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Jasleen Eye Hospital

 



Dry Eye Syndrome

Tears are a complex mixture of water, salts, oils, and proteins that help the surface of the eye remain smooth and uniform. Tears also wash away foreign material,such as allergens or bacteria, that may be harmful to the eye. Dry Eye Syndrome(DES) occurs when your natural tears are not able to adequately lubricate,coat, and protect the surface of your eyes. There can be many reasons for insufficient tears. In some cases, you may not produce enough tears or the tears that are being produced are of a poor quality so they evaporate more easily and do not cling to the surface of the eye properly. Age, hormonal imbalance, autoimmune disease, eyelid problems, medications, and environmental factors can directly cause or aggravate DES.

Dry Eye Symptoms and Signs

Common
symptoms and signs of DES include:

  • Usually affects both eyes, but one eye may be     affected more
  • Eye discomfort, such as stinging, burning or a     scratchy sensation
  • Eye redness and/or eyelid redness
  • Blurry vision or fluctuating vision
  • Tearing
  • Eye fatigue after reading for a period of time
  • Light sensitivity, including glare or starbursts   around lights
  • Irritation from smoke or wind blowing into the  eyes
  • Waking up with stringy material in the corner of  the eyes
  • Uncomfortable contact lenses, especially towards end of day
  • Eye infections, including from contact lens wear
  • Scarring of the cornea (front clear window of the  eye) in advanced cases

When dry eye symptoms affect vision or eye comfort, a detailed examination by your eye doctor can lead to treatment to improve or control these symptoms.

Composition of Tears

Tears consist of a mixture of water, oil, and mucus. Problems with any of these components may lead to DES.

  • Oil layer: Fatty oils, or lipids, are secreted by  small (meibomian) glands on the edge of the eyelid, near the eyelashes.
         Location of Meibomian Glands at inner edge of eyelid. In some cases of Dry  Eye Syndrome, the pores of the mibomian glands can get clogged preventing  oils from flowing onto the surface of the eye.   The oil forms a slick on the surface of the tears preventing evaporation of the underlying water layer. DES can develop when the meibomian glands
         become clogged and stop secreting oils properly. Meibomian gland  dysfunction (MGD) is more common with inflammation along the edge of the eyelids (blepharitis), rosacea, and other skin disorders.
  • Aqueous layer: The main component of tears is water mixed with salts, enzymes, and proteins.   A complex mixture of water, salts or electrolytes, proteins, oils or lipids,  mucin, and other molecules that interact to maintain a uniform tear film.This is produced by the lacrimal gland, which is
         located underneath the outer aspect of the upper eyelid. If the lacrimal
         gland becomes inflamed, its cells may no longer function normally and
         produce less aqueous.
  • Mucous layer: Special (goblet) cells on the white
         of the eye (conjunctiva) produce mucus, a thick, white material that coats
         the superficial cells the eye and helps bind the aqueous layer of tears to
         the surface cells.

Causes of Decreased Tear Production

  • Age. Tear production tends to diminish with age.
  • Female sex. DES is more common in women,  especially after menopause, due to alterations in hormones. Testosterone
         has been found to be important in the regulation of tears.
  • Medical conditions. DES is more common with   medical conditions such as rheumatoid arthritis, lupus, Sjogren’s
         syndrome, diabetes, and thyroid dysfunction.
  • Medications. Certain medications can decrease  production of tears.
  • Laser vision correction. Laser-assisted in-situ  keratomileusis (LASIK) is associated with DES, which usually improves over  several months after surgery.

Causes of Increased Tear Evaporation:

  • Inadequate Oils in the Tears. Blockage of the oil  tear (meibomian) glands on the edge of the eyelid can lead to easier tear evaporation. The Meibomian glands can become blocked and inflamed from chronic age-related skin changes, due to rosacea, and due to inadequate  cleansing of the eyelash region.

  • Eyelid problems. Blinking spreads a continuous  thin film of tears across the surface of your eyes. If you have an eyelid
         problem that makes it difficult to blink, tears may not be spread across  your eye adequately or your tears may evaporate too quickly, causing dry  eyes. Eyelid problems can include an out-turning of the lids (ectropion),  in-turning of the lids (entropion), or incomplete closure of the eyelids.

