Dry Eye

Dry eye is a common condition that affects millions of people when tears cannot properly lubricate the eyes, causing discomfort and sometimes affecting vision. Understanding the causes and available treatments can help you find relief and protect your eye health.

Table of contents

• What is dry eye?
• Other names for dry eye
• Types of dry eye
• Signs and symptoms
• What causes dry eye?
• Who is at risk?
• Possible complications
• How doctors diagnose dry eye
• Treatment options
• Lifestyle changes and home remedies

What is dry eye?

Dry eye is a condition that affects your tear film, which is the three layers of tears that cover and protect the surface of your eyes. You need a smooth and stable tear film to help you see clearly and comfortably^[2]. Dry eye occurs when your tears are not able to provide adequate lubrication for your eyes^[1].

Your tears are made of three layers: a lipid (oil) layer that lubricates and prevents evaporation, an aqueous (water) layer that nourishes and protects the cornea (the clear outer layer at the front of your eye), and a mucin layer that helps tears stick to the eye^[4]. Tears can be inadequate and unstable for many reasons. For example, dry eyes may occur if you do not produce enough tears or if you produce poor-quality tears^[1].

This tear instability leads to inflammation and damage of the eye’s surface^[1]. Dry eye is very common and affects millions of Americans every year^[3]. Nearly 16.4 million Americans have been diagnosed with dry eye^[3].

• Eyes
• Cornea
• Eyelids
• Lacrimal glands
• Meibomian glands
• Tear ducts

Other names for dry eye

dry eye syndrome (DES), dry eye disease, keratoconjunctivitis sicca (KCS), dysfunctional tear syndrome, lacrimal keratoconjunctivitis, evaporative tear deficiency, aqueous tear deficiency, LASIK-induced neurotrophic epitheliopathy (LNE)

Types of dry eye

There are a few types of dry eye disease^[2]:

• Aqueous deficient dry eye: This is when the lacrimal glands of your eyes do not produce enough aqueous tears. These tears make up the middle, watery layer of your tear film.
• Evaporative dry eye: This is when your tears evaporate too quickly, most commonly because of meibomian gland dysfunction. The meibomian glands create the lipid (oil) layer of the tear film^[4].
• Mixed dry eye: Some people have aqueous tear deficiency and tear instability. This means your eyes do not produce enough tears, plus your tear film is unstable.

Signs and symptoms

When you have dry eye, you may feel like there is something in your eye that just will not come out. This can feel like a scratchy, gritty or sandy sensation^[2]. Signs and symptoms, which usually affect both eyes, may include^[1]:

• A stinging, burning or scratchy sensation in your eyes
• Stringy mucus in or around your eyes
• Sensitivity to light
• Eye redness
• A sensation of having something in your eyes
• Difficulty wearing contact lenses
• Difficulty with nighttime driving
• Watery eyes, which is the body’s response to the irritation of dry eyes
• Blurred vision or eye fatigue

The symptom of watery eyes may seem confusing. But it is a very common part of dry eye syndrome. It happens when your meibomian glands are not making enough oil. So, the watery layer evaporates too quickly. In response, your lacrimal glands compensate by making too much water. This does not solve the underlying problem^[2].

Dry eye can make it more difficult to perform some activities, such as watching TV, using the computer, and reading^[4].

What causes dry eye?

Normally, glands above your eyes make tears that keep your eyes wet. Dry eye happens when your tears do not do their job^[3]. Causes of dry eyes include^[2]:

• Eyes that do not produce enough tears
• Tears that evaporate too quickly
• Both of these happening together

Eye dryness may occur on its own or along with other medical conditions. In some cases, dry eye is a sign of^[2]:

• Blepharitis
• Sjögren’s syndrome
• Thyroid eye disease

More than half of people with rosacea develop eye problems known as ocular rosacea. Approximately 80% of patients with ocular rosacea have meibomian gland dysfunction, which causes the eyelids to secrete fewer oils that blend with a patient’s natural tears^[15].

Several autoimmune disorders can affect the body’s ability to produce tears normally, including Sjögren’s syndrome, rheumatoid arthritis and myasthenia gravis, as well as other conditions such as Bell’s palsy and thyroid dysfunction^[6]. With lupus, dry eye disease can make eyes have a gritty feel and burning sensation^[15].

Nearly half of people with diabetes have dry eyes. The development of dry eye is often linked to a loss of nerves in the cornea (neuropathy). Without functional nerves in the cornea, tear production from the tear-producing lacrimal glands is decreased^[15].

Who is at risk?

