Dry Eye is a condition in which there is an insufficient quantity or quality of tears. Healthy tears are necessary for maintaining the integrity of the ocular surface and for providing comfortable clear vision. Dry Eye is a common and usually chronic problem – affecting women more commonly than men and occurring with increased frequency from age 45 and older.
There are many varieties and variants of this condition that has recently led to the suggestion that this condition be renamed Dysfunctional Tear Syndrome to better describe the full spectrum of signs and symptoms that are commonly seen.
There are three main types of dry eye:
The most common type is Evaporative Dry Eye – Tears are made up of three layers: oil, water and mucus…each layer serves a purpose in keeping the eye lubricated. In Evaporative Dry Eye the oil layer (outer surface of the tear film) is deficient (quantity and/or quality) allowing the tears to evaporate too quickly or not spread evenly on the eye. This is usually due to eyelid inflammation or Blepharitis. In an attempt to correct itself, the lacrimal glands produce more aqueous (watery) tears, which do not adhere well to the eye and often run down the cheek. Ironically, tearing such as this can be a sign of Dry Eye!
A less common cause is pure Aqueous Deficient Dry Eye – The eye does not produce enough aqueous tears due to reduced function or damage to the lacrimal glands from inflammation or as a side effect of certain medications.
Many cases of Dry Eye represent “mixed varieties” consisting of elements of both types listed above…one type of Dry Eye can predispose an individual to the other. Inflammation is the common denominator in all types of dry eye and is usually associated with an elevated salt concentration (hyperosmolarity) of the tears.
Dry eye can be caused and aggravated by many different factors. Click on each cause to learn more:
This refers to inflammation of the eyelids. There are many types of blepharitis. The variety most commonly associated with Dry Eye is Posterior Blepharitis in which the edge of the eyelids (just behind the roots of the eyelashes) is inflamed. This results in poor quality and/or quantity of oil secretion from the Meibomian glands, leading to rapid evaporation of the tears as described above. This effect of posterior blepharitis is referred to as Meibomian Gland Dysfunction or MGD.
Many people age 65 and over experience some symptoms of dry eye.
Women are more likely to develop dry eye due to hormonal changes; which may be most noticed at menopause but continue throughout life.
Deficiency of Omega 3
This includes “Fish Oil” (containing healthy essential fatty acids) deficiency or an imbalance of the Omega 6 / Omega 3 ratio. Many individuals consume an inadequate amount of seafood, nuts and seeds that contain healthy “anti-inflammatory” oils or subsist on a diet excessively high in the unhealthy “pro-inflammatory” Omega 6 oils found in processed foods especially those containing soybean oil.
Certain medications (diuretics, antihistamines, antidepressants, anticholinergics, etc.) can reduce the amount of tears produced. Topical medications (eye drops) used chronically for the management of glaucoma can cause or exacerbate ocular surface disease and Dry Eye. This is thought to be due mostly to the toxic effects of preservative chemicals.
Sjogrens Syndrome, Rheumatoid arthritis, Lupus and other “autoimmune disorders” as well as thyroid problems can contribute to the development of dry eye. Rosacea is a common skin condition which can affect the eyelids and tear function in approximately 50% of sufferers; leading to MGD and evaporative Dry Eye. Stroke, injuries and Bells Palsy can all cause or contribute to serious ocular surface drying.
Smoke, wind and dry climates can increase tear evaporation, exacerbating dry eye. Prolonged focusing on a computer screen for long periods of time (Computer Vision Syndrome) can decrease regular blinking, contributing to and aggravating dry eye.
Long term use of contact lenses, refractive eye surgeries (Lasik and PRK), cataract surgery , and heavy eye makeup use can all be linked to Dry Eye. Conditions that cause physical damage to the eye lids and ocular surface such as ocular cicatricial pemphigoid and burns can cause serious Dry Eye.
Symptoms of dry eye include:
Stinging or burning of the eyes
A sandy or gritty feeling
Periods of excess “reflex” tearing (thin watery tears that can run down the cheek)
Pain and redness
Blurred vision especially between blinks
Uncomfortable contact lenses
Decreased tolerance of reading or computer use
If you are experiencing any of these symptoms you may have Dry Eye. A complete exam by an eye doctor is your best first step to recovery. The experienced eye care professionals at the Center for Eye Care’s Dry Eye Clinic are available to help and will create a custom treatment plan based on your individual needs.