  • Environment. Wind exposure, high altitude,  computer work, reading, long-range driving, dry heat during the winter
         season can all be associated with more rapid evaporation of tears.

    • Medications Associated with Dry Eye Syndrome

    • Blood Pressure medicines, such as diuretics  (hydrochlorothiazide, Lasix)
    • Antihistamines (Cetrizine) and decongestants
    • Birth control pills
    • Antidepressants
    • Acne (Isotretinoin-based) medicines

    Some basic questions you may want to discuss with your
    doctor include:

    • What is likely causing   my dry eyes?
    • What kinds of tests do  I need?
    • Are my dry eyes likely temporary or chronic?
    • What are my treatment options?
    • What are the potential side effects of each treatment?
    • What are the alternatives to the primary approach that you're suggesting?
    • Is there a generic  alternative to the medicine you're prescribing me?
    • Are there any  brochures or other printed material that I can take with me? What websites  do you recommend?
    • When should I have a   follow-up visit?

    Diagnostic Tests for Dry Eye Syndrome

    • Measuring the volume and quality of your tears.
      •    
              Schirmer test. A filter strip with millimeter marking is placed on the lower eyelid. Tears flow onto this blotting
              paper for 5 minutes, measuring the amount of tears asorbed during this interval. The normal range is from 10 – 20 mm in 5 minutes. 
               
              Dye   Test. Various liquid dye eye drops can be applied to the surface of the  eye. Areas that have a good coating of tears will dilute the dye. The dye  will accumulate in drier regions because the tears are not adequate to
              rinse away the dye.

              Fluorescein (green) dry accumulates on the inferior portion of the eye as  there are insufficient tears to wash away the dye.

    Treatment of DES

    For most people with mild dry eyes symptoms, treatment involves over-the-counter eye drops and other simple remedies, such as wearing sunglasses when outside or drinking more water. Keeping the eyelid area clean and opening pores of tear
    glands in the eyelid are important for every dry eye patient. This can be done by cleansing the eyelash region (lid scrub) and applying heat and moisture (hot compress). If your dry eyes symptoms are persistent and more serious, there are a number of medical and surgical treatment options that can be of benefit.

    Treating the underlying cause of dry eyes

    Your  doctor will work to determine what's causing your dry eyes. In some cases these situations can be reversed. For instance, if a medication is causing your dry eyes, your doctor may recommend a different medication that doesn't cause that side effect. If your symptoms are worse with computer work, then taking breaks during the work day may be helpful. If you have an eyelid condition, such as a condition that makes it difficult to close your eye completely when you blink, your doctor may refer you to an eye surgeon who specializes in plastic surgery of the eyelids. If your signs and symptoms suggest an autoimmune condition,
    such as rheumatoid arthritis or Sjogren's syndrome, your doctor may refer you to a rheumatologist for evaluation.

    Environmental Modification

    If you experience dry eyes, pay attention to the situations that are most likely to cause your symptoms. Then find ways to avoid those situations in order to prevent your dry  eyes symptoms. For instance:

    • Avoid air blowing in your eyes. Don't direct hair  dryers, car heaters, air conditioners or fans toward your eyes.
    • Wear glasses on windy days and goggles while   swimming. The wraparound style of glasses may help reduce the effects of   the wind. Goggles protect your eyes from chemicals in pool water that can dry your eyes.

  • Add moisture to the air. In winter, a humidifier  can add moisture to dry indoor air.

  • Consider eyeglass shields to protect your eyes. Safety  shields can be added to the tops and sides of eyeglasses to block wind and  dry air from getting to your eyes. Ask about shields where you buy your  eyeglasses.

  • Take eye breaks during long tasks. If you're  reading or doing another task that requires visual concentration, take
         periodic eye breaks. Close your eyes for a few minutes. Or blink  repeatedly for a few seconds to help spread your tears evenly over your  eye.

