This article is part two of a two-part series. Part one ran last week and described the symptoms, causes, and biology of this affliction.
You’ve likely experienced the incredible discomfort of having something in your eye. Whether an eyelash or piece of sand or dirt, you doubtless stopped what you were doing and attempted to get it out. Imagine this feeling being present for hours, or worse, for days on end.
This feeling is an ongoing reality for people who suffer from dry eye disease (DED). Symptoms of DED range from mild irritation to severe pain. You may experience burning, excessive tearing, sensitivity to sunlight, eye redness, and eye fatigue. DED is a complex disorder with multiple factors that contribute to and intensify the disease.
Dry Eye Is Complex
DED is often entwined with meibomian gland dysfunction in a vicious cycle in which the conditions exacerbate one another. Meibomian glands are oil glands along your eyelid margin that secrete the oily layer of your tear film. This oily layer normally prevents your eye’s tear film from evaporating too quickly. When the meibomian glands don’t function properly, they don’t secrete enough of a film to keep the watery portion of your tear film from evaporating. This leads to increased evaporation of the tear film, which causes the eyes to become dry and irritated. The dryness makes your eyes susceptible to pathogens, such as bacteria and viruses, and triggers the immune system to spur a cascade of inflammation, which further exacerbates meibomian gland dysfunction.
If you have symptoms of DED, the first step is to see an ophthalmologist who’s able to begin teasing apart the factors causing and perpetuating your dry eye symptoms.
Each case of DED is unique. Determining the driving factors contributing to and aggravating the condition is vital for proper management of the disease. There isn’t a one-size-fits-all approach. A good ophthalmologist will take the time to figure out which factors are contributing most significantly and address those factors specifically in order to break the cycle. If your ophthalmologist suggests treatments that you’re uncomfortable with and doesn’t seem to have given you a thorough exam, it may be wise to seek a second opinion.
Methods for Determining the Cause of Your Dry Eyes
A comprehensive eye exam with a full history of your general and eye health is foundational.
To measure your tear production, your ophthalmologist may perform a Schirmer’s test or phenol red thread test.
For the Schirmer’s test, one free end of a calibrated strip of filter paper is placed within each lower eyelid. You will keep your eyes closed for five minutes. After the five minutes, the paper is removed and the degree of wetting is measured.
The phenol red thread test causes less irritation than the Schirmer’s test. It utilizes a thin cotton thread that has been saturated with phenol red, a pH indicator. One end of each thread hooks over the lower eyelid of each eye. The patient maintains their gaze with normal blinking for 15 seconds, then the thread is removed. The wet part of the thread where tear fluid soaked is red and is measured to indicate how dry the eyes are.
In addition to measuring tear production, your ophthalmologist may test tear quality. The tear ferning test is an effective method to assess tear quality and help diagnose dryness. The ophthalmologist takes a small sample of tear fluid and places it onto a sterile glass microscope slide. When it dries, it produces a characteristic crystalline pattern called a “tear fern” that can be used to determine the quality of the tear fluid.
Your ophthalmologist may also perform a tear break-up time (TBUT) test. With this test, fluorescein eye drops are inserted into the eye. The patient is instructed not to blink while the tear film is observed by the ophthalmologist. The amount of time from the last blink to the appearance of a dry spot in the tear film is the TBUT value.
There are other eye drops with special dyes that can be used to view the surface of your eye. They’re used to look for staining patterns that reveal dryness, decreased tear film, and damage to the cornea.
The concentration of solute particles in the tear fluid can also be measured. This is called a tear osmolarity test. When the concentration of solute particles is above a certain osmolarity, it’s evidence there isn’t enough fluid in the tears being produced.
Your ophthalmologist can also take a sample of your tears and send the sample to a lab. The lab can test for markers of DED and inflammation, such as decreased lactoferrin and elevated matrix metalloproteinase-9.
Treating Dry Eye Disease Outside of the Clinic
The main goal of DED treatment is to restore the eye surface to a place of homeostasis where inflammation is under control and the factors necessary for a healthy tear film are re-established.
Addressing Environmental Factors
Environmental factors such as smoke and windy or dry climates can cause dry eye symptoms. Use of a humidifier, as well as avoiding sitting in the direct path of airflow from an air conditioner or fan are smart strategies for protecting your eyes. In addition, moisture chamber glasses can be very effective in these environments to protect the eyes from losing substantial tear film due to rapid evaporation.
Staring at a computer or smartphone screen for hours each day can contribute to dry eye symptoms due to infrequent blinking and eye strain. It may seem like a small thing, but setting reminders to take a rest from staring at the screen can be very beneficial.