Treatment for dry eye depends on its causes and severity so it is very important to be examined by an eye doctor trained to diagnose and treat this condition. Both the quantity and quality of tears need to be taken into account when diagnosing dry eye.
Dry Eye can be confused with, and is often accompanied by, ocular allergies
The Dry Eye exam typically includes:
Patient History – to determine your symptoms, underlying health problems and environmental conditions that may be causing or aggravating your dry eye symptoms. This often includes a standardized Dry Eye Questionnaire like the Ocular Surface Disease Index (OSDI)
An external examination of the eye consisting of an evaluation of the eyelids, conjunctiva and cornea as well as a diagnostic expression of the meibomian glands of the lower eyelid.
External eye photography and/or meibomagraphy (high contrast photography of the meibomian glands)
Measurements of the quantity and quality of your tears – This may include a number of different tests including:
Tear volume measurement (Schirmer Test)
Evaluation of surface “staining” of the cornea with fluorescein
Evaluation of surface “staining” of the conjunctiva with lissamine green
Evaluation of the oil or lipid layer of the tears
Tear Film Break-Up Time (TBUT)
Tear Film Osmolarity Test (Salt Concentration of tears) with Tear Lab®.
MMP-9 (Inflammadry®) Test
Sjögren’s Syndrome Testing (Sjo® finger stick or blood samples)
Evaluation of the eyes and surrounding tissues for signs of conditions other than dry eye that may be complicating the picture such as allergy, infection, skin conditions, etc.
Other conditions can accompany or be mistaken for Dry Eye including ocularallergies, Floppy Eyelid Syndrome (loose eye lids associated with obstructive sleep apnea) and conjunctivochalasis which refers to redundant, loose conjunctiva (surface tissue of the eye) that disturbs normal tear spreading and drainage.
There are a number of simple, common sense measures that can benefit those who suffer from any type of dry eye. Be sure to check with your medical doctors regarding the safety and advisability of your following the recommendations listed below.
Hydration: Many of us fail to keep pace with our fluid needs and can become chronically dehydrated. Except for those who might be adversely affected by robust fluid intake (cardiac and renal problems, etc.), it is usually advisable for an adult to drink approximately eight 8 oz. glasses of water or other appropriate fluid substitute per day. This is approximately 2 liters. Fluid requirements obviously vary depending on climate exercise level and other factors but the above is a good general guideline.
Omega-3 supplementation…this is ideally achieved by ingestion of the natural foods that have the highest concentration of Omega 3…also good for joint and heart health:
seafood (in order of concentration of Omega-3):
black cod (sablefish)
seeds and nuts:
via supplement capsules:
“ester” form of Omega-3…this is the least desirable form of Omega-3 supplementation…it is quicker and easier to purify this form of Omega-3 fatty acids but it is not easily absorbable
“triglyceride” form of Omega-3…this is the naturally occurring form of Omega-3 found in seafood…it is more difficult and expensive to manufacture but provides a superior form of easily absorbable Omega-3.
Triglyceride form Omega-3 supplements are clearly labeled as such to avoid confusion. The Center for Eye Care provides this type of Omega-3 in a product manufactured by Physician Recommended Nutriceuticals (PRN), available in our Provisions Store located in the Optical Department. A liquid form is available for ease of administration.
Free Essential Fatty Acids (EFAs)…products such as Omega XL® consist of easily digestible and absorbable nutrients in small capsules
Environmental and Work Conditions: Management of humidity levels especially in the workplace can significantly improve symptoms. Consider the use of a small personal humidifier as needed. In addition, your proximity to HVAC registers / vents can expose the eyes to drying air currents; therefore it is important to optimize these conditions for ocular comfort. Observance of the 20/20/20 rule of thumb can also help…every 20 minutes, look 20 feet away for 20 seconds. This is a simple mnemonic which can be varied as needed for relief of excessive close range eye strain and the resulting aggravation of ocular surface drying. Outdoor exposure to wind, dust and excessive UV can have a dramatic drying effect. The use of appropriate protective eyewear is recommended, such as sunglasses with side wrap or side shields.
