What causes dry eye?
There are two main types of dry eye: aqueous deficient and evaporative.
- Aqueous Deficient Dry Eye accounts for less than 20% of dry eye cases and means that you are not producing enough of the aqueous, watery, portion of the tears. This type of dry eye tends to be related to an underlying auto-immune condition, such as, Sjogren's Disease or changes in hormones that inhibit secretions throughout the body including the lacrimal tear glands and salivary glands. As a general rule of thumb, if you have dry mouth you likely have dry eye. Typical treatments for aqueous deficient dry eye include:
- Lubricating eye drops or artificial tears to replace the tear volume that is lacking
- Prescription eye drops with immunomodulatory and anti-inflammatory effects (Restasis, Cequa, Xiidra)
- Prescription nasal spray that stimulates the production of reflex tearing (Tyrvaya)
- Punctal plugs, which are tiny medical devices that your eye doctor inserts into your eyelid to prevent tear drainage
- Evaporative Dry Eye Accounts for over 80% of dry eye cases and means that you are not producing enough of the oil portion of the tears. The oil layer of the tear film is what sits on the surface and prevents them from evaporating. When the oil layer is absent or lacking, you may be producing plenty of tears, but they evaporate too quickly. Tear Breakup Time (TBT) is a test your eye doctor will perform in which they have you hold your eyes open for as long as possible and determine when your tears first start to evaporate. Ideally, the tears stay on the eye for a minimum of 10 seconds. A good measure of how successful treatments are is to measure TBT before and after. The oil layer of the tear film is secreted by the meibomian glands, which run within the eyelids. Meibomian Gland Dysfunction (MGD) is when these glands become chronically clogged because of inflammation of the eyelid skin or within the eyelash follicles. Blepharitis is the name for this eyelid inflammation that can be broken down into different types depending on the location within the eyelid and the cause of the inflammation. Blepharitis and MGD tend to go hand-in-hand, so your eye doctor will make specific recommendations based on the appearance of your eyelids. Treatments for Evaporative Dry Eye target the eyelids and include:
- Warm Compresses. A true warm compress should last between 10-15 minutes, ideally with a mask that can be either microwaved or activated chemically to reach the optimal temperature and hold that level of heat for the duration of the treatment. If the meibomian glands are full of hardened oil, this treatment essentially melts the oil within the glands and then the compress or massaging motion physically expresses the oils into the tear film. Doing this routinely will maintain that the oils stay in a liquid state during the day. Unfortunately, without addressing the root cause of the inflammation, once you stop doing the warm compresses they will become clogged again. The meibomian glands will atrophy over time resulting in loss of the glands entirely if they are not treated properly and consistently over the years.
- Lid Scrubs. Cleaning of the eyelid margin with specialized wipes or foaming cleansers recommended by your eye doctor may be indicated when blepharitis is present. Common causes of blepharitis within the eyelash follicle can be infection by a bacteria or more commonly, infestation by mites known as Demodex. These mites tend to not only affect the eyelash follicle, but also the facial hair follicles leading to acne-like sores across the face. Demodex is not a bacteria, therefore antibiotics are ineffective. It has been discovered that tea tree is an effective treatment for Demodex, so your doctor may recommend specially formulated eyelid cleansers that are effective at killing Demodex without being toxic to the eye itself.
- BlephEx. This is an in-office treatment for blepharitis. Our eye doctor will use this device that has a rotating head that has been soaked in a special eyelid cleanser to completely scrub along your eyelash line and eyelid margin. It is immediately effective leaving the patient with less eyelid itching, irritation, and heaviness. This is a great starting point to get patients feeling better right away and setting them up for success with their at-home lid scrubs. Periodically, patients can come in for treatments when their symptoms begin to return or if they cannot keep up with at-home remedies.
