Dry Eye Syndrome Overview

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To help keep your eyes comfortable and your vision optimal, a normal, thin film of tears coats
your eyes. Three main layers make up this tear film:

The innermost layer is the thinnest. It is a layer of mucin (or mucus). This very thin layer
of mucus is produced by the cells in the conjunctiva (the clear skin that lines the eye).
The mucus helps the overlying watery layer to spread evenly over the eye.
The middle (or aqueous) layer is the largest and the thickest. This layer is essentially a
very dilute saltwater solution. The lacrimal glands under the upper lids and the accessory
tear glands produce this watery layer. This layer's function is to keep the eye moist and
comfortable, as well as to help flush out any dust, debris, or foreign objects that may get
into the eye. Defects of the aqueous layer are the most common cause of dry eye
syndrome, also referred to as keratoconjunctivitis sicca (KCS).
The most superficial layer is a very thin layer of lipids (fats or oils). These lipids are
produced by the meibomian glands and the glands of Zeis (oil glands in the eyelids). The
main function of this lipid layer is to help decrease evaporation of the watery layer
beneath it.

Dry eye syndrome (DES) is a common disorder of the tear film, affecting a significant
percentage of the population, especially those older than 40 years of age. DES can affect any
race and is more common in women than in men.
Medically Reviewed by a Doctor on 5/29/2014
Medical Author:
Andrew A. Dahl, MD, FACS

Dry Eye Syndrome Causes

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DES is a common disorder of the normal tear film that results from one of the following:

Decreased tear production

Excessive tear evaporation

An abnormality in the production of mucus or lipids normally found in the tear layer

Aqueous (watery) tear deficiency is caused by either poor production of watery tears or
excessive evaporation of the watery tear layer.

Poor production of tears by the tear glands may be a result of age, hormonal changes, or
various autoimmune diseases, such as primary Sjogren syndrome, rheumatoid arthritis, or
lupus.

Evaporative loss of the watery tear layer is usually a result of an insufficient overlying
lipid layer.

Some medications, such as antihistamines, antidepressants, beta-blockers, and oral

contraceptives, may decrease tear production.

If blinking is decreased or if the eyelids cannot be closed, the eyes may dry out because of tear
evaporation.

When you read, watch TV, or perform a task that requires close attention with your eyes,
you may not blink as often. This decreased blinking allows excessive evaporation of the
tears.
Certain conditions, such as stroke or Bell's palsy, make it difficult to close your eyes on
your own. As a result, your eyes may become dry from tear evaporation.

Abnormal production of mucin by the conjunctiva may occur.

This can result from chemical (alkali) burns to the eye or as a result of different
autoimmune diseases, such as Stevens-Johnson syndrome and cicatricial pemphigoid.
This abnormal production of mucin leads to poor spreading of the tears over the surface
of the eye. The surface of the eye can dry out and even become damaged, even though
more than enough watery tears may be present.

Insufficient lipid layers are the result of meibomian gland dysfunction, as with rosacea or as a
result of taking oral isotretinoin medication.

Meibomian glands are the oil glands in the eyelids that produce the lipid layer.
If the oil glands become blocked or if the oil is too thick, there may not be enough oil to
cover the watery tear layer to prevent its evaporation.

Also, if an infection is present along the eyelids or the eyelashes, called blepharitis, the
bacteria may breakdown the oil so there may not be enough oil.

Dry Eye Syndrome Symptoms

If you have DES, you may also experience the following symptoms:

Dry, gritty/scratchy, or filmy feeling in the eyes

Burning or itching in the eyes

Redness of the eyes

Blurred vision

A sensation of having a foreign body in the eyes

Light sensitivity

Symptoms seem to worsen in dry climates, in windy conditions, with higher temperatures, with
lower humidity, with prolonged use of your eyes (for example, reading, watching TV), and
toward the end of the day.
Sometimes a symptom of DES may actually be intermittent excessive tearing with DES. When
your eye becomes slightly dry and irritated, it may initiate reflex tearing with production of a
large amount of tears all at once to try to get moist and comfortable again. Unfortunately, your
eye can only handle so many tears at any one time; the rest pour over your eyelids and down
your cheeks. Those tears that pour down your cheeks do not help your eyes and are wasted. A
short time later, your eyes will become slightly dry and irritated again, and the whole process
may repeat itself.