  • Position your computer screen below eye level. If  your computer screen is above eye level, you'll open your eyes wider to
         view the screen. Position your computer screen below eye level. This may  help slow the evaporation of your tears between eye blinks.

  • Stop smoking and avoid smoke. Ask your doctor for  help devising a quit-smoking strategy that's most likely to work for you.

    • Lubricants

    • Over-the-counter tear drops. There are many   brands that are available at local pharmacies and grocery stores for the
           treatment of DES. Your doctor can review which brands may be more  effective for you. Generally, preservative-free eye drops, in twist-off   vials, are better tolerated if topical lubricants are needed frequently. Depending on symptoms, drops may need to be used more frequently. Some  people need to put drops in every hour, and some need eyedrops only once a   day.

  • Over-the-counter gels and ointments. These are  thicker lubricants that come in a tube, mainly to be applied right before
         going to sleep. They moisturize the eyes overnight and may be helpful for someone waking up with eye discomfort.

  • Prescription lubricants. There are some  prescription lubricants that may be more effective than over-the-counter
         lubricants.

  • Serum Tears and Platelet-enriched Plasma. For  severe cases of DES unresponsive to artificial tears or medications, a
         patient’s own blood can be drawn to be used as a natural eye drop. A  centrifuge, under sterile technique, is used to separate the red and white blood cells from the fluid in the blood. The fluid, or serum, is extracted and mixed with saline to create a 20% Serum tear solution. Serum contains  proteins, oils, growth factors, anti-inflammatory agents, and other
         components that can significantly improve the health of the ocular  surface.

    • Eyelid Health
    For people with eyelid inflammation (blepharitis) and other conditions that block the flow of oil to the eye, regular eyelid washing may help. Your doctor may recommend that you do this daily, even when you do not have dry eyes symptoms. stopping this daily routine may cause your dry eyes to return.

    • Hot Washcloth. Wet a clean cloth with hot water. Hold the cloth over your eyes for five minutes. Re-wet the cloth with hot water when it cools. Gently rub the   washcloth over your eyelids to loosen any debris. While this can be  helpful and soothing, it is difficult to maintain an adequate amount of  heat for a sufficient amount of time.
    • Mild Soap Cleanser to   Eyelid. Baby shampoo or other lid cleansers may be recommended by your  doctor. Put the soap on your clean fingertips and gently massage your  closed eyes near the base of your eyelashes. Rinse the soap completely
           away. Pre-moistened lid cleansing pads are also commercially available.

    Omega-3 Fatty Acid Supplements

    Some preliminary research has suggested that omega-3 fatty acids could help relieve dry eyes symptoms. These fatty acids, found in fish and vegetable oils, are thought to reduce inflammation in the body, including in the eyes and eyelids. Omega-3 fatty acids are available in foods (salmon, tuna, flaxseed, walnuts) and in supplements.

    Medications

    • Antibiotics.
           Antibiotics can decrease the amount of bacteria on the surface of the eye,  can open up the pores of tear glands, and can help reduce eye  inflammation. These are available in drop, ointment, and pill forms.

  • Anti-inflammatory
         Agents. These can be used to control eye irritation and inflammation from  chronic DES. Steroid and non-steroidal drops can be used to treat acute  symptoms of redness and burning. Topical cyclosporine (Restasis) can be  used on a long-term basis, including in patients with autoimmune  conditions or after LASIK, to promote increased tear production by glands  on the surface of the eye.

    • Office Treatment of DES

    • Closure of the Tear  Drain: Punctal Plugs. Normally tears drain through a canal in the inner  corner of each eyelid into the sinuses and nose. This is why tears don’t  normally spill down the cheek. Tiny silicone plugs or surgical cautery can
           be used to block the tear drain, allowing the tears to remain in contact with the eyes longer. Plug insertion is an easy, reversible procedure that  can be performed in the examination room and is usually covered by medical
           insurance.

  • Bandage Contact Lens. If  the eye is too dry, a soft, clear bandage contact lens can be applied to  protect the surface of the eye. Similarly, eye goggles can be worn at  night time.



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