Dry eye Syndrome is a very common condition that affects more than 2 million people in the UK, its incidence increasing with age, and affects more women than men. Dry eye occurs when people don’t have either enough tears, or the proper composition of tears.
The tear film is composed of three layers, which are co- dependent on the other for proper function. The outermost oily layer of the tear film is produced by the meibomian glands (which are in the eyelids), and helps reduces evaporation of the tears. The middle, watery layer is made by the lacrimal gland and washes away irritants. The inner, mucus layer is secreted by the goblet cells in the conjunctiva (mucous lining) of the eye and helps the tear film stick to the cornea.
Is a condition that affects the eyelid margins. It may also affect the tissues lining the lids and eyeball (the conjunctiva) and the window of the eye (the cornea). There are several different types of blepharitis, which may occur alone or in combination; these types involve either the lash bearing area (anterior blepharitis) or the area behind the lashes where the meibomian glands open (posterior blepharitis or meibomian gland dysfunction).
Blepharitis is an extremely common cause of DRY EYE in people over 40, although it can develop at any age and children suffer with it too.
The symptoms of blepharitis can include:
- burning, soreness or grittiness in the eyes
- crusty eyelashes, sticky / watery eyes
- red / itchy eyelids
Blepharitis can be caused by a bacterial infection, or it can be a complication of a skin condition such as:
- seborrhoeic dermatitis, which causes an itchy rash on the skin and scalp (seborrhoeic dermatitis of the scalp is called dandruff)
- rosacea, which causes the face to appear red and blotchy
Dry Eye Drops
There are many Dry Eye medications on the market, especially different forms of eye drops and ointments. Restasis is the only FDA approved eye drop for DED (dry eye disease) which been proven to work in chronic inflammatory dry eyes.
There are many different products available over-the-counter, or on prescription only. Although most artificial tears contain similar ingredients, they differ in the type of lubricant used, in their chemical properties & in the type (or lack thereof) of preservatives used. These are broadly classed under
HMC-based artificial tears work on the simple principle of lubricating the ocular surface in order to promote the integrity of the surface, but do not have viscosity-increasing properties.
Several brands of artificial tears:
Tears Naturale /Genteal (Alcon), contains hypromellose and a gentle preservative (polyquad in tears naturale).
Hypromellose (multiple pharma companies) contains hypromellose & generally the preservative is Benzylkonium chloride, which can destabilize the tear film.
Artelac (Bausch & Lomb) 0.32 % hypromellose.
Bion Tears (Alcon), contain hypromellose, dextran, zinc & bicarbonate and are only available on prescription. They are more beneficial in relieving dryness and irritation caused by Sjogrens.
Ilube (Moorfields Pharmaceuticals) contains 5 % acetylcysteine & hypromellose, both these ingredients work together for DED due to abnormal mucus production.
Tear-Lac (Scope Ophthalmics) contains 0.3 % hypromellose preservative free.
Carboxy methylcellulose (CMC) is a polysaccharide known as mucilage. They increase the residence time of tears as well as increase the viscosity of tears.
Commonly available CMC artificial tears include
Optive / Celluvisc / Refresh (Allergan) – contain CMC & provide osmoprotection against high osmolarity of the tear film in DED.
TheraTears (Advanced Vision Research) eye drops and liquid gel contain carboxymethycellulose and provide a tear matched electrolyte balanced solution for dry eyes.
Systane / Systane Ultra (Alcon) contains polyethylene glycol & HP guar. The HP guar in this artificial tear brand is gel-forming and offers unique properties that improve recovery of the ocular surface due to possible increased retention of the artificial tear drop, and increase in tear film break up time.
Systane Balance (Alcon) may be helpful in patients with conditions causing evaporative dry eye (e.g., meibomian gland disease).
Blink Tears (Abbott Medical Optics). Its contains polyethylene glycol, Hyaluronate with “ocupure” preservative and is clinically shown to improve tear film stability
Recent studies have shown that Sodium hyaluronate eye drops are useful in improving subjective symptoms (as well as the ocular health) of dry eye patients, treating lipid tear-deficient patients and managing Sjogrens syndrome patients. Sodium hyaluronate also seems to have protective effects on the corneal epithelium and may be useful in a wide variety of patients with dry eye.
Hylo-tears/ Hylo- forte (Scope Ophthalmics): preservative free 0.1 % /0.2 % Hyaluronate.
Artelac Rebalance (Bausch & Lomb) contains 0.15 % hyaluronate, Vit B12, mineral nutrients & an innovative preservative Oxyd.
Clinitas soothe (Altacor) 0.4% hyaluronate preservative free.
Lubristil (Moorfields Pharmaceuticals)?contains 0.15% hyaluronate preservative free.
Polyvinyl alcohol lubricates the ocular surface.