- Optilight Intense Pulsed Light (IPL). As the first and only FDA approved IPL treatment for dry eye, Optilight offers the closest thing to a cure for this form of dry eye. IPL has been used in dermatology for decades to eliminate the underlying inflammatory conditions that cause things like rosacea and acne. Evaporative Dry Eye is more of a dermatologic condition of the lids rather than an eye condition, which is why Optilight IPL is so effective. The dry eye protocol is 4 treatment sessions spaced 2 weeks apart and then maintenance sessions every 6-12 months based on the patient's symptoms and severity of disease. The treatments are applied to the cheeks and skin under the eyes while a protective eye shield is worn. IPL is not a laser and is a safe, yet powerful treatment that targets telangectasia blood vessels and pigment spots. With the significant dry eye relief also comes photo-facial effects leaving the facial skin looking more youthful, tighter, and with less redness and pigmentation.
- Meibomian Gland Expression. Whether it is in-office or at home, expression of the meibomian glands is the ultimate goal of these treatments. Ideally, with Optilight IPL and BlephEx, we our eye doctor can address the root cause of the inflammation that is causing the meibomian glands to clog, and then a combination of in-office and at-home expression of the glands will keep them flowing until another treatment is indicated. Once patients have meibomian glands consistently secreting healthy, liquid, clear oils with every blink, they will show improved TBT scores and significantly improved dry eye.
What are the signs and symptoms of dry eye?
The list of possible symptoms caused by dry eye is extensive and some of which can masquerade as other conditions. For example, itchy eyes may be thought to be allergies, but is more often a manifestation of dry eye or blepharitis. Blepharitis is inflammation at the base of the eyelash follicle, which is often caused by Demodex mites that are more active at night. If you are waking up with itchy and flakey eyelids, this is likely Demodex Blepharitis. Your eye doctor can easily diagnose blepharitis while looking at your eye lids and lashes under the slit lamp microscope and may suggest eyelid scrubs or an in-office procedure called BlephEx. As a general rule of thumb: if rubbing your eyes makes it feel better it is likely dryness or blepharitis, but if it makes the redness, swelling, itching worse, then it is likely allergies.
The constant, chronic irritation caused by dry eye can aggravate the sensitive nerves on the front surface of the eye to the point where it causes a radiating pressure or pulling sensation behind the eye. This eyestrain may be attributed to extended periods of time reading or on the computer, which can be a contributing factor, but can be relieved with treating the underlying dry eye. Our normal blink rate is around 20 blinks per minute, but when we are reading, on the computer, watching TV, or driving it can drop to 3 blinks per minute. If you have the evaporative form of dry eye, this means your eye can be left exposed for the vast majority of the time that you have to be focusing your hardest. By the end of a work day your eyes are so dry and irritated it can cause eyestrain and headaches, where the only relief is to close them until the next day. By improving the oil layer of the tear film, the tears can stay on the eye for longer durations in between blinks. If you use a lubricating eye drop or gel, that improved oil layer will also make the drop last longer, requiring lest frequent applications throughout the day.
Burning is a common symptom of dry eye. After each blink, our tears resurface and have a high water content. As our tears evaporate, there is less water content and they become more and more concentrated with the natural salts, proteins, and mucous that make up our tear film. When we finally blink or close our eyes again, those salty tears burn our eyes, much like opening your eyes while swimming in the ocean. We can dilute the tears with lubricating eye drops, gels, and ointments, but it is also important to maintain a healthy oil layer to prevent the tears from evaporating too quickly. Your eye doctor will set up a treatment plan such as: warm compresses, eyelid scrubs, eyelid foaming cleansers, IPL, and BlephEx treatments to allow your body to produce the highest quality tears on its own.
Grittiness can feel like sand or small pebbles are stuck in the eye. Blepharitis causes a flaking, dandruff-like, material to come from the eyelashes and can get into the eyes. This flakey material can cause foreign body sensation resulting in tearing, redness, and light sensitivity. Maintaining good eyelid hygiene is difficult without the proper cleansers. OcuSoft and Cliradex foaming cleansers have the correct formula to clean the eyelids and lashes without causing irritation when it gets in the eyes. BlephEx is an in-office treatment that uses a soft spongey tip soaked in an eyelid cleanser that rotates along the eyelids and lashes to relieve the bacteria, mites, Demodex, and flaking that occurs on the lids with blepharitis for immediate relief.
