Dry Eye Syndrome

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Introduction

Introduction

Dry eye syndrome, or dry eye disease, is a common condition that occurs when the eyes don't make enough tears, or the tears evaporate too quickly.

This leads to the eyes drying out and becoming red, swollen and irritated.

Dry eye syndrome is also known as keratoconjunctivitis sicca, or simply "dry eyes".

Symptoms of dry eye syndrome

The symptoms of dry eye syndrome are mild for most people, although more severe cases can be painful and lead to complications.

Symptoms usually affect both eyes and often include:

  • feelings of dryness, grittiness or soreness that get worse throughout the day
  • burning and red eyes
  • eyelids that stick together when you wake up
  • temporarily blurred vision, which usually improves when you blink

Some people may also have episodes of watering eyes, which can occur if the eye tries to relieve the irritation by producing more tears.

When to seek medical advice

See your high-street optician (optometrist) if you have persistent but mild symptoms of dry eye syndrome.

They can examine you to check if the problem is caused by an underlying condition, or they may refer you to an eye specialist.

Contact your optometrist or GP immediately if you have any severe symptoms. If this isn't possible, visit your nearest accident and emergency (A&E) department.

What causes dry eye syndrome?

Dry eye syndrome can occur when the complex tear production process is disrupted in some way. There are many different reasons why this can happen, although a single identifiable cause often can't be found.

Common causes include:

Although the condition may affect people of any age, your chances of developing dry eye syndrome increase as you grow older.

It's estimated up to one in every three people over the age of 65 experiences problems with dry eyes.

Dry eye syndrome is more common in women than men.

Read more about the causes of dry eye syndrome.

How dry eye syndrome is treated

Dry eye syndrome isn't usually a serious condition. Treatments are available to help relieve the symptoms, which include:

  • eye drops to lubricate the eyes
  • medications to reduce any inflammation
  • if necessary, surgery to prevent tears from draining away easily

If dry eye syndrome is caused by an underlying condition, treating this condition usually helps to relieve the symptoms.

Read more about treating dry eye syndrome.

Caring for your eyes

As well as medical treatments, there are some things you can do yourself to help prevent dry eye syndrome or reduce the symptoms.

These include:

  • keeping your eyes and eyelids clean and protecting them from dusty, smoky, windy and dry environments
  • using your computer or laptop correctly to avoid eye strain
  • using a humidifier to moisten the air
  • eating a healthy diet that includes omega-3 and omega-7 fats

Read more self-help tips for dry eye syndrome.

Further problems

Although dry eye syndrome may be uncomfortable, it doesn't usually cause any serious problems. The two main complications associated with dry eye syndrome are:

  • conjunctivitis - inflammation of the conjunctiva, the transparent layer of cells that covers the white part of the eyeball and the inner surfaces of the eyelids; most cases are mild and don't need specific treatment
  • inflammation of the cornea - in rare cases, severe untreated dry eye syndrome can damage the surface of the cornea (keratitis); this damage can make the cornea vulnerable to ulceration and infection, which could potentially threaten your sight

Contact your optometrist or GP, or visit your nearest accident and emergency (A&E) department immediately if you have any of the following symptoms, as they could be a sign of a more serious condition:

  • extreme sensitivity to light (photophobia)
  • very painful or red eyes
  • a deterioration in your vision

Causes of dry eye syndrome

Causes of dry eye syndrome

Dry eye syndrome can occur if your eyes don't produce enough tears or your tears evaporate too quickly.

This may happen if any part of the tear production process becomes disrupted and the quantity or quality of your tears is affected.

There are many different reasons why this can happen, although a single identifiable cause may not be found. Some of the possible causes are described below.

Hormonal changes

Hormones - powerful chemicals produced by the body - and the nervous system play an important part in tear production.

Hormones stimulate the production of tears. Changes in hormone levels in women can increase their risk of dry eye syndrome. For example:

Ageing

Dry eye syndrome is more common in older people. This may be because you produce fewer tears as you get older, and your eyelids become less effective at spreading tears over the surface of the eyes.

Environment and activities

Environmental factors can have a drying effect on your eyes, causing your tears to evaporate. These include:

  • sun
  • wind
  • dry climate
  • hot blowing air
  • high altitude

Certain activities can also contribute to dry eye syndrome, such as:

  • reading
  • writing
  • working with a computer

People tend to blink less frequently during activities that require visual concentration. This means the tear film evaporates or drains away more quickly than it's replenished.

