Dry eyes

Symptoms Of Dry Eyes

The symptoms of the dry eyes are often nonspecific and it does not always start with dryness. In fact, in various cases patients experience watery eyes as a symptom of dry eyes. This is because too much drying of the eyes causes the body to produce more tears to compensate for the water loss. 

The other signs and symptoms of dry eyes include:

• Blurred vision that fluctuates throughout the day

• Stinging and burning sensation in the eyes

• Gritty or scratch feeling in the eyes

• Red eyes

• Itching in the eyes (particularly in the cornea)

• Photophobia (increase sensitivity to light)

• Feeling of having some foreign substance in the eyes

• Stringy mucus near the eyes

• Sticky eyelids especially during morning

• Blepharitis (inflammation in the eyelids)

• Tired eyes with a desire to close eyes more often

• Feeling of heavy eyelids

• Difficulty in opening the eyelids

• Sharp and dull pain behind the eyes

• Difficulty in wearing contact lenses

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Causes Of Dry Eyes

Tears play a very important role in maintaining the overall health of the eyes by:

• Providing a smooth surface for optimal vision

• Protecting the cornea (the transparent, protective front part of the eye)

• Lubricating the eyes 

Tears form a multilayered film made of the following three layers that keep the eye smoothly lubricated:

• The superficial layer is made of lipids (fats or oils) lining the upper and lower eyelids. This layer seals the tear film to reduce evaporation.

• The middle layer is basically a dilute salt water solution. This layer helps in keeping the eyes moist, as well in flushing out any dust, debris, or foreign objects that may get into the eye. 

• The innermost mucosa layer, made up of mucus. This mucus helps the overlying watery layer to spread evenly over the eye.

Dry eyes develop when there is a problem in either of the layers, imbalance between tear production and drainage or loss of tear film stability. The various causes are discussed below in detail: 

1. Inadequate amount of tears: The reduced tear volume around the eyelids is the main cause of dry eyes. The various reasons for this are:

• Aging

• Health conditions like Sjögren's syndrome, rheumatoid arthritis (RA), lupus, scleroderma, sarcoidosis, xerophthalmia due to Vitamin A deficiency tend to decrease tear production

• Medications like antihistamines, decongestants, antidepressants, antihypertensives, and oral contraceptives.

2. Excessive tear evaporation: The symptoms of dry eyes can also develop due to increased evaporation of tears. This can occur due to the following:

• Less blinking: Long hours of reading, driving or working on a computer can reduce blinking and trigger evaporation of tears. Conditions like Parkinson's disease also reduce the frequency of blinking.

• Meibomian gland dysfunction: Meibonian glands are small oil glands on the edge of the eyelids. They produce the oil/ lipid layer that forms the superficial layer of tear film that protects against evaporation of tears. 

Blockage of these glands, more commonly associated with conditions like rosacea, psoriasis, scalp and face dermatitis or taking oral isotretinoin medication leaves inadequate lipid/oil to cover the watery tear layer to prevent its evaporation.

• Blepharitis: An infection along the eyelids or the eyelashes makes the bacteria break down the oil, leaving insufficient oil to prevent any evaporative loss of tears and dry eyes.

• Certain health conditions: Conditions such as stroke or Bell's palsy, make it difficult to shut the eyes. Hence, the eyes may become dry due to tear evaporation.

3. Abnormality in the production of mucus or lipids found in the tear layer: Chemical burns to the eye or some autoimmune conditions, like Stevens-Johnson syndrome and cicatricial pemphigoid can lead to abnormal production of lipids in the tear layer. This leads to poor spreading of the tears over the surface of the eye, thereby causing dryness despite the presence of sufficient tears.

4. Combination of the above factors

Risk Factors For Dry Eyes

1. Age

The risk of developing dry eyes increases with advancing age due to decreased tear production as a part of the natural aging process. People above 65 years of age mostly start experiencing symptoms of dry eyes. 

