Dry Eye Disease

Dry eye disease (DED) occurs when your tears aren't able to provide adequate lubrication for your eyes. Tears can be inadequate for many reasons. For example, dry eye may occur if you don't produce enough tears or if you produce poor-quality tears. You may have DED when you start thinking of your eyes and when your vision is not as clear as you want it to be. Your eyes may feel uncomfortable, sting or burn. Dry eye can be a temporary, periodic or chronic condition.

Types of Dry Eye Disease

  • Aqueous tear-deficient dry eye (ADDE): a disorder where the lacrimal glands fail to produce enough of the watery component of tears to maintain a healthy eye surface, 10 to 15% of dry eye.

  • Evaporative dry eye (EDE): a result from obstruction and inflammation of the meibomian glands, located in the eyelids. These glands make the lipid or oily part of tears that slows evaporation and keeps the tears stable, 50% of dry eye.

  • Mixed aqueous deficient dry eye and Meibomian gland dysfunction (MGD), 35% of dry eye.

Causes of Dry Eye Disease

  • Diseases of the glands, such as meibomian gland dysfunction, blepharitis, and eyelid problems, e.g. out or in-turning of the lids, or lid-laxity.

  • Infrequent blinking, associated with staring at computer or screens.

  • A side effect of some medications, including antihistamines, nasal decongestants, tranquilizers, certain blood pressure medicines, Parkinson’s medications, birth control pills and anti-depressants.

  • Skin diseases on or around the eyelids.

  • Pregnancy, or hormone replacement therapy.

  • Low testosterone levels in elderly male patients.

  • Refractive surgery, e.g. LASIK. The symptoms generally last three to six months, but may last longer in some cases.

  • Dry eye worsening after cataract surgery.

Complications

  • Eye infections. Without adequate tears, you may have an increased risk of eye infection.

  • Damage to the surface of eyes. If left untreated, severe dry eyes may lead to eye inflammation, abrasion of the corneal surface, corneal ulcer and vision problems.

  • Decreased quality of life. Dry eyes can make it difficult to perform everyday activities, such as reading.

Tests/Diagnosis

Tests may be used to determine the cause, type and severity of dry eye, and appropriate treatment and care of your dry eyes.

  • A comprehensive eye exam. Including a complete history of your overall health and your eye health.

  • Measuring the volume of your tears. Measuring your tear production by Schirmer test, MAYH dry eye assessment and tear by OCT.

  • Determining the quality of your tears. Using special dyes to determine the surface condition of your eyes.

  • An assessment of meibomian gland.  Examining structure of lid margin and secretion of meibomian glands, and taking picture of meibomian glands by Meibography.

  • Testing tear osmolarity (Tearlab, I-PEN® ): Quantitative measurement of osmolarity (concentration of dissolved salts in solution) of  tears. Abnormal results can indicate an imbalance in the tear film.

  • Testing Inflammation in the tear (InflammaDry®): Only, rapid, in-office test that detects (matrix metalloproteinase 9) MMP-9, an inflammatory marker that is consistently elevated in the tears of patients with dry eye disease.

Dry Eye Disease Treatments

For most people with occasional or mild dry eye symptoms, it's enough to regularly use over-the-counter (OTC) eye drops. If your symptoms are persistent and more serious, you have other options. What you do depends on what's causing your dry eyes.

Treating Underlying Cause of Dry Eyes

Depending on the causes of dry eye, your doctor may use various approaches to treat the causes and relieve the symptoms.

The first priority is to determine if a disease is the underlying cause of the dry eye (such as Sjögren’s syndrome or lacrimal and meibomian gland dysfunction). If it is, then the underlying disease needs to be treated.

If dry eye results from taking a medication, your doctor may recommend switching to a medication that does not cause the dry eye. If you have an eyelid condition, such as out-turning lids, you may be referred to a surgeon who specializes in plastic surgery of the eyelids.

If contact lens wear is the problem, your doctor may recommend another type of lens or reducing the hours you wear the lenses. In the case of severe dry eye, you may be advised not wearing contact lenses at all.

Procedures that May be Used to Treat Dry Eyes

  1. Using scleral contact lenses:  Newer contact lenses designed to help people with dry eyes. Some people with severe dry eyes may opt for special contact lenses that trap moisture and protect the surface of your eyes. These are called scleral lenses, bandage lenses or biologic corneal bandage devices.

  2. Unblocking oil glands:  Dry eyes caused by blocked oil glands can be helped by manual meibomain gland expression (MGE). Our method of MGE includes: A warm compress is applied prior to the expression. During the procedure, a paddle or cotton Q-tip is placed behind the lower and upper lid to assist in the expression of glands. Another treatment is called LipiFlow thermal pulsation. During the treatment, a device like an eyecup is placed over your eye. It delivers a gentle, warm massage to the lower eyelid.

  3. Lid hygiene and scrubs:  Cleaning the margin of eyelid for patients with blepharitis is applied with instruments, e.g. Eyelid exfoliation with LidPro. For demodex blepharitis, high concentration of tea tree oil (20% to 50% ) can be performed on the eyelids to eradicate the Demodex mites.

  4. Using light therapy and eyelid massage:  A technique called intense-pulsed light (IPL) therapy followed by massage of the eyelids helps dry eyes.

  5. Closing your tear ducts to reduce tear loss:  Your doctor may suggest this treatment to keep your tears from leaving your eye too quickly.

  6. Amniotic membrane: The amniotic membranes come from placental tissue and contain several different stem cells and powerful growth factors. Doctors use the membrane as a graft to help heal various eye surface diseases. The graft may be a treatment option for people with severe or persistent dry eye.

  • Thyroid disease, when the eye protrudes forward.

  • Cosmetic surgery, if the eyelids are opened too widely.

  • Chemical and thermal burns that scar the membrane lining the eyelids and covering the eye.

  • Allergies.

  • Long-term contact lens wear.

  • Immune system disorders such as Sjögren’s syndrome, lupus, and rheumatoid arthritis.

  • Exposure keratitis, in which the eyelids do not close completely during sleep.

  • Tear gland damage from inflammation or radiation

  • Wind, tobacco smoke or dry air (air conditioning or heating)

Meibomain Gland Expression

Prescription Medications Used to Treat Dry Eyes

  1. Eyedrops to control cornea inflammation:  Inflammation on the surface of your eyes (cornea) may be controlled with prescription eye drops, the immune-suppressing medication cyclosporine (Restasis, Ceque), lymphocyte function-associated antigen 1 (LFA-1) antagonist (Xiidra), or corticosteroids. 

  2. Drugs to reduce eyelid inflammation:  Inflammation along the edge of your eyelids can keep oil glands from secreting oil into your tears. Your doctor may recommend antibiotics to reduce inflammation.

  3. Eye inserts that work like artificial tears:  A tiny eye insert that looks like a clear grain of rice, applied for moderate to severe dry eye. Once a day, you place the hydroxypropyl cellulose (Lacrisert) insert between the lower eyelid and your eyeball.

  4. Tear-stimulating drugs:  Drugs called cholinergics (pilocarpine, cevimeline) help increase tear production. These drugs are available as pills, gel or eyedrops. Possible side effects include sweating.

  5. Eyedrops made from your own blood:  These are called autologous blood serum drops. They may be an option if you have severe dry eye symptoms that don't respond to any other treatment.

  6. Platelet Rich Plasma (PRP): PRP eye drops are derived from your own blood and composed of inactive platelets, bioactive proteins, and plasma. The platelets contain various natural growth factors. With their healing and anti-inflammatory properties, PRP drops have shown promising results in severe dry eye, are an option when conventional therapy fails to resolve dry eye disease.

Self-Care

  1. Artificial tear drops or gels and ointment:  These products help lubricate your eyes and temporarily release discomforts in the eyes. If your condition is long term, your doctor may suggest you use the drops even when your eyes feel fine to keep them well-lubricated.

  2. Preservative vs. nonpreservative drops:  You can use eyedrops with preservatives up to three times a day. But using the preservative drops more often can cause eye irritation. If you rely on eyedrops more than three times a day, nonpreservative drops are relatively safe.

  3. Drops vs. ointments:  Lubricating eye ointments coat your eyes, providing longer lasting relief from dry eyes. But these products are thicker than eyedrops and can cloud your vision. For this reason, ointments are best used just before bedtime.

  4. Eyelid hygiene:  You may be able to manage your dry eyes with daily eyelid hygiene to control inflammation on the eyelids with eyelid wipes, sol and/or cleanser. Nonpreservative lid products are recommended. The eyelid cleanser that contains low concentration of tea tree oil for patient with demodex blepharitis twice daily in order to eradicate the Demodex mites. Stopping lid hygiene daily may allow your symptoms to return. 

  5. Warm compress:  This method would melt blocked residue in the oil-secreting meibomian glands in the eyelids and release discomforts in the eyes. 

  6. Alternative medicine:  In some patients with dry eye, supplements or dietary sources may decrease symptoms of irritation, such as omega-3.

  7. Be aware of your environment:  Pay attention to the situations that are most likely to cause your symptoms. Then find ways to avoid those situations in order to prevent your dry eyes symptoms. Indoors, an air cleaner to filter dust and other particles helps prevent dry eyes. A humidifier also may help by adding moisture to the air.

  8. Avoid dry conditions and allow your eyes to rest:  When performing activities that require you to use your eyes for long periods of time you can do following things:

    Blinking Exercise and Tear Stimulation Exercise: Download PDF of instruction

  9. Wear glasses or sunglasses:  These glasses fit close to the face (wrap around shades) or that have side shields can help slow tear evaporation from the eye surfaces.