Certain medications

Several medicines are thought to cause dry eye syndrome as a side effect in some people, including:

Laser eye surgery

Some people who have had certain types of laser eye surgery find they have dry eye syndrome in the weeks after surgery.

The symptoms usually clear up after a few months, but in some cases may continue.

Contact lenses

Sometimes contact lenses irritate the eye and cause dry eye syndrome. Changing to a different type of lens or limiting how often you use your contact lenses usually helps resolve the symptoms, or you can try changing cleaning solutions or using preservative-free lubricant eye drops.

Medical conditions

There are a number of medical conditions that increase your risk of developing dry eye syndrome.

Many people with dry eye syndrome also have blepharitis or meibomian gland dysfunction (MGD). This is where the eyelid margins become inflamed, which can block the glands that produce oils for the tear film.

Blepharitis can occur at any age and in otherwise healthy people, although it sometimes occurs as the result of a bacterial infection or other conditions, such as rosacea, a skin condition that causes the face to appear red and blotchy.

Other medical conditions that can increase your risk of dry eye syndrome include:

  • allergic conjunctivitis - inflammation of the transparent layer of cells that covers the white part of the eyeball and the inner surfaces of the eyelids (conjunctiva) caused by an allergy, usually to pollen and dust mites
  • contact dermatitis - a type of eczema that causes inflammation of the skin when you come into contact with a particular substance you're sensitive to
  • Sjögren's syndrome - a condition that can cause excessive dryness of the eyes, mouth and vagina, which is also associated with fatigue and arthritis
  • rheumatoid arthritis - a condition that causes pain, swelling and inflammation in the joints that can affect any part of the body, including the glands around the eyes and inflammation of the white of the eye (scleritis)
  • lupus - a condition where the immune system attacks healthy body tissue, particularly blood vessels
  • scleroderma - a condition where the immune system causes inflammation of the blood vessels and areas of skin to become hard and thickened
  • previous trauma (serious injury) to the eyes - such as burns or exposure to radiation
  • Bell's palsy - a condition that causes weakness or paralysis to the muscles of one side of the face
  • HIV - a virus that attacks the body's immune system

Diagnosing dry eye syndrome

Diagnosing dry eye syndrome

Your high-street optician (optometrist) or GP can examine your eyes to confirm whether you have dry eye syndrome, and give you advice about treatment.

If the diagnosis is uncertain or specialist tests and treatment are required, you may be referred to a surgeon specialising in eye conditions (ophthalmologist) in hospital.

The tests carried out to assess the quality and quantity of tears are described below.

Fluorescein dye test

Eye drops containing a special yellow-orange dye are used so your specialist can see your tears more clearly. This helps them find out how long it takes for your eye to start drying out.

If there's damage to the surface of the eye, the fluorescein dye test may show up affected areas. The dye is only temporary and won't change the colour of your eye.

Schirmer's test

Small strips of blotting paper are hooked over your lower eyelid. After five minutes, the strips are removed and studied to determine how wet the paper is.

If the paper has wetted less than 10mm in five minutes, this indicates dry eye syndrome.

Lissamine green test

Lissamine green is a special dye in a paper strip. The strip is diluted with saline and dropped on to the surface of your eye.

The distinctive green colour of the eye allows the specialist to see early damage to the surface of the eye.

Treating dry eye syndrome

Treating dry eye syndrome

Treatment for dry eye syndrome helps to control the symptoms, but there's no cure. Some people may have recurring episodes for the rest of their lives.

The exact treatment for dry eye syndrome depends on whether symptoms are caused by:

  • decreased production of tears
  • tears that evaporate too quickly
  • an underlying condition

The first thing to consider is whether there are any obvious factors, such as a medication, causing the symptoms.

If your dry eye syndrome is caused by an underlying condition, your GP can prescribe treatment or refer you to an appropriate specialist.

You may also be able to help prevent dry eye syndrome or ease your symptoms by adjusting your environment, keeping your eyes clean, and improving your diet.

Read more about self-treating and preventing dry eye syndrome.

Lubricant treatments

Mild to moderate cases of dry eye syndrome can usually be treated using lubricant eye treatments that consist of a range of drops, gels and ointments.

These lubricants are often called artificial tears because they replace the missing water in the tear film. However, they don't contain the antibodies, vitamins and nutrients found in normal tears that are essential for eye health.