Clinitas Ultra (Altocor) contains PVA & povidone with a mild preservative
Murine Tears (Murine Eye Care), contains PVAl, povidone & six of the 11 major ingredients found in natural tears.
Castor/Soya bean oil aids in the reformation of the lipid layer of the tear film and prevents evaporation of the existing tear film. Oil-based eye drops are used in the treatment of meibomian gland disease.
Optive Plus (Allergan) contains castor oil
Emustil (Moorfields Pharmaceutical) is made from 7% Soybean oil and 3% Natural Phospholipids
Restasis (Allergan) – This is the only FDA approved medication for Dry Eye Syndrome. Recommended doses are 1 drop twice a day. It’s important to note that this medicine is not intended for instant relief, but rather a long-term medication that doesn’t have the side effects of steroid-based eye drops.
It’s important to know that long-term use of steroid eye drops can cause a rise in eye pressure and development of a cataract. None of the eye drops listed below should be taken without the consent of your eye care professional. They are Alrex, Lotemax, FML and Vexol.
Frequently Asked Questions
What are the main types of Dry Eye?
- Underproduction called Aqueous Deficiency, where there is poor production of fluid by the lacrimal glands.
- Evaporative – tears evaporate too quickly, where there is poor oil production by the meibomian glands.
- Combination – mixed Aqueous & evaporative type.
However ALL patients with dry eye can have an inflammatory component.
What are the Symptoms and Signs of Dry Eyes?
- Persistently gritty, sore, foreign body sensation
- Red, itchy
- Misty or blurred vision
- Sharp shooting eye pain
- Watery eyes (paradoxical)
Dry eye does not frequently cause blindness, but as it is such an uncomfortable condition, it is a common reason for seeking assistance. Furthermore, dry eye syndrome is associated with a decreased ability to perform activities that require visual attention, such as reading, computer work and driving a car.
Patients with the most severe disease are at increased risk of developing corneal infection, scarring or ulceration. These conditions can cause permanent vision loss, misdirected eyelashes or loss of eyelashes and entropion (chronic blepharitis), so it is important to seek urgent professional help if you have severe symptoms of dry eye.
Sjogren’s dry eye syndrome
Severe dry eye is sometimes caused by Sjögren’s syndrome, which is an uncommon autoimmune disorder that also results in dry mouth and often arthritis.
What Tests are performed for Dry Eye?
There are many tests that indicate you may be suffering with dry eye. Not all tests are always performed, but include:
Tear Meniscus: the height of the tear film along the lower lid border (reduced in dry eye).
Tear Break Up Time (TBUT) – The speed at which tears break up reflects evaporation (<5 seconds indicates dry eye)
Schirmer’s Test – A test to measure quantity of tear production where strips of sterile blotting paper are placed at the outer corner of the eye for 5 minutes and the length of wetting is measured. However it is not a very reliable test, as it does not comment on tear quality.
Tear Osmolarity – A test to measure the osmolarity of tears (high & variable in dry eye). This is an extremely reliable test, but does not help differentiate between the different types of dry eye.
Blink – An assessment of whether the blink is partial or reduced.
Ocular surface staining –with the help of topical drops, to evaluate the tear film and study ocular surface damage.
Assessment of Meibum expressibility (meibomian gland secretions), which indicates function of the oil glands.
Assessment of the Meibomian glands – with Meibography, to assess the drop out of meibomian glands
Management of Dry Eye
Avoid anything that can aggravate dryness, such as:
- Very warm rooms (a humidifier may help)
- Hair driers
- Contact lenses
Hormone Replacement Therapy (HRT)
HRT can aggravate dry eye. There is some evidence that, in older women, hormone replacement therapy makes dry eye worse; if you are using HRT, talk to your doctor about this.
What are the Dry Eye Treatment Options?
Lubricating eye drops
First line of treatment is the use of artificial teardrops or gels, which can be bought over the counter. You may need to try out different types to see what combination relieves your symptoms of dry eye. Preservatives in eye drops can aggravate your eye, and if you are using them more than 4 times/day, I recommend using non-preserved drops instead. Some newer lubricating drops try to replicate the tear film, thus have been shown to be of benefit and newer preparations are being researched.
Omega 3 supplements
Our modern diet is sadly lacking in sufficient quantities of Omega 3 and there is an overbalance of Omega 6, which contributes to inflammation. Omega 3 supplementation has been shown to be very useful for improving the function of Meibomian glands in blepharitis. It is mportant that the correct preparation be used, as not all Omega 3 preparations are biocompatible. While recent long-term studies indicate a somewhat better bioavailability for omega 3 fatty acids in triglyceride versus ethyl ester form, the cost of high-omega-3 concentrates is generally much greater for the triglyceride forms versus equal amounts of omega-3 in the concentrated ethyl ester form.
