Symptoms, Causes, and Treatment for Severe Dry Eye Syndrome
What Is Dry Eye Syndrome?
Itching, watering/tearing, burning, redness, blurry or cloudy vision, foreign body sensation (like a lash under the lids), and light sensitivity are all symptoms of a common condition known as Dry Eye Syndrome.
It affects just about everyone at some point in their lives. Many people suffer this syndrome chronically, leading to the inability to perform day-to-day activities and functions. It can be very uncomfortable and, if left untreated, can lead to scar tissue that causes permanent vision loss.
Chronic dryness is also known by the medical term keratoconjunctivitis sicca. This term can be deceiving to patients since conjunctivitis is also the medical term for pink eye, which is viral conjunctivitis.
Keratoconjunctivitis specifically refers to the cornea. The prefix kerato in Latin means cornea. Keratoconjunctivitis sicca is a Latin term and literally means dry inflammation of the cornea and conjunctiva. Before we get into the chronic version of the disorder, let’s take a look at intermittent dry eyes and its causes.
Intermittent or Evaporative Dry Eyes
The intermittent version of the disorder, also called evaporative dry eyes, can be caused by a number of different things. The most common complaint is irritation when reading or working on a computer. What most people don’t know is that this is completely normal.
When working on a computer, or reading for long periods of time, we don’t blink as much as we would normally. Blinking rehydrates the cornea with a fresh layer of tears. Because we’re concentrating when doing tasks up close, such as reading, we blink less and the tear film on the cornea evaporates more quickly. This can cause irritation such as a foreign body sensation (a sandy feeling), redness, burning, itching, scratching, cloudy vision and even light sensitivity (photophobia).
To prevent the cornea from drying out, artificial tears can be used periodically. These “fake tears” won’t evaporate as quickly as your own tears even if you don’t blink frequently. Taking breaks from reading or computer work at least every 45 minutes to an hour, and focusing on something in the distance or simply walking around for ten or twenty minutes will refresh the tear film.
The image above shows the difference between a hydrated cornea and one with an evaporated tear film, in the same eye. The eye has been dyed with a yellow drop called fluorescein. Using a cobalt blue filter on the slit lamp, the fluorescein allows us to visualize the tear film.
The upper arrow points to the healthy tear film. It is smooth and coats the eye properly. The lower arrow points to an area of the tear film that has been allowed to evaporate. Notice that it is on the lower quarter of the cornea. This is because the patient does not close their eyes completely when they sleep and the exposed tear film is allowed to evaporate. This causes the spotting you see in the image.
This spotting is actually little micro-abrasions on the cornea. They can make the eye feel like there is something in it constantly, and many patients mistake this sensation for an actual foreign body in the eye (like an eyelash). Artificial tears can help provide relief in this situation, but they need to be used frequently. Every two hours is preferable, but even four times a day will help.
Chronic Dry Eye Syndrome
Chronic, or severe dryness, is another story entirely. This syndrome, sometimes abbreviated as DES, is usually caused by one of the following:
- The Aging Process
- Meibomian Gland Dysfunction and Blepharitis
- Prolonged Contact Lens Wear (Corneal Desensitization)
- Autoimmune Disease (Evaporative Dry Eye Syndrome)
Let’s look at each cause individually.
The Aging Process
As we age, the lipid layer of the tear film becomes depleted. This layer's primary job is to keep the tear film from evaporating rapidly. Normal evaporation time should be over ten seconds; anything lower can be considered a symptom of dry eye.
This rapid evaporation can lead to chronic irritation, burning, itching and over production of tears (called epiphora). Epiphora is the body’s way of compensating for the rapid evaporation and it can cause tears to constantly stream down the face if the dryness is extremely severe.
Meibomian Gland Dysfunction (MGD) and Blepharitis
Meibomian glands, or tarsal glands, are oil secreting glands that are located in the tarsal plate of the eyelid.
These glands secrete meibum a substance rich in lipids (fats) and about 90 different proteins in the meibum secreted. It forms the lipid layer of the tear film, which protects the tears from evaporating.
These glands can be afflicted with chronic blockages, or the meibum can become thickened and no longer secreted easily. When the meibomian glands cease to function properly, the tear film evaporates causing the symptoms typically associated with dryness.
