Dry Eyes or Dry Eye Syndrome is one of the most frequent reasons people seek eye care. Dry Eyes can have a significant impact on our daily activities including reading, driving, working and even watching television. When most people think about having dry eyes, they mainly think about the common symptoms that cause discomfort such as dryness, grittiness or burning and do not even realize that in order to have normal vision, it is critical to have a sufficient quantity of healthy tears on the surface of the eye at all times.

It is estimated that in the United States alone, 20-30 million people have mild symptoms of dry eye and another 6 million women and 3 million men have moderate or severe symptoms of dry eye.

Understanding Tears and the Tear Film

The normal tear film is made up of three distinct layers. The innermost layer called the mucous layer, which directly coats the eye and helps the tear film “stick” to the eye. The mucous layer is produced by Goblet cells in the conjunctiva or “skin of the eye”. The middle layer, called the aqueous layer, is composed primarily of saline and electrolytes, and brings moisture and oxygen to the cornea. The Lacrimal Gland produces the aqueous layer, which is located under the outer portion of your upper eyelid. The outermost layer of the tear film is called the lipid layer, and it is responsible for preventing the tear film from evaporating. Tiny tubular glands in your eyelids produce the lipid layer.  All three layers are critical in maintaining a normal tear film. If any of the three layers of the tear film are deficient you may suffer the symptoms of dry eyes.

Dry Eye is an eye condition in which there is a deficiency of the tear film that is due to either an inadequate production of one’s own natural tears or an excessive evaporation of tears. Whether you suffer from inadequate production of tears or excessive evaporation of tears, or both, you may experience a decrease in the quantity and quality of your tear film resulting in the surface of the eye being affected.

Inadequate Tear Production

There are many potential reasons that you may not produce an adequate quantity of tears. A number of systemic conditions such as Sjogren’s Syndrome or autoimmune connective tissue diseases such as Rheumatoid Arthritis and Lupus Erythematosis may decrease the quantity of tears that you produce. Patients with Sjogren’s Syndrome may experience dry eyes as well as a dry mouth and arthritis.

Inflammation of the Lacrimal Gland will also cause patients to produce too few tears to maintain a normal and healthy tear film. Other factors that can cause the Lacrimal Gland to produce an inadequate amount of your own natural tears include long term contact lens wear, past eye infections, certain allergies and even vitamin deficiencies.

Excessive Evaporation of Tears

There are a number of factors that can cause an excessive evaporation of your tears. These can include environmental factors such as being exposed to forced hot air heat at home or at work, dry climates in general, air travel, reduced blinking from contact lens wear, reduced blinking from looking at a computer screen or reading for long periods of time, air pollution or even just blowing your hair dry.

Your tears may evaporate too quickly if you suffer from low-grade eyelid inflammation, called Blepharitis. Within your eyelids are tiny tubular glands called Meibomian Glands. Any inflammation of the eyelids, such as from Blepharitis, or a condition called Ocular Rosacea (http://www.emedicine.com/OPH/topic115.htm)

can cause the Meibomian Glands to stop secreting their oily film. This oily film is required as an outer layer of the tear film to prevent evaporation. Without the oily layer being present, it is very likely that you will experience a rapid evaporation of tears and symptoms of Dry Eyes.

This is an especially common problem for perimenopausal women, as it is believed that 75% of women in this age group have some presence of facial rosacea. This along with the general hormonal changes occurring during this time, make perimenopausal woman particularly susceptible to dry eyes.

Finally, your tear film may evaporate too quickly if the tears are not properly spread and replenished over the surface of the eye because of poor eyelid movement. This may be due to a number of factors including:

• Improper or incomplete closure of your eyes during sleep
• Eye “bulging” conditions that may be related to thyroid problems
• Loss of tone or shape of the eyelids so that they turn in or turn out, called entropion and ectropion.

Diagnosis of Dry Eyes

The proper diagnosis of dry eyes requires a thorough dry eye examination and dry eye consultation. Dr. Whitaker and the staff will take time to carefully review your medical history, eye history and eye conditions including any medications that you are taking. Please be sure to tell us about all of the medications you take or have taken recently, including not only the ones prescribed, but also those that you may have purchased on your own at the pharmacy.

Next, we will evaluate your tear production by using a specialized microscopic technique to observe the height of the tear film as well by using a clinical test called a Schirmer Test that allows us to actually measure the rate at which you produce natural tears. Dr. Whitaker may also use specially formulated dyes such as Fluorescein, Lissamine and Rose Bengal to help investigate the functioning of the various layers of the tear film as well as the underlying surface of the eye. This is not uncomfortable and will not interfere with your vision.

From this information, Dr. Whitaker will be able to make a proper diagnosis as to the particular cause of your dry eye syndrome and prescribe the necessary tear substitutes, eye drops and/or other options to help restore your tear film back to normal and make you more comfortable.

Treatment of Dry Eyes

Depending on the severity and the cause of your dry eyes, Dr. Whitaker may recommend a number of different treatment options.

If you have mild or even moderate dry eyes, the first course of treatment may be to use unpreserved artificial tears. The selection of the exact type of artificial tear eye drop can be important. Depending on the nature of your tear film deficiency, Dr. Whitaker may have you use a specific type of artificial tear that has different characteristics in terms of salt content and viscosity. Follow these instructions carefully.

In addition there may some environmental factors that you need to alter to make you more comfortable such as how and where you are exposed to heat ducts or fans blowing as well as attempting to keep the areas that you spend a great deal of time in at a proper humidity level.

Sometimes, if the oily layer of the tear film is deficient, Dr. Whitaker may suggest hot compresses or perhaps that you increase your consumption of oily fish or even take flax seed oil as a dietary supplement. Most likely you will be asked to drink plenty of water.

For patients with moderate to severe dry eyes who may have already tried using artificial tear eye drops without relief, the prescription of Restasis eye drops with or without the other treatments can often help alleviate your symptoms. Restasis works by preventing a type of inflammatory cell from entering the Lacrimal Gland and thus allows your Lacrimal Gland to function more effectively so that you can actually make more of your own natural tears. Restasis eye drops require several weeks of use to actually become effective, so please use these drops exactly as they are prescribed and please be patient.

In instances where these approaches do not help relieve your dry eye symptoms, Dr. Whitaker may suggest the insertion of tiny punctual plugs that will slow down or even stop the drainage of tears from the eye. These plugs are easily and comfortably placed in the Lacrimal Puncta in your eyelids. Initially you may have a temporary dissolving plug put in place to see if your dry eye symptoms are actually responsive to this treatment. If the results are good, it may be necessary to place a more permanent type of plug in the Lacrimal Puncta to effect a long-term solution.

Even with the above treatment options, there are some patients that may not respond as well as we would like due to some underlying low-grade inflammatory or infectious process. In these cases it may be necessary to also prescribe an oral antibiotic such as a doxycycline or an anti-inflammatory eye drop such as a corticosteroid eye drop.

As you can see, the diagnosis and treatment of dry eyes is complex and requires patience and persistence on the part of the eye physician and the patient. With careful diagnosis and a systematic therapeutic approach, sufferers of dry eye syndrome can most often experience considerable improvement.

Dr. Whitaker and the staff of Riverside Eye Center will use all necessary diagnostic procedures to help identify the source of your dry eyes and offer you the best possible solution. Please feel free to ask us about a dry eye consultation by calling Riverside Eye Center in Norway, Maine at 207.743.002 or Riverside Eye Center in Lewiston, Maine at 207-786-2500.

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