The constant, chronic irritation caused by dry eye can aggravate the sensitive nerves on the front surface of the eye to the point where it causes a radiating pressure or pulling sensation behind the eye. This eyestrain may be attributed to extended periods of time reading or on the computer, which can be a contributing factor, but can be relieved with treating the underlying dry eye. Our normal blink rate is around 20 blinks per minute, but when we are reading, on the computer, watching TV, or driving it can drop to 3 blinks per minute. If you have the evaporative form of dry eye, this means your eye can be left exposed for the vast majority of the time that you have to be focusing your hardest. By the end of a work day your eyes are so dry and irritated it can cause eyestrain and headaches, where the only relief is to close them until the next day. By improving the oil layer of the tear film, the tears can stay on the eye for longer durations in between blinks. If you use a lubricating eye drop or gel, that improved oil layer will also make the drop last longer, requiring lest frequent applications throughout the day.
Burning is a common symptom of dry eye. After each blink, our tears resurface and have a high water content. As our tears evaporate, there is less water content and they become more and more concentrated with the natural salts, proteins, and mucous that make up our tear film. When we finally blink or close our eyes again, those salty tears burn our eyes, much like opening your eyes while swimming in the ocean. We can dilute the tears with lubricating eye drops, gels, and ointments, but it is also important to maintain a healthy oil layer to prevent the tears from evaporating too quickly. Your eye doctor will set up a treatment plan such as: warm compresses, eyelid scrubs, eyelid foaming cleansers, IPL, and BlephEx treatments to allow your body to produce the highest quality tears on its own.
Grittiness can feel like sand or small pebbles are stuck in the eye. Blepharitis causes a flaking, dandruff-like, material to come from the eyelashes and can get into the eyes. This flakey material can cause foreign body sensation resulting in tearing, redness, and light sensitivity. Maintaining good eyelid hygiene is difficult without the proper cleansers. OcuSoft and Cliradex foaming cleansers have the correct formula to clean the eyelids and lashes without causing irritation when it gets in the eyes. BlephEx is an in-office treatment that uses a soft spongey tip soaked in an eyelid cleanser that rotates along the eyelids and lashes to relieve the bacteria, mites, Demodex, and flaking that occurs on the lids with blepharitis for immediate relief.
What in office treatments are available for dry eye?
Intense Pulsed Light (IPL): This is a treatment that has been around in dermatology for decades to combat inflammation and pigmentation of the skin. With the new Optilight IPL, there is now the first and only FDA approved IPL treatment for dry eye. Over 80% of dry eye is the evaporative form, which is a deficiency of the oil glands within the eyelids. The eyelids are skin and have many oil glands, just like the rest of the face. When there is redness, inflammation, acne, or pigmentation of the skin of the face, then it is almost certain that it is happening within the eyelids as well causing evaporative dry eye. The OptiLight IPL protocol is a non-invasive light based therapy that is applied along the cheeks from ear to ear and below the eyelids. It is effective at warming up the glands so that they can be expressed, killing bacteria and mites that live in our pores and follicles, promoting healthier cellular activity, reducing the telangectasia blood vessels that cause inflammation, and smooth out fine lines and pigmentation of the skin.
IPL is also an effective treatment for Chalazion and styes. When warm compresses aren't able to clear the blockage in the eyelid or if you need a quicker resolution because of an upcoming event and do not want to have the lesion surgically removed, IPL is a great option. With a quick, non-invasive light treatment directly on the eyelid, the chalazion or stye can start to show resolution within 3 days. When the chalazion or stye is fresh, it usually requires only one treatment. If the eyelid lesion has been present for months or is recurring, it may require 2-3 IPL treatments to completely resolve.
BlephEx: This is a powerful tool that comes in a small package. This handheld device has a rotating bit with a soft tip, which is soaked in a specially formulated eyelid cleanser. The rotating tip is then applied along the eyelid margin and eyelashes to scrub them clean. This is effective at reducing the presence of abnormal bacteria and Demodex mites that live in along the oil glands and in the eyelash follicles. This treatment provides immediate relief, leaving the eyelids feeling lighter and less itchy. The treatment can be done routinely as maintenance and works well when eyelid scrubs are done routinely as well.