Anyone can get dry eye, but you might be more likely to have dry eye if you^[3]:

• Are age 50 or older
• Are female
• Wear contact lenses
• Do not get enough vitamin A (found in foods like carrots, broccoli, and liver) or omega-3 fatty acids (found in fish, walnuts, and vegetable oils)
• Have certain autoimmune conditions, like lupus or Sjögren syndrome

The older you get, the more likely you are to develop dry eye. More women are affected than men. And the syndrome is more likely to flare up at times of hormonal change such as after menopause or during pregnancy or breastfeeding^[6].

Risk factors for dry eyes include^[2]:

• Environment and lifestyle factors: Things like the weather, how much time you spend looking at screens, contact lens use, smoking or allergies can increase your risk of dry eye.
• Medications: Taking certain medications can increase your risk of dry eye, including some that treat depression, allergies, blood pressure, glaucoma, menopause and pain. Birth control pills can trigger dry eye syndrome, and so can many other medications, including antidepressants, antihistamines, decongestants, antianxiety agents and diuretics or other blood pressure pills^[6].
• Medical conditions: Many different neurological disorders, eye diseases, autoimmune diseases and endocrine conditions can raise your risk of dry eye.
• Surgeries: Some eye surgeries increase your risk of dry eye, including LASIK, cataract surgery and surgery on your cornea.

Looking at screens can worsen dry eye symptoms. We do not blink as much when we are focusing on a screen, and this can worsen dry eye^[9]. Dry eye can happen if you spend a lot of time looking at your computer, tablet, or smart phone^[3].

Possible complications

Complications of dry eyes can range from mild to severe. These may include^[2]:

• Corneal scarring
• Corneal ulcers
• Eye irritation
• Infection
• Vision problems

If severe dry eye is not treated, it can sometimes damage your cornea, the clear outer layer at the front of your eye^[3]. Untreated, dry eye can cause pain, ulcers, or scars on the cornea, and blurry vision^[4]. Chronic dry eye disease can damage ocular tissues and in very serious cases, lead to scarring of the cornea. This damage can cause blurry vision and in severe instances, vision loss^[15].

How doctors diagnose dry eye

Your doctor can check for dry eye as part of a comprehensive dilated eye exam. The exam is simple and painless. Your doctor will give you some eye drops to dilate (widen) your pupil and then check your eyes for dry eye and other eye problems^[3].

An eye exam that includes a complete history of your overall health and your eye health can help your eye care specialist diagnose the cause of your dry eyes^[7]. Your healthcare provider may ask you to fill out a questionnaire about your symptoms^[2].

Tests and procedures that may be used to determine the cause of your dry eyes include^[7]:

• A test to measure the volume of your tears: Your eye care specialist may measure your tear production using the Schirmer tear test. In this test, blotting strips of paper are placed under your lower eyelids. After five minutes your eye care specialist measures the amount of strip soaked by your tears. Another option for measuring tear volume is the phenol red thread test. In this test, a thread filled with pH-sensitive dye (tears change the dye color) is placed over the lower eyelid, wetted with tears for 15 seconds and then measured for tear volume.
• A test to determine the quality of your tears: Other tests use special dyes in eye drops to determine the surface condition of your eyes. Your eye care specialist looks for staining patterns on the corneas and measures how long it takes before your tears evaporate.
• A tear osmolarity test: This type of test measures the composition of particles and water in your tears. With dry eye disease, there will be less water in your eyes.
• Tear samples: Tests to look for markers of dry eye disease, including elevated matrix metalloproteinase-9 or decreased lactoferrin.

To find out if you have dry eye, your doctor might also check the amount of tears your eyes make, how long it takes for your tears to dry up, and the structure of your eyelids^[3].

Treatment options

Treatment for dry eye usually depends on what is causing your symptoms. There are a few different types of treatment that can ease your symptoms and help keep your eyes healthy^[3]. For most people with occasional or mild dry eye symptoms, it is enough to regularly use nonprescription eye drops. If your symptoms are persistent and more serious, you have other options. What you do depends on what is causing your dry eyes^[7].

If something in your life or your environment is causing your dry eye, or making it worse, your doctor may suggest changes to help protect your eyes. For example, if a medicine you take for another health condition is causing dry eye, your doctor may also suggest that you try a different medicine^[3].

The first priority is to determine if there is an underlying cause of the dry eye (such as Sjögren’s syndrome or lacrimal and meibomian gland dysfunction). If there is, then the underlying disease needs to be treated^[4].

Over-the-counter eye drops: The most common treatment for mild dry eye is a type of eye drops called artificial tears. You can get these eye drops without a prescription. There are also over-the-counter moisturizing gels and ointments that may help your eyes feel better^[3].

Prescription medicines: If your dry eye is more serious, your eye doctor may give you a prescription for medicines called cyclosporine (Restasis) or lifitegrast (Xiidra). These medicines are both types of eye drops that can help your eyes make more tears^[3]. There are several FDA approved medication drops to help improve symptoms and signs of dry eye disease^[4].

