What is Dry Eye Disease?

Dry Eye Disease affects over 60 million Americans. Many people with Dry Eye Disease are totally unaware that they have the problem. While people may be aware that they have irritation of their eyes, they are not necessarily aware that the cause of their problem is Dry Eye. The most common symptom of dry eye is tearing. There are actually two types of Dry Eye Disease. The most common type, as one would imagine, is a decrease in tear production, which affects the aqueous (watery) layer of the tears. The second type is excessive evaporation of the tears, due to poor Meibomian Gland function. The Meibomian Glands are in the eyelid, and they add a layer of lipid (or oil) to the tears, which keeps the tears from evaporating. Too little of the lipid layer, and the tears evaporate too quickly after blinking, which creates dry spots. Both of these types of Dry Eye can cause symptoms such as burning, and foreign body sensation. Although it seems like the opposite should be true, Dry Eye Disease can actually cause watery eyes. This is because when the cornea, or front of the eye, is exposed to the air, the eye gets irritated, which causes it to water. This is known as Reflex Tearing, just like when you scratch or poke your eye, and it begins to water. With Dry Eye Disease, there is a vicious cycle of dryness, tearing, and burning, or irritation. If unchecked, this cycle eventually numbs the surface of the eye, and can result in scarring of the cornea, and decreased vision.

Photo by Perchek Industrie on Unsplash
Photo by Perchek Industrie on Unsplash

Our office uses a standardized questionnaire, which gives us some clues as to whether or not you have Dry Eye Disease. The questions focus on symptoms such as burning, stinging, itching, watering, redness of the eyes, pain, and blurred vision, especially while using a computer. We know that concentrated reading reduces blinking, and reduced blinking allows the tears to evaporate, aggravating Dry Eye Disease. Our questionnaire also is helpful in evaluating the degree of the problem. This can be determined by whether the symptoms are present all the time, most of the time, some of the time, rarely, or never. This information gives us a good idea as to how serious the problem is, and how best to treat it.

 

Dry Eye Disease is also frequently associated with Blepharitis, or eyelid inflammation. Eyelid inflammation affects the amount of lipid in the tears, and is the main reason for a rapid tear break-up, or evaporation. Symptoms of Blepharitis and Dry Eye are often the same, but symptoms that are worse in the morning, and include crusting and irritation of the eyelids, often point to Blepharitis as the cause. Many people have both conditions, and their eyes water all day, while evaporative tear dysfunction worsens as the day goes on, due to the constant increasing evaporation of the tears.

Tears are produced by the Lacrimal Gland, located behind the upper eyelid. When Dry Eye Disease is due to a decrease in the production of tears, this can be the result of age-related hormone changes, more commonly seen in women, but also seen in men. Many medications can also decrease the production of tears, including some drugs for hypertension, diuretics, antihistamines, antidepressants, and even Ibuprofen, among others. Heaters and air conditioners at home, or in the car, can also aggravate dry eyes.

The decrease in tear volume can be treated by Omega 3, Fish Oil, and Flax Seed supplements, which are available over-the-counter. Some feel the results of these supplements are variable.

Long-term treatments can include eye drop medications that stimulate the production of tears by blocking the inflammatory cause of Dry Eye Disease. The two best known prescription medications currently on the market are Restasis and Xiidra. Both of these eye drops are used twice a day and, over a period of time, will usually stimulate the lacrimal gland to secrete more tears. Once tears are produced, blinking pushes the tears into the small openings in the eyelids, called Punctae. These tear drain openings are present in both the upper and lower eyelids. Placing a Punctal Plug in just the lower drains can be all that is necessary to relieve the symptoms of Dry Eye Disease. This quick and painless office procedure typically reduces the need for using medicated eye drops, or taking tear production supplements. Punctal Plugs can be utilized for temporary placement (dissolving over approximately 1 to 6 months) or for permanent placement. Although permanent Punctal Plugs don’t dissolve, they can easily be removed if needed.

Another main cause of Dry Eye symptoms is Meibomian Gland Dysfunction. This is very common, and is frequently associated with Dry Eye Disease. The Meibomian Glands can become inflamed, either from allergy, infection, or inflammation. This can be caused by many different issues, such as eye makeup, or poor lid hygiene. Meibomian Glands are filled with lipids, or oils. When these glands are functioning properly, they drain the right amount of lipids into your tear film, at the base of your eyelashes. When these glands become blocked or infected, the lipids in these glands, either drain in excessive amounts, or don’t drain at all. This creates a quality of tears that is quite irritating to the eyes, causing discharge, and crusting on the eyelashes. The inflammation can be treated with antibiotic and anti-inflammatory drops, while also using hot compresses to help open up the clogged glands. Lid Scrubs, which are also available over-the-counter, are also very effective at helping to unblock the glands. Sometimes a mild oral antibiotic like doxycycline, which is used to treat skin conditions such as rosacea and eczema, can be utilized in treatment of Blepharitis and Meibomian Gland Dysfunction, as these conditions are often related. There are also new instruments on the market which are used in the ophthalmologist’s office. These instruments apply heat, along with compression of the Meibomian Glands, in order to restore healthy functioning, and improve eye lid health, as well as tear quality.

Alan I. Mandelberg, M.D.