Make Your Eyes Happy: Dry Eye Causes and Treatments

Disclaimer: I am an eye doctor at Premier Eyecare Associates. Many of the products and procedures I discuss are those that my practice offers, because I trust the peer-reviewed research or my own or my patients’ experiences backing them. I am also an Amazon Affiliate for a few products my practice does not provide but that I think could help my patients, and I earn a small commission from qualifying purchases. Ultimately, since all individuals are unique and I do not know your exact medical history, you should ask your own eye care provider about any medical advice or products mentioned.  However, know that all my recommendations are solely based on the best interest of my patients & readers. Thank you!

As an optometrist, dry eye is one of the top five complaints that I routinely hear from patients.  It is a topic that I am extremely passionate about since I myself suffer from it too!  If you are like me and suffer from dry eye – be it mild or severe – join me as we explore Dry Eye Disease…

1. Causes
2. Risk factors
3. Classic Symptoms
4. Treatments

What causes Dry Eye Disease?

If you were to look in a textbook, you would find that dry eye is “a chronic, multifactorial disease of the eye’s surface characterized by a loss of tear film homeostasis, resulting in irritating and sometimes debilitating eye symptoms.” Essentially what that means is that dry eye is a result of an imbalance of the natural components of your tears. This imbalance then starts to cause eye surface damage and inflammation which leads to irritation, red eyes, and possibly blurry vision.

Composition of tear film

Your tear film is made up of 3 layers: the mucin layer, the water layer, and the oil layer. While in reality these are not discrete layers (and instead form more of a mixture), it can be helpful for educational purposes to consider each a separate entity.  A simplified diagram can be seen below.

• The lowermost green layer is what is referred to as the mucin layer. This layer provides a slightly sticky surface so your tears don’t slide right off your eye. While it is technically possible to have an issue with this layer, this condition is rarer and so this post will primarily focus on the other two layers.
• The second (middle) layer is a water layer which is produced by your lacrimal glands that sit above the eyes. This layer is the primary part of the tear film that is protecting the surface of the eye – ensuring that the eye is moisturized and comfortable.
• The outermost layer is a thin layer of oil which is produced by the meibomian glands within your eye lids. The role of this layer is to provide a protective barrier and prevent the critical water layer from evaporating too quickly off the eye.

All Dry Eye Disease is ultimately the result of the water part of the tear film evaporating from the front surface of the eye and leaving the eye itself exposed directly to the air. This exposure causes irritation and inflammation, leading to dry eye symptoms.  To make matters worse, these symptoms then can lead to further eye surface damage, which just worsens the overall condition. It is possible to get stuck in this vicious cycle where the initial dry eye causes problems which worsens the dry eye itself.

Overall, all three parts of the tear film have to work together to protect the front surface of the eye.  If any one of these is not in balance, it can lead to dry eye.

Primary Types of Dry Eye

As you might have guessed, with two main tear layers, there are two main types of problems that can occur:

1. The water layer of the tear film is too low – I.e. the body is not producing enough tears (or they are draining too quickly).
2. The oil layer is too low – there is not enough oil keeping the water on the front surface of the eye

These two issues are the two classical types of Dry Eye Disease.  You might be experiencing one (or both!) of these.  If so, be sure to ask your optometrist which type you have as the treatments can differ.

Aqueous Deficient Dry Eye

The first type of Dry Eye Disease correlates to our first problem – inadequate water tear supply.  It is known as Aqueous Deficient Dry Eye Disease.

• The production of the water part of your tears is reduced but you have enough of the oil layer of your tears that would otherwise maintain a normal tear evaporation rate.
• Without enough of the water part of your tears, areas of the eye are exposed to air, resulting in damage, inflammation, symptoms, and signs of dryness.
• This cause is less common, but still occurs in at least 14% of dry eye patients.
• Often ADDE is caused by a medical condition like Sjögren syndrome, thyroid disease, rheumatoid arthritis, lupus, and others.
• There are several treatments for this condition… Find out more here!

Evaporative Dry Eye Disease

The second type of Dry Eye Disease correlates to the second problem – inadequate oil supply.  This is essentially the inverse of the first disease where instead of the water supply being low, the oil supply is too low. This type of disease is known as Evaporative Dry Eye Disease. This type of disease is caused by Meibomian Gland Dysfunction (MGD).

• This is the most common type of dry eye – with 86% of patients suffering from inadequate oil production (including myself)!
• The production of the oil part of your tears is reduced but the rate of water production is otherwise healthy.
• Without enough of the oil part of your tears, the natural protective layer which limits evaporation of the water off the eye is inadequate.
• The water layer evaporates quicker than it can be produced and areas of the eye are exposed to air, resulting in damage, inflammation, symptoms, and signs of dryness.

