Dry Eye

If you live in a dry climate like Las Vegas, you likely will have some symptoms related to either blepharitis or dry eye. These conditions lead to symptoms of burning, irritation, sandy or gritty feeling, dryness, or blurred vision. Fortunately, good treatments are now available to help your eyes feel better. In many cases, blepharitis and dry eyes are chronic conditions and will require treatment for a prolonged period of time. The goal of therapy is to keep your eyes comfortable with as little effort as possible. Our doctors have prepared this comprehensive guide to dry eye to help you to understand your treatment options. We believe that a well-educated patient can be a better team member as our office works with you to treat your dry eye condition. Our doctors will work closely with you to make sure your condition is treated and your symptoms controlled.

What is Blepharitis?

Blepharitis is diagnosed when your doctor sees a buildup of oily or flaky skin around the edges of the eyelids. There can also be redness to the skin and clogging of the oil glands around your eyes. This oil is necessary to keep the eye lubricated and prevent the watery tears from evaporating too quickly. There can also be an overgrowth of bacteria around the eyelids. All of these problems lead to eye irritation.

What is Dry Eye?

The eye needs to stay moist to feel comfortable and have a clear vision. There is a constant supply of tears that cover the front surface of the eye (the cornea). The tears are made by a fluid-secreting gland under the upper eyelid (the lacrimal gland). There is also a drainage system with small holes near the area where the eyelids come together. These openings drain the tears through small tubes down into the nose (That’s why you get a runny nose when you start to cry!).

Several abnormalities can lead to dry eye:

  • The tear gland does not produce enough fluid
  • The fluid evaporates too quickly (very common here in dry Las Vegas)
  • The quality of the tears is poor

Most people with Dry Eye have more than one of these abnormalities. The end result is the same – the eye feels irritated.

What is the purpose of your tears?

Your eyes are amazing! To feel comfortable and have clear vision, the surface of the eye needs to stay smooth and moist. Healthy tears have many functions. These functions are:

  • Provide nutrition to the cornea to keep it healthy
  • Provide moisture to the cornea to help keep it clear
  • Create a smooth layer on the cornea so that the light rays entering the eye can be focused so you can see clearly
  • Wash away debris and foreign objects that get into eye

What are the components of healthy tears?

Healthy tears are made of three thin layers. The layers that make up the tear film are:

  1. The mucus or mucin layer is produced by cells in the conjunctiva. The mucus layer creates a stickiness on the front of the eye so the water layer can stick onto the eye better.
  2. The water layer or aqueous, is in the middle and is produced by the lacrimal gland, a structure that sits under the upper eyelid. The water layer has nutrients and enzymes that keep the front of the eye healthy.
  3. The oil layer or lipid is produced by small glands in the upper and lower eyelids, called meibomian glands. The oil layer keeps the water layer on the eyes longer, by preventing evaporation. It also lubricates the eyelid as it moves over the eye during a blink.

What are unhealthy tears?

Some patients can’t understand why their eye seems moist but they have symptoms of eye irritation. In this case, there may be poor quality tears that are not working to keep the cornea healthy. Unhealthy tears occur when one of the three layers listed above are unbalanced or missing. The most common example is normal watery fluid but decreased oil coating. This leads to quick evaporation and tired eyes or burning irritation.

How do I know if I have dry eye or blepharitis?

There are some common symptoms that you might experience if you are having dry eye. These symptoms can include the following (most patients will experience a combination of these symptoms but generally not all of them):

  • A stinging, burning or scratchy sensation in your eyes (this may be worse when you read or work on the computer)
  • A sensation of having something in your eyes (foreign body sensation)
  • Eye redness
  • Stringy mucus in or around your eyes
  • Increased eye irritation from smoke or the wind
  • Eye fatigue, tired or heavy sensation
  • Sensitivity to light
  • Difficulty wearing contact lenses
  • Periods of excessive tearing
  • Blurred or fluctuating vision, often worse at the end of the day or after focusing for a long time

Why does dry eye cause blurry vision?

A common symptom of dry eye is periodic episodes of blurred or cloudy vision. Excellent vision requires a smooth corneal surface covered by a thin layer of tears. When the tear layer isn’t healthy, small dry spots develop which break up the incoming light rays and create a foggy or hazy vision. This is most common during extended periods of reading or working on the computer. If you find your vision gets foggy after 30-40 minutes of reading, keep some artificial tears by your chair and put them in every 15 minutes while you read. Improving the oil layer with hot compresses, manual expression, or the LipiFlow treatment may also help this symptom.