Management of Systemic Medications: check with your doctor regarding the possibility of reducing or eliminating certain medications that may be adversely affecting your Dry Eye (see medications listed above under CAUSES of Dry Eye)
Tear Substitutes / Artificial Tears: Many artificial tears are available over the counter. Let our experts tell you which drop is best for your condition. There are also special preparations that are only available in the eye doctor’s office or online which can provide prolonged relief due to longer retention time on the ocular surface. Oasis ®Tears are among this class of tear substitute.
Contact Lens re-wetting drops: Soft contact lens wearers often require specifically formulated “re-wetting” drops that can temporarily saturate the lens and supplement the natural tear film. These work to both counteract any associated relative dry eye and to “cushion” the lens and allow for smoother movement on the cornea. Excessive need for these drops may signal the need for refitting / replacing lenses or a reduction in wear time. Persistent discomfort and redness could signal a corneal infection or ulcer and should prompt an examination.
Ophthalmic Gels: are very effective for overnight lubrication of the eyes and can be critical for use in cases of exposure keratitis from lid abnormalities and thyroid eye disease. These gels should be applied to the eye just before sleep since they will cause significantly blurred vision for long periods, preventing reading or watching TV. Systane® Ultra Gel is available in the CEC Provisions Store for your convenience.
Anti-inflammatory Eye Drop Medications:
Corticosteroids such as Lotemax ® (loteprednol etabonate ophthalmic suspension), a prescription eye drop medication, can be used under physician supervision for short periods and can provide relief from the symptoms of Dry Eye when used judicially.
Restasis® (cyclosporine ophthalmic emulsion) is a long term prescription anti-inflammatory agent that can have a variably beneficial effect, most specifically in cases of aqueous deficient Dry Eye due to Primary or Secondary Sjogrens Syndrome.
Management of Blepharitis / Meibomian Gland Dysfunction (MGD)
Warm / Hot Compresses This is a mainstay of blepharitis / MGD treatment. Moist heat can help promote improved oil gland function when used consistently. This can be accomplished by using a simple face cloth soaked in hot tap water, wrung out and re-warmed /reapplied several times over a 5-10 minute period. Alternatively, there are many new products such as the Bruder Mask, which contains tiny moisture beads and can be heated in the microwave for seconds and then worn for a few minutes to provide effective relief.
“Fire and Ice” This is a regimen of moist heat application followed by cold compresses. The heat softens secretions and dilates the pores encouraging oil delivery to the tear film. Then the cold compress constricts the capillaries that can become dilated and engorged by the heat thus reducing the concentration of inflammatory chemicals common to all forms of blepharitis
Lid Hygiene / Cleaning Regimens Blepharitis is accompanied by an accumulation of dead skin cells, dried mucus, bacterial overgrowth and, in many women, impregnation of the delicate lid margin skin with mascara, eyeliner and other make-up residue. The inflamed eyelids must be continuously cleansed of these contaminants which will otherwise exacerbate the problem and lead to its chronicity. There are many products available for this purpose including Oasis® Lid and Lash Cleaner and various lid wipes. All are stocked at the CEC Provisions Store for your convenience.
Blephex® This is a quick and painless in-office procedure used to combat dry eye and blepharitis. This hand held device uses a spinning, medical grade, micro-sponge that gently exfoliates the lashes and eyelids to remove debris. The sponge is then disposed of and a new sponge is used for the next eye. After exfoliating, the eyes are thoroughly rinsed for immediate results.
Most patients feel instant relief of their symptoms after a single treatment. With the debris cleared out, the ducts can begin to restore natural tear production. To keep the eyelids healthy and maintain these results, it is recommended to get a BlephEx® treatment about every six months. Keeping your eyelids healthy and clean can save you time and money by reducing the need of drops.
