Dry eyes (Sicca)
Dry eyes is a common problem that affects many people. We see an increase of complains about dry eyes. People stare at computer and phone screens for a large quantity of the day and sit in air conditioned spaces. People who do not suffer from dry eyes can hardly imagine how irritating it can be.
MOISTURE REGULATION OF THE EYE
The eye is our most advanced organ. Our eyes can only function well when the outside (the cornea) is smooth and moist. In our ancestors eyes developed for under water use. In this wet environment keeping them moist was not an issue. But on land it became a big challenge. In our dry land biotope there is a continuous battle between enough moisture, too little (dry eyes) or too much (tearing eyes).
What we need is a thin smooth layer of fluid that lasts for 10 seconds, also known as tear film. The tear film keeps the eyes moist so that the incoming image can be projected onto the retina. Next to that it needs to protect the eye against dust, bacteria and small things like flies. Just a tiny amount of waterworn’t do the job. The tear consists of a couple of different components: water, mucus and oil.
The water is produced by the tear gland. The mucus is produced by goblet cells in the conjunctiva. The oil is produced by small glands in the eyelid (meibomian glands).
The oil layer seals the tear to outside air circulation. This prevents evaporation and secures that the tear remains evenly distributed over the eye. Each time you blink a little bit of oil is milked out of the meibomian glands.
WHY DO YOU GET DRY EYES?
The 2 best known causes of dry eyes are:
- The tear gland produces too little fluid.
- The meibomian glands in the eyelid are producing oil of insufficient quality and/or quantity.
Surprisingly malfunctioning meibomian glands appear to be the most common cause of dry eyes. This condition has several names: blefaritis, meibomitis or meibomian gland dysfunction (MGD). Less is known about the role of mucus in dry eye disease. In some cases of severe dry eyes the number of goblet cells is decreased.
Dry eyes can also occur when the eyelids do not close properly. It can be caused by Bell’s palsy, Graves’ disease or after eyelid surgery.
The last frequently occurring cause is a problem with the pain sensation (sensitivity) in the cornea. Someone who has lowered corneal sensation does not feel (or later on) that his/her eye is dry. This causes a decrease of the blinking rate and thus dry eyes. This problem often occurs after refractive surgery (LASIK), but can also be seen after a viral eye infection. If there is a problem in the production or distribution of the water, oil, mucus or sensitivity the tear film of the eye can not remain smooth and moist, with dry eyes as a consequence.
I DO NOT HAVE DRY EYES, I HAVE TEARING EYES
We hear this comment quite a bit. The term ‘dry eyes’ is a bit unfortunate. The correct term should be: a tearing disorder. There are two types of tears: basic tears and reflex tears. Good basic tears are always present. Their function is to make sure that the eye remains moisturized between blinking for at least 10 seconds. The reflex tears are called upon when the body receives the message that ‘something’ needs to be flushed out of the eye. This ‘something’ can be a foreign body such as a grain of sand or a fly but a very common cause is that the basic tears are not moisturizing the eye properly. The reflex tears have a different composition than the basic tears. Reflex tears are very effective to wash away a foreign body but they are completely ineffective if the problem is caused by insufficient basic tears. They do not provide the solution for the problem, and the problem keeps repeating. This is the reason why the patient with ‘dry eyes’ experiences ‘tearing eyes’ instead of dry eyes.
DRY EYES EXAMINATION
The examination starts with questions : how long, how bad, more grittiness or more tearing? Medication? Other diseases i.e. sarcoidosis or complains such as dry mouth? Previously used eyedrops and therapies.
During the examination the eye doctor will use many different types of instruments and tests. The Schirmer’s test and the fluorescein test have been around for over a hundred years but still very useful.
- the Schirmer’s test quantifies the tear production. The eye receives a drop of anesthetic, a smal paper strip is put behind the lower eyelid. After 5 minutes the paper is removed and the amount of tears can be read from the paper. A normal value is 15 mm or more. Less than 10 mm is considered abnormal. The main pitfall with the Schirmer is that someone with dry eyes can produce a higher or normal value because of reflex tears due to the paper strip or a few other reasons. We take this into consideration when reading the test.
