Dry Eye Disease

Are your eyes DRIED? (*Dry Red Irritated Eye Disease*)

Dry eye disease describes a spectrum of conditions that feature ineffective lubrication of the eye. Symptoms range from discomfort through to disabling pain, redness and fluctuating vision and can impact on many visual activities.

The underlying causes of dry eyes are complex and numerous and need a thorough examination for your optometrist to determine the cause and most appropriate treatment. At our Adelaide and Woodville practices our therapeutic optometrists are equipped with the technology to appropriately diagnose and treat dry eye disease.

For more information on our dry eye clinic, please see the links below:

Blepharitis

Meibomian Gland Dysfunction

Blephex

IPL (Intense Pulse Light)

Punctal Plugs

Eye Drops


What causes dry eye disease?

The tear film is made up of three elements:the mucin (mucous) layer, the watery aqueous layer and the oily lipid layer . 1 Specialised cells (such as goblet cells) embedded throughout the surface of the eye create the mucin component. The lacrimal gland under the bony aspect of the eyebrow secretes the watery aqueous component. The meibomian glands in the upper and lower eyelids secrete oil to make up the lipid component.

In most dry eye cases, the watery aqueous component is produced at normal quantities but evaporates too quickly. This is called evaporative dry eye. There are three main causes: blepharitis, meibomian gland dysfunction and environmental factors. 1

  • Blepharitis is inflammation of the eyelid margins. This is a chronic condition that arises from overpopulation of bacteria or mites (Demodex) along the eyelid margin and within eyelash follicles.
  • Meibomian gland dysfunction (MGD) is when the oil-producing meibomian glands stop working properly. This diminishes the lipid layer of the tear film, causing tears to evaporate too quickly.
  • Environmental factors such as air conditioning, extended screen time or wind can result in excessive tear evaporation, leading to dryness and irritation.

Severe cases of dry eye are due to low production of aqueous tears, referred to as aqueous deficient dry eye. This is less common than evaporative dry eye, and may be due to autoimmune disease, dehydration, poor sleep, medication or prior eye surgery. 1


Treatments and Care

Dry eye disease can be treated. Lubricating eye drops are helpful but are ineffective on their own for the most cases. Dry eye disease is best treated with a comprehensive, step wise, management system 2 which involves restoring proper function to meibomian glands, maintaining good eyelid hygiene, protecting the eyes, and using lubricants.


Step 1

Lifestyle changes

Adequate water intake and sleep. Chronic dehydration or poor quality sleep most certainly causes dry eyes and depending on the circumstances, may be relatively easy to address. 1

Minimise environmental triggers. Screen use is the biggest external factor on dry eyes. People stare more and blink less when concentrating, particularly when looking at screens so reducing unnecessary screen time, taking regular short breaks or even just being conscious of staring can reduce dry eye symptoms. Also, if appropriate, minimising drying medications, use of air conditioning or forced air heating, alcohol intake and ceasing smoking can be helpful​.1 Commercially available air humidifier devices may also offer relief.

Lubricants: Hylo Fresh/ Hylo Forte/ Thera Tears/ Tears Again Spray

Lubricating drops replenish the deficient tear film and are a fundamental component of dry eye disease management. There are many eye drops with varied ingredients and your optometrist will discuss the best option for you. Preservative free drops are essential to avoid further aggravation of the inflamed ocular surface. Often just switching to a preservative free lubricating drop can make a dramatic difference.

Omega 3 Supplements

These are only beneficial for individuals that don’t get enough omega 3 in their diet which typically means less than 2 serves of fish a week. In these cases ~1200mg/day of high quality fish oil can improve the quality of oil produced by the meibomian glands. 4

Warm Compresses

A warm compress helps to clear blocked meibomian glands by liquefying the thickened oil inside. The glands need to be heated to only 40-50 degrees but for a full 10 mins 5​ , followed by 1 minute of blink training. Performed regularly, this process helps to maintain regular function of the glands for an adequate protective lipid layer.

Blink Training

Proper blinking keeps your tears healthy by spreading tears and releasing oil from eyelid glands into the tears. Blink training, described on the last page, both promotes more complete blinks and also maximises the effect of warm compresses.

Optimel Manuka Honey

Medical grade manuka honey is antibacterial, reduces swelling and promotes healing and these qualities make it useful in treating meibomian gland disease . 6 It is easy to use but honey is mildly acidic which may cause temporary stinging on application - it doesn’t cause harm to the eyes on application.

Glasses and Sunglasses

Sunglasses are crucial for the health of everyone’s eyes but are particularly helpful protecting dry eyes from the harsh effects of wind. Clear glasses can be helpful for the same reason to protect from air conditioning even when no prescription is required.

