Tears produced by the eyes are necessary to keep them moist and comfortable. Dry eyes is a very common condition characterized by reduced tear production, excessive tear evaporation, and an abnormality in the production of mucus or lipids (fats or oils) normally found in the tear layer, or a combination of these.
Dry eyes cause several irritating symptoms such as stinging and burning sensation in the eye, blurred vision, and gritty or scratch feeling in the eye that affects quality of life.
This condition can result due to advancing age or several underlying systemic diseases such as Sjogren’s syndrome, arthritis, lupus, thyroid disorders etc. Various lifestyle factors such as exposure to dust, pollution, sun rays, computer screens, cigarette smoke also plays an important role in the development of dry eyes.
Dry eyes can be prevented and managed by adopting lifestyle changes such as limiting screen time, regular blinking, washing eyes frequently, staying hydrated, using a humidifier at home, and wearing glasses to protect the eyes. Artificial tears available as eyedrops is the mainstay therapy for this condition.
Any related symptoms of Dry eyes should not be ignored as it can lead to corneal ulcers, scarring, and even vision loss.
The symptoms of the dry eyes are often nonspecific and it does not always start with dryness. In fact, in various cases patients experience watery eyes as a symptom of dry eyes. This is because too much drying of the eyes causes the body to produce more tears to compensate for the water loss.
The other signs and symptoms of dry eyes include:
Blurred vision that fluctuates throughout the day
Stinging and burning sensation in the eyes
Gritty or scratch feeling in the eyes
Red eyes
Itching in the eyes (particularly in the cornea)
Photophobia (increase sensitivity to light)
Feeling of having some foreign substance in the eyes
Stringy mucus near the eyes
Sticky eyelids especially during morning
Blepharitis (inflammation in the eyelids)
Tired eyes with a desire to close eyes more often
Feeling of heavy eyelids
Difficulty in opening the eyelids
Sharp and dull pain behind the eyes
Difficulty in wearing contact lenses
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Tears play a very important role in maintaining the overall health of the eyes by:
Providing a smooth surface for optimal vision
Protecting the cornea (the transparent, protective front part of the eye)
Lubricating the eyes
Tears form a multilayered film made of the following three layers that keep the eye smoothly lubricated:
The superficial layer is made of lipids (fats or oils) lining the upper and lower eyelids. This layer seals the tear film to reduce evaporation.
The middle layer is basically a dilute salt water solution. This layer helps in keeping the eyes moist, as well in flushing out any dust, debris, or foreign objects that may get into the eye.
The innermost mucosa layer, made up of mucus. This mucus helps the overlying watery layer to spread evenly over the eye.
Dry eyes develop when there is a problem in either of the layers, imbalance between tear production and drainage or loss of tear film stability. The various causes are discussed below in detail:
1. Inadequate amount of tears: The reduced tear volume around the eyelids is the main cause of dry eyes. The various reasons for this are:
Aging
Health conditions like Sjögren's syndrome, rheumatoid arthritis (RA), lupus, scleroderma, sarcoidosis, xerophthalmia due to Vitamin A deficiency tend to decrease tear production
Medications like antihistamines, decongestants, antidepressants, antihypertensives, and oral contraceptives.
2. Excessive tear evaporation: The symptoms of dry eyes can also develop due to increased evaporation of tears. This can occur due to the following:
Less blinking: Long hours of reading, driving or working on a computer can reduce blinking and trigger evaporation of tears. Conditions like Parkinson's disease also reduce the frequency of blinking.
Meibomian gland dysfunction: Meibonian glands are small oil glands on the edge of the eyelids. They produce the oil/ lipid layer that forms the superficial layer of tear film that protects against evaporation of tears.
Blockage of these glands, more commonly associated with conditions like rosacea, psoriasis, scalp and face dermatitis or taking oral isotretinoin medication leaves inadequate lipid/oil to cover the watery tear layer to prevent its evaporation.
Blepharitis: An infection along the eyelids or the eyelashes makes the bacteria break down the oil, leaving insufficient oil to prevent any evaporative loss of tears and dry eyes.
Certain health conditions: Conditions such as stroke or Bell's palsy, make it difficult to shut the eyes. Hence, the eyes may become dry due to tear evaporation.
3. Abnormality in the production of mucus or lipids found in the tear layer: Chemical burns to the eye or some autoimmune conditions, like Stevens-Johnson syndrome and cicatricial pemphigoid can lead to abnormal production of lipids in the tear layer. This leads to poor spreading of the tears over the surface of the eye, thereby causing dryness despite the presence of sufficient tears.