- the fluorscein test. This test allows us to visualize scratches and dry spots on the cornea. It also shows the stability of the tear.
Besides we can examine and judge the meibomian glands by squeezing the eyelids. The sensitivity of the cornea is tested by placing a thin piece of paper on different spots on the cornea.
Two modern tests that we offer in our clinic are the meibography and the video analysis of the tear film. These examinations make it possible to measure the functionality of meibomian glands and are an important addition to the classic test.
Summarized we can do the following examinations:
- Fluorscein test (dry spots and stability of tear film)
- Schirmer’s test (quantity of tears)
- Eyelids (snap test and expression of meibomian glands)
- Sensibility (feeling of the cornea)
- Meibography (measurement of the quantity and volume of functioning meibomian glands)
- Video analysis (measurement of tear film)
TREATMENT
If the treatment of dry eyes would be something simple, there would not be so much issue about it. Usually we can reduce the symptoms but a definite cure is not possible.
The treatment of dry eyes requires several steps. For the individual patients it can be a long traject of trial and error until the best possible treatment has been found. The problem is that there can be more than one cause and each cause needs to be dealt with. Every treatment starts with some kind of eye drop (step one). The other steps depend on the problem.
There are many types of artificial tears: duratears, vidisic, hylo-comod, celluvisc, artelac, hylo-gel and hylo-dual. For most people with mild DED a few drops per day can be sufficient.. People with more severe DED will feel the need to use them much more often. All people with DED might benefit from additional therapy but in general only people with more severe symptoms will look for additional therapy. This could be a missed opportunity for people with milder symptoms: simple additional treatment with punctum plugs or IPL could make many of them nearly symptom free without the need to use drops.
Eyelid hygiene means that that patient gets the advice to put warm compresses on the eyelids and to clean the edges of the eyelids (see treatment blefaritis) with a cleansing swab with water or a special cleaning agent such as blefasol.
In healthy eyes meibom is a clear liquid oil. With blefaritis the meibom becomes turbid or even solid which causes it to be inefficient. Warm compresses can melt the congested fat in the meibomian glands.. Which then in turn gets distributed better in the tear film. A good method is to place a warm (not hot!) water drenched towel over closed eyelids and hold for a couple of minutes. A lot of people make the mistake of using a small cotton swab, but this cools down too fast.
There are a couple of medications available for dry eyes. These are: terra-cortril eye ointment (blefaritis), efracea/minocycline (rosacae), dexamethasone (we suggest against the use of this medication!) and ciclosporine. These types of medications are prescribed by an eye doctor and are not applicable to all patients. We don’t use them very frequently. Although this might change with the reimbursement of ciclisporine.
The name ‘punctum plug’ sounds scary to many people. We prefer to cal them ‘tear safers’. They are an effective solution in the treatment of dry eyes. You can compare them to a bathtub drain-stopper. The human eye has two drains for tears: one in the superior eyelid (punctum superior) and one in the lower eyelid (punctum inferior). The puncta are situated on the eyelid edge near the nose. If there is a stop placed in the lower tear drain, the tear can stay in the eye longer. Read more about punctum plugs.
Intense Pulsed Light is a relatively new treatment for ophthalmology. In dermatology, IPL is a well known treatment of rosacea. IPL was introduced to dry eye treatment when it was observed that people who received IPL treatment for rosacea also experienced an improvement of their dry eye problems. People with (rosacea) blepharitis have a problem with small blood vessels in the skin. These blood vessels are treated with IPL. A series of IPL treatments can improve the function of the meibomian glands. In our clinic we offer Intense Pulsed Light treatment. About 85% of people experience an improvement after IPL treatment. Unfortunately IPL is not reimbursed at the moment.
In some cases you can use special tools. Such as goggles to reduce evaporation (though barely used), another solution are special contact lenses such as bandage lenses or sclera lenses. These special lenses are not frequently used because it can be difficult to use them and there is also a risk of infection.