Meibomian Gland Expression: Meibomian Gland Dysfunction results in the oil within the glands of the eyelid to harden. If the oils are of a buttery consistency, we can heat them up and push them out. Warm compresses liquefy the oils within the glands and the expression is the manual motion of pushing those oils out. Doing this in-office, especially directly after an IPL treatment, can vacate the meibomian glands to make room for new oils to fill and flow naturally. Meibomian gland expression can provide an immediate relief of that heaviness of the eyelids and raw, burning feeling of the eye itself. Depending on how diligent you are with at-home warm compresses, this can be done in-office throughout the year to maintain comfort.
IPL is also an effective treatment for Chalazion and styes. When warm compresses aren't able to clear the blockage in the eyelid or if you need a quicker resolution because of an upcoming event and do not want to have the lesion surgically removed, IPL is a great option. With a quick, non-invasive light treatment directly on the eyelid, the chalazion or stye can start to show resolution within 3 days. When the chalazion or stye is fresh, it usually requires only one treatment. If the eyelid lesion has been present for months or is recurring, it may require 2-3 IPL treatments to completely resolve.
BlephEx: This is a powerful tool that comes in a small package. This handheld device has a rotating bit with a soft tip, which is soaked in a specially formulated eyelid cleanser. The rotating tip is then applied along the eyelid margin and eyelashes to scrub them clean. This is effective at reducing the presence of abnormal bacteria and Demodex mites that live in along the oil glands and in the eyelash follicles. This treatment provides immediate relief, leaving the eyelids feeling lighter and less itchy. The treatment can be done routinely as maintenance and works well when eyelid scrubs are done routinely as well.
Meibomian Gland Expression: Meibomian Gland Dysfunction results in the oil within the glands of the eyelid to harden. If the oils are of a buttery consistency, we can heat them up and push them out. Warm compresses liquefy the oils within the glands and the expression is the manual motion of pushing those oils out. Doing this in-office, especially directly after an IPL treatment, can vacate the meibomian glands to make room for new oils to fill and flow naturally. Meibomian gland expression can provide an immediate relief of that heaviness of the eyelids and raw, burning feeling of the eye itself. Depending on how diligent you are with at-home warm compresses, this can be done in-office throughout the year to maintain comfort.
What are things I can do at home to help with dry eye?
Your eye doctor will formulate a customized dry eye treatment plan based on the findings during your eye exam. There are many at-home remedies that complement any in-office treatments that are performed. Being diligent with the home care can mean less frequent trips to the eye doctor for treatments like IPL, BlephEx, and meibomian gland expression. Some of the main at-home treatments that your eye doctor may suggest and the reasoning behind them include:
Warm Compresses: The meibomian glands are specialized oil glands that run within your eyelids and open up at the eyelid margin. Every time you blink, they should secrete liquid oil that coats your tears to prevent them from evaporating. Over time, the oil within these glands can harden into a buttery-like consistency and little to no secretions are expressed upon blinking. What do you do to butter to liquefy it? You heat it up! It takes 10-15 minutes of sustained heat to liquefy the oils within the meibomian glands. The best way to achieve this is with specialized masks like that from Tranquileyes XL Advanced or TearRestore. They are reusable and create the perfect temperature of heat through a controlled chemical reaction that holds the temperature throughout the duration of the treatment. The Tranquileyes XL Advanced is the most effective, creating a complete warm moisture chamber over the entire eye. TearRestore has the advance of openings over the eyes so that you can still see while performing your warm compress treatment.
Eyelid Scrubs: One of the areas of our bodies that is cleaned the least frequently are the eyelids and eyelashes, because... you would get soap in your eyes! There are now foaming eyelid cleansers with specialized formulas designed for your type of dry eye. These are applied to a clean cotton ball or washcloth and then used to scrub at the base of the eyelashes and the eyelid margin (where eyeliner would go) to all 4 eyelids. OcuSoft Original is a good all-around and cost-effective solution for regular use. If you are diagnosed with the common Demodex mite infestation, Cliradex has the added benefit of Tea Tree Oil, which has been shown to kill demodex mites.