Adjusting Lifestyle and Diet
One of the simplest and most profound changes you can make for your dry eyes is to drink more water. Set timers to remind yourself to drink water to make sure you’re adequately hydrated throughout the day.
Smoking and drinking excessive alcohol can cause dry eye symptoms; quitting smoking and keeping alcohol use in moderation are two powerful ways to decrease dry eye symptoms.
In some cases, an underlying autoimmune disorder may be the cause of DED. For instance, autoimmune thyroid disorders, Sjogren’s syndrome, rheumatoid arthritis, and lupus can all cause decreased tear production.
Determining what exacerbates symptoms of your autoimmune disorder can be key to helping your dry eye symptoms. For instance, elderberry can increase the production of inflammatory cytokines such as IL-1 beta, TNF-alpha, IL-6, and IL-8. Elderberry is contraindicated for those with autoimmune disorders. Echinacea can worsen autoimmune symptoms and therefore may aggravate dry eye symptoms in individuals with autoimmune disorders associated with decreased tear production.
Controlling inflammation in the body is important for decreasing autoimmune symptomology. A diet rich in anti-inflammatory foods, such as omega-3 fatty acids, is helpful for lowering inflammation in the body and at the surface of the eye.
Research on the role of omega-3 fatty acid supplementation on dry eye symptoms has been highly variable, but a recent systematic review and meta-analysis demonstrated improved subjective symptoms in patients with DED who supplemented with omega-3 fatty acids.
A meta-analysis of clinical trials reveals evidence that omega-3 fatty acid supplementation “significantly improves dry eye symptoms and signs in patients with dry eye disease.”
A diet high in processed foods, unhealthy fats, and sugar contributes to inflammation in the body and may be linked to your dry eye symptoms. A cross-sectional survey of 103 subjects suggests that “lower inflammatory diets such as the Mediterranean diet may have a protective effect against dry eye.”
Sometimes a vitamin deficiency is the cause of DED.
Vitamin D deficiency causes symptoms associated with dry eyes. In one study, researchers found vitamin D supplementation to be effective in treating patients who were deficient in vitamin D and not responding to conventional DED treatments. Another study revealed vitamin D supplementation improved dry eye symptoms, ocular surface conditions, and tear quality in older individuals who had dry eye symptoms.
Some medications, such as some antidepressants, antihistamines, hormone replacement therapy, and blood pressure medicines, may cause dry eye symptoms. Decreasing the dose or finding an alternative may bring relief from dry eye symptoms.
For some DED patients, symptoms are mild enough that lubricating drops are enough to maintain comfort throughout the day.
There are two categories of lubricating drops: eyedrops with preservatives and preservative-free eyedrops. It is very important to use preservative-free eyedrops. In vitro and in vivo studies reveal preservative-free eyedrops result in the least amount of ocular surface disruption both clinically and on a cellular level. In particular, eyedrops with the preservative benzalkonium chloride (BAK) should never be used when a patient has DED.
Some over-the-counter lubricating drops come in the form of a gel, which can temporarily blur vision, but may give longer-lasting relief. Overnight ointments are another option to keep the eyes hydrated while you sleep.
When meibomian gland dysfunction is present with DED, as it often is, lipid-containing lubricants may provide better relief than lubricants without lipids.
It’s best to avoid drops that reduce redness through vasoconstriction as they can have a negative effect, called rebound hyperemia, in which your eyes become even more red and irritated.
Compresses and Lid Hygiene
For those with blocked meibomian glands, doing warm compresses daily is recommended to soften the meibum—the oily fluid that becomes part of the tear film—and allow it to flow out of the glands. A washcloth with warm water (around 113 degrees F) can be placed over the eyes for 10 minutes. There are also many different heating masks available on the market.
It’s also important to keep the eyelids clean. There are numerous types of eyelid wipes and cleansers available. You want to stay as natural as possible to avoid harsh chemicals on your eyes.
Clinical and Pharmaceutical Treatments
If the above modifications (environmental, lifestyle alterations, dietary habits, supplementation, and decreasing dosage of offending medicines) and basic treatments (lubricating drops, compresses, and lid washing) don’t successfully ameliorate dry eye symptoms, clinical and pharmaceutical treatments may be required. There are numerous options, but it’s important that your ophthalmologist tailor the treatment regimen for your specific case of DED.
If blepharitis—inflammation of the eyelids—is a compounding factor in your DED, your ophthalmologist may determine that a topical antibiotic is warranted. If there is an infestation of Demodex mites, they may treat your eyelids with tea tree oil or topical ivermectin.
