Dry Eyes

Our eyes work extremely hard to deliver on providing constant, pin-point accurate, instant visual input to the brain. The conjunctival mucus membranes and clear corneas rightly deserve completely moisturised comfort to this end. Tears lubricate the delicate ocular surface, maintaining clarity and health.

Dry eye basically occurs when there is a deficiency in either the quality or quantity of the tear film.

Eyes which feel dry or gritty are certainly no fun to live with. They tend to generally reduce life quality, making it difficult to undertake prolonged tasks of either work or entertainment. Some patients become quite depressed. Often vision clarity is impaired, intermittently fluctuating, made a little better through rapid blinking.

Correct management of dry eye begins with an accurate diagnosis and search for potential treatable causes. There are also several rare disease associations which are important to exclude.

The first priority, easily checked from the medical history, is to make sure that the dry eye is not merely a side effect of medication. Beta-blockers, anti-histamines, anti-depressants and others are notoriously overlooked. Check your own drug leaflets carefully for dry eye or dry mouth, and if these are reported then seek advice from your general practitioner as to whether a trial off or switch might be possible.

The second priority has to be ensuring the primary disease is not actually that of blepharitis or allergy as both are extremely common, easily missed, and treatable in their own right. Simple checks ensure there is no component of floppy eyelid syndrome, nocturnal exposure lagophthalmos (eyes opening whilst asleep), or neurotrophic keratopathy (numb corneal disease). Another common diagnostic oversight especially where discomfort symptoms appear more than signs might suggest is conjunctivochalsis (conjunctiva too loose) - and laser treatment can help. A rare disease called ocular cicatricial pemphigoid is also worthy of excluding by careful examination of the eye surface (plica and conjunctival fornices).

The third priority is to consider disease associations. In females, the hormonal changes of menopause are a common cause. The history will give pointers towards rarer diseases such as Sjogren’s syndrome, rheumatoid arthritis, collagen vascular diseases and sarcoidosis. X-ray treatment damage of the lacrimal glands is a possibility in cancer patients. Vitamin A deficiency is rare in the developed world unless there is a malabsorption gut disorder (I have diagnosed 2 cases in the UK).

 

Severity grading in dry eye is somewhat subjective, often an impression. The patient's symptoms weigh heavily in this determination. There are many signs doctors examine for, none perfect, some also subjective, and objective signs dependent on precision scrutiny. Tests done can give variable results. Frequency of usage of dry eye drops can be used as a marker. A whole picture approach is important. Overall, akin to Top Trumps, it is the highest card that offers the truest reflection.

After these factors have been addressed, the mainstay of treatment is with artificial tears. Regular usage through the day is important. A lubricating ointment at night can also achieve a useful moisture soak effect. It makes sense to try several different varieties of drops as there is no way to predict which will necessarily be best: a cost sensitive prescribing order proposal is attached. Punctal plugs are worth especial mention for a trial if there is little or no response after trying several artificial tears or there are severe symptoms.

 

There is an additional more physiological approach which may be tried. Direct stimulation of the lacrimal functional unit. The lacrimal glands (aqueous), meibomian glands (oil) and goblet cells (mucin wetting agent) all receive a reflex parasympathetic nerve supply. I suggest a smear of Vaporub below the nostrils, occasional forced yawns, and an emotional well-up good cry everyday. The latter will require something suitably stirring such as:

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a) Tearful 1

b) Tearful 2

c) Tearful 3

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For hormonal deficiency (eg menopause, low testosterone), or meibomian gland atrophy (eg Roaccutane)  - a smear of Testogel 5% directly onto the eyelid skin could be an option.

Other simple things which may help include: getting a good night sleep, having a healthy diet (add omega 3 oils), avoiding drying atmospheres (air conditioning in cars, central heating at home, smoke and dust). Keep reading or screen time to shorter durations with rest periods eyes closed and regular blinks. Plants and room humidifiers may be useful.