2. Gender

Women are more likely to develop dry eyes due to hormonal changes in their lifetime caused by pregnancy and menopause. The use of oral contraceptives is also linked to being associated with dry eyes. 

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3. Screen time

The exposure to digital screens is a well known risk factor for dry eyes. The continuous exposure to screen decreases blinking and triggers tear evaporation which is a significant factor for Dry eyes. 

4. Ethnicity

Studies suggest that dry eyes is more common in Asians as compared to the white population. 

5. Medical conditions

Several inflammatory and autoimmune conditions are also associated with an increased risk of dry eyes. They include:

• Rheumatoid arthritis

• Diabetes

• Thyroid dysfunction

• Blepharitis (inflammation of the eyelids)

• Rosacea

• Seborrhoeic dermatitis

• Staphylococcal infection

• Demodex mite infestation

• Bell's palsy

• Sjorgen’s syndrome

• Graft v/s host disease

• Herpes infection

• Hepatitis C

• Androgen insufficiency

• Heat or chemical burns

• Acne 

• Gout

6. Medications

The use of certain medications are also closely associated with dryness of the eyes due to decreased tear production. This includes medications for high blood pressure, allergies, anxiety, depression, cough, insomnia.

7. External exposure

Exposure to dry climate, chemical fumes, pollution, and sun increase the risk of developing dry eyes. Smoking and secondhand smoking both are the risk factors of dry eyes as it exposes the eyes to harmful irritants. 

The people living in air conditioners also have a higher chance of having dry eyes.

8. Contact lens

The use of contact lenses decreases the sensation of cornea and can lead to dry eyes. 

9. Previous eye surgery

Any eye surgery in the past such as LASIK (laser) surgery, lid surgery, or cataract surgery can decrease tear production and lead to dry eyes.

10. Eye drops

The excessive use of topical medications in the eyes for some other eye conditions such as glaucoma is also associated with the risk of dry eyes. 

11. Diet

Vitamin A and omega-3-fatty acids play a very vital role in maintaining the health of the eye. So, deficiencies of both can lead to dryness in the eyes.

Vitamin A deficiency is also called xerophthalmia, which can start from dry eyes and even progress to blindness in severe cases.

Diagnosis Of  Dry Eyes

The symptoms of dry eyes are very similar to eye infections and allergies. So, it is very necessary to distinguish between these diseases through specific clinical tests. Antiallergic medications, if given in dry eyes because of incorrect diagnosis may worsen the condition of the eye. 

1.Patient history and physical examination

The doctor takes patient history which includes information about the medications taken by patients, medical problems, and environmental factors which may contribute to the symptoms of dry eyes. The doctor also checks for:

• The amount of tears eyes are making

• The structure of eyelids

• Time, place, and diurnal variation of symptoms

• Workplace stress

• Living conditions (dry, dusty air and air conditioning)

• Systemic diseases

• Medication history

2. Examination of tear stability

Tear break up time (TBUT) 

This test diagnoses how long the tear film lasts after blinking. For this, a small amount of dye is placed in the eyes. The time up to which the dyed tear film covers the whole eye after blinking is recorded. The tear film does not last long in case of Dry eyes. 

3. Examination of tear volume

Schrimer’s test

This test assesses the quantity of tears produced by the eyes. In this, the eyes are desensitized by putting eye drops and then a small piece of paper is placed on the edge of the eyelid. The eyes are allowed to close for 5 minutes. The amount of moisture on the paper indicates the quantity of tears. 

Tear film meniscus

In this test, the height of the tear film is determined which helps in diagnosing the amount of tears produced by the eye. 

Tear meniscus height is 0.2 ± 0.09 mm in patients with dry eyes and 0.5 ± 0.02 mm in patients with healthy eyes. A foamy tear film is an indicator of an altered lipid layer in patients with meibomian gland dysfunction.

