Dry eyes

While a sad movie or a wedding can get your tears noticeably flowing, your eyes are actually producing tears all the time. Healthy eyes are continuously covered by fluid — a tear film designed to remain stable between blinks. A stable tear film prevents dry eyes and allows your eyes to maintain clear, comfortable vision.

Decreased production of fluids from your tear glands can destabilize the tear film, allowing it to break down rapidly and create dry spots on the surface of your eyes. An imbalance in the substances that make up the tear film also causes dry eyes.

Dry eyes are a common source of discomfort. Treatment of dry eyes aims to restore a more normal tear film to minimize your dryness, blurred vision and discomfort.

Signs and symptoms of dry eyes, which usually affect both eyes, may include:

  • A stinging, burning or scratchy sensation in your eyes
  • Stringy mucus in or around your eyes
  • Increased eye irritation from smoke or wind
  • Eye fatigue after short periods of reading
  • Sensitivity to light
  • Difficulty wearing contact lenses
  • Tearing
  • Blurred vision, often worsening at the end of the day or after visually focusing for a prolonged period on a nearby task

Tears are made up of more than just water. They’re a complex mixture of water, fatty oils, proteins, electrolytes, bacteria-fighting substances and growth factors that regulate various cell processes. This mixture helps make the surface of your eyes smooth and clear. Without tears, good vision is impossible.

For some people, the cause of dry eyes is an imbalance in the composition of their tears. Other people don’t produce enough tears to keep their eyes comfortably lubricated. Eyelid problems, medications and other causes, such as environmental factors, also can lead to dry eyes.

Poor tear quality
The tear film has three basic layers: oil, water and mucus. Problems with any of these layers can cause dry eye symptoms.

  • Oil. The outer layer, produced by small glands on the edge of your eyelids (meibomian glands), contains fatty oils called lipids. These smooth the tear surface and slow evaporation of the middle watery layer. When the oil layer is abnormal, the watery layer evaporates too quickly. Dry eye problems are common in people whose meibomian glands are clogged. Meibomian dysfunction is more common in people with inflammation along the edge of their eyelids (blepharitis), rosacea and other skin disorders.
  • Water. The middle layer, which is by far the thickest layer, is mostly water with a little bit of salt. This layer, produced by the tear glands (lacrimal glands), cleanses your eyes and washes away foreign particles or irritants. A shallow water layer can predispose you to tear film instability. If your eye produces only small, inadequate amounts of water, the oil and mucus layers can touch and cause the stringy discharge familiar to people with dry eyes.
  • Mucus. The inner layer of mucus allows tears to spread evenly over the surface of your eyes. Dry spots form easily in any part of the front surface of the eye (cornea) that has patchy loss of the mucus layer.

Decreased tear production
Dry eyes are common, especially for people older than 40. Tear production tends to diminish as you get older. When you’re unable to produce enough tears, your eyes become dry and easily irritated. The medical term for this condition is keratoconjunctivitis sicca (ker-uh-to-kun-junk-ti-VIE-tis sik-uh).

Although dry eyes can affect both men and women at any age, the condition is more common among women, especially after menopause. This may be due in part to hormonal changes. Damage to the tear glands from inflammation or radiation can hamper tear production. Dry eyes are also associated with some medical conditions such as diabetes, rheumatoid arthritis, lupus, scleroderma, Sjogren’s syndrome and vitamin A deficiency.

Refractive eye surgeries such as laser-assisted in-situ keratomileusis (LASIK) also may cause decreased tear production and dry eyes. Symptoms of dry eyes related to these procedures are usually temporary.

Poor lid function
Through blinking — normally at a rate of about once every 12 seconds — your eyelids spread a continuous thin film of tears across the surface of your eyes. Problems with your eyelids can impair the complex blinking motion required to spread these tears, resulting in dry eyes. Eyelid problems that may develop as you age include an out-turning of the lids (ectropion) or an in-turning of the lids (entropion).

Blepharitis, an inflammation along the edge of the eyelids, also may cause your eyes to feel dry and scratchy.

The types of common medications, both prescription and over-the-counter (OTC), that can be the causes of dry eyes include:

  • Diuretics, drugs commonly used to treat high blood pressure
  • Angiotensin-converting enzyme (ACE) inhibitors used to treat high blood pressure
  • Antihistamines and decongestants
  • Sleeping pills
  • Birth control pills
  • Certain antidepressants
  • Isotretinoin-type drugs for treatment of acne
  • Opiate-based pain relievers, such as morphine

Other causes of dry eyes
Dry eyes can be worsened by exposure to many environmental conditions that have a drying effect, such as sun, wind, high altitude, a dry climate, hot blowing air and the dry air that commonly occurs in the cabins of commercial airplanes.