When to Seek Medical Care

If you routinely experience any of the following symptoms, you should probably see your
ophthalmologist (a medical doctor who specializes in eye care and surgery):

eye pain,
excessive tearing,

dry, gritty/scratchy, or filmy feeling in the eyes,

burning or itching of the eyes,

redness of the eyes,

blurred vision,

a sensation of having a foreign body in the eyes, or

light sensitivity.

Exams and Tests

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During your eye examination, your ophthalmologist will most likely be able to diagnose DES
just from hearing your complaints regarding your eyes. As part of your eye examination, the
following tests may also be performed.

The front of your eyes are examined using a special microscope, called a slit lamp
microscope.
o The amount and thickness of the tear film are inspected.
o

The stability of the tear film is assessed by checking the tear break-up time.

The conjunctiva is examined to determine if it is too dry.

The cornea is checked to see if it has dried out or become damaged.

Different dyes may be used during your eye examination.

o

Fluorescein is a yellow dye that stains the cornea where the epithelial (surface)
cells have been worn away because of the lack of an adequate protective tear film.

Rose Bengal is a red dye that stains the cornea and the conjunctiva where the cells
are dead or dying as well as where healthy cells are inadequately protected by the
tear film.

Lissamon Green is a green dye which likewise can help differentiate between
normal and abnormal surface cells of the cornea and conjunctiva.

Schirmer tests measure the amount of tears produced by your eyes. Your ophthalmologist
places the end of a thin strip of filter paper just inside the lower eyelid. After a minute,
the filter paper is removed and the amount of wetting is measured. Less wetting of the
filter paper is more indicative of DES.

The osmolarity (salt content) of the tears may be measured. This is a newer test which has
been developed to aid in the diagnosis of DES.

If autoimmune diseases are suspected as a cause of DES, blood tests may be performed.
These blood tests check for the presence of different autoantibodies that may be
associated with DES.

Rarely a biopsy of the salivary glands may be performed. Certain disease processes affect
both the salivary glands, which produce saliva in your mouth, and the lacrimal glands,
which produce tears.

Self-Care at Home
To help alleviate your symptoms from DES, you may want to try these self-help tips at home.

A humidifier puts more moisture in the air. With more moisture in the air, your tears
evaporate more slowly, keeping your eyes more comfortable. Both furnaces in the winter
and air conditioning in the summer decrease the humidity in the air.
Excessive air movement dries out your eyes. Avoid having excessive air movement by
decreasing the speed of ceiling fans and/or oscillating fans.

Large amounts of dust or other particulate matter in the air may worsen the symptoms of
dry eye. In those situations, an air filter may be helpful.

Hot compresses and eyelid scrubs/massage with baby shampoo help by providing a
thicker, more stable lipid layer. This is especially helpful if you have meibomian gland
dysfunction, rosacea, or blepharitis. The heat warms up the oil in the oil glands, making it
flow more easily; the massaging action helps get the oil out of the glands. The cleansing
action decreases the number of bacteria that break down the oil.

Artificial tears and lubricating eyedrops and gels (available over the counter) help
provide more moisture and lubrication for the surface of your eye. They are typically
used about four times a day, but they can be used as often as needed. Preservative-free
solutions are recommended if you wish to use artificial tears more than six times a day.
There is no single over-the-counter drop that is best for everyone. Each individual will
determine which drop provides the most relief from symptoms. Some drops may have a
longer effect than others.

Lubricating eye ointments are much thicker than eyedrops and gels. Because ointments
are so thick, they last much longer than eyedrops and gels. However, because of their
thickness, ointments may blur your vision if used during the day. Therefore, they are
typically used to lubricate the eyes overnight while you are asleep.

If you notice your eyes are dry mainly while you are reading or watching TV, taking
frequent breaks to allow your eyes to rest and become moist and comfortable again is
helpful. Closing your eyes for 10 seconds every five to 10 minutes will increase your
comfort, as will blinking more frequently.

