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Sandbank Epitheliopathy of the Conjunctiva (SEC) A New Indicator in Dry Eye Diagnostics Useful for Optimized Ocular Surgery

Introduction: Increasing awareness of the importance of dry eye disease for the outcome of ocular surgery does emphasize the need for facilitated diagnostic of the ocular surface condition. Currently, corneal fluorescein staining is usually evaluated using the modified Oxford scale in which conjunctival staining is of minor importance and, based on the counting of dots, difficult to assess. We searched an alternative, easily accessible rating option to evaluate conjunctival changes associated with dry eye disease.

Methods: Using standard fluorescein staining, cobalt blue light, and yellow filter we investigated routinely the conjunctiva of patients over 6 months. The specific staining of the conjunctiva was documented digitally 0-30 seconds after instillation of the dye. The staining pattern of patients with dry eye was analyzed.

Results: A clearly distinct change of conjunctival staining on the bulbar conjunctiva was observed in eyes with tear film insufficiency. This sign is easily visible by the use of blue light with a yellow barrier filter. The sign is termed sandbank epitheliopathy of the conjunctiva (SEC). Its’ anatomical correlate are ripples of the conjunctiva that, clearly stained with Fluoresceine, do increase with the severity of dry eye. This specific conjunctival staining does vary with the severity of dry eye.

Discussion: A new conjunctival indicator dry eye disease is presented. The pathophysiological processes leading to SEC are outlined. The ease of access to see SEC gives an alternative to the grading conjunctival fluorescein staining with the Oxford scale. The SEC scale ranges from 0 to 3. The presence of conjunctival stress due to increased friction at the ocular surface does begin at SEC grade I. A practical guide with case illustrations is presented leading to a preliminary grading scale. Conclusion: Sandbank epitheliopathy of the conjunctiva (SEC) can be identified in patients with dry eye disease. As soon as SEC is clearly visible on the conjunctiva, pre- and postoperative treatment with tear fluid modifying agents such as gels or high molecular weight tear fluid substitutes or tear fluid additives is encouraged in order to minimize their potential negative impact on the surgical result.


Gysbert van Setten

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