With Evaporative Dry Eye being by far the most pervasive type of dry eye, I thought it would be useful to explore it in a little more depth.  One of the reasons that this particular type of dry eye is so prevalent (and still increasing!) is the proliferation of digital devices within our lives.  You naturally blink about 15 times per minute and with each blink, your eyes squeeze out just a bit of oil from your meibomian glands.  It is this oil that keeps that oil layer large enough to protect the water portion of the tears which is ultimately keeping your eye hydrated and happy. Digital devices all flicker really quickly. This flickering, known as refresh rate, is a common specification on TVs or computer monitors… check it out next time you are shopping.  The flickering, while not consciously noticeable, is perceived as motion by the eye, and our brains naturally slow down the blinking process in an attempt to focus.  This results in blink rates closer to 5 times a minute – 3 times slower than what your body naturally wants!  Less blinking means less oil enters the tear film. This low oil tear film then leaves the water layer exposed to rapid evaporation.

Due to flickering of device screens, the average person blinks 3x less frequently when using digital devices.

Association with Meibomian Gland Dysfunction (MGD)

Evaporative Dry Eye Disease is caused by a condition called Meibomian Gland Dysfunction (MGD). This condition occurs when the eye oils begin to harden and clog up meibomian gland opening. One of the dangers with MGD is that the glands that provide oil to the eye can atrophy and permanently die.  These glands run vertically within your eyelids and produce oils that should be the consistency of olive oil.  However, if the eye does not blink enough, or blink properly, these oils tend to build up and thicken into a consistency more like butter.  This thicker oil cannot be released into the tear film, so you have less liquid oil protecting the water layer from evaporating off the eye. This leads to the eye being exposed to air, which results in dry eye symptoms.  You can see in the image below a diagram of your meibomian glands. 

The two smaller images show both healthy and unhealthy glands.  The healthy glands produce nice clear, clean oils.  The unhealthy glands look a lot like pimples, with the oils thickening and blocking the glands.  If this blockage is left untreated, over time the gland beneath begins to stop the production of oils.  Once this production is stopped, the glands cannot be restarted.  It is important to check in with your optometrist who can help monitor the progression of MGD as well as help address some of these underlying causes.

It is also worthwhile to note that MGD can also lead to a host of other issues like lid gland infections (hordeolums/styes) or lid inflammatory disease (blepharitis).  Each of these other conditions are caused by bacteria which tend to gather in these blocked oil glands.  Ultimately, blepharitis, hordeolums, styes, meibomian gland dysfunction, evaporative dry eye disease – they’re all related, and they can all worsen each other if they aren’t treated.

Who does Dry Eye Disease affect?

In short, dry eye is extremely widespread and can affect anyone and everyone.  A study investigating the prevalence of Dry Eye Disease in Americans 18-years-old and older found that up to 9.3% of the United States adult population suffers from Dry Eye Disease.  Using that figure of 9.3%, that means that approximately 30 million men and women in the United States alone suffer from some degree of dry eye. That same study also found that Dry Eye Disease is nearly 2 times higher in women than men. Additionally, for both sexes, prevalence increases with age, and it is 3 times more likely to occur in people older than 50-years-old than in those between 18- and 49-years-old.

The two greatest risk factors are:

#1 – Older age
#2 – Female gender

Other risk factors for Dry Eye Disease include:

What are Symptoms and Signs of Dry Eye Disease?

Dry eye disease can affect the eyes in a variety of ways and present with a multitude of sensations. Symptoms and signs of Dry Eye Disease include:

• Overall dryness
• Burning
• Stinging
• Watery eyes (from reflex tearing)
• Itching
• Eye fatigue
• Soreness
• Sandy or gritty sensation
• Light sensitivity
• Intermittent filmy or blurry vision that improves with blinking
• Redness
• Mattering of the eyes
• Mucous discharge

How can I get my eyes to feel better right now?

In order to effectively fight Dry Eye Disease, it is critical to determine the root cause. Your best bet is a visit to an optometrist or ophthalmologist who can carefully examine your eyes and do this for you (schedule with me today!). At your next eye exam, be sure to tell your eye doctor about your symptoms and ask which type of Dry Eye Disease you have. If you have already had your yearly eye health exam, schedule a medical visit with your optometrist in order to evaluate your Dry Eye Disease and get these questions answered.