There are quite a number of helpful tools to heat up the meibomian glands.
WHAT TREATMENT IS RECOMMENDED FOR ME?
For each patient the therapy depends on what we find. As a rule of thumb one can state that one problem won’t cause problems. For example, someone with very few tears but of good quality won’t experience problems. People with dry eyes most likely have several problems that should all be addressed. The usual schedule is that we will start with drops, eyelid hygiene and warm compresses. If necessary followed by tear safers (plugs) and/or IPL.
WHAT CAN I DO MYSELF?
It depends on the cause of your complaints. If you experience irritation with dry air you could try air moisturizers or wear good (sun)glasses that stop the wind when you are outside. We also recommend you quit smoking and use more eye drops. People with rosacea and dry eyes can get more irritation after using coffee, tea, chocolate and alcohol or from too much sunlight. Other recommendations include: warm compresses, cleaning the eyelids and blinking more often.
FREQUENTLY ASKED QUESTIONS WITH DRY EYES
What eyedrops can I use against dry eyes?
There are my types of eye drops. These are called artificial tears. Examples are hypromellose, duratears, artelac, hylo-comod, hylo-dual, vidisic, etcetera.
What type of medication causes dry eyes?
There is a lot of medications that could cause dry eyes. If you think that this is your situation it can be a good tip to read the prescription. Known medication are: drugs for parkinson’s disease or incontinence, antidepressants, beta-blockers and diuretics.
What vitamins ensure less dry eyes?
There are no vitamins that help against dry eyes.
What complaints do you get from dry eyes?
Dry eyes can cause many problems and complaints. Burning, stinging, itchiness, grittiness a feeling of having dry sand in your eye, etc. This can cause blurry vision, tearing eyes and red eyes.
What treatments are there against dry eyes?
The classical treatment is eye drops (artificial tears) and/or warm compresses. If these two options do not work, treatment is possible by punctum plugs and IPL.
What causes dry eyes?
You get dry eyes if you do not produce enough tears and/or if the quality of the tear isn’t good enough to keep the eye moist. The exact cause is unknown.
When can you get dry eyes?
Dry eyes are not unusual when you get older, if you wear contacts or you underwent refractive eye laser surgery (lasik, prk, SMILE).
Can aging effect my dry eyes?
When you get older you produce less tears and the quality of the tears decreases. Your eyelids also get weaker and make its more difficult for the tear duct to flush the tears.
How can I treat dry eyes?
A complete cure is not possible. Treatment can solve some problems. A shortage of tears can be helped with punctum plugs, tear films not properly working can be helped by curing the inflammation on the eyelid with warm compresses and proper hygiene. Not properly working meibomian glands can be stimulated with warm compresses or IPL treatment. Next to that the most basic solution are eye drops.
How long do I have dry eyes after my laser eye surgery?
Treatment with a floater laser does not cause dry eyes. Only refractive eye laser surgery to improve your sight can cause dry eyes. In many cases this problem can only affect you for a couple of months, but for some patients it becomes a chronic misery.
How fast will treatment have effect om my dry eyes?
A punctum plug works quickly, usually after a couple of days. The IPL treatment takes a longer amount of time, up to a couple of months. Most patient experience an improvement after each treatment. After 3-4 treatments most complaints are greatly reduced.
How do I treat dry eyes myself?
There are some at home remedies that can work very well. Placing a warm wet cloth over the eyes, blinking more often, wearing (sun)glasses against wind, dust and pollen and using over-the-counter eye drops from a pharmacy.
How many times a day do I have to use eye drops?
It depends on the severity and what type of eye drop you are using. A lot of people can get through the day with one eye drop, but some continue to suffer even if they use the eye drops every hour. If that is the case, it ’s about time to look for different solutions. Usually, we advise using eye drops between 0 and 6 times a day. Somebody who gets treated with punctum plug can be complaint free afterwards, or would still have to use eye drops 2 times a day.