Step 2

Eyelid Hygiene

The eyelids are a difficult part of the body to adequately clean since soaps cause stinging if they get into the eyes. But good eyelid hygiene is an important element of managing dry eye disease . 1 Antibacterial lid foams or washes cleanse the eyelids and lashes while conditioning the skin around the eyes without any stinging or irritation.

Blephasteam

The blephasteam is an electronic eyelid warming device that guarantees optimal heating temperature of the eyelids for the correct length of time. Combined with in-office manual expression with your optometrist, it can be a useful addition or replacement to at-home lid warming and massage . 2

Blephex

For more severely irritated eyelids, an in-office exfoliation with the Blephex device, an electric brush, comprehensively cleans the eyelid skin of persistent built up debris and dry hardened skin. 3

IPL

Innovative Eye Care is the first practice in South Australia to offer Intense Pulsed Light (IPL) treatments for dry eye disease. IPL technology generates an intense pulsed light directed at the lower eyelid, providing a deep warming effect to the oil glands and reducing inflammation. 4 Four treatments are required to best manage MGD over a 10 week period.

Punctal Plugs

Tears should continually wash across the eye to keep it clean and comfortable and to drain away into a duct through the lower eyelid into the nose. It’s why your nose runs when you cry. When tear production is low, dissolvable or permanent (but removable if needed) plugs can be placed into the duct opening to improve dry eye symptoms and reduced reliance on lubricant drops. 1

Anti Inflammatory eye drops: FML/ Minims Prednisolone/ Cyclosporine/ Cromofresh/ Lomide

Inflammation and dry eyes are related in a complex way. Anti-inflammatory drops are used short term to break the cycle between inflammation and dryness, or allow other therapies to work. In some cases, over-the-counter mast-cell stabilizers can counteract inflammation as a result of friction that a normal tear layer would prevent. 7

Thick Lubricating Gels and Ointments at night: Genteal Gel/ VitaPos

Particularly useful for symptoms of dry eyes that are worse on waking in the morning, thick, long-lasting lubricants protect the eyes throughout the night. 2

Oral Medications

Low dose antibiotic tablets prescribed in conjunction with your GP can be effective in controlling the deeper inflammation within the meibomian glands and improve gland functioning. 4

Step 3

Autologous/allogeneic serum eye drops

Eye drops made from the serum of a person’s own blood, which has anti-inflammatory and repair functions, can soothe severely dry eyes and are prepared through the public hospital system. 4

Therapeutic contact lens options: Soft Bandage or Scleral lenses

Contact lenses are able to protect the surface of dry eyes by acting like a bandage and keeping moisture on the surface of the eye during lens wear or protecting the surface of the eye from the rubbing action of the upper eyelid during blinks. 4

Step 4

Long term steroid eye drops

In severe dry eye disease, inflammation becomes the primary problem and the long term use of prescription-only, preservative-free, anti-inflammatory eye drops is needed.

Surgery

The final stage options include surgery to permanently block tear drainage, to smoothen or tighten eyelid shape or gland transplantation. 2


References
  1. Clayton JA. Dry Eye. N Engl J Med. 2018 Jun 7;378(23):2212-2223. doi: 10.1056/NEJMra1407936.
  2. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575–628. doi:10.1016/j.jtos.2017.05.006
  3. Shen Lee B, Kabat AG, Bacharach J, Karpecki P, Luchs J. Managing Dry Eye Disease and Facilitating Realistic Patient Expectations: A Review and Appraisal of Current Therapies. Clin Ophthalmol. 2020;14:119–126. Published 2020 Jan
  4. doi:10.2147/OPTH.S228838
  5. Thulasi P, Djalilian AR. Update in Current Diagnostics and Therapeutics of Dry Eye Disease. Ophthalmology. 2017;124(11S):S27–S33. doi:10.1016/j.ophtha.2017.07.022
  6. Blackie CA, Solomon JD, Greiner JV, Holmes M, Korb DR. Inner eyelid surface temperature as a function of warm compress methodology. Optom Vis Sci. 2008;85(8):675–683. doi:10.1097/OPX.0b013e318181adef
  7. Albietz JM, Schmid KL. Randomised controlled trial of topical antibacterial Manuka (Leptospermum species) honey for evaporative dry eye due to meibomian gland dysfunction. Clin Exp Optom. 2017;100(6):603–615. doi:10.1111/cxo.12524
  8. Rodriguez-Garcia A, Macias-Rodriguez Y, Gonzalez-Gonzalez JM. Efficacy and safety of 0.1% lodoxamide for the long-term treatment of superior limbic keratoconjunctivitis. Int Ophthalmol. 2018;38(3):1243–1249. doi:10.1007/s10792-017-0588-1