Intense Pulsed Light (IPL) IPL is an option for patients who suffer from evaporative dry eye and haven’t seen adequate results from more conventional treatments. This painless treatment uses bursts of light directed at the lower eyelids and upper cheek areas to heat the blocked eyelid glands. Our physician then manually expresses and clears the residue from the eyelids allowing for instant results. IPL works best when combined with Blephex treatments and the general measures covered above. The number of treatments (Blephex® and / or IPL) needed depends on the severity of your condition. Contact our office for a consultation to see if IPL is right for you.
Combination Treatment The above two treatments (Blephex® and IPL) are synergistic and can be used together to enhance oil gland function in the eyelids leading to a more stable tear film.
Omega-3 supplementation (see above)
Topical Antibiotic / Steroid Medication Cortiscosteroid containing eye drops can effectively treat inflammation caused by and associated with blepharitis / dry eye and are safe for short periods. Prolonged use can cause cataracts and glaucoma and should always be used under physician supervision. Combination Antibiotic / corticosteroid drops are also used especially in evaporative dry eye due to blepharitis / MGD.
Oral Antibiotics Tetracycline-class oral antibiotics (particularly Doxycycline) can be very helpful in managing chronic severe blepharitis / meibomian gland dysfunction and rosacea. This may require prolonged use, which can be problematic due side effects and sunlight and dairy restrictions. Recently, the use of short-term azithromycin (5 day course) has been proposed as a similarly effective program with much less chance of adverse side effects and few restrictions.
Lipiflow® The Lipiflow® device is intended to compress and heat the eyelids in order to help improve meibomian gland function. Results can vary and the treatments are considerably more expensive than Blephex® and IPL and is not endorsed by the CEC Dry Eye Clinic.
All of the management options listed above can be used in different combinations and at different times at your physician’s discretion to reduce or eliminate the problems associated with chronic blepharitis / meibomian gland dysfunction. In most cases this is a chronic condition and will require continued efforts to keep signs and symptoms to a minimum.
These are tiny silicone inserts that can be placed in the tear drainage ducts of the eyelids to reduce drainage of both natural and instilled artificial tears. The plugs are very well tolerated and are not visible to others. They can be placed in both lower and upper lids and typically remain in place for many months at a time. This is a tear conservation measure that can provide a great deal of relief to many patients. They are inserted in the office by the eye doctor in just a few seconds and are usually covered by insurance.
Bandage Contact Lenses
These are thin, non-prescription breathable long term wear lenses that can serve as a protection of the ocular surface and as a reservoir of fluid from the natural tears or additionally applied drops.
Prescription Contact Lens Modifications
Contact lens wear may be inadvisable in individuals with Dry Eye. If soft lenses are desired they may need to be worn for shorter periods than usual. Rigid gas permeable lenses (RGPs), unlike soft lenses, do not require hydration and may be a better option for mild to moderate Dry Eye. These lenses are also easier to maintain and can provide better visual acuity than soft lenses.
Management of co-existing eyelid and ocular conditions
Ocular Allergies: Dry Eye and ocular allergies often co-exist or can be confused with each other. The eye doctor will seek to differentiate these and provide treatment as necessary.
Rosacea (see above) can be managed by avoidance of triggers (spicy foods, alcohol, sunlight exposure, excess emotional stress, etc.) and periodic treatment with tetracycline class antibiotics along with management of accompanying blepharitis / MGD. Intense Pulsed Light (IPL) can be very helpful for both the rosacea and any coexisting blepharitis / evaporative Dry Eye.
Ectropion (eversion of the lower eyelid) can result from laxity due to aging or to various injuries or inflammations. This can result in destabilization of the normal tear film, poor spreading of tears on the ocular surface and excessive evaporation of tears. Tearing due to dysfunction of the normal tear drainage apparatus can also occur. If significant, surgery may be indicated to restore normal tear function.
Eye lid weakness / paralysis from stroke, Bells Palsy or injury may require frequent use of lubricants (drops and gels) as well as surgical management to avoid excessive drying of the eye due to exposure, evaporation and poor tear spreading.
Conjunctivochalasis: if significantly interfering with proper tear physiology, this may require surgical repair which can be performed in the office.
