The Fine Art of Treating Dry Eye

Dry eyes can be unsightly, as well as painful.  Dry eyes can also be a chronic problem. There are many causes of dry eye symptoms. Therefore, when it comes to treatment, one size definitely does not fit all. The art in treating dry eye comes from recognizing the cause as well as contributing factors that can exacerbate this very common eye problem.  Once these factors are considered, a treatment regimen that targets these causes can be established.  Much like the customization of laser vision correction, Dr. Mandel tailors a regimen for each dry eye patient.

The Fine Art of Treating Dry Eye_Mandel Vision Blog PostSome common ocular symptoms of dry eye include:

  • Redness
  • Irritation
  • Discharge (typically clear or white)
  • Foreign body sensation – the feeling that there is something in the eye
  • Pain – typically described as a “stabbing” or “pins and needles” type of pain
  • Excessive tearing – this is known as “reflex tearing” which is the body’s way of compensating for dry eye.

There are many factors that can contribute to dry eye symptoms, which is why a thorough history is the key to effectively treating dry eye.  Keeping in mind that symptoms of dry eye may not be from dry eye at all, here are some of the most common ones:

  • Physical Factors:
  1. Poor tear film quality. There are 3 important and distinct layers of the tear film. Poor quality in any one of the 3 can lead to dry eye symptoms.
  2. Eyelids that do not have full closure due to heredity, entropion, ectropion and/or after cosmetic eyelid surgery, such as blepharoplasty.
  3. Incomplete blink. This means that the eye doesn’t fully close with each blink.
  4. Sleeping with eyes partially open.  This can lead to a condition called exposure keratitis.
  5. Blepharitis – this is one type of inflammation of the glands of the eyelid margin which can affect the quality of the tear film.
  6. A poorly fitting contact lens.  A contact that is too tight will not move adequately on the cornea, which deprives the cornea of both proper lubrication from the eye’s tear film, as well as much needed oxygen. This can be very dangerous as it can cause a corneal ulcer, which can lead to a blinding infection.
  7. Prior trauma to the cornea.  A corneal abrasion (a scratch on the cornea) can leave the topmost layer of the cornea, the epithelium, in a weakened state. This area of the epithelium can be prone to tears or rips in the future, at the site of the original injury.  This condition is called “recurrent corneal erosion” and typically happens in the morning, immediately upon opening the previously injured eye.
  • Environmental Factors
  1. Dry environments, such as that of an airplane
  2. Dusty environments, such as construction zones or saunas
  3. Extreme temperatures, both hot and cold
  4. Arid climates
  • Systemic Disease:
  1. Arthritis
  2. Thyroid Disease
  • Systemic Medications
  1. Allergy Medications
  2. Birth Control Pills
  3. Some medications used for the treatment of depression, anxiety, ADD/ADHD and similar conditions

An eye examination for the symptoms of dry eye can include:

  • Evaluating the tear film with the following tests:
  1. Visual inspection of the tear film under the slit lamp microscope.
  2. Staining of the tear film with flourescein dye to check for dry spots on the cornea.
  3. Measurement of the tear break-up time. This is the amount of time it takes for the tear film to evaporate.  In dry eye patients, often the tear break-up time is less than 5 seconds.
  • Evaluating the eye and its surrounding structures for primary or secondary causes of dry eye symptoms:
  1. Check the eyelid margins for signs of blepharitis.
  2. Check the physical anatomy of the eyelids for contributing factors, such as ectropion, entropion, eye exposure due to cosmetic eyelid surgery, etc…
  3. Check the functional anatomy of the eyelids during blinking to evaluate the blink reflex.

Treatments Include:

  • Lubricating Drops: There are many different types of drops out there which are tailored for the different layers of the tear film and the different causes of dry eye.  Choosing the appropriate one can make all the difference in the success (or failure) of dry eye management.
  • Lubricating Ointments and Gels: These are typically used at night, as they can blur vision temporarily, in order to keep the eye well lubricated during sleep.  It can be particularly helpful in patients who sleep with their eyes partially open, as it acts as a barrier between the eye and the air that can dry the eye out during the night.
  • Restasis Eye Drops:  While lubricating eye drops supplement tears, Restasis helps your body to produce more of your own, natural tears.
  • Nutritional Supplements to help improve the quality of the tear film, such as the omega-3’s from fish and flaxseed oils that your oil glands need to make the healthy oil that coats your tear film to reduce evaporation.* This healthy oil protects and moisturizes the eye and supports healthy tear function.*[i]  This supplement is only recommended for our female patients.
  • Punctal plugs: There are multiple types and sizes of punctal plugs which are tailored for each patient. We all have 4 puncta in the inner corners of our eyelid margins, 1 on the top eyelid and 1 on the bottom eyelid of each eye.  These puncta are tiny openings where the tears drain from the eye into the nasolacrimal gland.  Inserting either permanent silicone plugs or collagen absorbable plugs into these openings can help keep the eyes’ natural tears on the eye longer, which can decrease the symptoms of dry eye.  The best analogy to explain this simple, painless, in office procedure is to think of a sink filled with water.  Without a sink stopper, the water flows freely, and is lost down the drain.  With the stopper in place, the water stays in the sink.  The punctual plug is much like the sink stopper, keeping the tears on the eye, where they are needed.  Click here to watch a video animation of punctal plug insertion.
  • Oral and topical medications for blepharitis.   Antibiotics and anti-inflammatory medication, both in eye drop (topical) and systemic (oral) form, can be prescribed to treat the symptoms of blepharitis. This condition can contribute to and exacerbate the uncomfortable symptoms of dry eye.

Furthermore, eye doctors can sometimes miss the forest for the trees.  Dry eyes can be a symptom of a more complex systemic issue or disease.  Once again, a thorough history is the key to treating dry eye properly.  A detailed discussion with the patient which includes both ocular symptoms and general medical history is then followed by a thorough evaluation of the eye and its surrounding structures.  After recommending a tailored treatment for the dry eye symptoms, if systemic disease is suspected, Dr. Mandel will refer the patient to the appropriate specialist for systemic screening tests and/or blood tests.

So, as you can see, handing a patient just any generic bottle of artificial tears for the symptoms of dry eye is often not enough.  Now, you’re armed with enough information to be your own advocate in the quest for more comfortable, well lubricated eyes.

Change Your Vision, Change Your Life. Mandel Vision®

Related Blog Posts:  

Blepharitis:  What Is It and What Can I do About It?
Punctal Plugs – An Alternative for Dry Eye Symptoms

MGE:  A New Treatment for Dry Eye

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