What we typically call “Dry Eyes” is really more accurately described as “Dysfunctional Tear Film”. People with this condition may have no symptoms at all or may experience a variety of conditions which may give us irritated, dry feeling eyes. These can include one or more of the following:
- Decreased tear production
- Abnormal production of the oily part of the tears, so the tears evaporate too fast
- Decreased blinking rate so our lids do not repaint the surface of the eye with tears often enough.
- Abnormal lid function so the blinks are not complete.
- Infestation of the eye lashes with skin mites.
With these different causes, we use different treatments to correctly improve the problem associated with dry eyes. There are several tests that your doctor may do to determine which conditions are causing your problems and the best treatments for your condition.
Blepharitis is an ocular condition characterized by chronic inflammation of the eyelid, Meibomian glands located in your eyelids are responsible for the oil layer that stabilizes your tears. Blepharitis can cause meibomian gland dysfunction.
Dry eye syndrome is a chronic inflammatory disease that is closely associated with blepharitis and meibomian gland dysfunction. Signs and symptoms associated with the chronic inflammation can be redness of the eyelids, flaking of the skin on the lids, crusting at the lid margins, styes or chalazions, red eye, gritty sensations, itching, irritations and burning and foreign body sensation. Some patients experience dry eyes which can cause a certain degree of discomfort.
Poor or fluctuating vision is also very common in these conditions. Some patients may experience excessive tearing in the setting of dry eyes due to a lack of the stabilizing lipid layer of the tear film. Blepharitis and Dry Eye are chronic conditions.
There is no single “magic pill” that can cure dry eye. Instead, Dry Eye Syndrome is managed by several different treatments in an effort to minimize your chronic symptoms. After initiating one or more treatments, improvement should not be expected earlier than 6 weeks. It is unlikely that just one or two of the following recommendations will give you relief from significant dry eye syndrome. Instead multiple treatments are usually effective in minimizing symptoms and controlling periodic flare-ups.
I recommend to my patients elements of the following regimen for the treatment of dry eye. Often I start with the core conservative treatments for 6 weeks. Upon follow-up I will see what improvement has been noted. If needed I will add prescription or advanced measures as indicated.
Conservative, Non- Prescription treatments for Dry Eye:
Warm compresses: The compress should be very warm but not scalding hot. Apply the compress to both closed eyes for 10-15 minutes, 2 times a day. Commercially available heat masks work much better than a warm washcloth since the washcloth only retains heat for a few minutes at most.
Lid Cleaning: Specially made lid cleaners should be used to very gently clean the lashes and lid margins with your eyes closed. Rinse off completely afterwards. Do this twice a day after the warm compress. The lid cleaners come in a variety of different brands with advantages for each one. Your physician could make the best recommendation as to which brand to use. My personal preference for in most cases is the Oasis Lid and Lash cleaner, other brands include Ocusoft lid cleaning pads or Avenox lid cleaning solution.
Artificial Tears: Use preservative-free brands in individual vials only. The preservatives in bottles can worsen ocular surface disease. As a baseline use the tears 4 times per day. The cap may snap back on to the vials for later use, but keep the tips clean and throw the vial away the same day that it is opened. Do not keep opened vials more than one day. Placing vials in the refrigerator may help to soothe the eye with a cool drop. Oasis Tears are sold through doctors’ offices.
These tears contain a special compound to help maintain moisture on the ocular surface and help heal the eye. I often recommend Oasis Tears for the management of DryEye Syndrome. Refresh Plus tears also come in individual preservative-free vials. Although not as high quality as Oaisis tears in my opinion, the Refresh tears are more widely available at most pharmacies.
Omega-3 Fatty Acid (fish oil): For many years the long term use of Omega-3 fatty acids is thought to have a number of positive health benefits. Included among these benefits was thought to be the optimization of the Meibomian gland oil secreted into your tear film. Recent studies have called this benefit into question and now there is controversy surrounding the efficacy of fish oil for the treatment of dry eyes.