4. Combination of the above factors
The risk of developing dry eyes increases with advancing age due to decreased tear production as a part of the natural aging process. People above 65 years of age mostly start experiencing symptoms of dry eyes.
Women are more likely to develop dry eyes due to hormonal changes in their lifetime caused by pregnancy and menopause. The use of oral contraceptives is also linked to being associated with dry eyes.
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The exposure to digital screens is a well known risk factor for dry eyes. The continuous exposure to screen decreases blinking and triggers tear evaporation which is a significant factor for Dry eyes.
Studies suggest that dry eyes is more common in Asians as compared to the white population.
Several inflammatory and autoimmune conditions are also associated with an increased risk of dry eyes. They include:
Thyroid dysfunction
Blepharitis (inflammation of the eyelids)
Rosacea
Seborrhoeic dermatitis
Staphylococcal infection
Demodex mite infestation
Graft v/s host disease
Herpes infection
Hepatitis C
Androgen insufficiency
Heat or chemical burns
The use of certain medications are also closely associated with dryness of the eyes due to decreased tear production. This includes medications for high blood pressure, allergies, anxiety, depression, cough, insomnia.
Exposure to dry climate, chemical fumes, pollution, and sun increase the risk of developing dry eyes. Smoking and secondhand smoking both are the risk factors of dry eyes as it exposes the eyes to harmful irritants.
The people living in air conditioners also have a higher chance of having dry eyes.
The use of contact lenses decreases the sensation of cornea and can lead to dry eyes.
Any eye surgery in the past such as LASIK (laser) surgery, lid surgery, or cataract surgery can decrease tear production and lead to dry eyes.
The excessive use of topical medications in the eyes for some other eye conditions such as glaucoma is also associated with the risk of dry eyes.
Vitamin A and omega-3-fatty acids play a very vital role in maintaining the health of the eye. So, deficiencies of both can lead to dryness in the eyes.
Vitamin A deficiency is also called xerophthalmia, which can start from dry eyes and even progress to blindness in severe cases.
The symptoms of dry eyes are very similar to eye infections and allergies. So, it is very necessary to distinguish between these diseases through specific clinical tests. Antiallergic medications, if given in dry eyes because of incorrect diagnosis may worsen the condition of the eye.
The doctor takes patient history which includes information about the medications taken by patients, medical problems, and environmental factors which may contribute to the symptoms of dry eyes. The doctor also checks for:
The amount of tears eyes are making
The structure of eyelids
Time, place, and diurnal variation of symptoms
Workplace stress
Living conditions (dry, dusty air and air conditioning)
Systemic diseases
Medication history
Tear break up time (TBUT)
This test diagnoses how long the tear film lasts after blinking. For this, a small amount of dye is placed in the eyes. The time up to which the dyed tear film covers the whole eye after blinking is recorded. The tear film does not last long in case of Dry eyes.
Schrimer’s test
This test assesses the quantity of tears produced by the eyes. In this, the eyes are desensitized by putting eye drops and then a small piece of paper is placed on the edge of the eyelid. The eyes are allowed to close for 5 minutes. The amount of moisture on the paper indicates the quantity of tears.
Tear film meniscus
In this test, the height of the tear film is determined which helps in diagnosing the amount of tears produced by the eye.
Tear meniscus height is 0.2 ± 0.09 mm in patients with dry eyes and 0.5 ± 0.02 mm in patients with healthy eyes. A foamy tear film is an indicator of an altered lipid layer in patients with meibomian gland dysfunction.
Slit lamp test
In this, the quantity of tears produced by the eyes is measured through a microscope known as a slit lamp. A liquid is put into the eyes which helps in clear visualization of the tears. The practitioner looks in the eye and eyelids by directing a bright light into the eyes.
Tear film osmolarity
In this, the osmolarity of tears is determined. Tear osmolarity is a measurement of the concentration of salt in the tears. Normal osmolarity is essential for normal tear production. The value of osmolarity increases with the severity of the Dry eyes.
The surface of the eye is examined using a microscope (slit lamp) and dyes. Dyes help in visualizing the surface clearly. The common dyes used to study eyes are fluorescein and lissamine green.
Fluorescein staining
It is mostly used to assess corneal damage. The dye fluorescein is instilled into the tear film and studied after 1 to 3 minutes.
Lissamine green staining
It is mostly used to assess conjunctiva and lid margin damage. The dye fluorescein is instilled into the tear film and studied after 1 to 3 minutes.
Blink rate
Blinking plays a very significant role in keeping the eye moist by distributing the tear fluid over the eye surface. The normal blink rate is:
While speaking: 15.5 ± 13.7 blinks/minute
During reading and computer work: 5.3 ± 4.5 blinks/minute
The reduced interval between blinks by about 2.6 to 6 seconds indicates dry eyes.