Why does dry eye cause pain?

The cornea has many nerves that sense pain when irritated. In fact, the cornea has more nerves than any other tissue in the body. This is actually an important feedback system the eye uses to keep the eye healthy. When the tears are not lubricating the eye well, the corneal nerves become irritated. This sends the sensation of pain to the brain (usually burning, stinging, foreign body sensation, or tired eyes). It is a way the body has developed to be sure there are healthy tears to maintain a healthy eye.

Why does dry eye make my eyes feel irritated like there is something in them?

When tears are not functioning well, dry spots develop and the rough surface of the cornea rubs against the delicate tissues of the inner part of the eyelids. This gives the feeling that there is “sand” inside the eye.

Why does dry eye create more mucus in my eyes?

The tears are made up of three substances, water, oil, and mucus. In a dry environment, the watery portion will evaporate quickly leaving behind increased mucus. Another cause of increased mucus happens when the tear gland doesn’t make enough watery fluid, leaving a higher proportion of mucus on the eye surface. This can form crusty yellow material in the corner of the eye or thin strings of clear thick material.

Why does dry eye cause my eyes to water?

Anything that irritates the eye will cause a reflex action of increased tear formation. This may have happened to you when you got dust or sand in your eye. The eye automatically makes extra tears to wash the foreign material away. When you have dry eyes there is irritation and a signal is sent to your brain indicating the discomfort. The lacrimal gland that produces the watery portion of the tears is signaled to produce more tears. Unfortunately, these “watered” down tears (known as reflex tearing) are not effective in stopping the symptoms of dry eye. Cycles of dryness followed by excess tearing as a result of this reflex system are a common symptom of dry eyes.

What are causes or risk factors for developing dry eye?

Causes of dry eye may include the following:

  • Dry air in the environment (living in the desert)
  • Decrease in production of natural tears with age
  • Blockage of eyelid oil glands
  • Decreased blinking (this can occur during reading or when looking at the computer)
  • Inflammation
  • Blepharitis (condition of skin around the eyes)
  • Prior LASIK
  • Systemic diseases like Lupus or Rheumatoid Arthritis
  • Wind/fan blowing
  • Contact lens wear
  • Eye allergies
  • Excessive use of drops that contain preservatives
  • Eyelids not closing completely
  • Nutritional
  • Medication
  • Hormones
  • Skin disorders like Rosacea
  • Genetic

What medications can cause dry eye?

Some oral medications can make the tear glands produce less fluid. If you have dry eyes you should try to avoid these medications.

  • Antihistamines and decongestants
  • Some drugs used to treat high blood pressure like diuretics
  • Hormone replacement therapy
  • Certain antidepressants
  • Isotretinoin-type drugs that treat acne

How do eyelids affect dry eye?

Blinking is an important action the body uses to keep the eye moist. Each time you blink, the edge of the eyelid wipes the tears across the eye and pushes away any debris or foreign material that may have gotten on the surface of the eye. If the eyelids do not blink normally or don’t close completely, then the cornea is exposed to air and more evaporation than normal and it starts to become dry.

The following conditions can lead to dryness from exposure:

  • Upper eyelids that are too loose and are easily opened during sleep
  • Lower eyelids that are too loose and prevent eyes from closing completely
  • Eyelids that are kept open a little during sleep
  • Bell’s Palsy, a neurological disorder that prevents the eyelid from closing
  • Incomplete blinking, this can be measured with the LipiView test

Is Dry Eye dangerous?

Healthy tears have many functions. One of the main functions is to provide a clear layer of moisture on the cornea. Without a healthy layer of moisture, the normally clear cornea can develop scar tissue and start to become cloudy. In this very severe case of dry eye, it can lead to permanently blurred vision. Fortunately, this is quite rare and there are many treatment options along the way to bring the eye back to good health. Patients with dry eyes should have a good eye exam at least once or twice a year.

How can doctors tell if I have dry eye?

To determine what is causing your dry eye, our doctors will examine your eyes and tears under a microscope. He will look at your eyelashes to see if there is any debris or infection, at your oil glands to make sure they are producing enough oil, at the health of the tears as they move across the eye and at the cornea to see if it appears dry. By looking at all the parts of your eye, in addition to some tests, he will be able to find out the likely cause of dry eye and then create the best treatment plan for you.

What are some of the tests doctors will use to determine if I have dry eye?