Punctal plugs are little devices that are inserted in the eye’s puncta, tiny ducts that drain tears from the eye into the nasal cavity. Blocking these puncta allows tears to remain in the eyes longer. Temporary punctal plugs last for a few days to several months. They are often made of a material that breaks down over time, such as collagen. Semi-permanent plugs are designed to last for years. They are often made of material that is non-degradable, such as silicone.
There are also several treatment devices for removing blockages and expressing the meibomian glands.
LipiFlow Thermal Pulsation System is an increasingly popular treatment designed to remove meibomian gland blockages. The device uses a sterile activator to send heat pulses to meibomian glands while gently massaging the eyelids, unblocking the glands so the oil can flow freely.
ILux is similar to LipiFlow. It is a handheld device that warms and applies gentle pressure on your eyelids to unblock the meibomian glands.
In a clinical trial comparing iLux and LipiFlow for meibomian gland dysfunction treatment, both devices significantly improved meibomian gland function and symptoms, with no statistically significant differences in outcomes between devices.
Intense pulsed light (IPL) therapy is another therapy for those with meibomian gland dysfunction. With this therapy, gentle pulses of light are sent to the skin next to the eyes to decrease inflammation. These pulses warm hardened meibum blocking meibomian glands. In a three-year retrospective study, improvement in dry eye tear breakup time was found in 87 percent of patients after a series of IPL therapy sessions.
In addition to these therapies for unblocking meibomian glands, there are many types of prescription eye drops.
If your ophthalmologist thinks you have a bacterial infection contributing to your DED, he or she may prescribe antibiotic eye drops.
Topical secretagogues—substances that promote secretion—can be aqueous or mucin-based and may be utilized by your ophthalmologist to increase production of the aqueous or mucous layers of the tear film.
There are also anti-inflammatory drops that can be prescribed.
If symptoms of inflammation and potential or actual ocular damage reach a certain threshold, your ophthalmologist may prescribe a corticosteroid eye drop or gel drop, such as Lotemax to calm the inflammation and allow the eyes to heal.
Non-glucocorticoid immunomodulator eyedrops, such as those containing cyclosporin A, such as Restasis and Cequa, may be used. It’s important to note these eyedrops may take 3 to 6 months of use before a change is noticeable.
If the above treatments don’t bring relief, your ophthalmologist or an endocrinologist may prescribe an oral secretagogue, called a cholinergic, such as pilocarpine and cevimeline. These drugs stimulate the lacrimal gland to release more lacrimal fluid into the eyes.
Autologous blood serum eye drops are eye drops made from your own blood. To make these drops, a sample of your blood is processed to remove certain components, such as red blood cells. The blood serum is combined with a salt solution and placed into sterile eye dropper bottles.
The British Journal of Ophthalmology states, “While pharmaceutical lubricants offer little to no nutrition, eye drops made from autologous serum have a tear-like biochemical character and supply nutritional components.” This journal further notes that In vitro studies demonstrate autologous serum drops aid in the survival, proliferation, and migration of epithelial cells at the ocular surface.
Varenicline solution (Tyrvaya), is a nasal spray that helps treat dry eyes. Twice-daily administration of varenicline solution nasal spray was found to result in statistically significant improvements in DED symptoms over a four-week period in two studies.
Sometimes a surgical approach is necessary to bring relief and prevent further eye damage.
Amniotic membrane grafts, such as Prokera, can provide significant healing to corneal tissue that has been damaged. Amniotic membranes are part of the placenta and are donated by consenting mothers after cesarean section. These tissues are rich in stem cells and have natural anti-inflammatory and anti-scarring properties.
Surgeries that might be necessary to protect eyes at risk of severe damage from lack of moisture include salivary gland transplantation and parotid duct transposition.
Surgical punctal occlusion is a permanent way to block the tear ducts. With this surgery, heat or laser will scar the puncta so that tears can’t drain through the puncta, keeping tears in the eyes longer.
Finally, in severe cases, tarsorrhaphy may be needed to prevent the patient from going blind. This is a surgical procedure in which the eyelids are partially sewn together to protect the cornea from permanent damage due to dryness. This procedure is used as a last-ditch effort in patients who can’t adequately close their eyes or have a condition in which the cornea is exposed in a prolonged manner. Such instances may possibly occur with Bell’s Palsy, myasthenia gravis, traumatic brain injuries, Grave’s disease, tumors behind the eye, and Sjogren’s syndrome.
While researchers continue to work to find treatment options for patients with DED, it’s important to remember how our environment, lifestyle, and diet can influence the health of our eyes. Being purposeful about staying hydrated, stepping away from screens periodically, and eating natural foods with healthy fats and vitamins, can make a difference in not only our ocular health, but in the health of our whole body.
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