How can I get dry eyes with glasses?
Dry eyes occurs more frequently to people who have had refractive laser eye surgery or if they wear contact lenses. Even if you wear glasses, if you do not produce enough tears or if the quality of the tear is not good enough, you can get dry eyes.
How do I treat children with dry eyes?
Dry eyes cases are very rare with children. If children suffer from irritated eyes, it is usually caused by seasonal allergies. In most cases it is advised to try eye drops against the allergy first.
How is the treatments against dry eyes performed?
Cleaning the eyelids is done with a cotton swab drenched in water, blefasol or another similar product.
With punctum plugs/tears safers you first receive anesthetic drops. The tear punctum is stretched with a small instrument. Then the plug is inserted with tiny tweezers. We make sure that the punctum plug is inserted correctly, when this is the case you can go home. The treatment does not hurt.
For the treatment with Intense Pulsed Light (IPL) your eyes are closed with a special disposable eye mask. Gel is placed on the skin beneath your eye to improve the passage of the light into your skin. The IPL is placed on the skin at your cheek and with light flashes your skin is treated from ear to ear. When the treatment is done the gel and mask are removed. We have an IPL machine of the most expensive quality with inbuilt cooling. This greatly improves the comfort of treatment and we don’t need to use the uncomfortable icepacks before and after the treatment.
How long is the healing process after treatment?
If you are treated with punctum plugs, there is no healing process as they take effect immediately. IPL takes effect after 3 to 4 treatments. Usually there is a one month gap between treatments, so healing process is estimated between 3 to 4 months.
How expensive is it to treat your dry eyes?
Most artificial tears (eye drops) are ensured by insurance, some however are not. Though it fully depends on where you live and what type of insurance you have. Punctum plugs are usually covered by insurance, though we still recommend checking with yours.
How many times do I have to come back for check-ups after my treatment?
It depends on the success rate of the treatment. It is possible that people are complaint free after using eye drops, getting punctum plugs or after the IPL treatments. Check-ups are not necessary then. If complaints keep coming back, check-ups are recommended. Tear safers/ punctum plugs need to be replaced every 6 to 12 months. So we usually advice to come back after 6 months.
How quickly after treatments are my eyes no longer dry?
It depends on the type of treatment and if the correct problem is treated. Punctum plugs are usually within a few days. IPL treatment can be effective in a few days too but it usually takes several months (3 to 4 months). Eye drops are effective right away, but it will take some time to find the right type of eye drops or dosage.
Why do I have dry eyes after refractive laser eye surgery?
During refractory surgery nerve endings on the cornea are cut or damaged. This can cause disruption in the production of tears and this can be the reason why you get dry eyes. This occurs in most cases where treatment requires an incision being created on the cornea (with Lasik or SMILE treatment). We see less cases of dry eyes after (trans)PRK. During a floater laser treatment the cornea is not affected, so there is no risk of dry eyes.
Do I get dry eyes from smoking?
It is no surprise that smoking is bad for your health. Smoking increases aging and sagging of skin. Besides that the meibomian glands and tear quality are reduced. This can all cause dry eyes.
What should I do if I wake up with dry eyes?
You could try to use preventive measures such as taping your eyes shut before you go to bed, with medical bandages. Beforehand you can apply eye gel or eye ointment. It will take some practice to find the right way to do it. If the problem persists see an eye doctor.
What do I do when I have dry eyes and wish to wear contact lenses?
In some cases applying preservative free eye drops allow you to keep wearing contacts. Sometimes punctum plugs are needed, and in some cases it will be advised to try a different type of lens due to allergies. We advise you to discuss this with an optician or eye doctor.
What can I do against dry eyes during my pregnancy?
During your pregnancy you can safely use artificial tears, warm compresses or punctum plugs.
However, you absolutely cannot use dry eyes antibiotics (doxycycline) or get treated by IPL.
What can you do with dry eyes and allergies?
Anti-allergy pills or drops can be very helpful. Some people do get drowsy from these pills, so we advise you to test out which pills suit you best.