In addition, tasks that require intense visual concentration — such as working at a computer, driving or reading — tend to decrease your blink rate, thereby increasing tear evaporation.

If your eyes feel dry and irritated, your eye doctor can test both the quantity and the quality of your tears.

Your doctor may measure your tear production using the Schirmer tear test. In this test, blotting strips of paper are placed under your lower eyelids. After five minutes your doctor measures the amount of strip soaked by your tears.

Other tests use special dyes in eyedrops to determine the surface condition of your eyes. Your doctor looks for staining patterns on the cornea and measures how long it takes before your tears evaporate.

It sounds like a contradiction, but you may have dry eyes and still at times find yourself with tears streaming down your cheeks. Why?

Production of tears occurs in two ways. Basic tearing produces tears at a slow, steady rate and keeps your eyes lubricated. What’s called reflex tearing produces large quantities of tears in response to eye irritation or emotions. Reflex tears contain much more water than do basic tears, and they’re low in mucus and oils.

When your eyes become irritated from dryness, the lacrimal glands flood your eyes with reflex tears. Fluid overwhelms the tear ducts and overflows your eyelids. What’s more, because these tears are of poor quality, they don’t help the dryness. That may make you produce even more tears.

Most people with dry eyes don’t experience any long-term complications. However, if left untreated, severe dry eyes may lead to eye inflammation, infection and scarring on the surface of your cornea.

Effective treatment for dry eyes begins with a careful examination to determine which factors may be causing your symptoms. The goal of treatment is to keep your eyes moist.

  • Managing lid problems. If you have an eyelid condition, such as an anatomic abnormality or an incomplete blink that aggravates your dry eyes, your doctor may refer you to an eye surgeon who specializes in plastic surgery of the eyelids (oculoplastic surgeon). If your eyelids are inflamed due to blepharitis, your doctor may recommend regular cleaning of the area with a dilute solution of baby shampoo. Your doctor may also prescribe short-term, nightly treatment with antibiotic drops or ointment or treatment with an oral antibiotic, such as tetracycline or doxycycline.
  • Adding tears. You can usually treat a mild case of dry eyes with over-the-counter artificial tears. Your doctor or eye doctor can suggest which drops might be best for you. You can use lubricating drops that don’t contain preservatives as often as you need, even several times an hour, to provide relief. If the drops you’re using contain preservatives, you can safely use them up to four times a day. Be sure you don’t purchase eyedrops with a redness remover, as these may worsen your dry eye symptoms. Using lubricating drops proactively before you begin an activity that tends to aggravate your symptoms may help prevent symptoms. You can also use ointments to ensure lubrication. These ointments can blur vision, so it’s best to use them only at bedtime.
  • Conserving tears. Your eye doctor may also suggest methods to keep your natural tears around longer. This can be done by partially or completely closing your tear ducts, which normally serve to drain tears away. The tear ducts can be plugged with tiny silicone plugs. The closure conserves both your own tears and artificial tears you may have added. Silicone plugs can be removed or left in. A more permanent option is thermal cautery. In this procedure your doctor numbs the area with an anesthetic and then applies a hot wire that shrinks the tissues of the drainage area and causes scarring, which closes the tear duct.

People with mild dry eyes respond well to treatment with artificial tears. Some people have persistent symptoms and don’t respond to artificial tears alone even though their eyes appear fairly normal. Severe dry eyes require more aggressive treatment, such as the silicone plugs. People with severe dry eyes may also benefit from a special customized contact lens (Boston Scleral Lens). This lens rests on the white part of the eye (sclera), creating a fluid-filled layer over the cornea that keeps it from drying out.

Your doctor may prescribe cyclosporine (Restasis), a medication approved by the Food and Drug Administration (FDA) for chronic dry eyes. Restasis decreases inflammation on the eye surface and helps increase production of healthy tears. Some people experience a burning sensation in their eyes when using this drug. Don’t use Restasis if you currently have an eye infection or if you have a history of herpes viral infection of your eye.

When people experience intolerable irritation from dry eyes despite the frequent use of lubricating eyedrops, doctors may prescribe steroid drops to help reduce inflammation.

It’s been suggested that a high dietary intake of omega-3 fatty acids or dietary supplements may lower the risk of dry eyes. Additionally, researchers have been investigating the use of topical omega-3 and omega-6 fatty acids to treat dry eyes, and have had some success in animal studies.