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Dry Eye Syndrome (DES) Q&A
What is Dry Eye Syndrome?
Your tears function to protect and lubricate the eyes. Healthy tears not only provide a smooth comfortable ocular surface, but also promote improved and sustained vision. Dry Eye Syndrome (DES) is caused by the decline of the quantity and/or quality of the tears. This occurs when the tear glands in the upper and lower eyelids don't produce enough tears or don't produce healthy tears.
Unhealthy tears lead to irritation, scratchiness, burning, redness, discomfort, and poor and inconsistent vision. DES is the most common of all eye disorders, affecting approximately 20% of the U.S. population and is more prevalent in certain demographic groups.
The Complexity of Tears?
Your eyes are moistened by two different types of tears: lubricating (basal) and reflex tears. Lubricating tears are produced continuously to moisturize and protect the eyes. They contain natural anti-inflammatory, immune and anti-infective elements. Reflex tears are produce in response to sudden irritation (smoke, onions, foreign particles), injury or emotion. Ironically, the irritation from dry eyes can trigger reflex tearing, which flood the eye's surface. But because reflex tears don't have the proper lubricating composition, the discomfort persists. Ironically, "watery eyes" can actually be symptoms of DES. (top)
What Causes Dry Eye Syndrome?
DES has many causes, which explains why millions are affected. The most common causes include:
- The Aging Process - Tear flow normally decreases with age. In fact, approximately 75% of individuals over the age of 65 suffer from DES.
- Contact Lens Wear - Contact lens wear can increase tear evaporation and alter the feedback message from the cornea to the tear glands, reducing the stimulus for the lacrimal glands to produce tears.
- Hormonal Changes in Women - Various hormonal changes associated with pregnancy, oral contraceptives, and menopause can contribute to DES.
- Environmental Factors - People who are exposed to smoke, air pollution, high altitude, sunny, windy, cold or dry air conditions are at a greater risk for DES.
- Occupational / Recreational Visual Tasks - People who for occupational or recreational needs have sustained, concentrated visual tasks (driving, computer use, etc.) will find their natural blink reflex altered. This reduced blink frequency results in an increased tear film evaporation, which contributes to DES.
- Side Effects of Disease / Medications - There are several diseases and medications which can lower your ability to produce tears. Systemic medications that may lead to DES symptoms include:
- Antihistamines
- Antidepressants
- Antispasmodics
- Diuretics
- Oral contraceptives
- Hormone replacement therapy
- Sjogren's Syndrome - Sjogren's Syndrome is an immune system disorder characterized by inflammation and dryness of the mouth, eyes and other mucous membranes. This disorder damages the lacrimal glands and affects tear production.
- Laser Vision Corrective Surgeries - Laser refractive surgeries temporarily alter the natural feedback loop from the cornea to the lacrimal glands, thereby reducing the glands stimulation to produce tears. DES can develop in some cases and corrective therapies can decrease symptoms until the feedback loop regenerates, which can take many months following surgery. (top)
Testing beyond a normal eye examination is necessary to accurately diagnose and treat DES and would include:
- Dry Eye Questionnaire - Ironically, it's very possible to exhibit DES symptoms (burning, stinging, grittiness, etc.), without obvious clinical signs of surface damage. Filling out a well thought out questionnaire is essential to diagnosing DES. (Dry Eye Checklist)
- Slip Lamp Bio-microscope - A slit lamp bio-microscope allows practitioners to carefully detail the eye's surface health under significant magnification and would include:
- Evaluation of eyelids - The eyelid houses many of the glands responsible for producing tears, including the main lacrimal and meibomian glands. The lacrimal gland, which is found in the upper lids, produces the main bulk (aqueous) portion of the tear film. The meibomian glands are vertically aligned in the upper and lower lids and have opening just behind the eyelash follicles. These glands are responsible for producing the oil layer of the tear film that reduces evaporation.
- Evaluation of ocular surface cellular health - Excessive dehydration caused by DES results in inflammatory damage of the eye's surface. This damage is best viewed after the instillation of dyes (Fluorescein, Lissamine green, etc.). The conjunctiva (white surface) houses goblet cells that produce the mucous component of tears. Damage to these cells will significantly alter the tear's structure.
- Tear film volume - Testing for the volume of tears being produced will identify when DES is caused by an under production of the lacrimal glands. If present, this is most often an immune - based inflammatory reaction.
- Tear meniscus evaluation - Practitioners estimate volumes by reviewing the size and shape of the tear film adjacent to the lid's edge.
- Schirmer's Testing - This testing estimates tear volumes through the absorption of tears on thin paper strip.
- Evaluation of eyelids - The eyelid houses many of the glands responsible for producing tears, including the main lacrimal and meibomian glands. The lacrimal gland, which is found in the upper lids, produces the main bulk (aqueous) portion of the tear film. The meibomian glands are vertically aligned in the upper and lower lids and have opening just behind the eyelash follicles. These glands are responsible for producing the oil layer of the tear film that reduces evaporation.