Eye Lubrication: The three most common types of lubrication are drops, gels, and ointments. Eye drops have the advantage of being able to apply throughout the day without any affect on the vision. There are also many different formulas that can be customized dependent on the deficiencies of your own tear film. It is recommended to use preservative-free eye drops whenever possible. These typically come in single-use vials, but now are available in bottle form because of a newly developed dropper tip that prevents any regurgitation of the drop that keeps the contents inside from becoming contaminated. If you are using drops more than 4 times per day, then the preservatives can be toxic to the cornea and cause more harm than good. If you are using medicated eye drops for glaucoma and are suffering from dry eye, ask your doctor if there are preservative free options available.
Gel drops are thicker and can provide longer-lasting relief compared to drops. They do tend to smear the vision, so take care to apply the gel drop at least 10 minutes prior to driving or watching a movie to allow your eyes to regain clear vision.
Lubricating ointments are intended for overnight use. They come in a tube that can be squeezed onto a clean finger and then applied to the inside of the lower eyelid. The ointment will melt across the eye and definitely obscure the vision. It should be applied right before falling asleep to create a moisture barrier while sleeping. This is especially important for people that wake up with dry, red eyes, that sleep with their eyes partially open, have recurrent corneal erosions, or sleep with a CPAP machine.
Warm Compresses: The meibomian glands are specialized oil glands that run within your eyelids and open up at the eyelid margin. Every time you blink, they should secrete liquid oil that coats your tears to prevent them from evaporating. Over time, the oil within these glands can harden into a buttery-like consistency and little to no secretions are expressed upon blinking. What do you do to butter to liquefy it? You heat it up! It takes 10-15 minutes of sustained heat to liquefy the oils within the meibomian glands. The best way to achieve this is with specialized masks like that from Tranquileyes XL Advanced or TearRestore. They are reusable and create the perfect temperature of heat through a controlled chemical reaction that holds the temperature throughout the duration of the treatment. The Tranquileyes XL Advanced is the most effective, creating a complete warm moisture chamber over the entire eye. TearRestore has the advance of openings over the eyes so that you can still see while performing your warm compress treatment.
Eyelid Scrubs: One of the areas of our bodies that is cleaned the least frequently are the eyelids and eyelashes, because... you would get soap in your eyes! There are now foaming eyelid cleansers with specialized formulas designed for your type of dry eye. These are applied to a clean cotton ball or washcloth and then used to scrub at the base of the eyelashes and the eyelid margin (where eyeliner would go) to all 4 eyelids. OcuSoft Original is a good all-around and cost-effective solution for regular use. If you are diagnosed with the common Demodex mite infestation, Cliradex has the added benefit of Tea Tree Oil, which has been shown to kill demodex mites.
Eye Lubrication: The three most common types of lubrication are drops, gels, and ointments. Eye drops have the advantage of being able to apply throughout the day without any affect on the vision. There are also many different formulas that can be customized dependent on the deficiencies of your own tear film. It is recommended to use preservative-free eye drops whenever possible. These typically come in single-use vials, but now are available in bottle form because of a newly developed dropper tip that prevents any regurgitation of the drop that keeps the contents inside from becoming contaminated. If you are using drops more than 4 times per day, then the preservatives can be toxic to the cornea and cause more harm than good. If you are using medicated eye drops for glaucoma and are suffering from dry eye, ask your doctor if there are preservative free options available.
Gel drops are thicker and can provide longer-lasting relief compared to drops. They do tend to smear the vision, so take care to apply the gel drop at least 10 minutes prior to driving or watching a movie to allow your eyes to regain clear vision.
Lubricating ointments are intended for overnight use. They come in a tube that can be squeezed onto a clean finger and then applied to the inside of the lower eyelid. The ointment will melt across the eye and definitely obscure the vision. It should be applied right before falling asleep to create a moisture barrier while sleeping. This is especially important for people that wake up with dry, red eyes, that sleep with their eyes partially open, have recurrent corneal erosions, or sleep with a CPAP machine.
Where can I find the dry eye products recommended by my eye doctor?
DryEye Rescue is a fantastic resource for everything dry eye. You can trust these products because they are developed, tested, and approved by eye care professionals. These products range from lubricating eye drops, to warm compress masks, to beauty supplies that are safe and comfortable for use around the eyes. Use promo code SeeSharp10 for 10% off all orders!