Most lubricants are available without a prescription over the counter from a chemist.

There are many different types of eye drops and gels, and it's often worth trying a number of different ones to find one that suits you.

Sometimes you may have to use two or three different compounds to have the best effect. However, it's important you discuss any changes you wish to make to your treatment with your optometrist or doctor.

Preservative-free drops

Some eye drops contain preservatives to prevent harmful bacteria growing inside the medicine bottle. If your symptoms mean you need to use these eye drops more than six times a day, it's better to use preservative-free eye drops. 

This is particularly important if your ophthalmologist has told you that you have severe dry eye disease. Preservatives used in large quantities or over a prolonged period of time - months or years - may damage the delicate cells on the surface of the eye or cause inflammation.

If you wear soft contact lenses, you may also need to use a preservative-free lubricant, as preservatives attach to the contact lens and damage the eye. These types of eye drops may be more expensive.

If you have any difficulty putting in your drops, please discuss this with your doctor or optometrist. There are mechanical devices to help squeeze bottles, multi-dose bottles with valves, and single dose containers that may be easier for you.

'Oily' tear eye drops

Eye drops that replenish the oily part of the tear film and reduce evaporation from the surface of the eye are also increasingly being used. These preparations include synthetic guar gums or liposomal sprays.

Liposomal sprays are over-the-counter medications that aren't available on a prescription. They are sprayed on to the edges of your eyelids when your eyes are closed.

When you open your eyes, the solution spreads across the surface of the eye, creating a new oily film.

Oily tear drops are particularly useful if you have blepharitis or dry eye syndrome caused by your tears evaporating too quickly.

Eye ointments

Eye ointments can also be used to help lubricate your eyes and keep them moist overnight, as your tears can evaporate while you sleep if your eyes aren't fully closed.

These ointments tend to be used overnight because they can cause blurred vision.

If you wear contact lenses, don't use eye ointments while wearing them. Ask your pharmacist or GP for advice about alternative treatments that may be suitable for you.

Anti-inflammatory treatments

The underlying problem with long-term dry eye syndrome is inflammation in and around the eye. One of the anti-inflammatory treatments mentioned below may also be recommended, but these can only be obtained after you've seen an ophthalmologist.

Corticosteroid eye drops and ointments

Corticosteroids are powerful anti-inflammatory medications that can be given as eye drops or ointments in severe cases of dry eye syndrome.

They have side effects in around one in every three people, which may include:

  • cataracts 
  • raising the pressure within the eye

This group of treatments should only be used if you're being reviewed by an ophthalmologist at an eye clinic. You shouldn't use these treatments if you have no follow-up at an eye clinic.

Oral tetracyclines

Low doses of medications called tetracyclines can be used as anti-inflammatory agents for a minimum of three to four months, and sometimes for much longer.

The most common tetracycline used is doxycycline, but others, such as oxytetracycline and lymecycline, are sometimes also prescribed.

Ciclosporin eye drops

Ciclosporin is a medication that suppresses the activity of your immune system. It is sometimes used in the treatment of severe dry eye syndrome that doesn't respond to lubricants.

This treatment is only available through a specialist in dry eye syndrome at a hospital eye department.

Serum eye drops

Serum eye drops may be required in very rare cases where all other medications haven't worked. These are special eye drops made using components of your own blood or blood from a donor.

The treatment is only available from the NHS Blood and Transplant Tissue Service through an ophthalmologist and after funding is approved.

To make serum eye drops, one unit of blood is taken under sterile conditions, as for regular blood donation. The blood cells are then removed and the remaining serum is diluted and put into eye drop bottles.

Because of quality standards, this process can take several months before the treatment is finally available to use.

Treating underlying medical conditions

If you have an underlying medical condition that's causing dry eye syndrome, your GP will prescribe treatment for it or refer you to an appropriate specialist.

Surgery

If your dry eyes are severe and fail to respond to other forms of treatment, surgery may be an option. Two types of surgery sometimes used to treat dry eye syndrome are described below.

Punctal occlusion

Punctal occlusion involves using small plugs called punctal plugs to seal your tear ducts. This means your tears won't drain into the tear ducts and your eyes should remain moist.

Temporary plugs made of silicone are normally used first to determine whether the procedure has a positive effect. If it does, more permanent plugs can replace the silicone ones.