Slit lamp test

In this, the quantity of tears produced by the eyes is measured through a microscope known as a slit lamp. A liquid is put into the eyes which helps in clear visualization of the tears. The practitioner looks in the eye and eyelids by directing a bright light into the eyes. 

4. Examination of tear films

Tear film osmolarity

In this, the osmolarity of tears is determined. Tear osmolarity is a measurement of the concentration of salt in the tears. Normal osmolarity is essential for normal tear production. The value of osmolarity increases with the severity of the Dry eyes.   

5. Examination of the ocular surface

The surface of the eye is examined using a microscope (slit lamp) and dyes. Dyes help in visualizing the surface clearly. The common dyes used to study eyes are fluorescein and lissamine green. 

Fluorescein staining

It is mostly used to assess corneal damage. The dye fluorescein is instilled into the tear film and studied after 1 to 3 minutes. 

Lissamine green staining

It is mostly used to assess conjunctiva and lid margin damage. The dye fluorescein is instilled into the tear film and studied after 1 to 3 minutes. 

6. Examination of eye-lids

Blink rate

Blinking plays a very significant role in keeping the eye moist by distributing the tear fluid over the eye surface. The normal blink rate is:

While speaking: 15.5 ± 13.7 blinks/minute

During reading and computer work:  5.3 ± 4.5 blinks/minute

The reduced interval between blinks by about 2.6 to 6 seconds indicates dry eyes. 

Meibomian gland evaluation

Meibomian glands play a very significant role in maintaining overall health and stability of the eye. The gland produces meibum, the reduction of which can cause evaporative Dry eyes due to altered lipid composition. 

The function of the meibomian gland can be determined by evaluating meibum quantity and quality. The turbid and viscous appearance of meibum indicates dysfunction of the gland. 

Differentiating between insufficient tear production and excessive tear evaporation

The above tests also help in determining the cause of dry eyes:

• The reduced tear meniscus and low schirmer test indicates deficiency of tears.

• Altered lid margins, thickened meibomian gland secretion, reduced tear film break up time are an indicator of hyper evaporative dry eye. 

• Ocular surface damage and elevated tear film osmolarity can occur with both forms.

Evaluation for systemic disease

There are various diseases that may cause dry eyes, particularly primary Sjogren's syndrome. In various cases secondary Sjogren syndrome caused by other conditions may also cause dry eyes. Such conditions include: 

• Rheumatoid arthritis

• Lupus

• Progressive systemic sclerosis

• Dermatomyositis

Specialist To Visit

It is very important to consult doctor in case:

• You are experiencing burning, stinging, scratching or watery eyes especially in windy conditions

• Your symptoms are not going away by various proven home remedies

• Your vision is fluctuating while using digital devices even after using glasses

• You are facing difficulty in performing normal day to day activities

The doctors that may help to diagnose the dry eyes include: 

• General physician

• Optometrist 

• Ophthalmologist

Most people are unaware of the right eye specialist. Know about different eye specialists in detail. 

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Prevention Of  Dry Eyes

1. Blink consciously 

Blinking helps in spreading tears over the ocular surface and also keeps foreign matter and irritants out of the eyes. The act of blinking frequently, especially while using digital screens helps in keeping the eyes moist and prevents dryness. 

2. Boost the humidity

The dry climate often triggers dry eyes. The humidity can be increased by keeping the bowls of water around the room both at home and workplace. This helps in making the air humid. 

3. Avoid straining the eyes

Eyes strain when they are used to concentrate on something for a long period of time. Such eye straining activities should be minimized or avoided, if possible. This includes avoiding:

• using computers, smartphones, tablets and gaming consoles for a long time

• driving for a long time

• reading for a long time or in dim light

4. Protect your eyes

Eyes should be protected to avoid direct contact with triggers. This can be done by wearing protective glasses while using the screen, using sunglasses while going outside to reduce exposure to dry winds, sun, and smoke which can irritate your eyes.