Genteal Gel is a preservative-free ointment often used at bedtime. A preservative-free eye ointment at bedtime can protect the ocular surface while you sleep. If your eyes are especially dry upon waking this may help your symptoms. You should also avoid fans or blowing air sources while sleeping as these may cause evaporative drying of your ocular surface.
A humidifier placed by the bedside may be helpful in reducing evaporative drying while you sleep.
Avoid wearing eye makeup. This includes any mascara or eye liner. Makeup clogs the meibomian glands and pollutes the tear film with foreign particulate matter. Makeup also tend to have a high bacterial load.
Avoid soft contact lens use. Routine use of soft contact lens can contribute to Dry Eye. Overuse or abuse of soft contact lenses can lead to eye infections which may be serious.
Moisture Chamber Goggles. These glasses have a barrier that will form a humid chamber around your eyes to prevent evaporative loss of your tear film. They come in a variety of styles and brand names.
Prescription Medication for Dry Eye:
-Restasis twice a day (may take 3 to 6 months to see improvement). This medicine reduces ocular inflammation and has been shown to increase the amount of tears made by your ocular surface.
-Azasite twice a day for two weeks, then once every evening for four weeks. This antibiotic also has numerous anti-inflammatory properties, especially for the Meibomian glands.
-Lotemax 3 times a day for 2-3 weeks. This mild steroid eye drop can help jump-start the process of controlling ocular surface inflammation.
-Oral Medications: Doxycycline by mouth twice a day. Like AzaSite, Doxycycline has anti-inflammatory and antibiotic properties that especially help Meibomain gland dysfunction.
Many of these medicated drops may sting, this is normal. The stinging will resolve as the eye heals.
Other Physician Directed Treatment Options Are Available.
More advanced treatments may be tried after 6-8 weeks of standard therapy if you do not have relief:
-Punctal Plugs. Plugs may be placed in the tear drainage pathways out of the eyes. This may result in retention of more tears. This is not done if the eyes are inflamed – it is only done once the inflammation is under control and the Dry Eye symptoms persisit.
-Demodex (skin mite) eradication. People who have the skin mite Demodex living on their eyelashes may show improvement in Dry Eye Syndrome after eradication of these mites. Testing for this mite can be done in the office.
-Serum based tears: Special tears may be made at a compounding pharmacy from the serum component of your own blood. These tears have effective healing components for the ocular surface. Often times serum tears ore used in treating severe cases of dry eye.
-Scleral based contact lenses. These special lenses fit on the white part of the eye and vault over the cornea, constantly bathing the ocular surface in fluid.
-Eyelid surgery. In severe cases of Dry Eye a small portion of the lateral eyelids may be closed with a suture to keep the eyelids closer together and help protect the eye. This can also result in a more effective blink. The closure may be temporary or permanent.
As you can see there are numerous approaches to treating dry eye. There is no cure, only management of this condition. Remember, intermittent blurred vision, scratchy eyes, mucous discharge, watering eyes, painful eyes, all of these symptoms and many more may indicate a dysfunctional tear film. Treating dry eye is critical for the health of your ocular surface and for your best vision quality.
In patients who have had prior corneal transplants maintaining a healthy ocular surface is paramount to keeping your graft healthy. Many of the problems that eye doctors see everyday are related to or worsened by dry eye. Controlling this problem should give you better vision, more stable vision, and more comfortable eyes.
Yuri McKee, MD is a Board Certified Ophthalmic Surgeon with fellowship training in Corneal and Refractive Surgery. Dr. McKee specializes in advanced corneal transplant techniques, premium cataract surgery, anterior segment reconstruction, glaucoma surgery, LASIK and refractive surgery. He has authored peer reviewed articles on corneal transplantation and repair of dislocated intraocular lenses, and numerous chapters in textbooks.
