What is Dry Eye?
Dry eye is the instability of the tear film and/or a decrease in the tear film of the ocular surface which leads to chronic inflammation and damage overtime. Dry eye can occur for many different reasons and therefore can have many different treatments.
What are some of the symptoms of Dry Eye?
- Intermittent blurred vision
- Foreign body sensation
- Redness & Itching
- Heavy Eyelids
What are some causes of dry eye?
- Age (>40 years old)
- Gender (Female>Male)
- Contact Lens Wear
- Prolonged periods of near work (reading, computer screen, sewing etc.)
- Chronic Skin Conditions (Rosacea, Eczema, Atopic Dermatitis, Psoriasis, etc.)
- Autoimmune Conditions (Rheumatoid Arthritis, Sjogrens Syndrome, Lupus etc.)
- Thyroid disorders
- Environmental allergies
- Blepharitis (chronic inflammation of eyelids)
- Medications (diuretics, antihistamines, etc.)
- Medicated eye drops
- Make-up/Cosmetics (eyeliner, eyeshadow, mascara)
- Previous ocular surgeries (LASIK, PRK)
What is the tear film?
The tear film is the layer of tears that covers the front part of the eye. It is made up of 3 layers:
- Inner layer – Mucin layer
- Middle layer – Aqueous layer
- Outer layer – Lipid layer
The Mucin layer is produced by the conjunctiva (the clear skin of the eye). It’s role is to help stabilize the tear film and provide attachment of the other layers
The Aqueous layer is produced by our lacrimal gland and makes up 98% of the tear film. We get aqueous production from the gland every time we blink naturally. It contains important electrolytes and proteins our cornea needs for good health.
The Lipid layer is the outermost layer and it is produced by the oil glands in our eyelids (meibomian glands). Its role is to prevent evaporation of the aqueous layer.
What types of dry eye are there?
- Aqueous Deficient Dry Eye
- Evaporative Dry Eye (Lipid Deficient)
- Mixed (Aqueous deficient + Evaporative)
Aqueous deficient dry eye is when the lacrimal gland does not produce enough of the aqueous layer. This can occur naturally with age, with dehydration, when taking diuretics, in Sjogren’s Syndrome, during times of prolonged near work when our blink rate goes down, or if there has been damage or radiation in the lacrimal gland region.
Evaporative dry eye is when we are lacking a sufficient lipid layer and so our aqueous layer is not well protected and it evaporates quickly. This occurs when the meibomian glands do not produce enough oil or the oil they produce is not good quality. This can occur naturally with age, with inflammatory skin conditions (like rosacea), with chronic make up use without proper removal, or with blepharitis (a common eyelid skin inflammatory condition) for example. If meibomian glands are chronically clogged and inflamed they will atrophy and eventually shrink so much that they no longer function and we lose them. Once we lose them, they do not regenerate. It is very important to identify issues with the meibomian glands and address them so we can maintain them throughout our lifetime.
Most people have a mixed type of dry eye with risk factors for both aqueous and lipid deficiency
How impactful is dry eye?
Dry eye can really impact the quality of life for an individual because it can affect vision and the ability to perform every day tasks and activities. Instability of the tear film leads to instability of the vision. Without consistent vision things like reading, working, watching TV, painting and crafting all become more difficult to do and thus less enjoyable.
Dry eye can also impact future refractive surgeries (Cataract Surgery and LASIK Surgery). Without a smooth ocular surface pre-operative measurements of the cornea cannot be accurately taken and thus the person may not have an ideal visual outcome after surgery.
How do you diagnose dry eye?
Our doctors can diagnose dry eye during an examination with them along with special testing at our office. On a routine examination they will assess the quality of your tears and the quality of the oil your meibomian glands produce and they will assess the health of the cornea under the microscope.
We have technology that can take pictures of your meibomian glands so that they can better evaluate the structure of them and look for any existing damage. We also use a TearLab test which tests the osmolarity of your tears. This can alert us of the level of dry eye disease that you have.
How do you treat dry eye?
There are many ways to treat dry eye. The type of treatment depends on the cause and severity of dry eye. Below we will discuss a few different treatments and how they are effective
There are many different brands of over-the-counter artificial tears on the market. The purpose of artificial tears is to supplement your own natural tears and to make up for any deficit you have. They need to be used frequently and consistently in order to see a benefit. Our doctors can recommend specific brands for you based on your type of dry eye.
If tears are not enough many top brands also make over-the-counter ophthalmic ointments. They are thicker than regular tears and will make your vision blurry so they are best used before bedtime and they then provide you with overnight moisture as well.
The purpose of a hot compress is to open up the oil glands of the eyelid (meibomian glands) and to aid in the secretion of their oils which make up the very important lipid layer of our tears. If oils are not coming out of the glands and the lipid layer is depleted, the aqueous layer will evaporate fast and symptoms of dry eye will persist.