5. Limit screen time

Prolonged and continuous daily use of digital screens is one of the leading causes of eye disorders popularly known as computer vision syndrome (CVS). Dry eyes can be prevented by following the 20/20/20 rule. The rule states that take a 20-second break from your digital device every 20 minutes and look at something 20 feet away. Set an alarm on your smartphone as a reminder.

Here are several other ways that helps in preventing eye strain caused due to CVS:

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6. Quit smoking

Cigarette smoking exposes the eye to harmful chemicals that can cause dry eyes. It can be prevented by quitting both active and passive smoking. 

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Treatment Of Dry eyes

The treatment of dry eyes involves various steps and is based upon the severity of the conditions of the eye. 

Avoiding the triggers of dry eyes such as cigarette smoke, dry heating air, air conditioning etc is an important part of the protocol. 

1. Artificial tears

They are the mainstay therapy that are used in all grades of Dry eyes irrespective of the severity. They are benzalkonium chloride (preservative) free eye drops that are designed to increase the tear film stability. They are the preparations containing polyvinyl alcohol, povidone, hydroxypropyl guar, cellulose derivatives, and hyaluronic acid as the main agent. These drops are available in the form of gels, ointments, and solutions. 

In case of meibomian gland dysfunction, artificial tears containing lipids such as triglycerides, phospholipids, and castor oil are used. 

2. Anti-inflammatory medications

Inflammation in the ocular surface and lacrimal gland is observed even in moderately severe dry eyes. For this, anti-inflammatory treatment is required in cases of moderate to severe conditions of the eye. 

3. Topical corticosteroids

Studies have shown that instillation of corticosteroids for 2 to 4 weeks are helpful in reducing the symptoms of dry eyes. But, this therapy is used only for short-term use as long term therapy is associated with some complications. 

4. Topical cyclosporine A

Cyclosporine A is an immunosuppressant that aids in reducing inflammation. Topical application of cyclosporine increases production of tear and also reduces symptoms like blurry vision, ocular dryness, and foreign body sensation.

In case of cyclosporine intolerant patients, tacrolimus eye drops are used. 

5. Antibiotics

Several antibiotics with anti-inflammatory properties are also used to treat Dry eyes. They are used in case of meibomian gland dysfunction and blepharitis associated with Dry eyes. Some of the common antibiotics used for dry eyes are:

• Doxycycline

• Minocycline

• Azithromycin

6. Punctal plugs

These are tiny devices that are inserted into the tear ducts of the eye. They reduce drainage of the tears that help in keeping the eye moist. There are two types of punctal plugs

Temporary/dissolving plugs

These plugs are made of dissolving material such as collagen that ultimately absorbs into the body. They can last in the eye from a few days to months.

Semi-permanent plugs

These plugs stay in the eyes for years as they are made of longer lasting material such as silicone or acrylic. They can be removed by your ophthalmologist if needed.

7. Surgery

Various surgical options for treatment of dry eyes syndrome are:

• Tarsorrhaphy: It refers to surgical joining of upper and lower eyelids partially or completely to promote corneal healing

• Amniotic membrane transplantation: In this procedure a piece of amniotic membrane is applied to the surface of the eye in order to reconstruct the ocular surface.

• Keratoplasty: This is a surgery performed on the cornea, especially corneal transplantation. It is used in severe cases where persistent corneal ulceration and perforation are seen. 

Home-care For  Dry eyes

1. Avoid self medication

There are various medications that can cause dryness of the eye. It is necessary to consult your doctor while taking any medication. 

2. Focus on your diet

There are certain fatty acids, vitamins, and minerals that keep the eyes hydrated. These types of foods should be included in your diet. These include:

• Omega fatty acids (fish, oils, and dairy products)

• Vitamin A (pumpkins, apricots, carrots, tomatoes, spinach, and dairy products)

• Vitamin C (citrus fruits and juices such as orange, grapefruit, lemon, lime), apples, bananas, tomatoes, and cooked spinach)

• Zinc (whole grains, dairy products, sweet corn, peas, lentils, and nuts)

• Good sources of lutein and zeaxanthin include eggs, corn, kiwi fruit, grapes zucchini, and leafy greens such as spinach, kale, collards, and broccoli.

