Dry Eye

What is dry eye?

Dry eye is a condition that affects your tear film, the three layers of tears that cover and protect the surface of your eyes. You need a smooth and stable tear film to help you see clearly and comfortably. Disruptions to your tear film can cause uncomfortable symptoms like burning, itching, watering or blurred vision.

Many different factors can prevent your tear film from working as it should and lead to dry eye. That’s why healthcare providers consider dry eye a multifactorial disease. Its causes and risk factors are numerous and complex. So, it may take a while to get to the root of the problem and figure out what’s causing your symptoms. If you have dry eye, it’s important to establish care with an ophthalmologist or optometrist to manage your condition.

Types of dry eye disease

From its name alone, you might think dry eye disease simply means your eyes don’t produce enough tears. That’s actually only part of the story. There are several types of dry eye disease.

• Aqueous deficient dry eye: This is when your eyes don’t produce enough tears. Your lacrimal gland (in the upper, outer corner of each eye) produces your aqueous tears. These tears make up the middle, watery layer of your tear film. Some autoimmune conditions can cause inflammation in your lacrimal gland and prevent it from producing enough aqueous tears.
• Evaporative dry eye: This is when your tears evaporate too quickly. The most common cause is meibomian gland dysfunction. This means the glands in your eyelids that produce the outer, oily layer of your tear film don’t work properly. As a result, the oily layer is unstable and can’t protect the watery layer from drying up.
• Mixed dry eye: Some people have aqueous tear deficiency and tear instability. This means your eyes don’t produce enough tears, plus your tear film is unstable. Both of these problems lead to dry eye symptoms.

How common is dry eye disease?

Dry eye disease is common. Research estimates that 16 million people in the U.S. have dry eye. Around the world, dry eye affects tens of millions of people. It’s more common in Asia compared with North America and Europe. It’s also more common among people who’ve gone through menopause.

What can dry eye be a sign of?

Dry eye may occur on its own or along with other medical conditions. In some cases, dry eye is a sign of:

• Sjögren’s syndrome (about 10% of people with aqueous deficient dry eye have Sjögren’s syndrome).
• Diabetes (if you have diabetes, there’s about a 50/50 chance you’ll develop dry eye as a complication).
• Thyroid eye disease.
• Blepharitis.

What are the symptoms of dry eye?

When you have dry eye, you might feel like there’s something in your eye that just won’t come out. This can feel like a scratchy, gritty or sandy sensation. Symptoms may also include:

• Burning or stinging.
• Feeling sensitive to light.
• Blurred or changed vision.
• Mucus that comes out of your eye.
• Watery eyes, with excess tears running down your cheeks.

The watery eyes symptom may seem confusing. But it’s a common aspect of dry eye. It happens when your meibomian glands aren’t making enough oils for the outer layer of your tear film. So, the middle, watery layer of your tear film evaporates too quickly. In response, your lacrimal glands try to make more watery tears to compensate. But these tears can’t properly coat your eye, as the oily layer would. So, they can’t solve the underlying problem.

What causes dry eye?

Dry eye happens when:

• Your eyes don’t produce enough tears.
• Your tears evaporate too quickly.
• Both of these happen together.

Many different factors can make you more likely to develop dry eye disease or have symptoms that get worse over time.

Risk factors for dry eye disease

Some risks you can’t control. For example, the older you get, the more likely you are to develop dry eye. But other risks you may be able to manage through lifestyle changes or adjustments to your medications.

Talk to your provider if you have any of the risk factors listed below. You may be able to make some changes to lower your risk for dry eye or lessen bothersome symptoms.

• Environment and lifestyle factors: Things like the weather, how much time you spend looking at screens, contact lens use, smoking or allergies can increase your risk of dry eye.
• Medications: Taking certain medications can increase your risk of dry eye, including some that treat depression, allergies, blood pressure, glaucoma, menopause and pain. Anticholinergics, oral contraceptives and systemic retinoids can increase your risk as well.
• Medical conditions: Many different neurological conditions, eye conditions, autoimmune conditions and endocrine conditions can raise your risk of dry eye.
• Surgeries: Some eye surgeries increase your risk of dry eye, including LASIK, cataract surgery and surgery on your cornea.

How is dry eye diagnosed?