However, there are some general practices that you can try today to help alleviate your symptoms (but these are mostly temporary measures and do NOT actually cure Dry Eye Disease!):

For Temporary Relief at Home Try:

1. Changing your environment.

Since dry eyes are caused by the water evaporating off your eyes too quickly, try changing anything in the environment that accelerates the evaporation process. 

This can include:

• Pointing fans, vents, and heaters away from your eyes
• Using a humidifier
• Taking breaks from your computer, television, and other devices every 20 minutes and forcefully blinking to release oils from your eyelids into your tear film
  • Remember: When using these devices, you naturally blink 3 times less and thus your eyes are more prone to dry eye!
• Wearing safety glasses or goggles that protect you from chemicals, pollution, dust, and metal at your workplace

2. Using artificial tears or lubricating eye drops up to 4 times per day. 

Artificial tears and lubricating drops are designed to replace the water part of the tears that your eyes are either not producing enough of or are evaporating off the front surface too quickly.  These drops can be purchased over-the-counter at your local eye clinic, pharmacy, and grocery/convenience store. 

Some tips on choosing the right drops:

1. Do not use Visine (a decongestant that can get red out of the eyes temporarily) or antihistamine eye drops (for allergies) as these can worsen Dry Eye Disease symptoms and signs – this is one of the most common mistakes I see from my patients!
   • Check the “active ingredients” and if the bottle lists items with a purpose other than “lubricant” or “artificial tear” stay away from it for the purposes of treating dry eye.
2. I don’t have an allegiance to any artificial tear; you can start with a cheap drop – if it works, stick with it!  If it doesn’t, don’t assume all brands won’t work – brands use different formulations and preservatives. It is common to prefer one over another.
3. That said, if you are looking for a recommendation, I personally use (and love!) Blink Tears.  Blink uses a preservative called stabilized oxychloro complex (SOC) which naturally breaks down when exposed to air, so it is impossible to have a reaction to it! Blink has three different formulations, and Premier Eyecare Associates sells all three (request yours today):
   1. Blink Tears (for all day use but not safe for contact lenses)
   2. Blink Contacts (for all day use over contact lenses)
   3. Blink Gel (for use at night before bed)
      • This drop is thicker and stays on the front surface of your eye longer but can blur your vision
      • It is recommended for the 10% of us that keep our eyes cracked open while we sleep. I keep this on my nightstand.
      • I also use these before I cut an onion to dilute those chemicals that make me cry while I’m prepping dinner.
4. If an artificial tear irritates your eyes, you may be sensitive to the preservative in it, so talk to your optometrist if you respond better to some artificial tears than others. There are many preservative-free artificial tear options available now. These can come in clear, individual-use vials or multi-dose bottles.
   • If using the individual vials, you can use one vial as many times as you need to for 24 hours but it is important to throw the vial away after a day’s use, because there is no preservative protecting it from bacteria and other contamination.
   • Here are some preservative-free options:
     1. Individual vials for daytime use (There are so many! A whole other post to come about their differences…)
        • Refresh Relieva
        • TheraTears
        • Systane Hydration PF
        • Oasis Tears Plus
     2. Multidose bottles (10mL, or 300 drops – for those of us that use this stuff over 4-6X/day)
        • Freshkote PF Multidose – this is my FAVE for patients who also have Epithelial Basement Membrane Dystrophy. This drop is hypertonic, so it draws water to itself, helping corneal layers adhere to each other better – improving comfort and vision. It’s technically a salty drop that does NOT sting but feels so good!
        • Systane Hydration PF Multidose
        • Oasis Tears Multidose
        • Refresh Relieva PF Multidose
     3. Night-time relief
        • Refresh P.M. PF (ointment)
        • Systane Nighttime (ointment)
5. Some artificial tears have oil added to them for those who suffer from Evaporative Dry Eye Disease and MGD, and these artificial tears stay on the front surface of the eye longer. These include:
   • Refresh Optive Advanced (castor oil) and Refresh Optive Mega-3 (castor oil & flaxseed oil) from Allergan
   • Systane Balance and Systane Complete (mineral oil) from Alcon
   • Soothe XP (mineral oils)
   • Retaine MGD (mineral oils) from Ocusoft

How is Dry Eye Disease treated?

While the above tips can make your eyes feel better, and thus improve your quality of life, they do not cure your Dry Eye Disease. If you want to treat the root cause of the problem or if you experience moderate to severe dry eye symptoms after following the above tips, go back to your eye doctor and ask about further treatment.  This treatment will differ based on your specific type of Dry Eye Disease.

