Fergus Falls Optometric Center
"Family Eyecare from the Eyecare Family."
Dr. Mark D. Olmsted and Dr. Christine A. Olmsted
117 E. Lincoln Ave.
Fergus Falls, MN 56537
Appointments: 218-736-7555

Dry Eye Syndrome - 13 Feb 2005

Dry Eye Syndrome
13 Feb 2005

Dry Eye SyndromeDry eye syndrome, often referred to as ocular surface disease, is a very common source of discomfort for up to over 59 million Americans or one in five people. Symptoms include redness, burning, itching, scratchiness, tearing and light sensitivity.

There can be many causes of eye dryness. The common thread amongst these irritations is a poor tear layer on the surface from either inadequate tear formation or a faster than normal breakup time of the tearfilm. When people become symptomatic, they rub their eyes creating a vicious cycle of histamine breakdown, which produces inflammation and thusly more irritation to the conjunctiva (mucus membrane of the eye).

What types of things effect the tear layer negatively? Systemic autoimmune disorders such as rheumatoid arthritis, lupus, and Sjorgren's syndrome. Sjorgren's syndrome effects women in most cases and consists of dryness not only in the eyes, but in the mouth and any other mucus membrane in the body. It also causes joint pain and fatigue. If you suspect that you may have Sjorgren's, a multi-discipline approach is usually required. A logical first step is a visit with a rheumatologist. The patient's dentist may prescribe fluoride mouth rinse. The optometrist's approach will be mentioned later.

Some people have a condition known as blepharitis, which simply put, is the eyelid's version of dandruff. Dried skin oil and dead flakes of skin build up on the lids, especially at the lashline. This can be oily or crusty. Bacteria, especially staph, tend to set up shop on this extra debris. The tear layer is affected, not only from these crusts flaking into the tears, but also from toxins released from the bacteria.

Conditions that cause the eyelids to be loose or unusable make for a dry tear layer since tears will not be evenly spread across the surface by the lid as normal. Ectropion, where the lid pulls away from the eye from either aging or trauma, can cause dryness or sometimes excess tearing. A paralyzed facial muscle, which is caused by either a stroke or Bell's palsy, causes dryness because the patient is unable to blink on the effected side. Oculoplastic surgery is often required in these cases.

Side effects from medications can also cause dry eyes. Examples include over-the-counter antihistamines, sleep aids, birth control, decongestants, Accutane (for acne), diuretics (for hypertension or edema), beta-blockers for hypertension or glaucoma, some heart medications, ulcer remedies and many other oral medicines.

Other factors which create contribute to dry eye syndrome are high altitudes, sun and wind exposure, dry air (especially from indoor heating and air conditioning or a car's defroster) and aging. Post-menopausal women tend to have more dryness due to decreased estrogen.

Common activities, which cause us to blink less due to heavy concentration, such as computer data entry and video games, tend to put someone with a borderline tear layer into the dryness zone.

So, what can be done to manage dry eye syndrome? Something as simple a change in environment may help. If one lives in a very dry climate or has a very dry home during the winter, a humidifier may offer relief. "Visual hygiene" at the computer, where one just takes a break to do something else every fifteeen minutes, and consciously takes "blink breaks", can avoid some trouble with dryness.

Lifestyle choices for better health also aid in relief: 1) Drink 6 to 8 cups of pure water daily. Caffeinated drinks tend to act as a diuretic, drawing fluid out of our system. 2) Cigarette smoke is an irritant for dryness. People who live in a smoke free home will be more comfortable. 3) Good nutrition and vitamin supplements are also a factor. Zinc and vitamins A, C, E, and B6 are important nutrients in the production of a viable tear layer. Supplements containing either borage oil or evening primrose oil are being looked at by nutrition oriented eye doctors for being the building blocks of an essential fatty acid needed in many bodily functions, including a good tear layer. For many years artificial tears containing vitamin A have been available, which are said to increase the mucin production needed as a lubricating component in tears. While these nutritional claims are under study and make sense in theory, their benefits in dry eye therapy remain controversial in spite of patient reports of relief.