Besides looking at your eye under a microscope, the following tests may be done to determine which types of dry eye you have:

  • Schirmer test – small strips of paper are gently placed in between the eyelids to see how much fluid is produced. This test measures the fluid component made each minute by the lacrimal gland (tear gland).
  • Tear osmolarity – a small probe tests the tears to see if too much water has evaporated creating too much saltiness in the tears. Dry eye patients tend to have less water and more dissolved substances. This test can also monitor dry eye treatments to see if they are effective.
  • LipiView tear evaluation – a specially designed camera attached to the LipiView machine is able to focus on the tear film and tell if there is a good balance between the three layers that make up the tear film. The actual thickness of the oil layer can be measured. This machine can also take a picture of the oil glands to see the number and quality of the glands. It also measures the amount and duration of each blink. This new test should be part of each dry eye evaluation. This test is typically not covered by insurance but is a key test for helping identify the causes of dry eye.

What is the treatment for Dry Eye?

The different causes of dry eye and blepharitis may require different approaches to the treatment. Determining the cause of your symptoms is the first step. After our doctors have collected the needed information about your eyes, they will create a treatment plan best suited for you. Your treatment plan may include some of the following (see below for a detailed explanation of each treatment).

  • Lubricating tears (Artificial tears)
  • Lubricating gel or ointment
  • Warm compress/mask treatment
  • Lid hygiene
  • Punctal plugs or cautery
  • Humidifier in house
  • Adequate hydration
  • Restasis medication drops
  • Steroid drops
  • Lacrisert
  • Nutritional pill especially formulated for dry eye
  • Manual expression of meibomian glands
  • Lipiflow treatment
  • Intense Pulsed Light (IPL)
  • Moisture goggles
  • Antibiotic pills or drops
  • Hormone replacement therapy
  • Systemic treatment for systemic disease

How are Dry Eye and Blepharitis treated?

Although there are some differences between Dry Eye and Blepharitis, many people have both conditions to some extent, and the treatments overlap considerably. There is a stair-step approach to treating Dry Eye, starting with very simple steps, and working up towards more complex treatments. The steps are outlined below.

Lubricating artificial tears

The first step to improving irritation from both Dry Eye and Blepharitis is to supplement your natural tears with artificial tears. These over-the-counter products are available in our office, and most drug stores and supermarkets. These drops help to provide extra lubrication, as well as improve the quality of the tears covering your eye. For mild Dry Eye any brand of tear can be helpful. For moderate dry eye, you may need a better tear product. We recommend Retaine, Systane, or Refresh products. They can be used alone or with additional treatments to directly provide moisture to dry eyes. You should notice an immediate improvement when lubricating drops are put in the eyes. For mild symptoms you may only need them 2-3 times a day. For more severe symptoms, drops may be needed every 2-3 hours. If you use drops more than 4 times daily our doctors recommend Preservative Free artificial tears. Preservatives can irritate the eye if used too frequently. Preservative-free artificial tears come in small plastic vials. Once opened, the vial needs to be used within 24 hours. Make sure the tip doesn’t touch anything or else it can get contaminated.

Lubricating gels and ointments

Since the gel and ointment forms are thicker, they can be longer lasting and more soothing. However, when initially applied to the eye they can cause temporary blurring of vision. Ointments are typically placed in the eye at bedtime to provide moisture and lubrication overnight. Celluvisc is a terrific preservative free thick gel eye drop available over the counter.

Punctal plugs/cautery

If you still have symptoms using artificial tears a few times daily, or it is difficult to apply the tears frequently, then you may be a candidate for Punctal Plugs. These small, flexible, silicone plugs fit inside the tear drain in your eyelid and block the tears from leaving the surface of the eye. As an analogy, if you want to fill up your bathtub, you place the stopper in the drain. These small plugs for the eyelid are similar; they block the drain so more fluid stays on the surface of the eye. These plugs are placed during an office visit with a painless 5-minute procedure. Punctal Plugs are a good option for people who have an active or busy lifestyle and can’t easily stop during the day to put in eye drops. Because this procedure is simple and effective, our doctors recommend it for all patients with dry eye symptoms.

If the plugs irritate the eye or fall out easily then a different procedure can also be used to block the tear drains. Punctal cautery is a treatment done in the office. An anesthetic cream is placed in the tear drain (punctum), then a special hot wire is used to create a small burn that leads to scar tissue. This permanently closes the tear drain, increasing the amount of fluid around the eye. The main risk of this treatment is excess tearing. Cautery should not be done unless you had a good response to plugs in the past and didn’t have too many tears when the plugs were in place.

