Dry Eye Disease

What is it?

Dry eye is an extremely common and multifactorial condition which can cause eye discomfortand decreased vision. Dry eye can significantly limit your activities and impact your quality oflife. There is no cure for dry eye; however, with consistent treatment the symptoms of dry eyecan be improve and managed

Common Symptoms of Dry Eye:

  • Eyes feeling gritty/sandy/burning/stinging/scratchy/painful/sore
  • "Tired eyes," particularly at the end of the day or following focused activities
  • Light sensitivity
  • Eye redness
  • Itchy eyes and/or eyelids
  • Blurred and fluctuating vision, particularly fluctuations with blinking
  • Excessive tearing (this is a reflex reaction to dry eye)
  • Difficulty with activities such as driving, reading, watching TV, computer (when concentrating the blink is suppressed, leading to drying of the ocular surface)
  • Eye discomfort in windy conditions, low humidity, heating and air conditioning
  • Frequent blinking
  • Difficult wearing and tolerating contact lenses

Dry eye is considered to be a loss of homeostasis or balance for the normal protective mechanism of the eye, so that there is an imbalance of the water, oils, mucus, and proteins that make up the tears.  Sometimes the symptoms are made worse by eyelids that don’t blink effectively or by activities that involved prolonged staring.


What is happening?

There are multiple related issues that often occur simultaneously that together cause the symptoms people experience:

  • Tear film instability = tears that evaporate too fast
  • Hyperosmolarity = too much saltiness of the tears
  • Ocular surface inflammation = low grade inflammation of the front surface of the eyes that makes them more susceptible to minor injury
  • Damage to the surface = unhealthy or missing cells
  • Corneal nerve hypersensitivity = nerves that provide feeling to the eye that are “turned up” too high
  • Poor eyelid tone with inefficient blinking to spread the tears evenly over the eyes

In addition, over time, some people with develop behavioral and psychological issues around the chronic irritation of their eyes including pain sensitization, anxiety, and depression.

What causes these things to happen?

Aging is probably the single most important contributing factor for most people.  As we age, we can develop:

  • Tear production deficiency
  • Mucin deficiency – mucin is the coating agent that keeps tears evenly spread out on the eye – without enough mucin, tears start to “bead up” like water on a freshly waxed car
  • Meibomian Gland Disease (MGD) – a chronic, slow loss of the glands that make oils for the tears.  Oils keep the tears from evaporating and lubricate blinking.  MGD is worse in people with a common adult skin condition, known as rosacea
  • Conjunctivochalasis is a chronic loss of integrity of the white part of the eye which allows the surface layers to fold and bunch up, interfering with the spread of tears and causing redness and irritation
  • Floppy Eyelid Syndrome (FES) is a chronic, slow loss of strength in the tendons and tissues of the eyelid and may be associated with sleep apnea or chronic allergies
  • Eyelid Retraction – usually drooping of the lower eyelid that exposes too much of the eye to air, allowing it to dry out easily.  Although this is most commonly related to aging, scar tissue from eyelid surgery, trauma, or thyroid disease can also cause retraction
  • Eyelid ectropion – a condition in which the lower eyelid rolls away from the eye exposing it to the air
  • Eyelid entropion – a condition in which the lower eyelid rolls toward the eye so that the eyelashes are always rubbing the eye
  • Lagophthalmos – a condition where the eyes do not close fully

But other things can also contribute to dry eyes including:

  • Toxicity from cosmetics, pollution/smoking, and/or eye-drops (such as prostaglandins for glaucoma or the preservatives found in most eye drop formulations
  • Oral drugs such as antihistamines, decongestants, antidepressants and more
  • Hormonal changes such as menopause
  • Chronic infection of the eyelashes with bacteria or mites
  • Low humidity and increase in altitude (such as here, in Colorado)
  • Autoimmune diseases such as Sjogren’s syndrome, rheumatoid arthritis, and lupus
  • Paralysis of blinking from Bell’s palsy and other types of facial neuropathy

What tests can help sort out the problems?

A careful eye exam by an ophthalmologist or optometrist who specializes in dry eye will disclose the majority of the problems above.  The exam may include special tests such as:

  • Slit lamp biomicroscopy exam with stains to measure corneal injury
  • Matrix metalloproteinase-9 (Inflammadry test) to measure inflammation
  • Tear osmolarity to measure salt and mineral concentration
  • Meibography to measure oil gland disease and damage
  • Confocal microscopy to measure corneal nerve density

What can be done to alleviate the symptoms and improve eye health?

For some people, mild dry eye disease may be easily improved with just one treatment, such as artificial tears.  For others with severe dry eye and multiple causative factors such as oil gland disease and damage to the cornea, consultation with a specialist may lead to many medically necessary simultaneous treatments including:

  • Non-preserved artificial tears (can be used frequently and indefinitely). These typically come in small single use vials which can be used until gone as long as it is within 24 hours of opening
  • Night-time eye ointments
  • Steroid eye-drops (used short-term in most cases as these can cause problems with the eye for some patients after chronic use)
  • Serum tears (made from the person’s own blood/plasma)
  • Punctal plugs (to reduce the flow of tears awayfrom the eye into the nose)
  • Eyelid warm compresses and massage (a heated eye mask is preferred to using a hot towel as the heat is maintained for longer). Typically these are done for 5-10 minutes and may be done multiple times daily, once daily, or as needed
  • Omega-3 fatty acids taken orally as a nutritional supplement
  • Restasis (cyclosporine 0.05%) twice daily
  • Xidra (lifitegrast 5%) twice daily
  • Doxycycline oral capsules 50-100 mg once or twice a day
  • Lipiflow thermal pulsation and massage to the eyelid oil glands
  • Intense pulsed light (IPL) or broad band light (BBL) to the eyelid oil glands
  • Meibomian (oil gland) surgical probing
  • Reconstructive eyelid surgery
  • Scleral contact lenses
  • True-Tear intranasal electrical stimulator
  • Amniotic membrane transplantation (not helpful in controlled trials but can be anecdotally useful)
  • Protective glasses/sunglasses, home humidifiers, etc.

Our team can help with a small group of these tests and treatments, primarily focused on surgery of the eyelids.  Instead, most of the others can be performed or arranged by your local eye doctor.

In all cases, the key to optimal dry eye management is consistency.  Creating good habits and adhering to your prescribed regimen is critical to improve dry eye signs and symptoms. It can take weeks to months to achieve good results once your regimen has been tailored to your needs, as treatment includes healing the delicate epithelium, reducing inflammation and then maintenance of a healthy ocular surface. It is important to stick to your regimen even if you’re unsure if it is totally effective or if your eyes are feeling better, this will help your eye doctor customize your treatment regimen.


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