Dealing with Dry Eye Disease
Kenneth A. Beckman, MD, FACS
Dry eye disease is one of the most common conditions seen by ophthalmologists; but quite often, patients don’t realize that an abnormal tear film is the source of their discomfort. It is not necessarily intuitive that the symptoms someone experiences are related to a dry eye condition.
Typical symptoms of dry eye disease include burning, redness, itching, and tearing. Other symptoms commonly described include tired eyes, which worsen with prolonged reading or computer use, as well as fluctuating vision throughout the day. There is a wide range for the estimated number of people that suffer from dry eyes, somewhere between 6-43 million people in the US alone. Potential risk factors, which may contribute to the development of the disease, include age, gender, diet, diabetes mellitus, and environmental conditions1. Numerous other medical conditions, such as autoimmune diseases, as well as many systemic and topical medications may also contribute to the development of dry eye disease.
Dry eye disease may be thought of as instability of the tear film, which is actually made of three layers. The bottom layer, made of mucus, allows the tear film to spread over the eye surface. The middle watery layer provides most of the wetting and the bulk of the tear volume. The outer oily layer acts as a coating to the tear film and a barrier to evaporation. If any of these layers are deficient, dry eye disease may develop2. When the oil layer is deficient, the barrier to evaporation is depleted. This may lead to the symptoms of tired eyes and blurred vision. In response to the rapid tear evaporation, the tear glands then produce reflex tears, which are composed of a more watery or aqueous fluid. These reflex tears do not have the same makeup as the complex layered tear film already described, and these reflex tears tend to run excessively. Therefore, the patient may be complaining of too many tears, yet the problem is actually due to a tear film deficiency.3
A typical first line therapy for a deficiency in the patient’s tear film would be artificial tears. These are available without a prescription and come in various consistencies. If a patient requires artificial tears more than just a few times per day, it is important to use a tear that has no preservatives. The preservatives themselves, if used excessively, may actually worsen the eye irritation.
A common cause of dry eye disease may be a poor oil layer and rapid tear evaporation. This is likely due to disease of the lid margins. Along the lid margins, there are many oil glands that secrete oil to coat the tear film. If these glands become inflamed or blocked, an oil layer deficiency develops, leading to rapid tear evaporation. For this condition, many patients do well by using warm compresses or even gently scrubbing their lid margins with warm water, to help open the oil glands and improve the oil layer. Antibiotic eye drops or ointments can often improve this condition. Many doctors also add oral omega 3 supplements, which seem to help.
Typically, dry eye disease is associated with inflammation in the tear film. The inflammation leads to decreased tear production and low tear volume. Therefore, anti-inflammatory eye drops may be useful to help improve tear production. Cyclosporine-A drops, on the market as Restasis, are proven to increase tear production in eyes with dry eye disease associated with inflammation4. These drops are taken twice daily and may take weeks to months before improvement is seen. Frequently, steroid eye drops may be added initially to aid the anti-inflammatory effect until the Restasis effect starts.
Another treatment available, particularly for patients with low tear volume, is the placement of punctal plugs. The puncta are small holes in the lower and upper lids, which allow tear drainage into the tear ducts, rather than having the tears accumulate on the eye and run down the face. Punctal plugs are small devices, which are placed into the puncta to block the drainage and keep the tears on the eye longer. This can work well for many patients and give fairly rapid relief.
In summary, dry eye disease is an extremely common condition that can be quite troublesome for many patients. Recognizing the condition may be difficult for patients, and a detailed eye examination is necessary to determine the type of dry eye disease and the appropriate treatment.
Kenneth A Beckman, MD is director of corneal services at Comprehensive EyeCare of Central Ohio, and clinical assistant professor of ophthalmology at the Ohio State University. He specializes in cataract surgery, corneal transplant surgery and treatment of corneal diseases, general ophthalmology, and treatment of dry eye disease. He has been involved in multiple clinical trials relating to dry eyes and is currently an investigator in an FDA trial for the treatment of keratoconus using corneal crosslinking.
Comprehensive Eye Care of Central Ohio
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Westerville, Ohio 43082
- Stern ME, Schaumberg CS, Pflugfelder SC. Dry eye as a mucosal autoimmune disease. Int Rev Immunol 2013 Feb;32(1):19-65.
- American Academy of Ophthalmology Basic and Clinical Science Course, Section 8, External Disease and Cornea, 2004-2005:47-49.
- Gilbard JP. Dry Eye Disorders. in Principles and Practice of Ophthalmology, Vol 1. WB Saunders Co, Philadelphia, Pa. 1994:257-276.
- Restasis package insert, Allergan, Inc. Irvine, Ca.2013.