 

Warm compress/mask treatment

This treatment improves symptoms by increasing the amount of oil coating the eye surface. Tiny oil glands can become blocked with debris from dried skin, bacteria, excess mucus from eyes and hardened oil. By using warm compresses it softens the oil inside the glands, making it easier to come out when gentle pressure is applied, much like butter or margarine turn to a liquid form when heated on the stove or microwave. For the most thorough treatment, our office can supply you with a special mask designed to hold the heat for an extended period of time. Place the mask in the microwave for 25-30 seconds and then place the hot mask over the eyes for 5 minutes, then repeat. This soothing treatment is like a mini trip to the spa for your eyes. If you do not have the mask a washcloth can be used. Place a clean washcloth under very hot water from the faucet. Squeeze the cloth to remove excess water. Gently place the hot, moist cloth over your closed eyelids. Gentle pressure or rubbing over the lids can also be done. When the cloth cools, place it back under the hot water and repeat. Do this for 5-10 minutes every evening. With more severe symptoms you can do the treatment twice daily.

Antibiotic Pills

Dermatologists treat many skin conditions with oral antibiotics. Blepharitis is a type of skin condition that affects the eyelids. In cases of severe blepharitis, an antibiotic pill (Doxycycline, Tetracycline, Minocycline) can be used to help your eyes feel better. No one knows exactly how this pill works to improve blepharitis. It is NOT by killing bacteria, but through some other beneficial action, which helps your oil glands to function better. There can be minor side effects from Doxycycline such as stomach upset and sun sensitivity. Always wear sunscreen if you will be out in the sun for long periods of time. Let your doctor know if you are using blood thinners or other medications known to interact with antibiotics.

Lid scrubs/foam

All normal skin has bacteria living on the surface. With blepharitis, there can be an excess growth of bacteria around the eyelashes, which leads to worsening eye irritation. This overgrowth of bacteria occurs when there is a buildup of dead skin cells and oils around the skin and eyelashes of the eyelid. When the debris of dead skin, excess mucus and bacteria is removed, a potential source of inflammation and infection is also removed. There are three methods to cleanse the skin and improve the environment around the eyelids.

  • Individual towelettes – contain a mild detergent and antiseptic that cleans the eyelid. Use it to wipe around the eyelids and lashes nightly. Rinse with warm water. Available in our office and the grocery store or pharmacy.
  • Lid cleansing foam – this product contains foam, like shaving cream, that is rubbed on the eyelids and lashes each night. Rinse with warm water. Available in our office and the grocery store or pharmacy.
  • Baby Shampoo – can be used to cleanse the eyelids and lashes without irritating the eyes. Rub a small dot on your palm with water to create a bubbly solution and rub this on the eyelids and lashes. Rinse with warm water.

Humidify your bedroom

Dry air leads to increased evaporation and worsening dry eye symptoms. During certain times of the year, the air has less humidity. This is especially the case during the summer months when it is hot and dry outside, or the winter months when the heat is on the inside. In Las Vegas, it is difficult to humidify your entire house, but as you sleep a humidifier in the bedroom can lead to improved symptoms.

Adequate hydration

Staying hydrated is important to maintain an adequate supply of tears. Drinking enough water (half your body weight in ounces per day) provides the body with the necessary building blocks to create healthy tears.

Restasis

A prescription medication called Restasis is available to treat dry eyes. Restasis actually helps the eye to produce more tears by controlling inflammation on the eye and in the lacrimal gland. Restasis is a very dilute solution of Cyclosporine, an immunosuppressant medication used to control inflammation and decrease rejection in people with organ transplants. Restasis should be used twice a day in addition to any of the other dry eye treatments you are already using. As a prescription medication, it requires consistent use to be effective. The initial effect from Restasis may take 6-8 weeks to develop. Studies show an increasing beneficial effect of improved tear secretion up to one year after starting the medication. You may notice mild redness and stinging for a week or two after starting the medication.

Steroid drops

Steroid drops (Prednisolone or Fluoromethalone FML) can be used to treat some of the redness and swelling that can come with dry eye and blepharitis. These drops are usually used for a few weeks on an intermittent basis. Overuse of steroids can lead to premature cataracts and glaucoma. These medications are commonly used to get the symptoms of dry eye under control while more long-term treatments such as Restasis are getting started.

Lacrisert

Lacrisert is a tiny pellet that you place in the pocket behind the lower eyelids once a day. It slowly dissolves to release a thick gel onto the eye throughout the day. It is good for more severe dry eye and for patients who may have a hard time getting artificial tears in the eye regularly.

