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DRY EYE SYNDROME Diagnosis and treatment PATIENTS - FACT SHEET What is it? How is it treated? Dry eye syndrome is a disorder of the tear film due to tear Lifestyle and environment deficiency or excessive evaporation, which causes the eyes Following a diagnosis of dry eye syndrome, your doctor or to become dry, inflamed and uncomfortable and damages optometrist will initially focus on identifying and addressing the ocular surface. There are two main causes of dry eye: lifestyle/environmental factors that may cause or worsen your firstly a condition in which the eyes can’t make enough symptoms. These include: tears, sometimes called keratoconjunctivitis sicca, and • Smoky or dusty environments secondly where the tears evaporate too quickly. The most • Air conditioning/heaters in the home or car common cause of excessive tear evaporation is blockage and • Prolonged viewing of computer screens dysfunction of the Meibomian oil glands in the eyelids causing • Contact lens wear inflammation of the rims of the eyelids, which is also known • Use of redness-relieving eyedrops such as witch hazel as blepharitis. How is it diagnosed? A good level of daily water intake will also be encouraged to aid hydration. As omega-3 fatty acids may reduce tear Your GP may make a diagnosis of dry eye syndrome by evaporation and inflammation, oral supplements or dietary reviewing your symptoms and examining your eyelids, intake via oily fish (salmon, sardines) or flax seed oil is also considering your medical history and looking at any medicines often recommended. that you may be taking. An examination may also be carried out to check for other conditions and complications. Treatment of excessive tear evaporation: Following your initial consultation, your GP may refer you to Meibomian gland dysfunction (blepharitis) treatment an optometrist for a complete eye check-up. An optometrist will use specialist equipment to confirm whether you have Hot eyelid compresses and massage dry eye syndrome, blocked Meibomian glands (blepharitis) Blockage and dysfunction of the Meibomian oil glands in the or other conditions. eyelids (posterior blepharitis) is treated by using heat to warm Will I need to see a hospital doctor? up the oil glands and massage to encourage Meibomian oil to be expressed normally from the eyelids. Heat can be applied If the diagnosis of dry eye syndrome is uncertain or specialist to the eyelids with a folded up small flannel or face towel tests and treatment are required, your GP may refer you to an soaked in moderately hot water (not so hot as to burn the ophthalmologist. These are hospital doctors who specialise skin, but quite hot) and applied approximately 6 times given in eye disorders and surgery. The vast majority of cases, that the towel loses its heat every 30 seconds, to give a total however, do not need referral. of 3 minutes of heat on the eyelids. Alternatively a hot eye mask can be used for 3 – 5 minutes, for example the EyeBag http://www.eyebag.org/. Unblocking the Meibomian oil glands restores natural Meibomian “oily tears” to the tear film and ocular surface, which is important because this water-proof oily barrier stops evaporation of aqueous (watery) tears. Restoring this source of natural “oily tears” to the surface of Lifestyle modifications the eye can reduce the frequency of needing water-based A skin condition called rosacea is often associated with artificial tears and lubricants in the eyes. Meibomian oil gland blockage. Factors which exacerbate rosacea include factors associated with facial flushing, Eyelash cleaning such as eating hot chilli and curries, and alcohol. Avoiding If there is any stickiness of the eyelashes (usually noticed first these factors or minimising them for a few months can help thing in the morning on awakening), crusting or debris on the during an exacerbation of Meibomian oil gland blockage. eyelashes then this is called anterior blepharitis. The sticky Eating oily fish rich in omega-3 fatty acids and flax seed oil debris is due to thickened toothpaste-like material being supplementation have also been reported to improve function expressed from the Meibomian oil glands, rather than smooth of the Meibomian oil glands. clear oil. Stickiness of the eyelashes is treated by cleaning the eyelashes using a cotton bud and cooled boiled water, Treatment of keratoconjunctivitis sicca (lack of aqueous dilute bicarbonate of soda, dilute baby shampoo or proprietary tear production): preparations such as