Medical Treatment
Although no cure exists for DES, many treatments are available. Treatment is dependent on the
severity of DES; you may only require a humidifier or occasional eyedrops, or you may require
surgery to help treat DES.
Over-the-counter lubricating eyedrops, commonly referred to as artificial tears, may help relieve
your dry eyes. Some examples of these products include 20/20 Tears, Celluvisc, Comfort Tears,
Dry Eyes, Murine, Refresh, and Tears Naturale. Your ophthalmologist may also prescribe
medications to help with DES.

Medications
Certain prescription medications may help with DES.

Eye lubricants may be prescribed, including eye inserts. Cellulose is

contained in the insert and acts to stabilize and thicken the film of tears over
the eyes and to prolong the time the tear film works. The artificial tear insert
must be properly inserted, otherwise corneal abrasion may occur.
Cyclosporine A 0.5% (Restasis) helps decrease any inflammation on the
surface of your eye. This inflammation is thought to decrease the ability of
your eyes to maintain a healthy tear film. Used twice a day, cyclosporine
0.5% helps you make healthier tears on your own.
Corticosteroid drops (Lotemax, Alrex, FML, Vexol), either alone or used in
conjunction with Cyclosporine, reduce signs and symptoms of dry eye.
Although the FDA has not yet approved this group of drops for the treatment
of DES, they are being successfully used by many ophthalmologists.
Corticosteroid drops, if used in excess, may have some side effects, but new
formulations with fewer side effects have become available. Like all

medications, these should only be used under your doctor's supervision and
according to her or his instructions.

Nonsteroidal anti-inflammatory drops (Voltaren, Acular, Nevanac, Xibrom)

likewise reduce the inflammation associated with DES.

Antibiotics are used if you have blepharitis or meibomian gland dysfunction.

o

Antibiotic ophthalmic ointments, such as erythromycin and bacitracin,

among others, are used at night for about seven to 10 days to
decrease the number of bacteria that break down the lipid layer of
your tear film. These ointments also lubricate your eyes overnight.

Oral antibiotics, particularly tetracycline and doxycycline, not only help

to decrease the number of bacteria but also help to make the oil more
fluid so it flows out of the oil glands more easily. This is often used if
you have rosacea. There are many people who have rosacea of the
eyelids and do not have the typical changes of rosacea on the rest of
the face

Surgery
Different minor surgical procedures may help in the treatment of DES.

Near the inner corner of each eyelid are small openings, called punctae, that
are the beginning of the normal tear drainage system. A procedure known as
punctal occlusion can help by decreasing the normal drainage of your tears
off the eye and down the tear drainage system, into the back of your nose,
and down your throat. This occlusion is usually a very simple office procedure
and only takes a few minutes.
o Different punctal plugs or lacrimal canalicular plugs can be placed at or
just inside these openings to block the normal drainage of tears down
the tear drainage system. Just like a stopper that you put in the drain
of a sink to keep the water from flowing down the drain, these plugs
keep the tears that you have from flowing down the tear drainage
system. Therefore, your eyes stay more moist and comfortable, even if
you have fewer tears. These plugs can usually be removed very easily,
if necessary.
o

Sometimes, in severe cases of DES, these openings are permanently

closed, usually by cautery (burning) or laser. This accomplishes the
same thing as the plugs, but it is very difficult, if not impossible, to
reverse.

If you have difficulty closing your eyes for any reason, your eye may dry out
because of tear evaporation.

Lateral tarsorrhaphy is a procedure during which the lateral (outside)

one-third of your eyelids are sewn together to decrease the ability of
your eye to open widely and to help your eye close more easily.

If stroke or nerve damage keeps your eyelids from closing properly, a

small gold weight may be implanted into your upper eyelid to help it
close.

Other Therapy
Sometimes, people sleep with their eyes slightly open. If you do sleep this way, you might want
to actually tape your eyes shut at night.
Moisture chambers are plastic shields (similar to swim goggles) that help keep the eyes from
drying out by decreasing the evaporation of tears off the eye. The moisture chambers may be
used just at night if you sleep with your eyes slightly open, or they may be used all day, if
necessary

Follow-up
If you have mild DES, you may only need annual follow-up examinations with your
ophthalmologist.
If you have more serious DES, more frequent follow-up appointments are required, based on the
severity of your disease.

Prevention
DES cannot be prevented. If you develop DES, you can help decrease its effects through some of
the self-care suggestions listed above.
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