Last updated by Dr Sarah Brewer on
Having dry eyes is a common, underdiagnosed condition that affects as many as one in 14 adults overall, rising to 1 in 3 of those aged 50 plus. When it comes to people referred to an ophthalmology clinic, screening found that 54% had dry eye disorder that had not previously been picked up, many of whom also had blocked meibomian (oil) glands.
Symptoms of dry eyes
A few people experience symptoms of eye dryness on its own. Having dry eyes can affect the quality of your vision or your sight can become blurry between blinking, even if you don’t have other obvious symptoms of dry eye.
People with more pronounced dry eye disorder (known medically as keratoconjunctivitis sicca) complain of burning, stinging, grittiness, heaviness, tired eyes, a sensation of something in the eye, redness, light sensitivity (photophobia) and, perversely, over-watering, all of which are due to corneal irritation. If not treated, dry eyes can also lead to painful ulceration of the cornea.
Although dry eyes may not sound like a serious condition on its own, researchers in the United States who questioned 210 people, found that having dry eyes can severely affect your quality of life. Compared with those who had healthy tear production, those with dry eyes had worse scores for 35 out of 36 quality of life factors assessed, including pain and vitality. The only score which was not lower for those with dry eyes was mental health. This indicates that having dry eyes has a significant, negative impact on everyday life and daily activities – every blink can produce discomfort.
NB If your eyes feel sore, are red, you have a purulent discharge, or your vision is affected, seek immediate medical advice.
Causes of dry eyes
Dry eyes are due to faulty production of the protective tear film over the eye, either because of reduced tear secretion, or excessive tear evaporation, or both.
Tears act as a natural cushion, allowing your eyelids to sweep smoothly and comfortably over the front of your eyes when you blink. While you produce watery, salty, ‘reflex’ tears when you cry, the basal tears that you need to maintain visual clarity and eye comfort form three distinct layers, all of which are necessary to protect your eyes.
- The first layer contains mucus to help tears stick to the surface of the eye, plus immune proteins (eg antibodies) to protect the eye from infection.
- The second layer consists of a watery fluid and forms the main part of your tears
- The third layer contains a coating of oils that help to prevent tears from evaporating.
The most common cause of dry eyes is not blinking enough, especially when you are working on a computer screen, reading or watching TV and concentrating hard.
When you forget to blink, your tears will evaporate before they are replenished by the sweep of your eyelids.
Dry eyes due to evaporation of tears can also result from smoking, working in a room that is centrally heated or air conditioned.
Sometimes, dry eyes is associated with inflammation of the eyelids – a condition known as blepharitis. The symptoms of blepharitis include redness, soreness, itching and a crusty scale around the eye lashes. It often becomes worse during times of stress, and allergic reactions may play a role.
Dry eyes due to reduced production of tears can be due to medical conditions such as meibomian gland dysfunction (which reduces your production of the oily tear layer), Sjogren’s syndrome (or Sjogren’s disease) in which the immune system attacks the cells that secrete tears. Sjogren’s syndrome can also accompany other autoimmune conditions such as fibromyalgia, rheumatoid arthritis, and systemic lupus erythematosus (SLE).
Excess sun exposure can also cause dry eyes – see how to prevent this, below.
Could you have Sjogren’s syndrome?
Sjogren’s syndrome is an autoimmune disorder in which a type of immune cell called lymphocytes infiltrate and attack the glands that normally produce body fluids. These lymphocytes may also produce a range of antibodies that attack fluid producing cells.
The underlying immune destruction of salivary and tear glands is thought to develop slowly over several years. The symptoms of Sjogren’s syndrome tend to start over the age of 40 years and is thought to affect at least half a million people in the UK. For some reason, women are ten times more likely to develop Sjogren’s syndrome than men.
Sjogren’s syndrome symptoms
The main glands affected in Sjogren’s syndrome are the lacrimal (tear) glands leading to dry eyes, and the salivary glands leading to dry mouth. Sometimes vaginal dryness, nasal dryness and skin dryness occur, too. Even the internal organs such as the liver and pancreas can be affected, although this is less common. Other symptoms associated with an over-active immune system include fatigue, low mood, irritability, joint pains and headache.
