Anterior Segment Lacrimal System Dysfunction
Figure 1: Symptoms Checklist for Lacrimal System Dysfunction
over-activation of the immune system’s healing mechanisms – the inflammatory response and thickening of basement membranes. The sympathetic division of the autonomic nervous system does not fully mature until puberty, hence chronic parasympathetic overstimulation in children can result in congestive respiratory conditions (rhinitis, sinus congestion, middle ear disease, chronic cough, bronchitis, asthma, and pneumonia), which account for 65% of all new diseases seen by pediatricians. With improved competitive imbalance in the autonomic nervous system by the age of puberty, there is improvement in the overall health of children (for example, two-thirds of asthmatic children ‘outgrow’ their asthma).
Figure 2: VisiPlug™ Lacrimal Plugs—Non-dissolvable and Medium-term (Six Month) Dissolvable
In the anterior chamber of the eye, the inflammatory response may be a significant factor in glaucoma and cataract formation. Another chronically over-activated healing mechanism is thickening of basement membranes. This may also contribute to glaucoma, cataract formation, Fuch’s corneal dystrophy (thickening of Descemet’s membrane), and macular degeneration (thickening of Bruch’s membrane). Both healing mechanisms may be involved in the pathogenesis of vascular diseases and hypertension, and also may be critical factors in the pathogenesis of neoplastic diseases.
Neurotransmitter Depletion
Chronic dysregulation of the autonomic nervous system and chronic parasympathetic overstimulation may lead to the depletion of neurotransmitters such as acetylcholine. Neurotransmitter depletion—in particular, acetylcholine and norepinephrine depletion—are recognized as causative factors in Alzheimer’s disease and senile dementia, respectively.
Figure 3: Comfortear™ Punctum Plug—Non-dissolvable
Recommended Approach to Treatment Starting with the symptoms checklist followed by functional testing and LOT, clinicians will develop a strong conviction about the benefits of LOT and surgical procedures to decrease tear film evaporation. These result in elimination and cure of diseases—compared to prescribing therapeutic drops or lubrication therapy (which offers only symptomatic relief but no possibility of cure). Effective use of LOT involves occlusion of the upper canaliculi first, using either radio wave microcautery or non-dissolvable or long-term dissolvable lacrimal (see Figure 2)10 Figure 3).5,6
or punctum plugs (see
In severe cases, complete closure of all four canaliculi may be necessary. In addition, surgical procedures to decrease tear film evaporation may be necessary to lower afferent signals to normal low levels and to stop dysregulation and dysfunction.
Revisions to the National Eye Institute Classification of Dry Eye Disease
Chronic parasympathetic dominance increases vagal tone leading to a flood of efferent impulses being sent to multiple body systems which then fail to perform efficiently.7
factor in cardiac arrhythmias. Cardiac arrhythmias may greatly improve or completely disappear with the application of functional diagnostic tests, LOT and surgical procedures to reduce tear film evaporation.
Immune System Overstimulation
Chronic parasympathetic dominance also causes chronic overstimulation of the immune system. The combined dysregulation of the nervous system and the immune system (neuroimmune dysregulation)9
leads to 84 This increased vagal tone is a major
The National Eye Institute (NEI) classified dry eye disease (DED) based on two factors—tear evaporation and decreased tear production—identified by the Delphi panel chaired by Michael Lemp, MD.11,12
In addition, Robert
Herrick, MD, proposes the addition of a third factor—lacrimal excretory hyperactivity (LEH) (see Figure 4)—to the classification criteria. Evidence for LEH was reported by Marshall Doane, PhD, who conclusively demonstrated that the lacrimal excretory pump is 10–20 times too active in most people.13
This author recommends that the next periodic update to the 2007 Delphi panel’s guidelines11
US OPHTHALMIC REVIEW includes functional diagnostic testing to simulate
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