Frequently Asked Questions About Dry Eye:
1. Are dry eyes common?
Dry eyes are a very common problem for patients, especially for older patients in the dry climate area of Colorado. Many patients have dry eyes and don’t even realize it. The symptoms of dry eyes can vary and include: burning sensation, foreign body sensation, blurred vision, watery eyes, stinging, piercing eye pain, and others. As we age, many factors affect the quality and quantity of tear production: age-related hormone changes, tear-gland demise, medication side-effects, chronic exposure to environmental irritants, and increased incidence of autoimmune diseases. Eyelid malpositions contribute to dry eye symptoms because loose and poorly positioned eyelids (e.g., turned outward “ectropion”) cause the produced tears to be poorly distributed and moved across our eye surfaces.
2. How can my eyes be dry if they “water” all the time?
When our tear film isn’t healthy in terms of either or both quantity and quality of the tears, a compensatory mechanism occurs to increase tear production volume-wise. There is an attempt to make up what is missing qualitatively with a higher quantity of tears. The problem, however, is just like an automobile in that if you fill a gas tank with water, the gauge may say full but the engine won’t run well on watered-down gasoline.
3. Are there different types of dry eyes?
Yes, there are many types. Actually, a better term for dry eyes would probably be “dysfunctional tear syndromes.” Our tears have 3 layers on the eye: an outer lipid (fatty) layer that helps avoid evaporation off the eye; a middle aqueous layer, which is the thickest; and the innermost layer is the mucinous layer that is important for even distribution over the ocular surface. Dry eye states can occur from disruption of any of the above tear film layers.
4. How are dry eyes mostly commonly treated?
Because there are different types of dysfunctional tear syndromes (dry eye states), there are different types of treatment. For patients with tear deficient states (aqueous tear deficiency), most patients do well with almost any of the available over-the-counter drops (e.g., Systane Ultra). Some patients have a deficient lipid layer, and there are supplemental tear drops tailored for these patients (e.g., Systane Balance, Optive). Generally, most artificial tears that come in a bottle contain a preservative and should not be used more than 4-6 times daily. If artificial tears are needed greater than 4-6 times per day, then a preservative-free tear brand should be recommended (e.g., Genteal, Celluvisc, others). Most preservative-free artificial tear supplements come in individual “peel-top” packets that are easily carried. Preservative-free tears can be used as often as necessary. If you are having to dose your drops too often, then try using a thicker drop. Celluvisc is about the thickest preservative-free artificial tear. If the drops leave a sticky residue, then try using a thinner formulation. Some patients will mix different thickness drops until they find the best combination for their eyes. During visually demanding tasks (computer use, reading), drops should be placed before starting the activity. Some patients require ocular lubricating gels (e.g., Genteal Gel), ointments such as Refresh PM/Paralube or a generic equivalent. Eye ointments can be placed in the eyes very frequently if necessary and are well tolerated.
5. What is easiest way to apply eye drops or ointment into the eye?
Some patients find it easier when instilling a drop or ointment to gently pull down on the lower eyelid while looking upward to create a space between the eye and the eyelid for placing the medicine. Others gently close their eyes and place the drop or ointment in the inner corner of the eyelids and then open and close their eyes, fostering the entry of the drops or ointment into the eye.
6. What if the drops or ointments blur my vision?
This is unfortunately a very common issue when using drops or ointments. A good solution is to separate in time which eye is being treated so that one eye can “clear” up visually before instilling the medication to the other eye.
7. What else can I do to treat my dry eyes?
Many patients benefit with good eyelid hygiene by using over-the-counter eyelid wipes and/or using warm wet compresses over the eyes for 5-10 minutes a day. The warmth helps soften the oils in the eyelid glands so that they may better get into the tear film. Dietary supplements of omega oils and flax seed are also helpful. Many patients with dry eyes also have blepharitis, which are eyelid inflammatory disorders (“eyelid dandruff” and/or “constipated” oily glands). Diluted baby shampoo or tea tree oil on a warm/wet washcloth can also be very beneficial. Minimize or avoid use of ceiling or other fans that blow on your face.
8. What are punctal plugs?
Punctal plugs are placed into the small eyelid opening into the tear drains of the eye. Each eyelid has one tear drain opening (puncta) that drains into the tear drain system that carries the tears away from the eye. Many patients benefit from these plugs, but they can also cause problems (infection, eye discomfort, easy dislodgment, etc.). Generally, plugs can be removed if they aren’t helping or if the eyes water and tear too much, but they sometimes can become permanently embedded, requiring surgery to remove. Dr. Burroughs has to repair tear drain problems several times a year from tear plug complications, but the vast majority of patients do well with them and do not have any issues. It is generally not recommended to plug all 4 tear drain openings as this prevents the normal egress of tears off the eye and can cause a syndrome known as toxic tears since the tears become unhealthy and concentrated on the eye.
9. What is punctal occlusion?
Punctal occlusion is performed utilizing a small cautery tip to close the very most proximal portion of the puncta. It is safely performed in the office and carries none of the more serious complications of punctal plugs. It can be reversed, but this is only rarely needed. Dr. Burroughs has personally had this done on his upper eyelids because he has dry eyes.
10. Are there any prescription medications for dry eyes?
Restasis is a topical form of cyclosporine, which is an immunosuppressant. It works by reducing the inflammatory component of dry eyes. It is expensive and, though it has a high success rate, takes between 4-8 weeks to begin working. Most patients still require ocular lubricating drops during the day as the Restasis is only used in the morning and at night. Some patients also require a temporary use of ocular steroid drops during the initial phases of treating dry eyes, which require careful evaluation and monitoring by an eye doctor. Doxycycline/Minocycline are prescribed antibiotics used to treat acne that have a beneficial side-effect of loosening the oils in the eyelids so they get into the tear film better. They can increase sun-sensitivity and require a prescription but can be very helpful. Azasite is an antibiotic topical eye drop that also is beneficial for recalcitrant cases of blepharitis (eyelid inflammation), and they also can help with posterior eyelid margin disease by being used to “unconstipate” the oily glands.
11. What can be done while sleeping to help reduce my dry eyes?
Avoid the use of fans. Some patients will tape their eyes shut or buy or make a “moisture” chamber for their eyes. There are specific devices that may be purchased as well. Swim goggles are an alternative, and many patients need to use eye ointment at bedtime and then place the goggles over their eyes. Vaseline and saran wrap can also create a useful moisture chamber.
12. How can surgery help with dye eyes?
Punctal occlusion by cautery is an easy initial step that can be done in the office. Some patients have issues with closing their eyes (lagophthalmos), but Dr. Burroughs can improve eyelid closure to reduce lagophthalmos through various techniques that include reducing retraction of the eyelids, so that they close better. Additionally, some patients with paralysis of the muscles that close the eyes can benefit with the placement of either a gold or platinum eyelid weight. Other lower eyelid malpositions, such as entropion (in turning of the eyelid) or ectropion (out turning of the eyelid), are also beneficial treatments for both improving the discomfort of dry eyes but also to avoid infections and damage to the eye. Shown below are some slides of surgically repaired patients of Dr. Burroughs that was given during a lecture at a national meeting on dry eye.