Nutritional supplement formulated for dry eye

New research into the metabolic pathways of tear production has lead to the development of oral dietary supplements that improve dry eye symptoms. We have had good success with these products, with most patients feeling better, and some patients having a dramatic improvement in their symptoms. Our doctors may suggest that these supplements be added to your treatment program. Omega-3 oils have been found by research to alleviate some types of dry eye. Taking flaxseed oil or fish oil capsules can provide these Omega 3 oils. Some patients get ground flax seed meal and put it on salads and in smoothies. There are also specially made pills that combine not only Omega 3 oils, but also additional healthy oils mixed with vitamins found to support eye health. We have a premium Omega 3 fish oil capsule available in our office. Other options can be found in the grocery store or pharmacy.

Lipiflow and manual expression of meibomian glands

The oil layer is one of the most important layers of the tear film. These important oils lubricate the eye and prevent evaporation of the tears. Blepharitis causes the oil glands to become inflamed and produced a thick, poor quality oil (see picture). By softening the oil in the glands and expressing any unhealthy oil and debris, either by manual expression or with the specially designed Lipiflow method, healthy oil can be produced to keep moisture in the eye. Research has also shown this method to be more helpful than warm compresses alone. Although the Lipiflow treatment is expensive, a single treatment may be effective for up to one year. The manual expression is a less costly procedure but may have a little more discomfort than the Lipiflow device.

Intense Pulsed Light (IPL)

This is a skin treatment using light therapy, which was originally used to treat the fine blood vessels of Rosacea. When pulses of light are applied near the eyelids, patients experience improvement of dry eye through improved oil production from the meibomian glands.

Moisture goggles

These are goggles that keep the air around the eye more humid, limit evaporation of tears and keep out wind and irritants. They are particularly helpful for patients with severe dry eye. There are several different size and shape options available.

Azasite

This thick antibiotic eye drop can also be beneficial for the treatment of blepharitis. The eye drop is used once a day to help decrease the growth of bacteria around the eyelid as well as to help the oil glands to make better oil to soothe and lubricate the eye. The drop is very thick like honey. Try to keep the bottle stored with the tip pointed down to make it easier to squeeze a drop out of the bottle.

Tea Tree Oil

You may not want to read this section if you are a little bit squeamish about bugs. There is a small mite (Demodex) that lives in your hair follicles around the eyelashes and eyebrows. Every adult is likely to have a few of these mites on the skin and develop no symptoms or issues from the mite. However, in some patients, there is either an increased amount of mites or an allergic reaction to them. This leads to classic blepharitis symptoms with red crusty eyelids, itching, burning, and even blurred vision. This type of blepharitis does not respond to typical treatments and may require repeated application of Tea Tree Oil to kill the mites.

Systemic treatment for systemic disease

Certain disease can make it more common to have symptoms of dry eyes. In these cases treating the underlying condition can help with dry eye. Some of these systemic diseases are:

  • Diabetes
  • Rheumatoid Arthritis
  • Sjogren’s disease
  • Sarcoidosis
  • HIV
  • Graft vs Host disease

Why am I starting to develop dry eye symptoms now?

Changes in systemic medications, environment, eating habits, stress, age, eye surgery and sickness, can all have an impact on the production of healthy tears. As a result, a person can develop dry eye symptoms at any time.

How does LASIK/PRK cause dry eye?

Healthy corneal nerves are necessary to signal the body to create more tears when dryness develops. With refractive surgery, such as LASIK, the corneal nerves are cut. This disruption of the corneal nerves blocks the normal feedback mechanisms between the cornea and the tear gland and can cause worsening dry eye symptoms. You should not have LASIK if you already have dry eye symptoms that are not well controlled. The ICL or PRK are better options for patients with significant dry eye symptoms. NV Eye Surgery is one of the leading clinics in Las Vegas offering ICL lens implants to treat nearsightedness (myopia).

How can dry eye effect my life?

The effects of dry eye on the quality of life range from mild irritation to severely debilitating, and everything in between. Having dry eye syndrome can impact how long a person is able to read a book, look at the computer, go outside during windy or hot weather, make it difficult or painful to open the eyes and make vision blurry and difficult to see to work or drive. Working with our doctors and being part of a team focused on treating your condition and supporting you through the challenges associated with dry eye can help get you through even the most difficult days.

Summary

Hopefully, this information has been beneficial for you. Dry Eye and Blepharitis can be very frustrating conditions, but can almost always be controlled with a combination of the therapies discussed. Please feel free to discuss any questions or concerns with our doctors. Please consider referring your friends and neighbors with dry eye for an evaluation with Dr. DeBry and his dry eye team.