Treatment for Aqueous Deficient Dry Eye Disease

If your aqueous deficient dry eye disease is caused by a medical condition – Sjögren syndrome, thyroid disease, rheumatoid arthritis, lupus, among others – make sure you visit your primary care physician to ensure that any underlying conditions are being treated and is stable. The body is one interconnected unit and other ailments can manifest themselves in the eye, even if the eye itself is not the root cause of the problem.  Treating the symptoms without addressing the core problem will only result in a temporary relief.

Remember, Aqueous Deficiency means that you don’t produce enough of the water part of your tears. Treatment options include replacing your tears, keeping what you do produce on the eye longer, and reducing inflammation that can block your tears from getting to the front surface of the eye.

First line treatment options include:

• Artificial tears – your optometrist can suggest an artificial tear specific to your needs.
• Traditional anti-inflammatory eye drops, ointments, or pills that your optometrist must prescribe (like some low-dose antibiotics, steroids, Xiidra, Restasis, etc.).  These are commonly used in addition to artificial tears to directly target eye inflammation and help alleviate eye surface discomfort.
• Wearing moisture chamber eyewear at night while you sleep (like Tranquileyes or Eyeseals), indoors at the office (7Eye indoors), or outdoors while working in the yard or biking (7Eye outdoors)
  • Remember, 10% of people don’t completely close their eyes when they sleep, leaving the bottom of their eyes exposed to dryness all night. Your optometrist has ways of figuring out if you are one of the 10% in clinic!
  • Moisture chamber goggles keep your eyes in a humid environment continually. Your tears will evaporate but stay in the chamber to keep your eyes comfortable.
  • 7eye by Panoptx has a number of cute dry eye moisture glasses for indoor and outdoor use!

If these are not effective, your optometrist may suggest a second line treatment or procedure:

• Bandage contact lens or scleral lens. 
  • These lenses create a physical barrier which keeps the cornea hydrated, protects it from dry eye damage, and relieves dry eye symptoms.
  • Scleral lenses also have an added benefit of simultaneously correcting vision – fighting two problems at once! (Scleral Lens Clinic post coming soon!)
• Customized prescription eye drops – These eye drops are specially designed and manufactured to treat your specific needs, outside of what is commonly available. 
• Punctal plugs
  • Many optometry offices, including mine (Premier Eyecare Associates), offer temporary and permanent punctal plugs.
  • Your puncta are drainage structures in all four of your eyelids, at the lid margin, towards your nose that drain tears as you blink.
  • Plugging these drainage structures keeps the water part of your tears on the front surface of your eye, improving signs and symptoms of dry eye.

Treatment for Evaporative Dry Eye Disease or Meibomian Gland Dysfunction

Like aqueous deficient dry eye, Evaporative Dry Eye Disease and Meibomian Gland Dysfunction can also be related to medical conditions like acne, rosacea, and other inflammatory conditions, so the first step in treatment is ensuring that you are visiting your primary care physician for proper treatment of your underlying condition. You don’t want to be just treating symptoms while ignoring the actual cause!

Remember earlier when I mentioned that meibomian gland dysfunction or evaporative dry eye disease is worsened by and can cause blepharitis (bacterial lid disease) and hordeolums and styes (infections of lid glands)? It’s important that if you suffer from dry eye symptoms and have any of these conditions, that you address each one to protect your meibomian glands from atrophy, prevent painful lid infections, and improve your signs and symptoms of Evaporative Dry Eye Disease.

Once all other conditions are controlled, you can begin to help treat Evaporative Dry Eye itself.  Since this is by far the more common cause of dry eye, you will notice there are a wider array of techniques and technologies to address signs and symptoms.

At home treatment routine includes:

• Oil-based artificial tears for comfort (discussed earlier) – these supplement your own oil production and water tear supply
• Omega-3 supplements – My favorite is EZ Tears which is specifically formulated for the eye and is clinically proven to improve tear quality and quantity in a matter of weeks (learn more here!).
• Prescription anti-inflammatory eye drops, ointments, or pills (low-dose antibiotics, steroids, etc.)
• Daily lid hygiene and lid scrubs to treat blepharitis and remove biofilm from meibomian gland openings to minimize oil clogging of meibomian glands
  • I personally use Vision Cleanse on a cotton round every morning on my eyelids and on my lashes to treat my blepharitis and improve my meibomian gland treatment. Vision Cleanse is a hypochlorous acid spray that kills both bacteria and viruses but is broken down by skin proteins after a time on the lid surface. Here’s how to use it. I love it since it is extremely effective in terms of both treatment and cost (each bottle contains 330 sprays).  It is produced by Pure & Clean in my home state of Missouri!
  • Other lid scrubs include:
    • Ocusoft Original lid scrub (must rinse off the eyes after application)
    • Ocusoft Plus lid scrub (don’t have to rinse off the eyes after application)
    • Cliradex