Meibomian gland evaluation
Meibomian glands play a very significant role in maintaining overall health and stability of the eye. The gland produces meibum, the reduction of which can cause evaporative Dry eyes due to altered lipid composition.
The function of the meibomian gland can be determined by evaluating meibum quantity and quality. The turbid and viscous appearance of meibum indicates dysfunction of the gland.
The above tests also help in determining the cause of dry eyes:
The reduced tear meniscus and low schirmer test indicates deficiency of tears.
Altered lid margins, thickened meibomian gland secretion, reduced tear film break up time are an indicator of hyper evaporative dry eye.
Ocular surface damage and elevated tear film osmolarity can occur with both forms.
There are various diseases that may cause dry eyes, particularly primary Sjogren's syndrome. In various cases secondary Sjogren syndrome caused by other conditions may also cause dry eyes. Such conditions include:
Lupus
Progressive systemic sclerosis
Dermatomyositis
It is very important to consult doctor in case:
You are experiencing burning, stinging, scratching or watery eyes especially in windy conditions
Your symptoms are not going away by various proven home remedies
Your vision is fluctuating while using digital devices even after using glasses
You are facing difficulty in performing normal day to day activities
The doctors that may help to diagnose the dry eyes include:
General physician
Optometrist
Ophthalmologist
Most people are unaware of the right eye specialist. Know about different eye specialists in detail.
Blinking helps in spreading tears over the ocular surface and also keeps foreign matter and irritants out of the eyes. The act of blinking frequently, especially while using digital screens helps in keeping the eyes moist and prevents dryness.
The dry climate often triggers dry eyes. The humidity can be increased by keeping the bowls of water around the room both at home and workplace. This helps in making the air humid.
Eyes strain when they are used to concentrate on something for a long period of time. Such eye straining activities should be minimized or avoided, if possible. This includes avoiding:
using computers, smartphones, tablets and gaming consoles for a long time
driving for a long time
reading for a long time or in dim light
Eyes should be protected to avoid direct contact with triggers. This can be done by wearing protective glasses while using the screen, using sunglasses while going outside to reduce exposure to dry winds, sun, and smoke which can irritate your eyes.
Prolonged and continuous daily use of digital screens is one of the leading causes of eye disorders popularly known as computer vision syndrome (CVS). Dry eyes can be prevented by following the 20/20/20 rule. The rule states that take a 20-second break from your digital device every 20 minutes and look at something 20 feet away. Set an alarm on your smartphone as a reminder.
Here are several other ways that helps in preventing eye strain caused due to CVS:
Cigarette smoking exposes the eye to harmful chemicals that can cause dry eyes. It can be prevented by quitting both active and passive smoking.
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The treatment of dry eyes involves various steps and is based upon the severity of the conditions of the eye.
Avoiding the triggers of dry eyes such as cigarette smoke, dry heating air, air conditioning etc is an important part of the protocol.
They are the mainstay therapy that are used in all grades of Dry eyes irrespective of the severity. They are benzalkonium chloride (preservative) free eye drops that are designed to increase the tear film stability. They are the preparations containing polyvinyl alcohol, povidone, hydroxypropyl guar, cellulose derivatives, and hyaluronic acid as the main agent. These drops are available in the form of gels, ointments, and solutions.
In case of meibomian gland dysfunction, artificial tears containing lipids such as triglycerides, phospholipids, and castor oil are used.
Inflammation in the ocular surface and lacrimal gland is observed even in moderately severe dry eyes. For this, anti-inflammatory treatment is required in cases of moderate to severe conditions of the eye.
Studies have shown that instillation of corticosteroids for 2 to 4 weeks are helpful in reducing the symptoms of dry eyes. But, this therapy is used only for short-term use as long term therapy is associated with some complications.
Cyclosporine A is an immunosuppressant that aids in reducing inflammation. Topical application of cyclosporine increases production of tear and also reduces symptoms like blurry vision, ocular dryness, and foreign body sensation.
In case of cyclosporine intolerant patients, tacrolimus eye drops are used.
Several antibiotics with anti-inflammatory properties are also used to treat Dry eyes. They are used in case of meibomian gland dysfunction and blepharitis associated with Dry eyes. Some of the common antibiotics used for dry eyes are:
These are tiny devices that are inserted into the tear ducts of the eye. They reduce drainage of the tears that help in keeping the eye moist. There are two types of punctal plugs
Temporary/dissolving plugs
These plugs are made of dissolving material such as collagen that ultimately absorbs into the body. They can last in the eye from a few days to months.
