Dry eyes

The symptoms of dry eyes are often nonspecific and do not always begin with dryness. In fact, in various cases, patients experience watery eyes as a symptom of dry eyes. This occurs because excessive 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 scratchy feeling in the eyes
• Red eyes
• Itching in the eyes (particularly in the cornea)
• Photophobia (increased sensitivity to light)
• Feeling of having a foreign substance in the eyes
• Stringy mucus near the eyes
• Sticky eyelids, especially in the morning
• Blepharitis (inflammation of the eyelids)
• Tired eyes with a desire to close them more often
• Feeling of heavy eyelids
• Difficulty in opening the eyelids
• Sharp and dull pain behind the eyes
• Difficulty in wearing contact lenses

Do you wear contact lenses? Have a look at some of the common mistakes that contact lens wearers make!

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 a dilute saltwater solution. This layer helps keep the eyes moist and flush out any dust, debris, or foreign objects that may enter the eye.
• The innermost mucosa layer is 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 any of the layers, an 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, and xerophthalmia due to Vitamin A deficiency tend to decrease tear production.
• Medications such as 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: Meibomian glands are small oil glands on the edge of the eyelids. They produce the oil/lipid layer that forms the superficial layer of the tear film, protecting against evaporation of tears.
• Blockage of these glands, 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 eyelashes makes the bacteria break down the oil, leaving insufficient oil to prevent 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, leading to dryness 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 results in poor spreading of the tears over the surface of the eye, causing dryness despite the presence of sufficient tears.
4. Combination of the above factors.

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. Individuals over 65 years of age often begin experiencing symptoms of dry eyes.
2. Gender
   Women are more likely to develop dry eyes due to hormonal changes throughout their lifetime, particularly during pregnancy and menopause. The use of oral contraceptives is also linked to an increased risk of dry eyes.
3. Screen Time
   Exposure to digital screens is a well-known risk factor for dry eyes. Continuous screen exposure reduces blinking and triggers tear evaporation, which significantly contributes to dry eyes.
4. Ethnicity
   Studies suggest that dry eyes are more prevalent in Asians compared to the white population.
5. Medical Conditions
   Several inflammatory and autoimmune conditions are associated with an increased risk of dry eyes, including:
   • Rheumatoid arthritis
   • Diabetes
   • Thyroid dysfunction
   • Blepharitis (inflammation of the eyelids)
   • Rosacea
   • Seborrhoeic dermatitis
   • Staphylococcal infection
   • Demodex mite infestation
   • Bell's palsy
   • Sjogren’s syndrome
   • Graft versus host disease
   • Herpes infection
   • Hepatitis C
   • Androgen insufficiency
   • Heat or chemical burns
   • Acne
   • Gout
6. Medications
   Certain medications are closely associated with dryness of the eyes due to decreased tear production. This includes medications for high blood pressure, allergies, anxiety, depression, cough, and insomnia.
7. External Exposure
   Exposure to dry climates, chemical fumes, pollution, and sunlight increases the risk of developing dry eyes. Smoking and secondhand smoke are both risk factors, as they expose the eyes to harmful irritants. Individuals living in air-conditioned environments also have a higher chance of experiencing dry eyes.
8. Contact Lenses
   The use of contact lenses can decrease corneal sensation, potentially leading to dry eyes.
9. Previous Eye Surgery
   Any past eye surgery, such as LASIK (laser) surgery, lid surgery, or cataract surgery, can reduce tear production and contribute to dry eyes.
10. Eye Drops
    Excessive use of topical medications for other eye conditions, such as glaucoma, is also associated with an increased risk of dry eyes.
11. Diet
    Vitamin A and omega-3 fatty acids play a vital role in maintaining eye health. Deficiencies in either can lead to dryness in the eyes. Vitamin A deficiency, known as xerophthalmia, can begin with dry eyes and may progress to blindness in severe cases.

The symptoms of dry eyes are very similar to those of eye infections and allergies. Therefore, it is essential to distinguish between these conditions through specific clinical tests. Administering antiallergic medications for dry eyes due to incorrect diagnosis may worsen the eye condition.

1. Patient History and Physical Examination

• The doctor gathers patient history, including information about medications, medical problems, and environmental factors contributing to dry eye symptoms.
• The doctor checks for:
• The amount of tears produced by the eyes
• The structure of the eyelids
• The 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 assesses how long the tear film lasts after blinking. A small amount of dye is placed in the eyes, and the time until the dyed tear film covers the entire eye after blinking is recorded. The tear film does not last long in cases of dry eyes.