• Warm compresses every day or every other day
  • The goal of a warm compress is to heat the lid oils back to the olive-oil consistency it was designed to be.  One of the best compress methods is to use a Bruder mask warm compress.  There’s no mess, it’s safe for frequent use, it’s antibacterial and non-allergenic, and it’s washable and reusable. Call Premier Eyecare to get your Bruder mask!
    • To use a Bruder mask you simply heat the mask in a microwave for 20 seconds and place it on your closed lids for 10 minutes. The MediBeads technology contained in the mask continuously absorbs water molecules from the air and stores them inside the beads such that when microwaved, the water is release as clean, soothing moist heat. The Bruder mask maintains the 40-41.5⁰C temperature needed to melt oils for the entire 10 minutes.
    • After melting the oils this way, you massage the oils out of your eyelids by using clean fingers to roll the lids from your brow and towards your eyeball for the upper lid and from your cheek and towards your eyeball for the lower lid.
    • P.S. This is also the treatment for hordeolums and styes! Though uncomfortable, it’s important to melt the oils and massage the puss out of an infected gland.
  • You can also use a washcloth under warm water for your warm compresses, but this is messy and oftentimes, your washcloth won’t maintain the required temperature to heat your oils.
    • Tip – If you do this, as you feel the washcloth start to cool off, you can slowly unravel it and keep the next innermost part of the washcloth on your closed lids for best heat maintenance.

In office treatment options include:

• Lid margin debridement
  • Your eye doctor can remove the biofilm off of your meibomian gland openings at your lid margin. Biofilms can block meibomian gland openings and make it difficult to express oils. If this biofilm is present, your warm compresses and lid massage will not work.
• iLux thermal pulsation
  • Some optometry offices (like Premier Eyecare!) offer iLux as a treatment for MGD or Evaporative Dry Eye Disease. iLux is a relatively new, in-office treatment which uses a thermal pulsation system to deliver therapeutic heat directly to the front AND BACK of the lids. Warm compresses only heat the front surface of the lids. iLux then melts the oils and subsequently massages them out to return your meibomian glands to their natural production state.
  • Many patients are too busy to perform daily warm compresses and/or their warm compresses at home do not always bring enough heat or maintain heat to the oils. iLux is clinically proven to do just that and jumpstarts dry eye maintenance at home. Benefits last 12-18 months in most patients. Some of my patients love this procedure and schedule it with me twice a year.
  • If you live in North-West Missouri, have moderate to severe meibomian gland dysfunction, and require a jumpstart to your at-home treatment, you can call to schedule treatment here.

“The iLux procedure makes [MGD] treatment a breeze … Since the iLux treatment was introduced to me, I’ve had 5 done now …

My eyes no longer feel dry and scratchy.
I no longer have any burning and itching.
I no longer have eye straining headaches.
I have better quality of vision.
Overall my eyes feel HEALTHIER.”

– Kym –

In summary…

Dry Eye Disease is a relatively common disease affecting almost 10% of people.  It is caused by evaporation of the tear film which leaves the surface of the eye exposed. Dry Eye Disease includes several different mechanisms, with each having its own corresponding treatments.  Dry Eye can greatly affect your quality of life, eye comfort, and vision, but it doesn’t have to.  Thankfully, there are many treatment options and scientists and doctors are working on more.  Early detection and treatment can go a long way toward restoring stable, comfortable vision.  If you or someone you know suffers from Dry Eye, share this post with them and encourage them to reach out to their eye doctor.

If you live in North-West Missouri and would like to schedule a dry eye consult with me or need to order any dry eye treatment products, feel free to contact Premier Eyecare Associates here.

References

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2. K.F. Farrand, M. Fridman, I.O. Stillman, D.A. Schaumberg. Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older. Am J Ophthalmol, 182 (2017), pp. 90-98.
3. M. Horton, M. Horton, E. Reinhard. Master the Maze of Artificial Tears. Review of Optometry (2018).
4. C. Kent. Three New Algorithms For Treating Dry Eye. Review of Ophthalmology (2017).
5. A. Hellem, G. Heiting. Meibomian Gland Dysfunction (MGD): The Cause of Your Dry Eyes? All About Vision (2021).
6. M.B. Abelson, S. Oberoi. Treating Dysfunctional Meibomian Glands. Review of Ophthalmology (2006).