AT A GLANCE: Dry eye disease can cause burning, grittiness, excessive tearing and blurred vision that interferes with reading, driving and screen use. Here are five key things you will learn about dry eyes from ophthalmologists David H. Aizuss, MD, and Vincent K. Young, MD, in this article:
- Dry eye develops when the eyes do not produce enough tears or tears evaporate too quickly.
- Burning, stinging, grittiness, excessive tearing and fluctuating vision are common symptoms of dry eye.
- Aging, screen time, contact lenses, low humidity, health conditions and certain medications can contribute to dry eye.
- Artificial tears, warm compresses and regular screen breaks may help control symptoms of dry eye.
- Persistent discomfort, blurred vision or underlying health conditions warrant an eye examination.
For people with dry eyes, each blink may leave behind burning, grittiness, blurred vision or the nagging feeling that something is stuck in the eye. Those symptoms can affect far more than comfort, making it harder to read, drive, work at a screen or wear contact lenses.
The AMA’s What Doctors Want Patients to Know™ series gives physicians a platform to share what they want patients to understand about today’s health care headlines and how to take charge of their health through preventive care.
In this installment, two physicians took the time to discuss what patients should know about dry eye disease. They are:
- David H. Aizuss, MD, an ophthalmologist in Calabasas, California, and immediate past chair of the AMA Board of Trustees.
- Vincent K. Young, MD, a comprehensive ophthalmologist in Philadelphia with Jefferson Health and chief of the division of ophthalmology at Jefferson Einstein Philadelphia Hospital.
Jefferson Health is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Dry eye means your eyes aren’t producing enough tears
“Dry eye disease, first of all, is a horrible name for the disease because so often the patient’s symptoms include excessive tearing,” Dr. Young said. “But at any rate, dry eye disease is a situation where the normal state of the tear film on the front of the eye—the cornea—is somehow incorrect, either through a lack of production or through a more rapid evaporation.
“And the results are the same, which is that the front surface does not get the moisture that the cells on the surface demand,” he added. “As a result, there is the reflex production of tears, which is often excessive and causes a lot of the symptoms, one of which is excessive tearing.”
Where you live can contribute to dry eye
While dry eye disease can occur any season throughout the year, it largely varies based on “where you are,” Dr. Aizuss said. “If you live in Chicago, it’s going to be worse when you’re having air conditioning, but it could be worse in the winter when you have heat on because both of those can dry you out.”
Meanwhile, “if you live in Southern California, it’s an all year thing,” he said. “If you live in Florida, you’re probably worse in the wintertime and better in the summertime when it’s more humid.”
There are two main types of dry eye
“The first type is called evaporative dry eye. That’s the most common type,” Dr. Aizuss said. “That’s where your tears evaporate too quickly because the oil glands in your eyelids don’t produce enough of the oily product of your tears to keep them from evaporating.”
“Some of the most common causes of that type of dry eye is aging, rosacea in some patients, working long hours on a computer screen, reading where we blink less frequently, contact lens wear—which sucks the water out of your eyes—incomplete blinking, and in women as estrogen levels drop, their eyes become drier,” he added.
“Then there is the second type of dry eye, which is where you have an aqueous deficiency. You’re not producing enough tears from your lacrimal glands, so that type of dry eye is from aging,” Dr. Aizuss explained. “You can have it from various autoimmune diseases, such as Sjogren’s syndrome. You can get it from some medicines, such as antidepressants, diuretics and antihistamines. Some people can also have aqueous deficient dry eye from prior eye surgery or from radiation from thyroid eye disease.”
Burning or stinging is a common symptom of dry eye
Symptoms of dry eye may include burning, stinging, redness, light sensitivity, eye fatigue, excessive tearing and a gritty sensation. Vision may also fluctuate, sometimes improving briefly blinking, explained Dr. Aizuss.
“If I blink a few times, I see better,” is a common description from patients, he added.