LidCare or Blephagel. Artificial tears and lubricants Oral antibiotics The term ‘artificial tears’ is commonly used to describe drops, A 3 month course of oral tetracyclines such as doxycycline solutions and liquid gels applied directly into the eye. Artificial helps to restore Meibomian oil gland function, reduce tears don’t have all the components of real tears - they mainly inflammation of the ocular surface and eyelids and promote just act as a lubricant. The term ‘ocular lubricants’ generally production of better quality tears. Antibiotics are used refers to more viscous products such as ointments. Your here in a similar fashion to treatment of acne oil glands by doctor or optometrist may recommend or prescribe artificial dermatologists, rather than solely for their anti-bacterial effect. tears or an ocular lubricant in addition to addressing the above Topical azithromycin antibiotic eye drops have recently been lifestyle and environmental factors. If frequent use of artificial shown to have a similar effect on Meibomian oil gland function tears or ocular lubricants does not control dry eye symptoms, as oral tetracyclines do. hydroxypropyl methylcellulose inserts (lacriserts) may be considered. These are small pellets that contain artificial tears. Artificial tears and lubricants They must be inserted under the eyelid once-daily, to help Replenishment of tears and lubrication to the ocular keep the surface of the eye moist.. surface is important in the setting of rapid tear evaporation. This is discussed further below, in treatment of keratoconjunctivitis sicca. Anti-inflammatory eye drops and ointments A limited course of steroid eye drops and ointments may be necessary if there is a lot of inflammation on the ocular surface associated with the blepharitis (blepharoconjunctivitis). Blepharoconjunctivitis is not an infection which can be transmitted to others. It is a term used to describe inflammation of the mucosal lining covering the white of the eyeball and the undersurfaces of the eyelids (conjunctivitis) which is associated with blepharitis. Topical cyclosporine is a steroid-sparing anti-inflammatory treatment which promotes improved Meibomian oil gland function and increased tear production, but has a slow onset of effect, usually several months. Punctual occlusion Salivary gland autotransplantation If frequent use of artificial tears or ocular lubricants does not In this procedure, some of the glands that produce control dry eye symptoms, providing blepharitis has been saliva are removed from the lower lip and grafted into treated, insertion of small plugs to seal the tear drainage the side of the eyes. The saliva produced by the glands passages near the nose, helps tears to pool and thus protect acts as a tear-substitute. This procedure is not frequently the eyes. Temporary plugs made of silicone are normally used performed now because the quality of salivary tears does not first to see if there is a positive effect. If so, the tear drainage replicate that of natural tears. passages can be permanently sealed shut, using a laser or cautery. Consult your doctor or optometrist if you think you may need treatment for dry eye syndrome. Medicines Further information can be found in our fact sheet Anti-inflammatory medicines including topical steroids ‘Dry Eye Syndrome – Causes and Symptoms’ and topical cyclosporine can be used to help reduce the inflammation associated with more severe cases of dry eye syndrome. Anti-mucus eye drops can help in severe dry eye, to improve the quality of the tear film and reduce eye discomfort. Specialist oral medication in the form of tear secretagogues may be necessary in advanced keratoconjunctivitis sicca. Your doctor will provide more information on these if they are needed. Specialised spectacles Some cases of dry eye syndrome can be treated using specially made glasses, known as moisture chamber spectacles. These wrap around the eyes like goggles, helping to retain moisture and protecting the eyes from irritants. Their popularity is increasing as modern designs look like sports sunglasses, unlike the more cumbersome appearance of earlier versions. Specialist contact lenses If regular contact lenses are causing dry eye syndrome, specially designed ones are available to help overcome the problem. Your optometrist or ophthalmologist will be able to give you more information on contact lens options. Surgery Surgical procedures including reducing the eyelid aperture may be an option if dry eye syndrome doesn’t respond to other forms of treatment.