What Is Dry Eye?
The eye needs a healthy tear film to feel comfortable and see well. The tears are made from 3 layers: the oil layer, the water layer, and the mucus layer. Each layer is crucial to making a healthy tear film. The lipid layer helps tears from evaporating quickly, the water layer lubricates the eye, and the mucus layer helps mix the two together.
- Age (the body becomes more dry as we get older)
- Eye irritation (eg. eye allergies, exposure to circulating air, eye drop preservatives)
- Decreased blinking (eg. computer work, reading, watching TV, Parkinson’s disease)
- Previous eye surgery (eg. LASIK or cataract surgery)
- Autoimmune disease (eg. Sjogren’s, Rheumatoid Arthritis)
- Rosacea (skin inflammation)
- Blepharitis (eyelid inflammation)
- Meibomian Gland Dysfunction (inflammation of eyelid oil glands)
- Incomplete eyelid closure during sleep
- Blurry vision
- Eye strain
- Eye pain
- Eye redness
- Eye pressure sensation
- Gritty eyes
- Itchy eyes
Dry Eye without symptoms does not require treatment. However, if symptoms persist, there are several treatments available. It is important to remember that Dry Eye is a chronic condition that does not go away but can be improved.
Artificial tears are lubricating eye drops that try to mimic your natural tears to help improve symptoms by adding more moisture. They can be used up to 5 times a day. The preservative in the drops can cause toxicity if used too frequently. Popular brands include Refresh, Systane, Blink, TheraTears, Retaine, and Soothe.
Drops that come in individual vials and are labeled “preservative free” can be used every 1-2 hours. It is important not to use drops more than every hour to avoid washing out normal growth factors that form on the eye surface.
The eye drops also come in a “gel” composition. The gel is a little thicker and blurs the vision for a few seconds. However, the gel retains moisture and prolongs the lubricating effect of the eye drops. The gel drops can also come in the “preservative free” preparation, eg. Refresh Celluvisc.
Certain people do not fully close their eyes at night or still wake up with irritated eyes. Placing a small amount of moisturizing ointment in the eye right before going to sleep will lubricate the eyes overnight and help retain moisture. There are 2 types of nighttime ointments – thick gel or Vaseline-based ointment. The gel is a little easier to put in the eye but may dry up by the morning. The ointment lasts longer but may be a little harder to place in the eye.
- Popular Thick Gel Drops: Genteal Gel Severe, Systane Nightime Gel, TheraTears Nightime Liquid Gel, Refresh Celluvisc
- Popular Nighttime Ointments: Soothe PM, Systane Nighttime, Genteal Severe Ointment, Retaine PM
Warm compresses can help melt the oils naturally made in the eyelids to help improve flow and tear quality. Warm compresses are ideally done 1-2 times a day but can be done more frequently.
A damp towel or dry eye mask is heated (hot, but not burning hot) and then placed over closed eyes for 3-4 minutes. The mask is then removed and its important to forcefully blink 15 times or massage the eyelids to help the liquefied oil to flow out.
Examples of dry eye masks:
ThermalOn, Rhein Fire and Ice, MicroBeads Compress, Bruder Moist Heat Compress.
Control of Blepharitis
Blepharitis is the build-up of old skin and mucous debris on the eyelashes which results in bacteria built up and inflammation. This causes eye irritation and exacerbates dry eye symptoms. There are several ways to help remove debris.
The eyelashes are first wet with warm water to help soften the debris for 20-30 seconds, then the lashes are washed with Johnson and Johnson baby shampoo (does not burn eyes).
Eyelid scrub wipes can be used instead of baby shampoo. Popular brands include OcuSoft Eyelid Scrubs, CliraDex Eyelid Scrubs, Gentle Formula Tea Tree Facial Cleaner, and OcuSoft HypoChlor.
Closing the Tear Ducts
The tears are produced by the eye tear glands and then drain into the nose as they pass over the eye surface through 2 tear ducts (located in the inner upper and lower eyelids). The tear duct openings can be plugged to keep more tears on the eye surface. The plugs are equivalent to a tiny wine cork. Dissolvable plugs can be placed which last for 3-6 months. Permanent plugs can be placed which may be removed later but may fall out on their own from rubbing the eyelid. The tear ducts can also be permanently closed in the office with a quick 1-minute procedure after demonstrating symptom improvement with plugs.
Punctal Plugs and Punctal Cautery
Dry eye plagues billions worldwide and no single cure has been found. Most patients experience relief with artificial tears, however, in some people that may be insufficient. The eye naturally produces tears in the tear gland located within the eye socket near the temple. The tears then wash across the eye surface and drain through 2 nasolacrimal tear duct openings located in the upper and lower eyelid close to the nose. In some patients, it is possible to place tiny dissolvable “corks” in the tear ducts in order to plug them and keep them closed. This will keep more natural tears on the eye surface to help with dry eye symptoms. The plugs may fall out from eye rubbing and some patient may find them irritating. In those cases, it is possible to permanently seal the tear duct in the office with a 5-minute procedure.
Consuming healthy oils such as Fish Oil or Omega-3 capsules may improve dry eye symptoms. A recent dry eye study comparing Omega-3 with olive oil showed improvement in symptoms with no difference between the two supplements. Therefore, switching to olive oil for cooking and salads could be done instead of taking extra supplements
Prescription Eye Drops
There are 2 eye drops currently FDA approved to help treat Dry Eye Symptoms – Restasis and Xiidra. The medications help to decrease the inflammation on the eye surface in an attempt to increase tear production. The drops are used twice a day to improve symptoms. Common side effects include burning on installation and bad taste once they go down the throat. Occasionally, a short course of eye drop steroids can be used but carries a higher side-effect profile.
The macrolide class of antibiotics (Doxycycline and Azithromycin) is thought to be absorbed by the eyelid oil glands and decreasing inflammation and improve symptoms of dryness. The antibiotics can be taken daily for several months to help improve symptoms. They have a tendency to make skin more prone to sunburn and may cause heartburn and stomach irritation. Azithromyin is available as an eye drop with a much better side effect profile.
Serum is the most natural way to replace tear deficiency and mimics the body’s own tear production. A phlebotomist will come to your house and draw your blood. A pharmacist will then use that blood to make a concentrated mixture of your natural hormones and growth factors and ship them in little vials. These new drops are then placed in the eye to help restore the surface and improve symptoms. This treatment is not covered by insurance and costs around $200 for a 2 month supply.
The eyes can develop allergy symptoms much like the nose. The symptoms usually trigger itching and irritation. The most effective treatment is avoidance of the allergy trigger (pets or plants). Otherwise, over the counter allergy drops like Zaditor or Alaway can be used twice a day as needed. Prescription allergy drops which are more potent like Pazeo, Lastacaft, Patanol, or Pataday are also available.
Red Eye Relief
It is important to avoid tears with “Red Eye Relief.” Red eye relief drops constrict blood vessels on the eye surface and can cause rebound eye irritation.
Lumify (Bauch & Lomb) is a new over the counter eye drop which provides a more healthy option for red eye relief. The medication constricts blood vessels but with a much smaller chance of causing ischemia and rebound eye irritation.