Blepharitis is a common yet annoying condition. It can be described as dandruff of the lids. The skin around the lashes becomes scaly and starts to flake. If left untreated, the debris can clog the meibomian glands causing MGD and dryness. Blepharitis is typically a chronic disease that needs to be treated daily, but can be easily controlled.
Corneal Desensitization Caused by Prolonged Contact Lens Wear
Contact lenses are a phenomenal invention. They allow many people with difficult prescriptions to be able to see without glasses. However, wearing contact lenses for prolonged periods, even if you take them out nightly, leads to corneal desensitization.
Once the cornea has become desensitized, it can no longer prompt the eye for tears, and allows the eye to dry out. This can cause the contact lens wearer to be unable to continue wearing lenses altogether or drastically reduce the length of time they can wear the lenses comfortably. There is treatment for this, which can allow the patient to keep wearing contacts for years to come.
How to Cure Chronic Dry Eyes
Inadequate tear production or a depleted lipid layer can be the result of autoimmune diseases such as Sjogren’s syndrome, lupus, rheumatoid arthritis, or Wegener’s granulomatosis. In these diseases, the immune system attacks normal, healthy cells and tissue causing inflammation and damage.
In the case of Sjogren’s syndrome, the exocrine glands that produce tears and saliva are attacked by the immune system and destroyed. This prevents the eye from producing enough tears to keep the eye moist and clean.
The tear film not only hydrates the cornea, with each blink it also flushes out microbes and other debris from the eye. When the tear film is not sufficient to keep the eye moist, it also can’t keep the eye clean, which can lead to chronic infections and eventually permanent vision loss.
Even metabolic diseases can cause dry eye syndrome. Conditions such as diabetes can upset the delicate balance of the tear film. The medications for these diseases also cause dryness. Many, like Glucophage (metformin), can even cause dehydration because of the frequent urination they cause.
Cataract and Refractive Surgeries
Whenever surgery is performed on the eye, whether it is cataract, LASIK or even retinal surgeries like pars plana vitrectomy surgery, the eye will become dryer after the procedure than it was before. This is because most eye surgeries affect the cornea in some way causing it to become desensitized and unable to tell the eye it needs tears.
Normally, this isn’t a major issue for the patient and artificial tears usually remedy the problem. There are certain instances where patients may have more severe complications after surgery that result in severe dry eye syndromes, especially if the patient already had dry eyes prior to surgery. For these patients, more aggressive treatments may be necessary to alleviate symptoms and improve quality of life.
Prescription and Over the Counter Medications
Last, but not least, medications. There are many pharmaceuticals on the market today that can dry out the eyes. Specifically, narcotics pain medications are notorious for drying out the eyes and the mouth as well.
Several narcotic pain and anxiety medications have a reputation for this drying effect including:
- Vicodin (hydrocodone)
- Percocet (oxycodone)
- Valium (diazepam)
- Xanax (alprazolam)
- Ultram (tramadol)
Many hypertensive medications and antidepressants also have this effect. Depending on the dosage of the medication, artificial tears should suffice, unless large amounts of painkillers or other narcotics are being taken. These cases may need further therapy to alleviate symptoms.
There are many treatments available for DES. Artificial tears are the first line of defense for DES, especially for dryness caused by reading and computer or other near work.
I typically recommend that patients use artificial tears about ten minutes before they start reading or working on the computer. This hydrates the cornea, and since artificial tears last longer than our own tears, the eyes stay moist longer.
I also recommend that my patients use artificial tears four times a day minimum if they have any trouble with DES. I suffer the condition myself and in the mornings, upon waking, my eyes feel like sandpaper. I keep a bottle of Refresh tears on my night stand, and before I get up I put a couple drops in, and I’m back to normal.
For many people with this syndrome, the symptoms are worse in the morning. This is because most of us don’t close our eyes completely when we sleep, which allows the tear film to evaporate and consequently, the cornea dies out causing cloudy vision and a severe foreign body sensation (like something is in the eye).
This is exacerbated by ceiling fans overhead and air conditioning vents pointed at or over your bed. If you absolutely must have a ceiling fan on when you sleep, instilling an ointment prior to retiring for the night will keep the moisture from evaporating.
However, in the morning when you awake, your vision will be very cloudy and you’ll need to rinse them to clear the vision. Use artificial tears to rinse the eyes, not water. Water will dry out the eye; however, you can wash the lids gently with soap and water to remove any excess ointment that may be stuck to the eye lashes.