• Vitamin E (whole grain cereals, almonds, hazelnuts, sunflower seeds, sweet potato, and peanut butter)

3. Keep yourself hydrated

Water helps in the formation of tears. Dehydration can trigger the symptoms of dry eyes especially if you are living in a hot and dry environment. 

4. Take adequate sleep

Not getting enough sleep can lead to dry and itchy eyes. It is also observed that the eyes may produce less tears after a night of insufficient sleep. Adequate sleep may help in faster recovery of the patient having dry eyes.

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5. Maintain eye lid hygiene

Eyelids should be kept clean. Hot compresses on eyelids and warming masks are advised as they are known to increase tear film stability and thickness of the lipid layer. 

6. Avoid dry environment

Dry climate triggers dryness in the eyes. Such situations can be avoided like avoiding air getting blown in your eyes by directing car heaters away from your face.

Complications Of Dry Eyes

1. Eye complications

The inadequate tear production can lead to several complications in the eye which can range from mild to severe. Initially, dry eyes cause little discomfort, but without the proper medical attention, the condition can damage the cornea. 

The complications of the dry eyes include:

• Fluctuations in vision

• Scarring of the cornea

• Infectious keratitis (infection of cornea caused by bacteria, viruses, fungi and parasites)

• Eye ulceration 

• Eye infections

• Eye inflammation

• Wound in the cornea

• Conjunctivitis

• Vision loss

2. Other complications

The chronic dry eyes affects quality of life and can lead to: 

• Anxiety

• Depression

• Sleep disorders

• Mood disorders

• Dyslipidemia

• Migraine headaches

Alternative Therapies For  Dry eyes

Herbal-based drugs

Goji berries

This tree is native to Asia and its fruits, commonly known as goji berries are known for its medicinal and nutritional values. The administration of goji berry extract has been found to relieve Dry eyes. This is confirmed by various tests such as  Schirmer's test score and tear breakup time (TBUT).

Polygonum cuspidatum

It is a plant that is found in North America and Asia and is frequently used in traditional Japanese and Chinese medicine. Studies have shown that the administration of the extract of this plant helps in preserving the eye through its anti-inflammatory properties. 

Chamomile

The washing of eyes with chamomile tea is used for the treatment of eye infections and other eye diseases. 

Living With  Dry eyes

1. Try home remedies

There are various home remedies which provide relief in dry eyes. This includes applying warm compress to the eyes, taking fish oil supplements, drinking plenty of water, and increasing the humidity at work or in your house by using a humidifier. 

2. Try scleral contact lens

The people who wear contact lenses and develop dry eyes should use scleral lenses instead of traditional lenses. These lenses are placed over the white part of the eye known as sclera. They protect the eyes and keep them hydrated for a long period of time. 

3. Take regular breaks

It is very important to take frequent short breaks and blink eyes regularly while reading or working on computer screens. Keep your eyes closed for sometime when possible such as during a phone call. This will decrease the strain on your eyes. 

4. Adjust the position of computer screens

The total eye surface exposure and tear evaporation is reduced when we look down. This helps in keeping the eye moist. The same can be applied while working on computer screens by keeping them at a low level. 

5. Make necessary light adjustments

The people having dry eyes suffer from photosensitivity which is triggered by bright lights. This can be reduced by avoiding bright bulbs immediately overhead. This will help in reducing brightness and also minimize reflection on surfaces such as on computer screens. 

6. Stay away from vents

It is advised to stay away from vents as the dry air blowing directly in your eyes can make dry eyes worse. 

7. Keep eye drops handy

The patient of dry eyes should always keep the eye drops with them so that it can be used whenever the person starts to feel drying of eyes. 

8. Join a support group

Connecting with people having similar condition can help in discovering various things that could help in faster recovery.