Patients with blepharitis need to use frequent lid scrubs immediately after soaking the area with a warm compress. This greatly reduces the dry eye symptoms that these people experience. Lid scrub preparations can be in either a bottled liquid or in pre-moistened pads. These products are milder than baby shampoo, so no eye irritation will occur if they get in the eye. Lid scrubs are available without a prescription from a pharmacist or an eyecare office.

Over-the-counter artificial tear preparations are widely available and are a first line of defense against dryness. Here's what to consider:: 1) Stay away from drops that have decongestants that "get the red out" if you are using the drops for dryness only. Decongestant eyedrops are wonderful for short-term use in mild allergies or during a recovery from a cold virus. They are overkill for dry eye complaints and can actually have some negetive side effects if overused. 2) Non-preserved drops are easier on the eye than preserved drops, since there is not the possibility of preservative allergy or irritation. 3) If you feel like you need to use eyedrops for dryness, a good rule of thumb is to use them at least 4 times a day to keep your tear layer on a more even keel throughout the day. However, preserved artificial tears should NOT be used more than 4 times a day, due to the risk of irritation from the preservative. So, for moderate dry eye symptoms one should use a non-preserved drop or a drop like Genteal (my current favorite) which has a preservative which breaks down to oxygen and water on contact with the eye. These can be used up to every hour if necessary without problems. 4) There are thicker, non-preserved drops available for use during the day for more moderate to severe cases of dryness. These stay in contact with the eye longer, but distort the vision temporatily upon instillation.

The next step, if drops alone don't cut the muster, is to add a bedtime ointment (i.e. Refresh P.M.) or a gel (i.e. Genteal Gel). These products lay a thick layer of lubricant on the eye for extended periods of time. Because of their thickness however, they distort one's vision significantly, so they are usually reserved for bedtime. Some people prefer the gel to the ointment, since it cleans off the lids much easier in the morning.

If drops and gel don't allow for enough relief, the next level is to plug the tear drainage system. In a normal situation this system maintains a constant balance between eye moisture production, evaporation and drainage. If someone has dry eyes, whether it is from poor production or fast tear breakup time, we can block the drainage port (punctum) in the nasal corner of the lid. What tears are available will stay on the eye longer, greatly increasing comfort. This punctal occlusion technique uses a permanent silicone implant to block the punctum, very much like putting a cork in a bottle or putting an old fashioned rubberstopper in a sink or tub. While these are considered permanent, they may be removed in the rare situation when it is necessary. Punctal occlusion is usually started with a dissolvable trial plug. This procedure is very comfortable and usually done with a topical anesthetic. Optometrists can provide this service, which is covered by Medicare or major medical insurance. Punctal plugs often put a person with moderate dry eyes who suffers from contact lens intolerance back into a part-time wearing schedule again. I am an example of such a person. My wife, Dr. Chris Olmsted, "plugged me" about a year ago. Now that I'm in a sport activity where glasses are not a good idea, I am able to wear soft contacts again.

Recently, the prescription medication Cyclosporine, an immunosuppressant drug, was under study as a therapeutic eyedrop for dry eye. It's effect is to make the cells which produce tear layer mucus to "reawaken". While it appeared to work in the short term, when the drops were discontinued the mucus production decreased again and the dryness returned. Because of this questionable effectiveness, the FDA did not approve it for this use. However, it is possible that it may be available in the future in some way for dry eye therapy.

Dry eye syndrome, while often considered a minor problem, can be very complex and serious in severe cases because tears not only lubricate the eye, but also act as a protective layer against infections. However, with appropriate diagnosis from an eyecare professional and treatments mentioned in the article, it is something that can be managed well, allowing for more comfortable, healthier eyes.

Dr. Mark D. Olmsted