A study that tried to identify some of the early signs that might herald the onset of Sjogren’s syndrome identified salivary gland swelling, early loss of teeth, and periods of excessive salivary production which may occur before the more typical symptoms of dry mouth or dry eyes develop.
Other experts suggest suspecting that Sjogren’s is present if you need to drink water to swallow food, wake up at night with a dry mouth, or need to carry water with you at all times. For women, the so-called ‘lipstick sign’, in which lipstick keeps sticking to the front teeth, may be a useful indicator of dry mouth.
Because of the wide range of symptoms, and the slow, insidious onset, there can be long delays of 8 to 9 years, before diagnosis is made.
If you have persistently dry eyes and/or a dry mouth, and generally feel pretty rubbish, do see your doctor as you could have Sjogren’s syndrome.
Treatment of dry eyes
The treatment of dry eyes will depend on the underlying cause. Dry eye symptoms increase in the winter, so use radiator humidifiers to add moisture to the atmosphere if needed.
If symptoms are related to working on a computer screen, try the 20-20-20 rule – every 20 minutes, look away about 20 feet in front of you for 20 seconds. You may be advised to perform blinking exercises, and to use lubricating eye drops (artificial tears) or a lubricating mist that you spray onto closed eyelids (it will find its own way into your eyes to support your tear film).
Here’s a great exercise to soothe and rest your eyes: Sit comfortably with your eyes closed. Gently place your slightly cupped palms over your eyes to block out light. Do not apply any pressure to the eyeball. Breathe deeply and concentrate on the darkness for at least 10 mins, 3 times a day.
If dryness is due to blocked meibomian glands, which secrete oils, you may be advised to apply hot compresses. These help to ‘melt’ the thickened oils, open up the blockages and restore a normal tear film balance. To see if this might be the problem, look at the edge of your lower eyelid. If you can see little raised white bumps, these are mostly likely blocked meibomian glands.
If dry eyes is associated with inflammation of the eyelids, or blepharitis, in which the edge of your eyelids are crusted, or appear excessively oily, stop using all cosmetics, face creams, perfume/colognes and shampoos, then gradually re-introduce them, one at a time, to see if any retrigger the problem. Use hypoallergenic toiletries – the gentlest shampoos, soaps and moisturizers are those formulated for new-born babies. Blepharitis wipes and other cleansing products are also available.
The most usual way to resolve dry eye symptoms is by instilling refreshing eye drops to moisturise the surface of your eyes. These drops supplement your own, natural tears with artificial tears. During 2016, in England along, almost 2 million packs of carbomer eye drops were prescribed, plus 2.4 million packs of hypromellose drops, and almost a million other drops used to treat dry eye conditions. It really is a common problem.
Best eye drops for dry eyes
Eye drops containing hypromellose or polyethylene glycol, are the traditional medical choice of treatment as artificial tears. You can apply them as frequently as needed, which may be as much as every hour to obtain adequate relief. If this is the case, look for drops that contain carbomers, as these are designed to cling better to the eye surface and can reduce the frequency of application to four times a day.
If these still don’t relieve your symptoms, you may have abnormal levels of mucin protein in the lower level of your basal tears. Drops containing polyvinyl alcohol can increase the persistence of the tear film and are useful when the ocular surface mucin is reduced. If tears seem too sticky, then eye drops containing a combination of hypromellose with acetylcysteine (which breaks up mucus) may help.
Sodium hyaluronate eye drops are also used in the management of tear deficiency. Hyaluronate attracts water to help keep tears liquid.
If you have sensitive eyes, look for drops that are preservative free.
Diet for dry eyes
To help increase the quality of the tears you make, drink plenty of fluids to avoid dehydration. Increase your intake of oily fish, such as sardines, mackerel, herring and salmon. These fish provide omega 3 oils which improve the quality of the tear oil film, and help to reduce inflammation. Other good sources of omega-3 include seeds – especially pumpkin seeds and flax seeds, or nuts – especially walnuts. Drizzle flaxseed or pumpkin seed oil over vegetables and salads, for example.