In more severe cases, the tear ducts are sealed using heat (cauterised). This permanently seals the drainage hole to increase the amount of tears on the surface.

Salivary gland autotransplantation

Salivary gland autotransplantation is an uncommon procedure that's usually only recommended after all other treatment options have been tried.

This procedure involves removing some of the glands that produce saliva from your lower lip and placing them under the skin around your eyes. The saliva produced by the glands acts as a substitute for tears.

Self-help advice for dry eye syndrome

Self-help advice for dry eye syndrome

There are a number of things you can do to help prevent dry eye syndrome or ease your symptoms.

Environmental factors

Certain environments can irritate your eyes. Keep your eyes protected from:

  • wind
  • hot air
  • smoke
  • dust

Wrap-around glasses may provide good protection. Avoid smoky environments, and you should try to stop smoking if you smoke.

Avoid using eye make-up. Eyeliner and mascara can block the glands in the eyelids and cause the area around your eyes to become inflamed.

Specialised eyewear

Some cases of dry eye disease can be treated using specialised eyewear. These include specially made glasses called moisture chamber spectacles. These wrap around your eyes like goggles, helping to retain moisture and protecting your eyes from irritants.

If your previous contact lenses were causing dry eye disease, special contact lenses are also available. You should discuss various options with your optometrist.

Adjust your computer

If you regularly use a computer, make sure your computer workstation is set up correctly to minimise eye strain. Your monitor should stand at eye level or just below it.

If you use a computer at work, most employers have a health and safety officer or an occupational health representative who can advise you.

You should also make sure to take regular breaks away from your computer screen every hour.

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Use a humidifier or air filter

A humidifier, such as a cool mist device, at work and home will moisten the surrounding air and can help reduce your symptoms.

Opening windows for a few minutes on cold days and longer in spring and summer will also help keep air moist and prevent a build-up of mould.

If you work or live in a particularly dusty environment, you may also find it useful to use an air filter.

Keep your eyes clean

Good hygiene will help improve dry eye syndrome, particularly if you have blepharitis.

There are three main ways you can maintain eyelid hygiene. These should be performed once or twice a day:

  • use a warm compress to make the oil produced by the glands around your eyes more runny
  • gently massage your eyelids to push the oils out of the glands
  • clean your eyelids to wipe away any excess oil and remove any crusts, bacteria, dust or grime that might have accumulated

Advice on how to do this is described below.

Warm compresses

  • boil water and leave it to cool to a warm temperature
  • soak a clean flannel or eye pad in the warm water and gently place this over the eyes for around 10 minutes
  • reheat the compress periodically by soaking it in warm water, ensuring the flannel doesn't become cold

You can also buy a special microwaveable compress for your eyes to use instead of a flannel.

Eyelid massage

  • gently massage your closed eyes by rolling your little finger in a circular motion
  • take a cotton wool bud and, with your eyes shut, gently roll it downwards on the upper eyelid towards the lashes and edges of the eyelids - this helps to push the melted oil out of the glands, although you won't see anything come out
  • repeat this process along the whole width of the upper and lower eyelids

This process may cause your eyes to become slightly irritated at first, a bit like getting soap in your eyes, but this is normal and should get better with time.

Lid margin hygiene

Various eyelid-cleaning solutions and eyelid wipes are available commercially, or you can try making one at home.

For a homemade solution, fill a bowl with one pint of boiled water and allow it to cool to a warm temperature. Then add a teaspoon of bicarbonate of soda.

Once you've made a cleaning solution:

  • soak some clean cotton wool in the solution and remove crustiness from around the eyelids, paying special attention to the eyelashes
  • repeat this process if necessary using a clean piece of cotton wool
  • dip a clean cotton bud into the solution and gently clean the edges of the eyelids by wiping the cotton bud along the bases and lengths of the lashes

Diet

There's some evidence to suggest a diet high in omega-3 fats can help improve dry eye syndrome.

The best sources of omega-3s are oily fish, such as:

  • mackerel
  • salmon
  • sardines
  • herring
  • fresh or frozen tuna - not canned, as the canning process sometimes removes the beneficial oils

Aim to eat at least two portions of fish a week, one of which should be oily fish.

You can also get omega-3s from various nuts and seeds, vegetable oils, soya and soya products, and green leafy vegetables.

Omega-7, or sea buckthorn oil, has also been found to be helpful.

Read more about eating a healthy diet.