- Tear breakup time - Tear film breakup time testing allows practitioners to determine if a contaminated tear film is the cause of DES. If present, this is likely do to infectious or inflammatory reactions on the eyelid edges or within the meibomian glands.
- Expression of meibomian glands - Practitioners can gently express fluids from the meibomian glands to determine their health. (top)
Depending upon the cause and intensity of DES, treatment may be as simple as using artificial tears a few times a day. In more advanced and persistent cases, however, prescriptions medications, nutritional and environmental modifications, and non-surgical treatments may be necessary to control DES and limit progressively worsening damage.
- Artificial Tears / Ocular Lubricants - Artificial tears are the first-line treatment for DES. Properly utilized, they increase tear volume and lubrication, providing surface protection and enhanced comfort. It is vital that appropriate artificial tears be chosen and that they are utilized properly. For example, artificial tears with vasoconstrictors ("removes the red") will actually increase surface drying. In addition, any artificial tear that is preserved should be limited to 4 times per day usage. It is also important that artificial tears be used on a regular schedule. Don't wait for discomfort before initiating use.
- Eyelid Hygiene - Contaminated eyelid surface and dysfunctional meibomian glands disrupt the tear film and result in increased evaporation. In these cases, we often recommend eyelid scrubs to clean the lid surface and warm compresses with message to create a more healthy expression from the meibomian glands.
- Nutritional Options - Nutritional adjustments can have a significant impact on hydration of all mucous membranes, including your eyes. The following general tips should prove helpful:
- Limit the intake of substances that act as a diuretic, such as caffeine and alcohol
- Drink plenty of water
- Avoid smoking and second-hand smoke
- Follow nutritional recommendations for intake of omega 3 and 6 fatty acids (add a link to nutritional guidelines)
- Limit the intake of substances that act as a diuretic, such as caffeine and alcohol
- Environmental Modifications - Certain environmental conditions are more likely to induce DES symptoms. In addition, sustained visual concentration (reading, driving, etc,) results in a decreased blink reflex, increasing exposure of your eyes to the drying effects the environment. The below recommendations should reduce DES symptoms:
- Avoid direct airflow around your face from fans, automobile air conditioning vent, etc.
- Use sunglasses outdoors, especially in dry windy conditions
- Utilize a humidifier, either larger versions to fill a room or small personal options on your desktop to provide moist air and reduce tear evaporation
- Position your computer below eye level
- Blink frequently, consider utilizing frequent, repetitious reminders to blink (Ex. turning a page while reading, completing or reading an email, etc.)
- Avoid direct airflow around your face from fans, automobile air conditioning vent, etc.
- Contact Lens and Care System Options - Certain contact lens materials are far better at providing clean, wet surfaces, which offer more consistent, long lasting comfort and vision. In addition, not all contact lens care systems are best suited for lens wears with DES. Generally, we have found that hydrogen peroxide systems (ClearcareTM) are best suited for lens wearers with DES. We can guide you to the most appropriate contact lens design and solution systems for your specific needs.
- Prescription Medications - When necessary, we utilize prescription medications to treat the underlying causes of DES and promote improve ocular health. In most cases, prescription eye drops can effectively treat eyelid, lacrimal gland or eye surface infections and/or inflammation. In particular, one ocular medication has been developed (Restasis) to specifically treat inflammation of the main lacrimal gland. This topical cyclosporine (0.05%) has been reported to increase tear production and improve DES symptoms. In some cases, however, systemic medications may be needed to treat more broad based conditions (ex. acne rosacea). When present, it is very important to treat these underlying causes of DES. Once controlled, DES symptoms typically improve and can be better treated with the above non-prescription options.
- Non-surgical Treatments - Once all infectious and inflammatory causes of DES have been addressed, a simple non-surgical procedure is available that provides long-term relief through the use of tiny plugs call "punctal or canaliculus occluders." This treatment decreases the tears' flow from the eye's surface - through opening in the eyelids (punctum) - into the nasal cavity. Generally, we begin with temporary (collagen) plugs to determine if punctal occlusion is effective. If so, we then insert more permanent plugs for long-term relief. These plugs can either lie at the eyelids surface (punctal) or be positioned below the surface (canaliculus). They can also be placed in the lower lids, upper lids, or both lids depending upon the severity of your DES. (top)
Please understand that DES is a chronic eye disease that may have been developing for many years before the symptoms became noticeable. We are not likely to reverse these symptoms in a few days. Generally, we begin with aggressive therapy and this therapy will be reduced as your condition improves. (top)
Are These Treatments Covered by Medical Insurance Plans?
In many cases, your major medical plan does cover the costs associated with DES treatments. Our staff will provide insight into your specific plan and its coverage. (top)
How do We Get Started?
It is very important for you to have a comprehensive eye examination prior to initiating any DES therapy. During this examination we will determine the basic health and refractive state of your eyes. Following this evaluation, you will be scheduled for a DES evaluation to address your specific symptoms, underlying causes, and appropriate treatment plan. Contact us to set up your initial, comprehensive eye examination. (top)
