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Dry Eye Body Text GraphicWe’re living in a world of dry eyes. So many of our patients have dry eyes that it has almost become an accepted disease. “Have you noticed any eye or vision-related problems over the last year?” our optometrists will ask their patients. “No everything’s been just fine,” patients will respond. “Except that my eyes burn and water like crazy all 12 hours that I work at the computer.” Wait, what!? If the most sensitive part of the body, the cornea, gets dry and irritated, the effect on comfort and vision can be dramatic so why wait to resolved the issue? We’ve seen patients go from 20/20 vision down to 20/80 vision or worse just because of eye dryness. There is a great deal of dry eye-related research that has allowed optometrists to effectively diagnose and manage dry eyes –this means that dry eye isn’t something to be endured, but something that should be diagnosed and treated promptly.

There are many factors that can contribute to dry eye including age (patients older than 50 tend to have drier eyes), patients that have had corneal refractive surgery (including LASIK, PRK, and radial keratotomy), patients using certain medications (including some blood pressure medications, antihistamines, antidepressants, anti-acne medications, eye drop preservatives, and oral contraceptives), and those patients having certain systemic diseases such as diabetes, rheumatoid arthritis, lupus, scleroderma, Sjogren’s syndrome, or thyroid disorders. Other common risk factors for developing dry eye syndrome include abnormal lid posture, engaging in activities that reduce blink rate (including reading and computer use), and just living at altitude here in Colorado where the air is notably dry!

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Figure 1 – A healthy eye without any staining.

A healthy eye has a full, unbroken layer of tears in front of it. The first refractive surface of the eye is the tear layer. A spotty layer of tears isn’t just a comfort issue –a poor tear film can affect that person’s quality of vision. Our optometrists use a substance called sodium fluorescein to evaluate the health of the cornea (the transparent, outer layer of the eye) and the conjunctiva (the transparent skin that surrounds the white part of the eye). We use this substance by adding it to a patient’s tear layer and observing whether or not it sticks to the cornea. Because sodium fluorescein tends to stick to dry parts of the cornea, we can assess the type of eye dryness associated with the staining. In a healthy eye, insertion of sodium fluorescein doesn’t result in any staining at all (see Figure 1).

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Figure 2 – This eye demonstrates diffuse, even staining from general dryness.

Eyes that have general dryness have staining throughout the cornea and conjunctiva (see Figure 2). These eyes tend to get more and more dry throughout the day, and this dryness may be related to medication, wind/air exposure, or Computer Vision Syndrome. If the eyes are even moderately dry, they may not be able to recover on their own and may require medical intervention. Dry eye therapy for these eyes may include over-the-counter artificial tears, prescribed eye medications and ointments, or punctal plugs which help the eyes retain more of their moisture. Another type of therapy includes using special contact lenses designed to hold moisture up against the eye.

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Figure 3 – This eye demonstrates staining only along the bottom portion of the cornea.  Because the upper lid adequately covers the top portion of the cornea, there is no staining there.

If only the bottom portion of the cornea is staining (see Figure 3), this is a sign that the eyes are not closing completely while sleeping or that the patient has an incomplete blink. This common condition is called “lagophthalmos.” As a result, the bottom part of the cornea stains with the sodium fluorescien, but the top portion of the cornea is normal and healthy. This condition can be caused when patients sleep face-down on pillows with the pillow tugging at the edge of the lids, or if air currents blow across the patients face at night. If adjusting sleep posture isn’t an option, taping the lids shut at night might be prudent. Eye ointments, essentially medications dissolved in petroleum jelly, can be prescribed for night-time use to help insulate the moisture of the eye from the air.

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Figure 4 – This eye has heavy staining throughout the cornea and conjunctiva as well as an over-production of tears resulting in classic Paradoxical Dry Eye.

One of the most common dry eye-related complaints patients have for our optometrists is that their eyes water. Sometimes the cause of watery eyes are a blocked tear duct (which is usually treated with a simple in-office procedure), though more frequently, a watery eyes is the result of dryness. We call this a “Paradoxical Dry Eye” (see Figure 4) because this condition is usually represented by a dry eye that waters. What happens is that the cornea and conjunctiva are dried out and the lacrimal gland overcompensates by creating too much tear volume. Tears are supposed to stay in your eyes and maintain a corneal barrier (see description of tear anatomy below) but in Paradoxical Dry Eye, tears end up running out of the corners of the eye and down the cheek. For this type of dryness, our eye doctors will try to thicken your tears to keep them in place against the corneas and this can often be accomplished with over-the-counter viscous artificial tears.

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Figure 5 – This image highlights the 3 layers of the tears labeled 5A, 5B, and 5C.

So what is it about tears that make them act like they do? Tear anatomy explains how tears are designed to function properly (see Figure 5). In Figure 5C, we see the mucus layer. The goal of the mucus layer is to hold the remaining tear layers up against the eye. The mucus layer serves as the junction between the structural surface of the cornea and the tear layer. Should something disturb the mucus layer, the tears will not sit ideally against the cornea and Paradoxical Dry Eye can result. Figure 5B shows the aqueous layer. This builds the bulk of the tear film, and is comprised mainly of salt and water. In an eye with a lack of tear production, the aqueous layer will be diminished and result in a generally dry eye as seen above in Figure 2. Figure 5A shows the oil layer. The oil layer acts as the icing on the cake, keeping the aqueous layer from evaporating between blinks. Meibomitis is a common lid disease that prevents oil from entering the tears. If there is a deficiency in the oil layer, dry eye can result. Treatment for this variation of dry eyes involves lid therapy and special lipid-fortified eye drops that help restore the oil layer in the tears.

There are many variations of dry eye, and it is important to have the proper diagnosis in order to initiate treatment. Our optometrists are here to help! If your eyes are dry, know that a world of technology exists to help you – call us today to schedule your dry eye consultation. A brief visit with our optometrists can help get your eyes feeling great! (303) 450-2020.

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