Dry Eye Treatment

What is dry eye?

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Our eyes are naturally covered by a thin film of tears that lubricate the eye and stop the surface of the eye from drying.  When you blink, the film of tears spreads over the eye. In doing so it maintains a smooth and clear surface important for good vision.  When there is abnormalities in sustaining this tear film then dry eye occurs.  Symptom of dry eye is different between different individuals.  Some patients can have severe dry eyes with minimal symptoms and some patients can have mild dry eyes with severe symptoms.

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How does tear film work?

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The tear film is made of three layers:

• An oily layer

• A watery layer

• A mucus layer

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The oily layer is the outer most layer of the tear film. It makes the tear surface smooth and prevents evaporation of the tear film.  The oily layer is secreted by the meibomian glands, these are multitude of small glands that line the edge of the eyelids.

The watery layer is the middle of the tear film. It makes up most of what we see as tears. This layer cleans the eye, washing away particles that do not belong in the eye. This layer comes from the lacrimal glands in the eyelids.

The mucus layer is the inner layer of the tear film. This helps spread the watery layer over the eye’s surface, keeping it moist. Without mucus, tears would not stick to the eye. Mucus is made in the conjunctiva. This is the clear tissue covering the white of your eye and inside your eyelids.

Normally, our eyes constantly make tears to stay moist. If our eyes are irritated, or we cry, our eyes make a lot of tears. But, sometimes the eyes don’t make enough tears or something affects one or more layers of the tear film. In those cases, we end up with dry eyes.

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A thin film of tears is swept over the eye surface every time you blink. A watery layer of tears is topped with an even thinner coat of lipids (fatty compounds) that help to preserve the film. To maintain eye comfort and health, the tear film needs to remain intact between blinks.

If you have dry eye syndrome, you don't have enough of the right kind of tears to keep your eyes comfortable.

This can happen if you don't produce enough tears to keep the eye surface moist, or if tears do not stay on the eyes long enough. Over time, the resulting dryness can damage the surface of the eyeball.

Who gets dry eye?
Dry eye can affect anyone, but is more common as we get older because we produce a smaller volume of tears. Dry eye is particularly common in postmenopausal women and people with arthritis.

Some medications can trigger dry eye, as can some general health conditions. People with dry eyes typically find it difficult to wear contact lenses. They may also have more problems in air-conditioned environments such as offices or supermarkets.

There is no cure for dry eye, but its symptoms can be alleviated.

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How are watering eyes investigated and treated?

Your eye specialist will examine the eye and look at what is the exact cause of the watery eye (eg. whether there is dry eye or whether there is a problem with tear drainage).

Your eye specialist will look for blockages in your tear ducts.  This is done with local anaesthetic eye drops to help reduce any discomfort and then inserting a tiny probe into the narrow drainage channels on the inside of your eyelid to determine whether they are blocked. Saline fluid may also be injected into your tear duct to see whether it comes out to the inside of your nose normally.  If it does then you will be able to taste the saltiness of the saline.

Another test involves placing a drop of special dye in each eye. If there's a significant amount left in your eyes after five minutes of normal blinking, your tear ducts may be blocked.

Scans of your tear ducts may sometimes be carried out. These can involve either injecting or placing special dyes into the tear ducts and then taking X-rays or other scans to help pinpoint the location of the blockage.  This is usually done by a doctor in a Radiology facility.

 

Treatment

If watering eyes aren't interfering with your life, you may choose not to have treatment.  If you're producing extra tears as a result of dry eye syndrome, you may be offered lubricating eye drops and advised to use more lubricating eye drops during activities that can aggravate your symptoms (such as avoid reading, watching TV and using a computer).  Medication may be needed if the cause is an allergy or infection.

Blepharitis – if there is evidence of blepharitis then it might help to get into a habit of performing eye lid cleaning every day.  This is performed by hold a clean warm, damp cloth over the affected eye for five minutes – at the same time, gently massage your eyelids with the cloth to loosen any material that might be blocking the eye glands.  

Additional treatment such as BlephEx eyelid cleansing system, IPL (intense pulse light) therapy, or Lipiflow treatment may also be required for significant blepharitis.

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Minor procedure

In cases where irritation is caused by an inward-growing eyelash or a foreign object, such as a piece of grit, these can be removed by your eye specialist.

Persistent inward-growing eye lashes can be prevented from regrowth by cryotherapy procedure or electrolysis.  Your eye doctor will talk to you about such option.

 

If your lower eyelid rolls inwards (entropion) or sags outwards (ectropion), a minor operation carried out under local anaesthetic may be recommended.  This is usually performed in theatre or in a treatment room.  The most common procedure involves tightening the tendon that holds the outer eyelid in place to give it extra support, as well as reinforcing the connections that keep the eye lid in the correct rotation. 

 

Surgery for blocked tear ducts

Tear ducts allow excess tears to drain away. If a blocked tear duct is causing watering eyes, it can be treated with surgery.  If you have an infection in your tear sac (where excess tears from your eyes drain into), it'll need to be treated with antibiotics first before surgery. Left untreated, the infection could spread to your eye socket.

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Dacryocystorhinostomy (DCR)

Dacryocystorhinostomy (DCR) is a common surgical procedure used to treat blocked tear ducts.  This surgery nowadays is commonly performed with endoscopic guidance.  An endoscope is a narrow, flexible tube with a light at the end.

The surgery involves creating a new channel from the tear sac to the inside of your nose. This channel allows tears to bypass the blocked part of your tear duct.  During the surgery your eye surgeon will remove a very small piece of bone from the side of your nose, allowing the tear sac to drain directly into the nasal cavity.

A very thin silicone tube is often inserted to keep the channel open. Within a few months, the tube will be removed and the channel should stay open without it.

The DCR procedure is typically carried out under general anaesthetic takes up to an hour to perform.  Most DCR surgery is carried out as a day case procedure, which means you can go home the same day.  You'll be given instructions to follow when you're discharged, such as not blowing your nose for a week after surgery.  You may also be given some eye drops or ointment to use to prevent infection and inflammation, as well as a nasal spray.

There could be some bruising and swelling around your nose and eye, which should improve over a few days or weeks. You may also experience nosebleeds for a few days.

 

Blocked canaliculi

If the drainage channels on the inside of your eye (canaliculi) are completely blocked by tears, an operation to drain them may be required.

This usually involves inserting a small glass tube to drain the tears.
 

Treating watering eyes in babies

Watering eyes often improve in babies without the need for treatment.

Massaging the tear ducts may help dislodge tears that have collected in the upper part of your baby's tear duct, as well as encouraging the tear duct to develop.  This can be done by applying light pressure with your first (index) finger and massaging from the corner of your baby's eye towards their nose. Repeat the massage several times a day for a couple of months. Wash your hands before massaging.  You can also soak a cloth with warm water and hold it against your baby's eye. This may encourage the tears to drain.

If your baby has an eye infection (conjunctivitis), this may need to be treated with antibiotic eye drops.

 

Probing for babies

In 9 out of 10 cases, the tear duct opens by itself before your baby is one year old.  But if your child is over a year old or has repeated infections caused by the blocked tear duct, a procedure may be recommended to open their tear duct using a probe.  A special balloon attached to the probe is sometimes used to expand the tear duct.  This will be carried out under general anaesthetic. Only a very small number of babies with watering eyes require this type of treatment.