What is Dry Eyes? Symptoms, Causes and Treatment
What is Dry Eye Disease?
8 in 10 Australians will suffer from dry eye symptoms according to the latest Optometry Vision Index Report. This is a chronic, multifactorial condition, and we are fortunate to be living in a time when the knowledge on ocular surface disease is rapidly expanding. Broadly speaking, we can classify dry eye into;
Aqueous Deficient Dry Eye- this is where the body is simply not producing enough tears
Evaporative Dry Eye- this is related to the quality of the tears. We need three layers to our tears- oil, water and mucus. If the oil our body is producing and secreting is not sufficient, or the quality is not good, this will create an unstable tear film and lead to the tears evaporating off the eye. This is by far the more common type of dry eye.
What Causes Dry Eyes?
There are many potential causative factors for dry eye, and some patients will tick a few of these boxes. Some of the risk factors are:
Age: as we get older our tear production naturally decreases
Gender: women are more likely to suffer with dry eye than men, and especially at times in life when hormone balance is off, like post-partum and menopause
Medications: Certain commonly used medications will contribute to or exacerbate the problem
Environmental Factors: A dry climate (such as that experienced in a Fremantle summer!), air conditioning, wind
Eye Conditions: some eye conditions are very much associated with dry eye, like blepharitis and meibomian gland dysfunction
Systemic Conditions: some diseases like thyroid disease, Sjogren’s syndrome to name a couple, leave you more likely to develop dry eye
Digital Device use: spending a lot of time onscreen causes our blink rate to reduce significantly and can play a part in developing dry eye
Eye Surgery: your eyes may be dry following eye surgery like cataract surgery or LASIK
What are the Symptoms of Dry Eye?
The symptoms that our patients commonly report are a stinging, burning or gritty foreign body like sensation. The sensation of having something in your eyes is often accompanied with blurred vision, especially when doing certain activities or in certain environments, together with sensitivity to light.
How is Dry Eye Diagnosed?
Our Fremantle optometrists will initially take you through a detailed case history and we often use grading systems where we ask our patients to rate their symptoms to use as a benchmark. This allows us to track the effectiveness of our dry eye treatment plans.
A robust dry eye evaluation will include most, if not all of the following tests:
Tear Film Osmolarity: Dry Eye Disease causes hyperosmolarity (a concentration of the tear film)
Slit Lamp assessment: this is a high-powered microscope which allows us to inspect the tissues of the eye under illumination and magnification to identify any abnormalities. We will ascertain whether there is any blepharitis or meibomian gland dysfunction contributing to the problem. We will often instil a yellow dye called Fluoresceine into your eye to check for any damaged areas on your cornea
Tear Volume: we assess the volume of tears on the front of your eye to ensure enough are being produced
Tear Quality Assessment: we will assess how long your tears last in front of your cornea before breaking up and exposing the cornea
Assessing Meibomian Gland integrity: we will use an instrument which allows us to visualise your meibomian glands to assess whether they have atrophied or shortened, and sometimes we will express some oil from them to ensure that it is the ideal consistency
By the time we have completed all these tests, we should be in no doubt around the type of dry eye you may be suffering from and its severity.
What are the Treatments for Dry Eye?
This is very much dependant on the results of the tests that we do, the cause and type of your dry eye and the symptoms experienced.
Lubricating eye drops
Warm compresses
IPL treatment
Punctal plugs
Lacrimal lavage
Prescription eyedrops
Lubricating Eye Drops
A commonly adopted approach to treating the consequences of dry eye is to add a tear film supplement in the form of lubricating eye drops. Most drops on the market are more effective at managing aspects of aqueous deficiency dry eye rather than meibomian gland dysfunction. In order to treat meibomian gland dysfunction effectively, it is necessary to look at the composition of an eye drops and to use those that contain an oily layer to help reduce tear film evaporation.
Warm Compresses
Heat can be applied by means of warm eye compresses to the meibomian glands to reduce the viscosity of the meibum and facilitate expression from the gland into the tear film. Meibum forms a stabilising layer and helps to reduce tear film loss due to evaporation.
IPL Treatment
For Eyes Optometrist has the advanced Lumenis M22 IPL system for the treatment of meibomian gland dysfunction. The machine was FDA approved in 2021 for improving signs of dry eye disease due to meibomian gland dysfunction.
The treatment uses a highly selective wavelength of light 590nm delivering 10-15 J/cm2 in short, controlled pulses of light. Treatment involves applying IPL in a sweep from temple to temple stimulating the skin and tissue around the eyes. The treatment uses a chilled treatment head to ensure patient comfort with the additional benefit is that the span between treatments is reduced and the beneficial impact of IPL treatment is accelerated. The treatment is safe and strict clinical guidelines are adhered to throughout the treatment. Eye shields are used during treatment to protect the eyes from the bright light pulses.
There are now several clinical studies indicating the success of IPL treatment on the management of dry eye. The primary effect of IPL is to break the inflammatory cycle by treating the root cause of dry eye disease.
A typical treatment protocol will involve treatments on day 1, 15, 29 and 43. Depending on the severity of the initial condition and beneficial response additional treatments can be scheduled at 3 – 6 months followed by top up treatments at 6 – 9 monthly intervals.
What are reasonable expectations from IPL treatment?
Anecdotal evidence suggests that for the first and second treatments minimal or no improvement may be noted. After three treatments, improvements are likely to be noticed by patients together with an improvement in clinical signs. The great majority of patients start to notice an improvement after 4 treatments. A cautiously optimistic approach is to expect improvement after 4 – 5 treatments together with a reduction in the use of lubricating eye drops.
Gland expression may be added to the protocol to facilitate improvement. It is important to note that improvements are incremental over time and that the results are not instant.
If blepharitis is present, lid margin debridement may also be required prior to treatment and will typically also involve the use of an eye lid scrub.
Punctal Plugs
Punctal Plugs can be an effective option for those with mainly Aqueous Deficient Dry Eye but can also be used for those with Meibomian Gland Dysfunction.
Punctal (silicone) plugs are tiny devices that are inserted into the lower and/or upper puncta tear ducts in office. These can be used to keep your eyes natural tears on the surface of your eye for longer to relieve the symptoms of dry eye disease. Punctal plugs can be temporary dissolving which can last a few days up to a few months, or semi-permanent which are longer lasting.
Lacrimal Lavage
Lacrimal irrigation is a procedure used to flush out or improve tear flow through the tear drainage system. Reasons why this may be necessary include obstruction in the tear drainage system, flushing of a punctal plug and infection. During the procedure, sterile saline is flushed through a lacrimal cannula through the punctum, through the lacrimal system.
Prescription Eyedrops
Steroid sparing eyedrops or immunosuppressants can also be used in those cases where severe dry eye is present, and the use of traditional eye drops are insufficient. These aim to supress the eye’s own inflammatory response and can also increase tear production.