In more severe cases of dry eye, the eye might become inflamed and anti-inflammatory medications including steroid eye drops may be prescribed for short-term use.
This is an ophthalmic preparation of Cyclosporine, which is useful in decreasing inflammation and in Sjogren’s syndrome.
Punctal Occlusion (temporary or permanent) may be an option offered by your ophthalmologist in severe cases. This involves blocking ducts within your eyelid. Used incorrectly punctal occlusion can sometimes cause more problems especially in inflammatory dry eye.
Lid Hygiene : Warm compresses and Scrubs
Mainstay to treat anterior & posterior blepharitis. The Meibomian glands in the eyelids get blocked and as a result lead to evaporative dry eye.
This is an effective and simple option to provide warmth to the eyelids without the fuss of hot water etc. The EyeBag is placed in a microwave oven for 30 seconds, and then placed on the closed eyelids for about 10 minutes following which massage/scrubs can be performed.
An electrical pair of goggles that provides warmth and steam to treat MGD. Many patients prefer using this device although it is a slightly more expensive option, as it offers moist heat.
A highly sophisticated treatment option that warms the lids and squeezes them to evacuate meibum within the oil glands. Excellent for kick starting treatment in selected cases, the use of regular lid hygiene is recommended to maintain the health and function of the glands.
How can blepharitis be treated?
Blepharitis cannot be cured, but symptoms can be controlled with good eye hygiene and lubricant eye drops.
Blepharitis is a chronic (long-term) condition. Most people experience repeated episodes followed by periods with no symptoms.
Eye hygiene for Anterior Blepharitis
It is important to clean your eyelids every day, whether or not you have any symptoms. Good eye hygiene helps ease your symptoms and prevents them from reoccurring. Follow the steps below to keep your eyes clean:
1. Apply a warm compress (a cloth or tissue dipped in with warm water) to your closed eyelids for five to ten minutes. Gently rub the compress over your closed eyelids for two to three minutes to help loosen any crusting.
2. Use a cotton bud moistened with boiled cooled water and gently rub the edge of your eyelids to clean them. If you have difficulty using a bud use proprietary cleaning pads e.g: Supranettes wipe by Alcon, Lid Care pads by CIBA, or Blephaclean/ Blephasol wipes by Spectrum Thea, or Ocusoft /Ocusoft plus eye pads by Scope Ophthalmics.
Carry out these steps twice a day at first, then once a day when your symptoms have improved.
Eye hygiene for Posterior Blepharitis
It is important you perform Hot compress and eyelid margin massage every day
Step 1: Hot Compress
Either heat the lids with a flannel soaked in hot water Or use a heat pad such as the “Eyebag” from www.eyebagcompany.com. Apply to closed eyes for 4-5 minutes. Reheat as necessary.
Step 2: Massage
Express the oily secretions from the meibomian glands by using a cotton bud or your finger. Firm pressure is required to milk the secretions towards the gland opening on the lid margin. Use a rotary motion down (or up) towards the lid margin. Work your way across the whole upper and lower lid. Do NOT stretch the lid
Step 3: Add Lid Scrubs or Wipes
Gently rub the edge of your eyelids with lid wipes to clean them, if you have mixed anterior & posterior blepharitis (Lid wipes advised are: Supranettes wipe by Alcon OR Lid Care pads by CIBA OR Blephaclean/ Blephasol wipes by Spectrum Thea OR Ocusoft /Ocusoft plus eye pads by Scope Ophthalmics).
If you have blepharitis that does not respond to regular cleaning, you may be prescribed a course of antibiotic ointments or steroids. You will need to use these for four to six weeks.
You may be prescribed:
- fucithalmic or maxitrol steroid/antibiotic eye ointment (to be rubbed gently onto the edge of your eyelids as prescribed)
- 1 % azithromycin eye drops
In some circumstances, you may be prescribed oral antibiotics (e.g Doxycycline or Azithromycin) at the start of your treatment. For example, oral antibiotics may be prescribed when it is clear that a skin condition, such as rosacea, is aggravating your blepharitis. Oral antibiotics may also be recommended if your blepharitis does not respond to other treatment.
Most people respond well after treatment, hence it is important for you to finish the course of antibiotics, even if your symptoms get better.
Doxycycline used to treat blepharitis has been known to make people more sensitive to the effects of the sun. Therefore, avoid prolonged exposure to sunlight and using sun lamps or sun beds while you are taking them.
Treating Other Conditions
You may need to use an anti-dandruff shampoo on your scalp and eyebrows if you have:
- seborrhoeic dermatitis
- dandruff (dry, flaky skin on your scalp)
If you have dry eye syndrome, which frequently occurs alongside blepharitis, you may need separate treatment for this, such as lubricant eye drops.
What happens if Blepharitis is not treated?
- Dry eye syndrome
- Meibomian cyst