru M, et al. -i!a!y o pun!tum plug treatment in short break&up time dry eye. 7ptometry @ision S!i )**3;3#(3G+#34%.
%%. ang , onn D, Simpson 0L, ones L. Pre!orneal and pre& and postlens tear ilm thi!kness measured indire!tly /ith opti!al !oheren!e tomography. =n"est 7phthalmol @is S!i
)**%;55(4G )#)53.
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Referensi%5. Shen M, Li , ang , et al. ?pper and lo/er tear menis!i in the diagnosis o dry eye. =n"est 7phthalmol @is S!i )**2;#*(4G)+))4.
%#. :guyen P, Huang D, Li Y, et al. Correlation bet/een opti!al !oheren!e tomography&deri"ed assessments o lo/er tear menis!us parameters and !lini!al eatures o dry eyedisease. Cornea )*9);%9(4G43*#.
%4. @eres B, 0apasEto >, 'osina&Hagyo ', et al. =maging lid¶llel !onjun!ti"al olds /ith 7C0 and !omparing its grading /ith the slit lamp !lassii!ation in dry eye patientsand normal subje!ts. =n"est 7phthalmol @is S!i )*99;#)(4G)25##9.
%+. 'anellopoulos B, Bsimellis 1. =n "i"o %&dimensional !orneal epithelial thi!kness mapping as an indi!ator o dry eyeG preliminary !lini!al assessment. Bm 7phthalmol)*95;9#+(9G4%3.
%3. u M, Shin 1, Hoshi S, et al. 0hree&dimensional "olumetri! human meibomian gland in"estigation using polariEation&sensiti"e opti!al !oheren!e tomography. >iomed7pt )*95;92(%G%*#*%.
%2. Mathers D, Daley 0-. =n&"i"o obser"ation o the human tear ilm by tandem s!anning !ono!al mi!ros!opy. S!anning 9225;94(#G%942.
5*. akamatsu 0H, Sato -B, Matsumoto Y, et al. Conjun!ti"al =n @i"o Cono!al S!anning Laser Mi!ros!opy in Patients /ith Sjogren Syndrome. =n"est 7phthalmol @is S!i)*9*;#9(9G955#*.
59. Jhang N>, Chen , Chen , et al. 0ear dynami!s and !orneal !ono!al mi!ros!opy o subje!ts /ith mild sel&reported oi!e dry eye. 7phthalmology )*99;993(#G2*)+.
5). Plugelder SC, Solomon B, Stern M-. 0he diagnosis and management o dry eyeG a t/enty&i"e&year re"ie/. Cornea )***;92(#G4552.
5%. -ron :. Conta!t lens&indu!ed !hanges in the anterior eye as obser"ed in "i"o /ith the !ono!al mi!ros!ope. Prog Aetin -ye Aes )**+;)4(5G%235%4.55. 0uominen =S, 'onttinen Y0, @esaluoma MH, et al. Corneal inner"ation and morphology in primary SjogrenOs syndrome. =n"est 7phthalmol @is S!i )**%;55(4G)#5#2.
5#. Lin H, Li , Dong :, et al. Changes in !orneal epithelial layer inlammatory !ells in aKueous tear&dei!ient dry eye. =n"est 7phthalmol @is S!i )*9*;#9(9G9))3.
54. =brahim 7M, Matsumoto Y, Dogru M, et al. 0he ei!a!y, sensiti"ity, and spe!ii!ity o in "i"o laser !ono!al mi!ros!opy in the diagnosis o meibomian gland dysun!tion.7phthalmology )*9*;99+(5G44#+).
5+. Hong , Jhu , Jhuang H, et al. =n "i"o !ono!al mi!ros!opy o !onjun!ti"al goblet !ells in patients /ith SjogrenOs syndrome dry eye. >r 7phthalmol )*9*;25(99G95#53.
53. akamatsu 0H, Sato -B, Matsumoto Y, et al. Conjun!ti"al in "i"o !ono!al s!anning laser mi!ros!opy in patients /ith Sjogren syndrome. =n"est 7phthalmol @is S!i)*9*;#9(9G955#*.
52. :i!hols '', oulks 1:, >ron B, et al. 0he international /orkshop on meibomian gland dysun!tionG eFe!uti"e summary. =n"est 7phthalmol @is S!i )*99;#)(5G92))2.
#*. >ron B, >enjamin L, Snibson 1A. Meibomian gland disease. Classii!ation and grading o lid !hanges. -ye (Lond 9229;#(PtG%2#599.
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#). 0omlinson B, >ron B, 'orb DA, et al. 0he international /orkshop on meibomian gland dysun!tionG report o the diagnosis sub!ommittee. =n"est 7phthalmol @is S!i)*99;#)(5G)**452.
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