The type of hot compress you use matters. A wash cloth is not a sufficient hot compress because it does not hold the heat that you need long enough (at least 10 minutes!). We recommend a beaded heat mask that you can put in the microwave. Having moist heat on the eyelids for 10 minutes a day is the best way to take care of your meibomian glands and keep them functioning.
Our eyelids are exposed to the air and environment we put them in all day long. The lids and lashes accumulate debris, dust and allergens from the air. Make up is also frequently applied to the eyelid region and can (if not properly applied or not properly removed) accumulate in the pores of the meibomian glands and clog them. Lastly, our eyelid margins are a mucus membrane just like the gums of our teeth are, and just like the gums get coated in a biofilm daily so do our eyelid margins. Keeping the pores of our meibomian glands open and clean is very important to their function. There a many different brands of eyelid cleaners that are healthy for the eyelid margin and there are also some make-up removers out there you should avoid. Our doctors can recommend specific brands for you based on your eyelid health and some are available at our office.
Sometimes advanced lid cleaning is required if at-home lid cleansers are not enough. In cases of Blepharitis a more thorough cleaning is needed to remove debris from the base of the eyelashes. Our office offers Blephex as an in-office procedure done to deep clean the eyelid margins and lashes for patients.
Topical Anti-Inflammatory Drops
Chronically dry eyes and dysfunctional eyelids eventually lead to chronic inflammation in the tear film. Inflammation alters the osmolarity and increased osmolarity can alert us to how dysfunctional the tear film is.
When dry eye is elevated to this level artificial tears and eyelid hygiene are not likely enough to relieve symptoms. The next step is to use a prescription anti-inflammatory eye drop. These drops are not steroids so they are safe for long term use. There are 3 different FDA approved dry eye drops available for doctors to prescribe and they are to be used in conjunction with artificial tears and hot compresses for optimal results. All of the prescription drops are dosed twice daily and need to be used consistently for at least 1-2 months for best results. Our doctors can discuss each of these options with you and recommend the best one for you based on your level of dry eye.
In severe cases steroid eye drops need to be used to help treat elevated ocular surface inflammation. These are generally not used long-term as they carry some long term side effects but they are safe to use for short intervals. They are very valuable in severe cases of dry eye.
Once our tears serve their purpose on the front surface they drain through small holes on the lower and upper eyelids near our nose called puncta. They drain through a tubular network into a duct which then drains down the back of our nose and eventually our throat. Punctal plugs are small plugs that are placed in these holes (puncta) to reduce the rate of drainage so that your tears and any artificial tears you use will stay on your ocular surface longer. They are a very safe and are extremely small, so small that you don’t even feel that they are there. Some plugs are permanent (silicone) and some dissolve (collagen) over the course of 3 or 6 months and need to be replaced.
Intense Pulsed Light (IPL)
IPL is an emerging and very successful treatment in eyecare for dry eye – specifically evaporative dry eye. It uses pulses of light of specific wavelengths and energy through the skin. It helps dry eye in a few different ways: First, the light energy that is emitted warms the meibomian glands which helps them express their oils easier. Secondly, the wavelength of light targets small blood vessels that are often seen on the eyelid when there in is inflammation present. These are the same kind of small blood vessels that can been seen on the cheeks and nose of those with facial rosacea. These vessels are a pathway for inflammation. The light shrinks these vessels which decreases inflammation and redness thus helping dry eye. Third, IPL has been shown to reduce the presence of a common eyelid mite (yes we said mite!) called demodex which contributes to dry eye. The last effect of IPL is a bonus – you get collagen tightening as well! Not only does it help dry eye but you also get an aesthetic bonus with this procedure. Our doctors and technicians can perform this procedure for your in our office as part of your dry eye treatment plan.
Scleral lenses are hard contact lenses but are bigger than the traditional hard contact lenses (RGPs). These lenses are filled with a preservative free moisturizing agent and placed on the eye. The cornea is in a continuous all day bath of lubrication so you get all day relief from symptoms. A prescription is built into these lenses so you also have clear vision while wearing them as well. They require a fitting session with one of our doctors as they are a large lens and requires practice to insert and remove. They are invaluable in cases of dry eye where eyelid exposure is an issue, for example incomplete blinks or inability to close eyelids due to bell’s palsy or a stroke.
Amniotic tissue has been used in many areas of healthcare for decades and we are very fortunate in eye care to have had it develop into a treatment for various ocular surface diseases including dry eye! The amniotic tissue is taken from healthy mothers who donated their tissue to the medical field after delivery. The amniotic sac tissue contains many amazing proteins and natural anti-inflammatory properties along with stem cells that make in a miraculous tool for rehabilitating the ocular surface tissue. Amniotic membranes come in wet and dry forms and both are placed on the surface of your eye like a contact lens. They are worn for about 1 week as they dissolve and then the contact lens or amnion holder is removed from your eye by our doctors. The purpose of this treatment is to decrease the inflammation on the surface, as well as to regenerate damaged corneal cells that have been chronically deteriorated from dry eye.