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What is Dry Eye Disease and How To Treat It

What is Dry Eye Disease and How To Treat It

By: Tiffany Cochran, MD • Posted on April 25, 2022


Dry eye disease is a common reason for scheduling an appointment with a healthcare clinician. It frequently leads to eye discomfort, lower eyesight and reduced quality of life, particularly for people over age 50. Dry eye disease affects nearly 350 million individuals worldwide. About 50-60 percent of perimenopausal and menopausal women experience dry eyes.

This disease impacts the quality of tears leading to overall poor eye health. Nontreatment of dry eye syndrome increases the risk for eye infections, abrasion and inflammation of eye structure causing damage to the cornea (the front surface of the eye). This results in eye pain, ulcers and permanent vision problems.

Causes of Dry Eye Disease

Multiple factors have been identified in contributing to the development of tear and eye structural disease:

  • Autoimmune diseases like Sjogren, rheumatoid arthritis, systemic lupus erythematous vasculitis (inflammation of blood vessels from immune response), systemic sclerosis, and primary biliary cirrhosis can cause dry eye disease.
  • Certain medications like antihistamines, betablockers, diuretics and anti-muscle spasm prescriptions (baclofen, Flexeril®, or Bentyl®) can lead to drier eyes.
  • Vitamin deficiency can trigger dry eyes as well as contact lenses, seasonal allergies, lower humidity, high windy areas, job exposure and aging.
  • Dry eyes can stem from conditions affecting the eye structures (abnormal Meibomian glands or eyelid infection/inflammation) which can lower blink rate or consistency of eyelid surface.
  • It is thought that perimenopausal and menopausal women produce less androgen (male) hormone production, causing fewer secretions from meibomian (oil) and lacrimal (tear) glands in the eyelid. Meibomian glands produce essential oils for tears—less oil production results in more tear evaporation and thus drier eyes. The eyelids become inflamed and tear production and tear quality become poor, all causing dry eye syndrome.
  • Estrogen plays a role as well since women can experience dry eye symptoms at certain times of their monthly cycle. Dry eyes are a side effect related to hormonal contraceptives.

How Rosacea Can Affect the Eyes

Rosacea is a common persistent skin inflammatory disease affecting facial and eye anatomy:

  • Serious eye problems can develop even if the rosacea on the skin is mild
  • Ocular rosacea is a relapsing inflammatory condition of the eyes and its structures. It often requires continual treatment
  • Rosacea affects the meibomian gland causing dysfunction, chronic scarring of meibomian gland orifices, and eyelid margin telangiectasis. Ultimately, eyes become irritated and dry
  • Diagnosis of rosacea is often overlooked because eye symptoms are mistaken for allergies or side effects of contact lenses
  • About 50% of individuals with rosacea will develop symptoms in their eyes

Dry Eye Disease Risk Factors

  1. Female gender
  2. Being > age 50
  3. Diagnosis of connective tissue disease such as Sjogren’s syndrome or Rheumatoid arthritis
  4. Use of contact lens
  5. Certain medications: diuretics, antihistamines, anti-depressants, and isotretinoin
  6. History of bone marrow transplant
  7. Low testosterone levels
  8. Perimenopause or menopause

Symptoms of Dry Eye Disease

  1. Swollen, red eyelids (most common sign)
  2. Red, bloodshot eyes
  3. Pink eye (conjunctivitis)
  4. Redness and swelling around eyes
  5. Crusty eyelids or eyelashes
  6. Tearing or dry eyes
  7. Burning
  8. Itching
  9. Sensitivity to light
  10. Blurry vision (if cornea or front surface of eye involved)
  11. Foreign body sensation (sensation of something in eye)
  12. Recurrent eyelid infections

If you have any of these symptoms, you should schedule an appointment with your primary care clinician for a referral to a dermatologist or ophthalmologist.

Treatments for Dry Eye Disease

The main goal of treatment for dry eye disease focuses on restoring tear production, in which multiple treatments may be needed.

7 lifestyle habits that help improve dry eyes

  1. Eye hygiene
    1. Gently clean eyelids with a cloth daily. Use special eyelid cleaning products or baby shampoo mixed with warm water
    2. Regularly warm compresses improve oil flow from eyelid glands and keep eyelids clean. Apply a warm cloth or pad several times daily as recommended by a dermatologist. This is to remove debris and keep gland ducts open
    3. Eyelid scrubs keep eyes clean and free of infection
  2. If you use electronic devices frequently, be sure to take many breaks and blink often
    1. If you can, try to limit screen time. People on screen 24/7 blink less, which affects tear production
  3. Protect your eyes
    1. Wear sunglasses to block harmful sunlight and dry air and wind
  4. Avoid triggers like pollen, smoke, spicy foods, alcohol, sunlight, heat, cosmetics and soaps which can worsen symptoms
  5. Consider using a humidifier to help moisten the air around you
  6. Light exercise, especially aerobic exercise, may increase tear production
  7. Eat healthy and limit high sugary foods
    1. Vitamin A and omega-3 fatty acids help with good tear production