There are several causes of dry eye
“Screen time contributes to dry eye because we blink less frequently when we’re looking at a computer while we’re reading,” Dr. Aizuss said, noting that “the average frequency goes from 20 blinks per minute down to five to seven when you’re concentrating. So, your eyes dry out because we replenish our tear film by blinking.”
“The second cause is in women as estrogen levels decrease, their eyes get drier. We see more women with dry eye than men,” he said. “The third thing is contact lenses. Contact lenses are primarily made of water. So, if it’s a choice between who gets the water, your eyeball or the lens, the lens is going to suck the water out of your eye to keep it moist.”
Additionally, “some people have low level inflammation of their eyelid margins called blepharitis. That causes dry eye because it damages the meibomian glands that produce the mucin layer of our tears,” Dr. Aizuss explained. “Another cause is low humidity environments. If you live in California, you’ll more likely have dry eye than if you live in Chicago in the humidity of the summertime. But if you’re in an airconditioned environment, humidity goes down, your dry eye will be worse.”
Seasonal allergies can exacerbate dry eye
“Seasonal allergies can exacerbate dry eye, not because of the allergy necessarily, but because of a medicine you take to control the allergies,” Dr. Aizuss noted. That is because the medicines for seasonal allergies “tend to be drying.”
For example, “Zyrtec, Allegra, those are drying,” he said. “Some people use Visine, Opcon-A, Naphcon-A. These are all vasoconstricting agents and they can be drying, which is why we discourage their use in patients with dry eye.
Aging is the main risk factor for dry eye
“There are various risk factors for dry eye, such as aging,” said Aizuss. “The other risk factors besides aging and hormone levels are various connective tissue diseases.”
For example, dry eye disease can be associated with “Sjogren’s syndrome, rheumatoid arthritis and systemic lupus erythematosus,” he said, emphasizing “there’s a whole gamut of connective tissue diseases that can contribute to dry eye.”
Certain medications can cause dry eye
“Glaucoma drops can contribute to an ocular surface irritation that leads to abnormal production,” Dr. Young said. “But the big players are medications like antihistamines, antidepressants and anti-anxiety medicines.
“All of those medications, which are frequently used in our society, are potential sources of dry eye syndrome,” he added. “Another medication is diuretics, which can cause your eyes to dry out.”
That is why “this really should be a multi-physician effort to try to manage. If it is an eye problem, the eye doctor is going to be primary in it,” Dr. Young said. “But primary care certainly plays a role in helping patients understand that there are lots of factors that are not specifically ocular that contribute to dry eye so that at least the patient has a better understanding of the chronicity of it and the difficulty with which we find ourselves trying to treat it.”
For example, “if antidepressants are causing a person’s dry eyes, it’s hard for me as an eye doctor to treat that as long as they’re on that medication. That’s where modification of medicines will help,” he said.
Dry eye can lead to vision disturbance
“Anything that can disturb the surface of the eye long-term can cause disturbance of vision,” Dr. Aizuss said, noting “the cornea needs to be kept smooth and moist. If you have chronic dry eye, the cornea starts getting stippled—it’s little dry spots.”
“That can affect your focus and it can cause blurred vision,” he said. “Secondly, severe dry eye can actually lead to ulceration of the cornea and even perforation of the eye. That’s very rare, but it can happen.”
“Other complications of dry eye are symptoms of pain and light sensitivity,” Dr. Aizuss said, noting “there are types of dry eye related to diseases such as thyroid eye disease. You need to treat the thyroid problem.”
Dry eye can contribute to migraines
“Sometimes, because your eyes bother you, it can be a trigger for migraines,” Dr. Aizuss said. In that case, “you’ve got to treat the migraine.
“But before treating the migraine, if you’ve got dry eye, it’s good to treat the dry eye so you don’t have a trigger of a migraine,” he added.
There are several ways to diagnose dry eye
“You can diagnose dry eye by having patients fill out a survey. There are a couple of different survey instruments where they’re asked questions about their symptoms,” Dr. Aizuss said. “You can diagnose it by doing what’s called a Schirmer test where you put a little piece of filter paper on the edge of the eyelid and you measure their tear production over a certain defined period of time. It’s not terribly accurate.”