Ocular Cicatricial Pemphigoid: This is a rare and potentially serious systemic autoimmune condition. Though lubricant and steroid drops can help to ameliorate symptoms, this requires long term systemic treatment with “immunomodulator” drugs such as cyclophosphamide, methotrexate and mycophenolate by an experienced internist or rheumatologist.
Management of co-existing systemic conditions
Primary Sjogrens Syndrome: This is a systemic autoimmune condition which causes a combination of Dry Eye and Dry Mouth due to inflammation of the lacrimal and salivary glands. This can also affect other systems in the body and is diagnosed by clinical signs / symptoms and blood tests. Most recently a simple and very accurate in-office test (Sjo®) can be performed and requires a simple fingerstick sample of blood.
Secondary Sjogrens Syndrome: this refers to Dry Eye and Dry Mouth in association with another rheumatoid condition such as Rheumatoid arthritis.
Consultation with and co-management by a rheumatologist is usually advisable for optimized treatment of these conditions. Use of the proper systemic anti-inflammatory medications is critical to proper management of these potentially serious disorders. In addition, one of the more commonly used medications for these conditions is Plaquenil (hydroxychloroquine) which can, in turn cause damage to the eye (maculopathy) when used for a number of years making continuous monitoring by the eye care professional a standard of care.
Thyroid Eye Disease: Ocular involvement can occur across the spectrum of thyroid conditions, particularly in Graves Disease. The eyes can become protuberant (“proptosis” or “exophthalmos”) and, due to poor lid closure, can result in evaporative Dry Eye due to exposure of the eye, especially overnight. Co-management by both ophthalmic experts and internists / endocrinologists is critical to successful treatment of this potentially vision threatening condition.
Preparation for Eye Surgery
Dry Eye can cause a number of problems for patients undergoing cataract or laser vision correction surgery:
Dry Eye can lead to inaccurate measurements of the eye’s curvature that are critical to proper Intraocular Lens calculations. It is necessary to thoroughly treat any co-existing Dry Eye prior to taking final measurements.
Active Dry Eye and blepharitis can increase the risk of a serious intraocular infection after cataract surgery (endophthalmitis). It may be wise to perform thorough lid cleaning with Blephex® and possible IPL before performing surgery (cataract or vision correction surgery).
The visual results from both cataract and laser vision correction surgery depend on the presence of a healthy tear film which should be optimized prior to the surgery by any / all means necessary.
Management of Severe / Vision Threatening Dry Eye
Most cases of Dry Eye are manageable by some or all of the measures discussed above and, though Dry Eye can be professionally or personally debilitating, it can frequently be managed to allow for resumption of preferred activities. There are, however, very serious vision threatening degrees of Dry Eye that require more advanced treatments including:
Moist Chamber Goggles: These are tight fitting, specially constructed goggles that will allow for the build up of moisture on and around the eyes by preventing evaporation.
Scleral Contact Lenses: These are large diameter, rigid, gas permeable lenses that vault the cornea and allow for accumulation of a reservoir of moisture bathing the cornea while still allowing for oxygen transmission through the lens and in to the cornea. These require special fitting kits and expertise and are not yet widely available.
Autologous Serum Eye Drops: This is a a solution made from a patient’s own blood sample. The blood is centrifuged to remove the cellular elements and formulated by a special compounding pharmacy into eye drops. The natural healing substances within the serum help to restore the integrity of the dried and damage ocular surface.
ProKera® Amniotic Membrane Device: This is contact lens-like device consisting of a thin sheet of human amniotic membrane derived from placentas that is stretched around a flexible support ring and inserted by the eye doctor on the eye for a period of time to promote healing of severely damaged tissues. The healing elements of the natural placental tissue provide the needed support for restoration of the ocular surface.
The results I have seen from Blephex are fantastic. There was a tremendous improvement in the way my eyes look and felt by the next day. I no longer need the Restasis drops and have had improved eye check-ups since having the procedure.
Before I had the Blephex treatment I always felt like I had sand in my eyes. They were red, dry and irritated. All of these symptoms were relieved after my first treatment; four months have passed and I still feel relief. The procedure was a breeze and I would do it again without hesitation.
To schedule your appointment or for more information about the clinic: