Dry Eye Disease

Dry eye is a broad term that covers a spectrum of specific conditions and used to describe the eye's inability to maintain healthy lubrication and can be a debilitating condition. As a result of poor lubrication, the cornea and conjunctiva become inflamed and irritated. Symptoms include dry, stinging, burning eyes, inflammation, irritation and redness, excessive tearing and foreign body sensation. This can be extremely debilitating in the day-to-day lives of sufferers. Left untreated, there is a risk of permanent damage to the ocular surface and eyelids. The underlying causes of dry eyes are complex and numerous and need a thorough examination for your optometrist to determine the cause and most appropriate treatment. At our Adelaide and Woodville branches our therapeutic optometrists are equipped with the technology to appropriately diagnose and treat dry eye disease.

For more information on our dry eye clinic, please see the links below:

Blepharitis

Meibomian Gland Dysfunction

Blephex

IPL (Intense Pulse Light)

Punctal Plugs

Eye Drops

There are many causes of dry eye. These fall into several broad categories that come with particular treatments. There can be some overlap between the types of dry eye, making the condition challenging for both the practitioner and patient to manage. The tear film is made up of three layers: the mucin (mucous) layer, the watery aqueous layer and the oily lipid layer.

Specialised cells (such as goblet cells) embedded throughout the surface of the eye create the mucin layer. The lacrimal gland under the bony aspect of the eyebrow secretes the watery aqueous layer. The meibomian glands in the upper and lower eyelids secrete oil to make up the lipid layer.

In most dry eye cases, the watery aqueous layer is produced at normal quantities but quickly evaporates. This is called evaporative dry eye. There are three main causes: blepharitis, meibomian gland dysfunction and environmental factors.

Blepharitis is inflammation of the eyelid margins. This is a chronic condition that arises from overpopulation of bacteria and mites (Demodex) along the eyelid margin and within eyelash follicles.

Meibomian Gland Dysfunction (MGD) is when the oil-producing meibomian glands stop working properly. This diminishes the lipid layer of the tear film, causing aqueous tears to quickly evaporate.

Environmental factors such as air conditioning, extended screen time or wind can result in excessive tear evaporation, leading to dryness and irritation.

Severe cases of dry eye are due to low production of tears, referred to as aqueous deficient dry eye. This is far less common than evaporative dry eye, and is usually due to autoimmune disease, medication or eye surgery.


Evaporative dry eye

The majority of dry eye problems are due to evaporative dry eye. This is when the aqueous water component of the tears is produced at normal quantities but is quick to evaporate, leading to dryness.

To understand evaporative dry eye, it’s important to understand what makes up the tear film that usually keeps your eyes wetted. The tear film is made up of an inner mucus layer, a middle aqueous layer and an outer oil layer.

Evaporative dry eye from meibomian gland dysfunction

Evaporative dry eye is most commonly caused by meibomian gland dysfunction (MGD), also known as posterior blepharitis. In this condition, the oil-producing glands in the lids become ineffective. The oil produced by the meibomian glands forms the outermost layer of the tear film and prevents evaporation of the watery aqueous component of the tears. It follows that when the oil layer is compromised, the eye will become dry more quickly. It is important to note that treatment with drops designed for aqueous deficient dry eye will not be as effective for MGD caused evaporative dry eye, as the tears will still be unstable and quick to evaporate. For more information about MGD and its treatments visit our meibomian gland dysfunction page here. The newest and most exciting treatment for MGD at Innovative Eye Care is the use of intense pulsed light (IPL) to improve oil gland function and expression.

Environmental evaporative dry eye

Even patients with normal eyes can get evaporative dry eye if they spend time in heated, air-conditioned or low-humidity environments. The wind and dust can also dry eyes out, much like clothes on a washing line. Prevention can be helpful here by using wrap-around glasses when outdoors, or using eye drops as recommended by your optometrist before and during situations that cause your eyes to dry out.

Some patients that do not blink fully or who keep their eyes open for long periods such as when staring at a computer screen may also have symptoms of dry eye. This is because the part of the eye’s surface that is not regularly wiped with fresh tears by the lid will dry out and become irritated.

Aqueous deficient dry eye

This condition is less common than initially thought and in reality is the ‘true’ dry eye. The problem is due to decreased production of the watery component of the tears from the lacrimal glands in the eye. Aqueous deficiency is most frequently associated with autoimmune diseases (most notably Sjögren’s Syndrome and rheumatoid arthritis). Other well-known causes are LASIK or other laser eye surgeries, where patients can experience dryness temporarily or even permanently due to severing of the corneal nerves. Medical treatments such as radiation or chemotherapy may have side effects which cause permanent damage to the lacrimal glands that produce most of your tears. Certain medications may cause aqueous deficiency including antihistamines, nasal decongestants, tranquilizers, certain blood pressure medicines, Parkinson’s medications, birth control pills, hormone-replacement therapy and anti-depressants. The incidence of dry eye increases with age as we naturally produce less tears.

There are a variety of clinical signs that point towards a diagnosis of aqueous deficient dry eye (some will overlap with other conditions like meibomian gland dysfunction). These include:

  • Symptoms of dry eyes without signs of lid disease or meibomian gland dysfunction
  • Low or absent height of tears when viewed by your optometrist’s microscope
  • Characteristic stained appearance of the cornea and conjunctiva when viewed with special dyes
  • A low period of time before your tears ‘break-up’ or dry out over the eye surface
  • The appearance of a rough surface on the part of the lid that moves across the dry ocular surface with every blink
  • Low wetting of a special dry eye testing strips

Certain technologies are coming into use in optometry practices including machines that can measure tear osmolarity (which is elevated in dry eye), inflammatory markers (which are released into the tear film in dry, irritated eyes) and tear film properties. These should make the diagnosis of dry eye conditions easier in the future.

Treatments for dry eye


Fortunately, dry eye disease can be treated. With appropriate care, comfortable and well-lubricated eyes can be achieved, restoring quality of life. Lubricating eye drops alone are not an effective treatment for the majority of cases. Dry eye disease is best treated with a comprehensive, stepwise, management system which involves restoring proper function to meibomian glands, maintaining good eyelid hygiene, protecting the eyes, and using lubricants.

Step 1

Lubricants: Hylo Fresh / Hylo Forte / Thera Tears / Tears Again / Genteal Gel / VitaPos

Lubricating drops replenish the deficient tear film and are an essential component of dry eye disease management. Most dry eye disease patients will always need to use some form of ocular lubricant for comfort and eye health. Lubricant eye drops. These can have a baffling range of ingredients, but all add to the deficient tear film. Preservative free options such as Hylo-Fresh and Hylo-Forte are best since the preservatives in multi-use eye drop bottles can further aggravate the inflamed ocular surface. Thicker drops, gels or ointments may be used for more severe dry eye or at night during sleep. Your optometrist will advise which drops are best for your eyes. Most dry eye patients will always need to use some form of ocular lubricant throughout the day for comfort.

Omega-3 Supplements

Nutritional modifications to include higher amounts of omega-3 fatty acids. Only beneficial for individuals with low dietary omega-3, supplementation improves the quality of oil produced by oil glands in the eyelids.\ Visit our page on nutrition and eye health here.

Heat and Massage

A warm compress helps to clear blocked meibomian glands by liquefying the thickened oil inside. The glands need to be heated to 40-50 degrees for 10 mins, followed by 1 minute of blink training. Performed regularly, this process helps to maintain regular function of the glands for an adequate protective lipid layer.

Blink Training

Proper blinking keeps your tears healthy by spreading tears and releasing oil from eyelid glands into the tears. Blink training, which is described on the last page, both promotes more complete blinks and also maximises the effect of warm compresses. There is also a free blink training app: https://apps.apple.com/au/app/donald-korb-blink-training/id941412795

Manuka Honey

Medical grade manuka honey is antibacterial, reduces swelling and promotes healing and these qualities make it useful in treating meibomian gland disease. It is quick and easy to use but honey is mildly acidic - which doesn’t cause damage to the eyes - but may cause temporary stinging and redness on application.

Sunglasses

Sunglasses are crucial for all of us to wear, but have even more benefits for those with dry eye disease. Along with sun protection, sunglasses keep eyes sheltered from the drying effects of the wind and other irritants.

Step 2

Eyelid Hygiene

The eyelids often don’t get washed well enough since no one likes getting soap in the eyes. But good eyelid hygiene is an important way of managing dry eye disease. Antibacterial lid foams or washes cleanse the eyelids and lashes while conditioning the skin around the eyes without any stinging or irritation.

Blephex

For more severely irritated eyelids we can perform an in-clinic microdermabrasion with the Blephex device, an electronic brush that comprehensively cleans and renews eyelid skin.

IPL

Innovative Eye Care is the first practice in South Australia to offer Intense Pulsed Light (IPL) treatments for dry eye disease! IPL technology generates an intense pulsed light directed at the lower eyelid, reducing inflammation and stimulating the meibomian glands to return to their normal function. Four treatments are recommended to best manage MGD. These are performed over a 10 week period.

Punctal Plugs

The tear system normally functions by constantly producing tears that wash across the eye to keep it clean and comfortable and drain into a duct through the lower eyelid into the nose. It’s why your nose runs when you cry. So when tear production is low, dissolvable or non-dissolvable but removable plugs can be placed into the duct opening to improve dry eye symptoms and reduced reliance on lubricant drops.

Anti Inflammatories

Inflammation and dry eyes, like the chicken or the egg metaphor, are in a vicious cycle where one causes the other and we often don’t know which came first. Prescription anti-inflammatory drops are used in some cases to break the cycle and allow other therapies to work.

Inner Eyelid Irritation: Lomide / Cromo-Fresh

Without a nice tear layer for the eyelids to glide over they can cause friction on the eye and subsequent inflammation similar to allergy and so anti-allergy drops can be used.

Oral Medications

Low dose antibiotic tablets prescribed in conjunction with your GP can be effective in controlling the deeper inflammation within the meibomian glands.

Step 3

Secretagogues

Prescription eye drops that stimulate production of primarily the water part of the tears

Autologous/allogeneic serum eye drops

Eye drops with healing properties made from the serum of a person’s own blood is available in SA through the public hospital system.

Therapeutic contact lens options: Soft bandage lenses or Rigid scleral contact lenses

Contact lenses are able to protect the surface of dry eyes by acting like a bandage and keeping a constant layer of tears on the surface of the eye during wear.

Step 4

Steroid eye drops

In severe dry eye disease, inflammation is the primary problem and strong prescription anti-inflammatory eye drops

Surgery

Blink Training

Meibomian glands, found in your upper and lower eyelids, produce oil (lipids) that are essential to eye health. But the eyes require adequate blinks to express oil from the meibomian glands. The lipid layer is the front line of defence for the eye and ocular surface. Having a lipid layer over the eye stabilizes the tear film, which is essential to clear vision and comfort. Proactive patients in combination with warm compresses, will see results. Blinking exercises will result in reduced eye discomfort and improved ocular surface health. Impress your optometrist by being diligent; do your exercises as prescribed and improvements should be evident at your next appointment.

What else can I do?

Think blink! Consider your environment and the times of day you find your eyes most uncomfortable. For example: pay attention to blinking when working on a computer or smartphone or take a moment to do your blink exercises if you start to experience discomfort.

Blink Exercise

Open eyes. Count 1 , 2. Close eyes. Count 1, 2. Squeeze eyes. Count 1, 2.

Open eyes. Count 1 , 2. Close eyes. Count 1, 2. Squeeze eyes. Count 1, 2.

Repeat for 1 minute

References

Clayton JA. Dry Eye. N Engl J Med. 2018 Jun 7;378(23):2212-2223. doi: 10.1056/NEJMra1407936.

O’Neil, Erin C. ; Henderson, Matthew ; Massaro-Giordano, Mina ; Bunya, Vatinee Y. Advances in dry eye disease treatment. Current Opinion in Ophthalmology, 2019, Vol.30(3), p.166(13)

Hosseini, Kamran ; Lindstrom, Richard L ; Foulks, Gary ; Nichols, Kelly K. A randomized, double-masked, parallel-group, comparative study to evaluate the clinical efficacy and safety of 1% azithromycin-0.1% dexamethasone combination compared to 1% azithromycin alone, 0.1% dexamethasone alone, and vehicle in the treatment of subjects with blepharitis. Clinical ophthalmology (Auckland, N.Z.), 2016, Vol.10, pp.1495-503

Albietz JM1, Schmid KL1. Randomised controlled trial of topical antibacterial Manuka (Leptospermum species) honey for evaporative dry eye due to meibomian gland dysfunction. Clin Exp Optom. 2017 Nov;100(6):603-615. doi: 10.1111/cxo.12524. Epub 2017 Jun 6.

Craig JP, Chen YH, Turnbull PR. Prospective trial of intense pulsed light for the treatment of meibomian gland dysfunction. Invest Ophthalmol Vis Sci. 2015 Feb 12;56(3):1965-70. doi: 10.1167/iovs.14-15764.

Borchman D. The optimum temperature for the heat therapy for meibomian gland dysfunction. Ocul Surf. 2019 Apr;17(2):360-364. doi: 10.1016/j.jtos.2019.02.005. Epub 2019 Feb 19.

Blackie CA, Solomon JD, Greiner JV, Holmes M, Korb DR. Inner eyelid surface temperature as a function of warm compress methodology. Optom Vis Sci. 2008 Aug;85(8):675-83. doi: 10.1097/OPX.0b013e318181adef.