Wearing a sleep mask is another option. A sleep mask will help keep the eyes closed and block out most of the air. Even with a sleep mask, you may still wake up with dryness and need to use artificial tears to alleviate the irritation.
Where Do Punctal Plugs Go?
The next most common treatment for DES is punctal plugs. These tiny plugs are inserted into the puncta (the opening into which the tears drain) to keep the tears in the eye longer. Plugs are a great option for those who have moderate to severe dry eyes.
There can be problems with punctal plugs, however. Some patients can be allergic to the materials in the plugs, which is usually collagen or silicone. Allergies can be managed with antihistamine drops such as Zaditor or Pataday, or the plugs can be removed.
Infections can also occur, which typically resolve with antibiotics. In the case of chronic infections the punctal plugs should be removed.
The puncta can also be cauterized (burned) shut. Punctal plugs can be removed, but once the puncta is cauterized, it’s permanent. This is usually the last resort for dry eyes that don’t respond to drops, or plugs since it is a bit drastic. It works quite well however, and can be an option for those who had allergic reactions or infections from typical punctal plugs.
Treatments for MGD and Blepharitis
For meibomian gland dysfunction, or MGD, a warm compress is placed on the eyes for about 15 to 20 minutes twice a day and artificial tears are used for comfort.
Lid scrubs and topical ointments (such as Maxitrol) are given in cases of chronic inflammation and blockages. On occasion, when nothing else works, doctors will prescribe oral antibiotic treatment along with the other treatments listed previously.
Blepharitis is treated easily with lid scrubs twice a day. Scrubbing the lids with a commercially available medicated pad found at any drugstore can keep symptoms under control (Ocusoft makes an excellent one).
A washcloth and baby shampoo can also be used to scrub the lids and alleviate symptoms. Warm compresses can help keep MGD from causing styes to form on the eyelid.
Some cases of blepharitis don’t respond to the lid scrubs in which case antibiotic ointments applied to the lids twice a day is usually the preferred treatment. Maxitrol ointment is a common treatment for blepharitis and is usually given in combination with lid scrubs and warm compresses.
Autoimmune Disease and Immunosuppresants
In cases of autoimmune disease and DES that results from medications, only one treatment has proven effective for patients who have tried everything else.
Restasis, or cyclosporine, is an ophthalmic emulsion drop that suppresses the immune system and prevents further destruction of the tear film. In the majority of patients, Restasis is given with Lotemax or Alrex for the first month due to the stinging sensation initially felt when the drop is instilled.
After about six months to a year of continual use twice a day, most patients notice a dramatic decrease in their symptoms. For those whose symptoms are caused by the medications they take, Restasis is an excellent option if the medication cannot be discontinued.
How to Prevent Dry Eye Syndrome
I get this question quite a bit. Unfortunately, there isn’t a whole lot you can do to prevent severe dry eye syndrome, especially if it is caused by an underlying autoimmune disease that has yet to manifest.
Taking vitamins fortified with Omega 3-6-9 compounds, or drinking fluids fortified with these compounds (like hemp protein in almond milk) can help keep the tear film in good health.
Scrubbing the lids with either lid scrubs or baby shampoo and a wash cloth can help prevent MGD and blepharitis.
Managing environmental elements like ceiling fans and air conditioners can help prevent symptoms. When driving with the air conditioner on, point the vents down toward the floor, not directly at you or up at the windshield.
Pointing the vents directly toward you is self-explanatory; the air goes directly toward the face. When the vents are pointed up toward the windshield, the air bounces of the windshield and right into your eyes.
Taking breaks when working on a computer or reading is essential in preventing dry eye symptoms. I typically recommend breaks every 45 minutes to my patients who use a computer for long periods of time or who are voracious readers for at least 10 minutes to rest the eyes. Keeping rewetting drops nearby is also a good idea.
One of the most important things a person can do to keep the eyes healthy is to wear sunglasses anytime you are outside.
Even if it’s a cloudy day, there are still dangerous UV rays that can damage the delicate tissues in the eye. Always wear sunglasses, even if you think you don’t need to due to rain or cloudy weather.
Last but not least, eat a diet rich in leafy green vegetables, fruits, nuts and omega fatty acids. A healthy diet will prevent free radicals from causing permanent damage and keep your eyes healthy long into old age.
© 2012 Melissa Flagg COA OSC