Dry Eyes, Etiologigies, types, signs and symptoms, differential diagnosis, management and optometry roles

1. DRY EYES
Raju Kaiti
Optometrist, Dhulikhel Hospital
Kathmandu University Hospital
Dry eye is a condition in which there are insufficient tears to lubricate and nourish the eye. Tears
are necessary for maintaining the health of the front surface of the eye and for providing clear
vision. . Tears provide lubrication, reduce the risk of eye infection, wash away foreign matter in
the eye, and keep the surface of the eyes smooth and clear. People with dry eyes either do not
produce enough tears or have a poor quality of tears. Dry eye is a common and often chronic
problem, particularly in older adults and in those who works in VDU for prolong periods. Dry
eyes can result from an improper balance of tear production and drainage.
 Inadequate amount of tears—Tears are produced by several glands in and around the
eyelids. Tear production tends to diminish with age, with various medical conditions, or as
a side effect of certain medicines. Environmental conditions such as wind and dry climates
can also affect tear volume by increasing tear evaporation. When the normal amount of tear
production decreases or tears evaporate too quickly from the eyes, symptoms of dry eye can
develop.
 Poor quality of tears—Tears are made up of three layers:
oil, water, and mucus. Each component serves a function in
protecting and nourishing the front surface of the eye. A
smooth oil layer helps to prevent evaporation of the water
layer, while the mucin layer functions in spreading the tears
evenly over the surface of the eye. If the tears evaporate too
quickly or do not spread evenly over the cornea due to
deficiencies with any of the three tear layers, dry eye
symptoms can develop.
What causes dry eyes? (Etiologies)
The development of dry eyes can have many causes. They include:
 Age- dry eye is a part of the natural aging process. The majority of people over age 65
experience some symptoms of dry eyes.
 Gender- women are more likely to develop dry eyes due to hormonal changes caused by
pregnancy, the use of oral contraceptives, and menopause.
 Medications- certain medicines, including antihistamines, decongestants, blood pressure
medications and antidepressants, Isotretinoin-type drugs for treatment of acne can reduce the
amount of tears produced in the eyes.

2.  Medical conditions- persons with rheumatoid arthritis, diabetes, Lupus, Scleroderma,
Sjogren's syndrome, Vitamin A deficiency and thyroid problems are more likely to have
symptoms of dry eyes. Also, problems with inflammation of the eyelids (blepharitis),
inflammation of the surfaces of the eye, or the inward or outward turning of eyelids can cause
dry eyes to develop.
 Environmental conditions- exposure to smoke, wind and dry climates can increase tear
evaporation resulting in dry eye symptoms. Failure to blink regularly, such as when staring
at a computer screen for long periods of time, can also contribute to drying of the eyes.
 Other factors- long term use of contact lenses can be a cause of dry eyes. Refractive eye
surgeries, such as LASIK, can cause decreased tear production and dry eyes.
 Eyelid problems
Blinking spreads a continuous thin film of tears across the surface of your eyes. If someone has
an eyelid problem that makes it difficult to blink, tears may not be spread across eyes
adequately or tears may evaporate too quickly, causing dry eyes. Eyelid problems can include
an out-turning of the lids (ectropion) or an in-turning of the lids (entropion). Also
Meibomianitis can also cause dry eyes.
Additional causes
Other causes of dry eyes include:
 Wind
 Dry air (Air Conditions, Heaters)
 Tasks that require enough concentration that you blink less often, such as working at a
computer, driving or reading
Symptoms
Symptoms, which usually affect both eyes, may include:
 A stinging, burning or scratchy sensation in your eyes
 Stringy mucus in or around your eyes
 Increased eye irritation from smoke or wind
 Eye fatigue
 Sensitivity to light
 Eye redness
 A sensation of having something in eyes, Foreign Body Sensation
 Difficulty wearing contact lenses
 Periods of excessive tearing
 Blurred vision, often worsening at the end of the day or after focusing for a prolonged period

3. Signs
 Diffuse redness
 Lusterless cornea
 In severe cases, Superficial Punctate Keratitis
 Stringy mucus in or around eyes
 Watery eyes
 May be associated with Lid abnormalities
How are dry eyes diagnosed?
Dry eyes can be diagnosed through a comprehensive eye examination. Testing, with special
emphasis on the evaluation of the quantity and quality of tears produced by the eyes, may
include:
 Patient history to determine any symptoms the patient is experiencing and the presence of
any general health problems, medications taken, or environmental factors that may be
contributing to the dry eye problem.
 External examination of the eye, including lid structure and blink dynamics.
 Evaluation of the eyelids and cornea using bright light and magnification.
 Measurement of the quantity and quality of tears for any abnormalities. Special dyes
may be instilled in the eyes to better observe tear flow and to highlight any changes to the
outer surface of the eye caused by insufficient tears. Schirmer’s test, Tear Break up Time,
Rose Bengal Staining, Phenol Thread test, Interferometry and other procedures are
diagnostic procedures of diagnosing dry eyes qualitatively and quantitatively.
Using the information obtained from testing, eye care practitioners can determine if one has dry
eyes and advises on treatment options.