What can I do against dry eyes and glaucoma?
People with glaucoma often experience dry eyes as a side effect from the anti-glaucoma drops. We advise preservative-free eye drops. The best solution can be an SLT-laser treatment. In severe cases filtering surgery might be indicated.
What can I do against dry eyes with parkinsons or MS?
People who suffer from Parkinson or MS blink less than usual. This can lead to dry eyes. It can help to consciously blink more often. On top of that you can use artifical tears or any other therapy if indicated.
What can I do against dry eyes and diabetes?
People with diabetes can get dry eyes but its not specifically related to diabetes. A shortage of tears can be helped by reducing the flushing of the tears with punctum plugs, insufficiency of tear film can be treated by eyelid hygiene. Or you can stimulate the meibomian glands with warm compresses or IPL. Next to that you can use eye drops as treatment.
What can I do with dry eyes and arthritis?
People with arthritis can suffer from very dry eyes. In some cases tear gland does not make any tears at all. We advise to use eye drops. With other problems with advise contacting an eye doctor.
What can I do against dry eyes during menopause?
Woman can experience dry eyes during and after menopause. As a first step we advise the use of artificial tears (eye drops). If that is not enough we suggest other treatments such as warm compresses, punctum plugs or IPL.
What do I need to do with dry eyes and watching TV?
We advise you to blink more often or use eye drops. A lot of people blink less while watching TV.
What do I need to do against dry eyes that are sensitive to light?
This is a sign that the eyes are still too dry. It can be wise to start with a more intensive treatment. It is also possible that there is another cause. We advise you to contact your eye doctor if complaints are persistent.
What should I do if I see black spots and have dry eyes?
Those two problems are not connected. If you suffer from floaters it is important to have your eyes checked for possible retinal tears or detachment.
What side effects can I expect after treatment?
An occurring problem is that people can get over sensitive to the preservatives that are in the artificial tears. If this is the case for you, we advise you to switch to a brand without preservatives.
You can have a allergic reaction to antibiotics (itchiness and red spots in the face). Immediately stop with taking the antibiotics and consult your doctor and apothecary.
A shallow punctum plug can sometimes scratch the eyes. This is a reason to remove the plug. Sometimes the plug can fall out on its own. The plug will need to be placed again.
People that are using eye drops can become allergic to the preservatives used in the artificial tears. If this is the case,we advise you to switch to a preservative-free eye drop/
You can have a allergic reaction to antibiotics (itchiness and red spots in the face). Immediately stop with taking the antibiotics and consult your doctor and apothecary.
A superficial silicone punctum plug can sometimes scratch the eyes. The plug will then need to be removed. Sometimes the plug can fall out on its own. The plug will need to be placed again. For both reasons we prefer to use dissolvable punctum plugs that are placed slightly deeper in the tear duct.
With deep placed acrylic non-dissolvable punctum plugs (‘smartplug’) infections can occur and the plug will need to be removed surgically. We do not use this type of plug in our clinic. We use the dissolvable punctum plugs.
IPL can cause burns of the skin. If this is the case, however, the treatment was not correctly applied or the patient has stayed in the sun too much against the advice. If IPL is treated to people with a dark skin, there can be discoloration. This is the reason why we work with a checklist during the intake for IPL.
Can I drive after the treatment?
After treatment you can drive, unless your pupils were dilated by eye drops.
Is the treatment insured?
That depends on where you live and your insurance. We advise you to call your insurance company regarding this information. Except for IPL most treatments are insured.
When do dry eyes need to be treated in a clinic/hospital?
If treatment with your general practitioner are not helping, it can be helpful to visit a specialist.
When are dry eyes dangerous?
The cornea serves as a barrier against infections. A dry cornea is slightly damaged and therefore more prone to infections. A bacterial infection on the cornea can permanently damage the eyesight. Falling asleep while wearing your contact lenses or not having proper hygiene with contact lenses is a notorious cause for nasty corneal infections.