Semi-permanent plugs
These plugs stay in the eyes for years as they are made of longer lasting material such as silicone or acrylic. They can be removed by your ophthalmologist if needed.
Various surgical options for treatment of dry eyes syndrome are:
Tarsorrhaphy: It refers to surgical joining of upper and lower eyelids partially or completely to promote corneal healing
Amniotic membrane transplantation: In this procedure a piece of amniotic membrane is applied to the surface of the eye in order to reconstruct the ocular surface.
Keratoplasty: This is a surgery performed on the cornea, especially corneal transplantation. It is used in severe cases where persistent corneal ulceration and perforation are seen.
There are various medications that can cause dryness of the eye. It is necessary to consult your doctor while taking any medication.
There are certain fatty acids, vitamins, and minerals that keep the eyes hydrated. These types of foods should be included in your diet. These include:
Omega fatty acids (fish, oils, and dairy products)
Vitamin A (pumpkins, apricots, carrots, tomatoes, spinach, and dairy products)
Vitamin C (citrus fruits and juices such as orange, grapefruit, lemon, lime), apples, bananas, tomatoes, and cooked spinach)
Zinc (whole grains, dairy products, sweet corn, peas, lentils, and nuts)
Good sources of lutein and zeaxanthin include eggs, corn, kiwi fruit, grapes zucchini, and leafy greens such as spinach, kale, collards, and broccoli.
Vitamin E (whole grain cereals, almonds, hazelnuts, sunflower seeds, sweet potato, and peanut butter)
Water helps in the formation of tears. Dehydration can trigger the symptoms of dry eyes especially if you are living in a hot and dry environment.
Not getting enough sleep can lead to dry and itchy eyes. It is also observed that the eyes may produce less tears after a night of insufficient sleep. Adequate sleep may help in faster recovery of the patient having dry eyes.
A sound sleep keeps the mind calmer and also helps in preventing uninvited headaches on weekends. Explore our range of products that may help you to get better sleep.
Eyelids should be kept clean. Hot compresses on eyelids and warming masks are advised as they are known to increase tear film stability and thickness of the lipid layer.
Dry climate triggers dryness in the eyes. Such situations can be avoided like avoiding air getting blown in your eyes by directing car heaters away from your face.
The inadequate tear production can lead to several complications in the eye which can range from mild to severe. Initially, dry eyes cause little discomfort, but without the proper medical attention, the condition can damage the cornea.
The complications of the dry eyes include:
Fluctuations in vision
Scarring of the cornea
Infectious keratitis (infection of cornea caused by bacteria, viruses, fungi and parasites)
Eye ulceration
Eye infections
Eye inflammation
Wound in the cornea
Vision loss
The chronic dry eyes affects quality of life and can lead to:
Sleep disorders
Mood disorders
Dyslipidemia
Migraine headaches
Goji berries
This tree is native to Asia and its fruits, commonly known as goji berries are known for its medicinal and nutritional values. The administration of goji berry extract has been found to relieve Dry eyes. This is confirmed by various tests such as Schirmer's test score and tear breakup time (TBUT).
Polygonum cuspidatum
It is a plant that is found in North America and Asia and is frequently used in traditional Japanese and Chinese medicine. Studies have shown that the administration of the extract of this plant helps in preserving the eye through its anti-inflammatory properties.
Chamomile
The washing of eyes with chamomile tea is used for the treatment of eye infections and other eye diseases.
There are various home remedies which provide relief in dry eyes. This includes applying warm compress to the eyes, taking fish oil supplements, drinking plenty of water, and increasing the humidity at work or in your house by using a humidifier.
The people who wear contact lenses and develop dry eyes should use scleral lenses instead of traditional lenses. These lenses are placed over the white part of the eye known as sclera. They protect the eyes and keep them hydrated for a long period of time.
It is very important to take frequent short breaks and blink eyes regularly while reading or working on computer screens. Keep your eyes closed for sometime when possible such as during a phone call. This will decrease the strain on your eyes.
The total eye surface exposure and tear evaporation is reduced when we look down. This helps in keeping the eye moist. The same can be applied while working on computer screens by keeping them at a low level.
The people having dry eyes suffer from photosensitivity which is triggered by bright lights. This can be reduced by avoiding bright bulbs immediately overhead. This will help in reducing brightness and also minimize reflection on surfaces such as on computer screens.
It is advised to stay away from vents as the dry air blowing directly in your eyes can make dry eyes worse.
The patient of dry eyes should always keep the eye drops with them so that it can be used whenever the person starts to feel drying of eyes.
Connecting with people having similar condition can help in discovering various things that could help in faster recovery.