4. Possiblecomplicationsofdryeyesyndrome
 Ulceration of the cornea - inflammation linked to severe and untreated cases of dry eye
syndrome can damage the surface of the cornea, leading to ulceration (scarring). The patient's
vision may become affected.
 Conjunctivitis - most conjunctivitis caused by dry eye require no treatment. Sometimes,
however, conjunctivitis can become chronic (long-term or recurring) and severe. In such cases
the patient should see a health care professional.
 Reflex tears - it is ironic that people with dry eye syndrome may sometimes produce too
many tears. There are two types of tear production: 1. Basic tears; tears are produced at a slow
and steady rate. 2. Reflex tears - tears are produced in large quantities in response to some
irritant or emotion. Reflex tears have much higher water content and much lower mucus and
oils content than do basic tears.
Differential Diagnosis
 Bell Palsy
 Blepharitis, Adult
 Conjunctivitis, Allergic
 Contact Lens Complications
 Floppy Eyelid Syndrome
 Keratoconjunctivitis, Superior Limbic
 Keratopathy, Neurotrophic
 Ocular Manifestations of HIV
 Ocular Rosacea
 Thyroid Ophthalmopathy
Management
Treatments for dry eyes aim to restore or maintain the normal amount of tears in the eye to
minimize dryness and related discomfort and to maintain eye health.
Dry eyes can be a chronic condition, but your optometrist can prescribe treatment to keep your
eyes healthy, more comfortable, and prevent your vision from being affected. The primary
approaches used to manage and treat dry eyes include adding tears, conserving tears, increasing
tear production, and treating the inflammation of the eyelids or eye surface that contributes to the
dry eyes.
 Adding tears—Mild cases of dry eyes can often be managed using over-the-counter artificial
tear solutions. These can be used as often as needed to supplement natural tear production.
Preservative-free artificial tear solutions are recommended because they contain fewer

5. additives that could further irritate the eyes. However, some people may have persistent dry
eyes that don’t respond to artificial tears alone. Additional steps need to be taken to treat their
dry eyes.
 Conserving tears—An additional approach to reducing the symptoms of dry eyes is to keep
natural tears in the eyes longer. This can be done by blocking the tear ducts through which
the tears normally drain. The tear ducts can be blocked with tiny silicone or gel-like plugs
that can be removed, if needed. A surgical procedure to permanently close tear ducts can also
be used. In either case, the goal is to keep the available tears in the eye longer to reduce
problems related to dry eyes.
 Increasing tear production—Prescription eye drops that help to increase production of tears
can be recommended by your optometrist, as well as omega-3 fatty acid nutritional
supplements.
 Treatment of the contributing eyelid or ocular surface inflammation—Prescription eye
drops or ointments, warm compresses and lid massage, or eyelid cleaners may be
recommended to help decrease inflammation around the surface of the eyes.
 Punctal Plug insertion.
 Specialist eyewear - some patients benefit from wearing moisture chamber spectacles, which
wrap around the eyes like goggles. The spectacles help retain moisture in the eyes, as well as
protecting them from wind and other irritants. Moisture chamber spectacles are more popular
than they used to be because of their current sporty designs. They used to have an unattractive
design and were unpopular.
 Salivary gland transplantation - this surgical procedure is only ever considered in persistent
and severe cases that have not responded to other treatments. Some of the salivary glands are
removed from the lower lip and grafted, or placed into the side of the eyes. The saliva they
produce becomes a substitute for tears.
Self-Care
Steps those can be done to reduce symptoms of dry eyes include:
 Remembering to blink regularly when reading or staring at a computer screen for long
periods of time.
 Increasing the level of humidity in the air at work and at home.
 Wearing sunglasses outdoors, particularly those with wrap around frame design, to reduce
exposure to drying winds and sun.

6.  Using nutritional supplements containing essential fatty acids may help decrease dry eye
symptoms in some people. Ask eye care practitioner if the use of dietary supplements could
be of help for your dry eye problems.
 Avoiding becoming dehydrated by drinking plenty of water and fluids.
 Proper arrangement of Monitors of Visual Display Units, slightly 20-25 degrees down from
eye level
 Use of Anti-Reflection Coating spectacle for computer use.
Optometric Management
Optometrists can actively participate in Dry eyes work ups, diagnosis and management. Proper
counseling about all the DOs and DO NOT DOs should be done. Prescribing Anti-Reflection
Coated spectacles for VDU users and sunglasses for outdoors will help the patients. Beside these,
Optometrists can actively be a part of Dry Eyes management in all activities as mentioned above
in management part.