Healthcare providers diagnose dry eye through your medical history, an eye exam and testing.

Medical history

Your provider may ask you to fill out a questionnaire to learn about your symptoms and medical history. You should be prepared to provide lots of information, including:

• Eye-related symptoms and how long you’ve had them.
• Environmental factors that make your symptoms worse.
• Other symptoms, including dry mouth, cavities, mouth ulcers, fatigue and joint pain.
• Allergies.
• History of eye diseases.
• History of other medical conditions, including allergies and chronic viral infections.
• History of surgeries.
• Whether you smoke or are around second-hand smoke.
• How often you wash your eyelids, and what products you use.
• History of trauma to your eye area.

Eye exam

Your provider will give you a thorough eye exam to check the health of your eyes and determine what’s causing your symptoms. During your exam, your provider:

• Looks for signs of dry eye.
• Looks for other possible causes of your symptoms, besides dry eye disease.
• Checks the health of your tear film (the three layers of tears that cover your cornea).
• Performs testing.

Tests that diagnose dry eye

There’s no single test that diagnoses dry eye. Rather, providers may use many tests, including:

• Slit lamp exam: This test checks the amount of tears your eyes produce. The provider shines a light into each of your eyes and uses a microscope to examine your eyes and eyelids.
• Schirmer’s test: This is another way to check your tear production. The provider places a tiny piece of paper along the edge of your eyelid and leaves it there for several minutes. Your eye produces tears in response, and your provider then measures those tears by looking at how much of the paper they cover.
• Tear breakup time (TBUT) test: This test checks how quickly your tears evaporate. The provider puts dye into your eye and uses a microscope to see how long your tear film remains stable (doesn’t break up). They measure the amount of time between your last blink and when the first dry area shows up on your cornea. A time of fewer than 10 seconds can signal dry eye disease.

Healthcare providers also may order other tests, such as antibody tests, to check for underlying conditions that could be causing your dry eye.

How do you fix dry eyes?

The goals of dry eye treatment include:

• Easing your symptoms and soothing your eyes.
• Helping you see clearly.
• Minimizing or avoiding damage to the surface of your eyes.
• Treating the underlying cause.

There are many possible treatments that may help you (described below).

Your provider will decide which treatments are most appropriate for you based on the severity of your symptoms and any underlying conditions you have. You may need to try many different treatments before finding a solution that works best for you.

Home remedies and changes to your environment

Your provider may suggest you start with home remedies, especially if your symptoms are mild. Here are some things you can do:

• Avoid environmental triggers. These include anything that makes your symptoms flare up. Common triggers include cigarette smoke, air vents blowing toward your face, wind and allergens. It may help to wear wraparound glasses or sunglasses when outdoors.
• Use a humidifier in your bedroom. Depending on where you live, your home may have very low humidity levels (less than 25%) during the winter when you’re using the heat. This can make your dry eye symptoms worse. A humidifier can help.
• Place a warm compress over your eyes. Purchase a heat mask for eyes at any drug store and leave it on your eyes for 10 minutes. This can help ease your symptoms and allow your meibomian glands to produce more lipids.
• Give your eyes a rest. Take frequent breaks when you’re reading or using a computer. Practicing the 20/20/20 rule may help. Every 20 minutes, stop and focus your eyes on something 20 feet away for 20 seconds. Also, while reading or using screens, try to remember to blink often to help your tear production.
• Take omega-3 fatty acid supplements. Some research shows these supplements may support tear production and help your symptoms. Talk to your healthcare provider before taking any supplements since they may interact with some medications.

Eye drops

There are many types of eye drops your provider may recommend. Talk to your provider about the options that are best for you.