“There is a newer method where we measure the concentration of the tears—the tear osmolarity,” he said. “So, if you have very concentrated tears, that comes from being dry. I actually use that in my office because it’s more objective than subjective.”
“Another way of diagnosing dry eye is by looking at the tear film. There’s something called the tear film breakup time,” Dr. Aizuss explained. “The average person has a tear film breakup time of greater than 10 seconds. We put a little dye in the tear film, we watch the film, and you see when it starts to have a little breakup, and you count one to 10.
“If you’re less than 10, you tend to be dry. If you’re less than five, you have severe dryness,” he added. There are also “vital dyes that we put in the eye. Fluorescein, which is a dye we put in when we’re checking somebody’s pressure, lets us coat the tear film and we can see how fast the ear film is.”
“There are two other dyes. One is called lissamine green, which shows areas of staining of the conjunctiva because there’s poor tear film or mucus accumulation,” Dr. Aizuss said. “There’s another one called rose bengal. So, areas will stain pink if you have a disrupted tear film.”
Artificial tears are a key treatment for dry eye
“Treatment No. 1 for dry eye is artificial tears. Lubrication is important,” Dr. Aizuss said. “You can’t hurt yourself with artificial tears unless they’re preserved tears and you’re putting them in too often. The preservatives and the tears can become irritating. You’re best off using a preservative-free drop when in doubt.”
“If you’re using a regular eye drop that has preservatives, don’t use it more than four times a day,” Dr. Aizuss noted. “If it’s preservative-free, you can put it in every hour, every half hour, no problem.”
Another treatment for dry eye is “if there’s abnormal meibomian glands in the eyelids, you can treat them with heat,” he said. “So, there are hot compresses where you can buy these masks you heat up in the microwave for 30 seconds and lay on the couch for 10 minutes and heat your eyelids. That’s very helpful.”
The length of time for dry eye to go away varies
There are varying lengths of time for how long it will take for a person’s dry eye to go away, depending on the severity of the condition.
It also “requires a lot of patience on the part of our patients because it is something that is very frustrating and difficult,” Dr. Young said. “When you have all of these conditions that contribute to dry eye that patients sometimes cannot modify on their own, then we’re sort of clawing our way uphill when it comes to fixing it.”
Give your eyes a break from the computer
“If you’re doing prolonged computer work, I tell people 20-20-20,” said Dr. Aizuss. “After 20 minutes, give yourself a break.
“Then look off and focus on something far away for 20 seconds and give yourself a 20 second break,” he noted.
Use a hot compress on closed eyes daily
“I like to recommend, especially as we get older, to use hot compresses regularly, whether you are having symptoms or not because keeping those glands flowing is a smart thing to do,” said Dr. Young. “To keep that oil surface as well as we can produce it will keep our vision clearer, keep us freer of symptoms that lead to things like chronic eye rubbing.
“You know how likely it is for that person who has the gritty feeling in their eyes to want to rub their eyes?” he said. “That can very likely compound the problem or create a separate problem, such as bacterial conjunctivitis.”
“When you take a bath or shower or if you’re just sitting, take a hot washcloth and hold it against your closed eyes. That makes a huge difference,” Dr. Aizuss said.
If discomfort persists, contact your doctor
“If you’re having discomfort that persists, you should visit your doctor. If you notice change in vision, you should visit your doctor,” Dr. Aizuss said. “If you’re having anything besides dryness, if you’re having dryness with blurred vision, see the doctor.”
“Those are good reasons to go to the doctor,” he said. “If you have underlying medical problems that could be contributing to dry eye—history of thyroid disease, autoimmune diseases or other inflammatory diseases—it’s wise to have a checkup,” he said, emphasizing that “those are good reasons to go to the doctor.”
“Routine examination by your eye doctor is something that is advisable for pretty much everyone,” said Dr. Young. “Certainly, if there are any symptoms, then that’s the time to see your doctor for sure. But routine examination should be part of correct self-management.”