Medicine to reduce eyelid inflammation can help. Inflammation along your lash line can clog oil glands and keep them from releasing oil. Antibiotics, in the form of pills, eye drops or ointment, can reduce inflammation and get your oil glands working properly again. Your doctor may prescribe them for shorter periods of a few weeks at a time, or you may take them long term^[9].

Eye drops for cornea inflammation help when an overactive immune system causes inflammation on the surface of your eyes (the cornea) that leaves them dry and irritated. Eye drops targeting inflammation, such as cyclosporine (Restasis) and liftegrast (Xiidra), help patients produce more tears. Corticosteroids can also be used to reduce this inflammation^[9].

Punctal plugs: These block the drainage canals, small circular openings at the inner corners of the eyelids where tears drain. The effects last around six months^[4].

A thermal pulsation device opens blocked oil glands. Thus, tears evaporate slower, reviving fluid stability. These treatments aim to preserve natural tears^[13].

If contact lens wear is the problem, your doctor may recommend another type of lens or reducing the number of hours you wear your lenses. In the case of severe dry eye, your doctor may advise you not to wear contact lenses at all^[4].

Lifestyle changes and home remedies

For mildly dry eyes, minor daily tweaks can help your eyes feel a lot better. Several lifestyle changes can help reduce dry eye symptoms^[19]:

• Avoid blowing air into your eyes: Direct your blow dryer, car heating vents, air conditioner and fans away from your eyes.
• Use a humidifier: It is especially important to add moisture to dry, indoor air during the winter months.
• Rest your eyes: Take a break and close your eyes for a few minutes before returning to your book or using your laptop.
• Position your computer screen below eye level: Not opening your eyes as wide reduces the evaporation of tears between eye blinks.
• Avoid smoke: If you smoke, talk with your doctor and develop a plan to help you quit. It is also important to avoid secondhand smoke.
• Block wind and dry air: Wearing wraparound sunglasses and adding safety shields to the tops and sides of eyglasses can protect your eyes from these irritants.

Practice the 20-20-20 rule. Take a 20-second break every 20 minutes to look at something 20 feet away. If that is too frequent, try every 30 minutes or every hour^[16]. Blink frequently when looking at screens. Blinking coats the eyes with a nice, smooth layer of tears. This layer protects the eyes from drying out too fast^[11].

Wash your eyelids and lashes: When you wash your face, you need to pay careful attention to your eyelids and eyelashes, because this is where many tear glands are located. Use warm water and baby shampoo or a preservative-free eyelid cleanser to gently clean your upper and lower eyelids^[11]. There has been a big push to practice lid hygiene, which is something we should all do 1 to 2 times per day. Clean your eyelids with an eyelid wipe, available at your local drugstore^[16].

Massage your eyelids: Regular eyelid massage and meibomian gland expression can provide relief from dry eye symptoms. Begin by applying a warm compress to closed eyelids for several minutes. This helps to soften the oils in the meibomian glands, making them easier to express. Using clean fingers, gently massage the eyelids. For the upper eyelid, apply a downward motion towards the lashes; for the lower eyelid, use an upward motion. Regular practice of this routine, ideally twice daily, can lead to significant improvements in eye comfort and health^[11].

Stay hydrated: Your body needs adequate water to maintain a healthy tear film. Dehydration can lead to insufficient tear production, making your eyes feel dry and gritty. Make sure you drink at least 8 glasses of water per day (and even more if you are consuming caffeine or alcohol). You could also add water-rich foods like cucumbers, watermelon, oranges, and celery to your diet to keep your body and eyes hydrated^[17].

Make diet adjustments: What you eat directly impacts your eye health. Omega-3 fatty acids found in salmon, flaxseeds, and walnuts support healthy tear production. Vitamin A from carrots, sweet potatoes, and leafy greens helps keep eyes moist. Vitamin C from citrus fruits and bell peppers also supports eye moisture. You should try to eat less salty, processed food. Too much salt can dry out your body and make dry eye symptoms worse^[17].

Control your environment: Several environmental factors can aggravate dry eye symptoms, such as dry air, harsh weather conditions, smoke, and allergens. To protect your eyes, you should use a humidifier to add moisture to indoor air, especially in the winter when heaters dry out the air. Make sure to also always wear sunglasses when going outdoors. For airborne allergens and smoke, keep your home well-ventilated and use an air purifier to reduce irritants^[17].

See your health care provider if you have had prolonged signs and symptoms of dry eyes, including red, irritated, tired or painful eyes. Your provider can take steps to determine what is bothering your eyes or refer you to a specialist^[1].