• Artificial tears: Artificial tears lubricate and soothe your eyes, temporarily relieving symptoms. They’re available over the counter, but you should check with your provider before trying them. Some versions contain lipids, which can help prevent tear evaporation. However, artificial tears don’t treat the underlying cause of dry eye disease.
• Ointments: If your eyes dry out while you sleep, you can use a thicker lubricant at night, such as an ointment.
• Topical cyclosporine A eye drops (Restasis®): Cyclosporine A eye drops treat inflammation in your tear glands so they produce more and better quality tears. You use them twice daily in each eye. Most people see improvements in their symptoms after three months. You may feel some stinging when you first start using the drops, but this usually goes away the longer you use them.
• Lifitegrast (Xildra®) eye drops: Lifitegrast eye drops also treat inflammation in your tear glands, and you use them twice daily. These drops treat both the signs and symptoms of dry eye disease. While full effectiveness isn’t reached for 90 days, you may have some benefit within two weeks.
• Varenicline (Tyrvaya®) nasal spray: Varenicline increases basal tear production by directly stimulating your trigeminal nerve.
• Autologous serum drops: If your dry eye is severe, your provider may recommend autologous serum drops. These are custom artificial tears made from your own serum (part of your blood). This treatment is often effective, but it’s expensive, and your insurance may not cover it.

Punctal occlusion

If your eyes don’t produce enough tears, punctal occlusion (temporary or permanent) may be a helpful option for you. Through a painless procedure, a provider inserts a plug into the tear drain (punctum) in your lower eyelid. This “plugging” allows more tears to stay in your eyes.

With temporary punctal occlusion, the plug dissolves quickly. If your dry eye improves, your provider may then suggest permanent punctal occlusion. In this case, your provider uses a silicone plug that stays in your tear ducts for as long as needed.

In-office procedures

Your provider can perform in-office procedures to help your dry eye. Some common options include:

• Thermal pulsation therapy (Lipiflow®): Thermal pulsation therapy helps people who have an unstable tear film due to meibomian gland dysfunction. It gently massages and warms your eyelids to help your meibomian glands produce oil.
• Intense pulsed light (IPL) therapy: This therapy involves using pulses of light to melt the thick substances that block your meibomian glands. This helps open up your glands so oil can flow through them freely.

Therapeutic contact lenses

Dry eye disease can make the simple act of blinking very painful. That’s because your eyelid rubs against the dry, irritated surface of your eye. Therapeutic contact lenses can help by protecting and lubricating the surface of your eye. These lenses come in several forms, including:

• Soft bandage lenses: These lenses protect your eyes and help heal any damage to your cornea.
• Rigid scleral lenses: These lenses are larger and come into contact with your sclera (the white part of your eye) rather than your cornea. They protect and lubricate your eyes while also correcting your vision.

Your provider will discuss the different contact lens options with you to find the most suitable option.

How can I reduce my risk of dry eye?

Dry eye disease has many causes, so it can be hard to prevent. You may be able to reduce your risk by:

• Visiting a healthcare provider for yearly checkups. A primary care physician can help you with your overall health. If you’re concerned about developing dry eye, talk to your provider. Ask if anything in your medical history or medications list puts you at risk. And ask what you can do to lower that risk.
• Managing underlying conditions. Many different conditions, including diabetes, can lead to dry eye. Talk to your healthcare provider about your risk for diabetes, and follow their advice for managing your blood sugar levels.
• Making lifestyle and environment changes. There’s a lot you can do in your daily life to lower your risk of dry eye. If you use a computer daily, take frequent breaks. Avoid cigarette smoke. Add a humidifier to your bedroom and other rooms where you spend a lot of time. Plus, ask a provider for other suggestions to help keep your eyes lubricated and healthy.

Does dry eye go away?

Dry eye is a chronic condition. It doesn’t have a cure, but treatments can help manage your symptoms.

You may have to try several different treatments to find what works best for you. This can be a stressful process, but it’s worth the effort. Talk to your provider if your current treatments aren’t working or you want to discuss other options.

How do I take care of myself?

Living with dry eye isn’t easy. Many people experience stress, anxiety and exhaustion from trying to manage symptoms. If your condition affects your quality of life, talk to your healthcare provider. You may need to try many different treatments before finding an approach that manages your symptoms.

Keep in mind that millions of people have dry eye. So, you don’t have to deal with it alone. Connect with support communities online, and ask your provider for suggestions. Sharing your challenges with others who understand what you’re going through can be a huge help in your day-to-day life.

When should I see my healthcare provider?

Your ophthalmologist will tell you how often you need to come in for appointments. If other medical conditions are causing your dry eye, you may need regular follow-ups with other healthcare providers, too. Be sure to go to all of your appointments so your care team can monitor your condition and help you receive treatment.

Call your ophthalmologist if you experience:

• New symptoms.
• Symptoms that get worse.
• New side effects from treatments.