Avocado and macadamia nuts contain monounsaturated fats which are also beneficial for dry eyes. Antioxidant vitamins and carotenoid plant pigments (lutein, zeaxanthin, betacarotene, lycopene) help to protect the eyes from sun damage and are found in yellow, orange, red and dark green fruit and vegetables such as sweetcorn, spinach, pumpkin, sweet potatoes and tomatoes. Lutein in particular protects the eye because its yellow colour filter out damaging blue light. Lutein has been described as ‘nature’s sunglasses’.
Supplements for dry eyes
Omega-3 fish oil or krill oil supplements can help, but the most effective treatment is sea buckthorn oil by mouth.
Sea buckthorn oil capsules are a traditional oral treatment for dry eyes. Its combination of omega-7 fatty acids and antioxidants improve the function of Meibomian gland cells that secrete oil into the tears.
Taking sea buckthorn oil supplements for 3 months can relieve eye redness and burning.
Bilberry extracts are traditionally used to help many eye disorders and appear to help stabilise the tear film.
Excess sun can cause dry eyes
Most people are well aware of the dangers too much sun poses to the skin, but it is equally damaging to your eyes. While wearing sunglasses helps to protect the eyes, they need to be chosen carefully – dark glasses that do not screen out UV light can actually cause more harm than good, by encouraging the pupils to dilate so more of the damaging UV rays get through.
Excess sun exposure can cause light can even cause painful burns to the cornea (photokeratitis), especially when sunlight is reflected and magnified by snow, sand or water, as these bright surfaces reflect glare to magnify your sun exposure. Even a clean pavement can reflect sunlight, so be careful where-ever you sense a glare.
Long-term exposure to excess sunlight can also cataracts (clouding of the normally clear eye lens), macular degeneration (breakdown of part of the retina leading to loss of vision), benign growths on the eye (eg a membranous pterygium which usually forms on the eye near the nose), and even cancer of the eyelids and surrounding skin. Solar retinitis and permanent scarring of the retina can occur from staring directly into the sun eg when viewing a solar eclipse.
The more exposure you have to ultraviolet rays during your life, the greater your chance of developing dry eyes or these other eye conditions. You are most at risk if you work outdoors, have light-coloured eyes, have had laser eye surgery (which thins the cornea), or are taking certain drugs which increase sensitivity to sunlight (eg tetracyclines, phenothiazines, psoralens and allopurinol).
Wear sunglasses if you have dry eyes
Sunglasses not only protect against the sun, but also prevent excess drying from cold winds, hot air, and stop dust and other irritants flying into your eyes. I wear sunglasses all year round when outdoors as I am very sensitive to bright sunlight – my eyes are pale green, and I have had three laser eye surgeries which have thinned my cornea.
Choose your glasses carefully, however.
- Select sunglasses that block 99% or 100% of all UV light (NB labels advising ‘UV absorption up to 400nm’ is the same as 100% protection) – these don’t have to cost a lot. Don’t buy sunglasses without a label, or if the label doesn’t specify UV protection.
- Sunglasses that are polarised or have antireflective coatings will decrease reflected glare, but check they also provide UV protection.
- Sunglasses that are close-fitting, or wrap-around, help prevent light, wind and dust entering your eyes from around the frame of the glasses.
The effectiveness of UV-absorbing contact lenses against sun-related eye disorders has not yet been established so, still wear sunglasses when going out.
If you work outdoors, wear a wide-brimmed hat or baseball-cap, as well as sunglasses – even on cloudy summer days as UV rays can pass through haze and thin clouds. If you spend prolonged time in the sun or on the water, wear close-fitting goggles or sunglasses that absorb both UVA and UVB light.
Never look directly at the sun!
Contact lenses and dry eyes
While getting the tear balance right is important for everyone, it’s especially important if you wear contact lenses. A new generation of daily disposable lenses are specifically designed to retain moisture, with the same water content as the cornea (78%) and which mimic the lipid layer of your tear film. As well as preventing dehydration, these new lenses allow normal levels of oxygen to reach your eye, and provide continued comfort even after 16 hours wear. For more information, speak to your optometrist.
And, whether or not you solve your dry eye problem, continue to have regular eye tests, at least once a year, or as often as your optometrist advises.
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