Lubricating eye drops and ointment

Artificial tears
  • Artificial tears or lubricating eye drops and ointments can provide partial relief for dry eye disease. Artificial tears maintain moisture for eyes. However, avoid eye drops for red eyes as they can worsen ocular rosacea.
  • Drops should not be used more than 4 to 6 times per day as exposure to significant amounts of preservatives can damage the eye surface and lead to conjunctivitis. Preservative-free artificial tears are less irritating to the eye surface and may be used a little more frequently.
Autologous serum tears
  • Autologous serum tears or platelet-rich plasma are treatment options that both contain anti-inflammatory and growth factors that help in treating dry eye disease and support healing of the eye surface.
Tetrahydrozoline
  • Tetrahydrozoline, a vasoconstrictor (narrows blood vessel walls), is helpful for lubricating the eye or reducing eye redness. It can lead to rebound redness with chronic use as the body becomes less responsive to this drug.
Emulsion formulated eye drops
  • Emulsion formulated eye drops replace oil to tear production which reduces evaporation of tears. This eye drop is an excellent choice for patients frequently with blurry vision and improves blinking.
Lubricating eye gels
  • Use lubricating eye gels and ointments at bedtime to avoid daytime blurry vision.
Corticosteroid eye drops
  • Corticosteroid eye drops lower redness and swelling, but can cause drug-induced glaucoma, cataract formation, or both when used for greater than 4 weeks. It should only be prescribed by an ophthalmologist.

Hormonal-related dry eye treatment

Using hormonal therapy for treatment of dry eyes remains debatable due to the lack of consistent results. Although its use is controversial, dry eye symptoms decreased about 51% after two weeks in 10 of 12 patients who received the novel androgen formulation Cyclodextrin®.

Medications that reduce eyelid inflammation

Antibiotic use
  • Antibiotic pills/ointments are treatments for eye infections and are used to reduce inflammation in eyes and skin, especially if related to rosacea.
  • Doxycycline modified release can be used daily for up to 6 weeks to help with dry eyes.
  • If contraindicated, erythromycin or azithromycin may be used.
Other anti-inflammatory treatments
  1. Restasis® or topical cyclosporine acts to increase tear production in patients who have dry eye due to eye inflammation by inhibiting the activity of certain immune cells in the body.
  2. Topical ivermectin (an antiparasitic medication) cream applied to the eyelid skin helps reduce inflammation.
  3. Xiidra® or Lifitegrast ophthalmic lymphocyte function-associated antigen-1 (LFA-1) antagonist is an eye drop that reduces inflammatory cell binding, meaning less eye inflammation.

Devices

  1. Scleral contact lenses are large-diameter rigid lenses that can offer temporary reservoir for tears or ophthalmic medications, increasing contact time to front surface of eye or cornea.

Procedures

  1. Surgery is recommended for people with abnormal eyelid anatomy or function preventing proper closure as well as those with recurring symptoms of Bell’s palsy.
  2. Corneal transplants or grafts are possible for severe dry eye disease.
  3. A punctual plug is placed by a procedure involving the insertion of silicone or collagen plugs into the opening of the tear duct creating a surgical closure to decrease drainage. This plug increases the time that tears and eye medications are in contact with cornea and reduces flow away from the eyes.
  4. Intense pulsed light (IPL) therapy may be considered as treatment for dry eye disease caused by ocular rosacea. This treatment requires direct application of light in various wavelengths to the skin, but there is limited evidence on the effectiveness and safeness of this treatment.

Be Strong, Be Healthy, Be in Charge!
- Tiffany Cochran, MD

Resources
  1. Ocular rosacea. The College of Optometrists. Accessed March 05, 2022.
  2. Rosacea treatment: eye problems. American Academy of Dermatology. Accessed March 05, 2022.
  3. Hakim FE and Farooq AV. Dry eye disease: an update in 2022. JAMA. 2022;327(5):478–479. doi:10.1001/jama.2021.19963
  4. Matossian, Cynthia et al. Dry eye disease: consideration for women's health. Journal of women's health (2002) vol. 28,4 (2019): 502-514. doi:10.1089/jwh.2018.7041

Tiffany Cochran, MD is a Women's Health Fellow in Cleveland Clinic's Specialized Women's Health Fellowship program. Dr. Cochran received her Bachelor of Science from Valdosta State University and her Doctorate of Medicine from Morehouse School of Medicine. She also has an MA in Healthcare Administration.



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