3. Examination of Tear Volume

• Schirmer’s Test: This test evaluates the quantity of tears produced by the eyes. The eyes are desensitized with eye drops, and a small piece of paper is placed on the edge of the eyelid for 5 minutes. The moisture on the paper indicates the quantity of tears.
• Tear Film Meniscus: This test determines the height of the tear film, helping to diagnose 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 healthy individuals. A foamy tear film indicates an altered lipid layer in patients with meibomian gland dysfunction.
• Slit Lamp Test: This test measures the quantity of tears produced by the eyes using a microscope called a slit lamp. A liquid is introduced into the eyes for clear visualization of the tears, allowing the practitioner to examine the eye and eyelids under bright light.

4. Examination of Tear Films

• Tear Film Osmolarity: This test measures the osmolarity of tears, which indicates the concentration of salt in the tears. Normal osmolarity is essential for proper tear production, and the value increases with the severity of dry eyes.

5. Examination of the Ocular Surface

• The surface of the eye is examined using a microscope (slit lamp) and dyes, which enhance visualization. Common dyes used include fluorescein and lissamine green.
• Fluorescein Staining: This method assesses corneal damage by instilling fluorescein dye into the tear film and observing it after 1 to 3 minutes.
• Lissamine Green Staining: This method evaluates conjunctival and lid margin damage by instilling lissamine green dye into the tear film and observing it after 1 to 3 minutes.

6. Examination of Eyelids

• Blink Rate: Blinking is crucial for keeping the eye moist by distributing tear fluid over the 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
• A reduced interval between blinks of about 2.6 to 6 seconds indicates dry eyes.
• Meibomian Gland Evaluation: Meibomian glands are essential for maintaining overall eye health and stability. They produce meibum, and a reduction can lead to evaporative dry eyes due to altered lipid composition. The function of the meibomian gland is assessed by evaluating the quantity and quality of meibum. A turbid and viscous appearance of meibum indicates gland dysfunction.

Differentiating Between Insufficient Tear Production and Excessive Tear Evaporation

• The tests mentioned above help determine the cause of dry eyes:
• A reduced tear meniscus and low Schirmer test indicate a deficiency of tears.
• Altered lid margins, thickened meibomian gland secretions, and reduced tear film break-up time suggest hyper-evaporative dry eye.
• Ocular surface damage and elevated tear film osmolarity can occur with both forms.

Evaluation for Systemic Disease

• Various diseases may cause dry eyes, particularly primary Sjogren's syndrome. Secondary Sjogren syndrome, caused by other conditions, may also lead to dry eyes. Such conditions include:
• Rheumatoid arthritis
• Lupus
• Progressive systemic sclerosis
• Dermatomyositis
• Other systemic abnormalities such as Parkinson's disease, androgen deficiency, thyroid disease, and diabetes have also been associated with dry eyes. Clinical diagnosis of these diseases is performed in case of any suspicion.

1. Blink consciously

Blinking helps spread tears over the ocular surface and keeps foreign matter and irritants out of the eyes. Frequent blinking, especially while using digital screens, helps keep the eyes moist and prevents dryness.

2. Boost the humidity

The dry climate often triggers dry eyes. Increase humidity by placing bowls of water around the room at home and in the workplace, which helps make the air more humid.

3. Avoid straining the eyes

Eye strain occurs when focusing on something for extended periods. Minimize or avoid such activities, including:

• Using computers, smartphones, tablets, and gaming consoles for long durations
• Driving for extended periods
• Reading for long periods or in dim light

4. Protect your eyes

Protect your eyes from direct contact with irritants by wearing protective glasses while using screens and sunglasses outdoors to reduce exposure to dry winds, sunlight, and smoke.

5. Limit screen time

Prolonged use of digital screens is a leading cause of eye disorders, commonly referred to as computer vision syndrome (CVS). Prevent dry eyes by following the 20/20/20 rule: 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 to help prevent eye strain caused by CVS:

6. Quit smoking

Cigarette smoking exposes the eyes to harmful chemicals that can lead to dry eyes. Quitting both active and passive smoking can help prevent this condition.

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, and air conditioning is an important part of the protocol.

1. Artificial Tears
   Artificial tears are the mainstay therapy used in all grades of dry eyes, regardless of severity. They are benzalkonium chloride (preservative) free eye drops designed to increase tear film stability. These preparations contain polyvinyl alcohol, povidone, hydroxypropyl guar, cellulose derivatives, and hyaluronic acid as the main agents. These drops are available in the form of gels, ointments, and solutions. In cases of meibomian gland dysfunction, artificial tears containing lipids such as triglycerides, phospholipids, and castor oil are used.
2. Anti-inflammatory Medications
   Inflammation of the ocular surface and lacrimal gland is observed even in moderately severe dry eyes. Anti-inflammatory treatment is required for moderate to severe conditions of the eye.
3. Topical Corticosteroids
   Studies have shown that instillation of corticosteroids for 2 to 4 weeks can help reduce the symptoms of dry eyes. However, this therapy is intended for short-term use, as long-term therapy is associated with potential complications.
4. Topical Cyclosporine A
   Cyclosporine A is an immunosuppressant that aids in reducing inflammation. Topical application of cyclosporine increases tear production and reduces symptoms such as blurry vision, ocular dryness, and foreign body sensation. In patients intolerant to cyclosporine, tacrolimus eye drops are used.
5. Antibiotics
   Several antibiotics with anti-inflammatory properties are used to treat dry eyes, particularly in cases of meibomian gland dysfunction and blepharitis associated with dry eyes. Common antibiotics include:
   • Doxycycline
   • Minocycline
   • Azithromycin
6. Punctal Plugs
   Punctal plugs are tiny devices inserted into the tear ducts to reduce tear drainage, helping to keep the eye moist. There are two types of punctal plugs:
   • Temporary/Dissolving Plugs: Made of dissolving material such as collagen, these plugs can last from a few days to months.
   • Semi-permanent Plugs: Made of longer-lasting materials such as silicone or acrylic, these plugs can remain in the eyes for years and can be removed by an ophthalmologist if needed.
7. Surgery
   Various surgical options for the treatment of dry eyes syndrome include:
   • Tarsorrhaphy: Surgical joining of the upper and lower eyelids, either partially or completely, to promote corneal healing.
   • Amniotic Membrane Transplantation: A piece of amniotic membrane is applied to the surface of the eye to reconstruct the ocular surface.
   • Keratoplasty: A surgery performed on the cornea, especially corneal transplantation, used in severe cases involving persistent corneal ulceration and perforation.

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:

   • Omega fatty acids: Fish, oils, and dairy products
   • Vitamin A: Pumpkins, apricots, carrots, tomatoes, spinach, and dairy products
   • Vitamin C: Citrus fruits and juices (orange, grapefruit, lemon, lime), apples, bananas, tomatoes, and cooked spinach
   • Zinc: Whole grains, dairy products, sweet corn, peas, lentils, and nuts
   • Lutein and zeaxanthin: Eggs, corn, kiwi fruit, grapes, zucchini, and leafy greens (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 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 fewer tears after a night of insufficient sleep. Adequate sleep may help in the faster recovery of patients with dry eyes. A sound sleep keeps the mind calmer and helps in preventing uninvited headaches on weekends. Explore our range of products that may help you to get better sleep.

5. Maintain eyelid 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 environments

   Dry climates trigger dryness in the eyes. Such situations can be avoided by directing car heaters away from your face to prevent air from blowing directly into your 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 proper medical attention, the condition can damage the cornea. The complications of dry eyes include:

• Fluctuations in vision
• Scarring of the cornea
• Infectious keratitis (infection of the cornea caused by bacteria, viruses, fungi, and parasites)
• Eye ulceration
• Eye infections
• Eye inflammation
• Wound in the cornea
• Conjunctivitis
• Vision loss

2. Other Complications

Chronic dry eyes affect 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 recognized for their medicinal and nutritional values. The administration of goji berry extract has been found to relieve dry eyes, as confirmed by various tests such as Schirmer's test score and tear breakup time (TBUT).
• Polygonum cuspidatum: This plant 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 preserve eye health through its anti-inflammatory properties.
• Chamomile: Washing the eyes with chamomile tea is utilized for the treatment of eye infections and other eye diseases.

1. Try home remedies: There are various home remedies that provide relief for dry eyes. This includes applying a warm compress to the eyes, taking fish oil supplements, drinking plenty of water, and increasing humidity at work or in your home by using a humidifier.
2. Try scleral contact lenses: Individuals 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 the sclera. They protect the eyes and keep them hydrated for an extended period.
3. Take regular breaks: It is important to take frequent short breaks and blink regularly while reading or working on computer screens. Keep your eyes closed for a short time when possible, such as during a phone call. This will help decrease eye strain.
4. Adjust the position of computer screens: The total eye surface exposure and tear evaporation are reduced when looking down, which helps keep the eyes moist. This can be applied while working on computer screens by keeping them at a lower level.
5. Make necessary light adjustments: Individuals with dry eyes often suffer from photosensitivity triggered by bright lights. This can be reduced by avoiding bright bulbs directly overhead, which helps minimize brightness and reduces reflection on surfaces such as computer screens.
6. Stay away from vents: It is advisable to stay away from vents, as dry air blowing directly into your eyes can exacerbate dry eye symptoms.
7. Keep eye drops handy: Patients with dry eyes should always keep eye drops with them to use whenever they start to feel dryness.
8. Join a support group: Connecting with others who have a similar condition can help in discovering various strategies that may aid in faster recovery.