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  • Causes & Diagnosis

Different Types of Dry Eye Disease

  • Last updated January 6, 2023

8 min read

Jovi Boparai MD Profile Picture
Written byJovi Boparai, MD
Edward Lai, MD Amanda C. Kahn, MD
Reviewed by Edward Lai, MD Amanda C. Kahn, MD
Jovi Boparai MD Profile Picture
Jovi Boparai, MDCo-founder & CEO of CorneaCarePhiladelphia, PA

Bio

Dry eye disease is tough! I get it. I have struggled with dry eyes for several years from contact lens use, and from spending countless hours looking at computer screens. In college, my dry eyes got so bad that I couldn’t wear contact lenses, because of a constant “foreign body sensation” when I had them in. I had to stop reading every 30 minutes because my eyes would start to burn and my vision would get blurry. I tried a plethora of treatments and nothing seemed to work. Dry eye disease was not only impacting my eyes, but also my emotional wellbeing. It was preventing me from enjoying life, and getting in the way of my professional training. I felt overwhelmed, frustrated and hopeless.

It was only when I realized that my dry eyes were linked to my lifestyle, environment and overall health did things start to make sense. I noticed that on days when I spent less time on the computer, my eyes felt better. My symptoms would flare when it was windy, or when there was low humidity. I knew that if I wanted to get ahead of my dry eyes, I needed to not only treat my eyes, but to also address my lifestyle. I started a consistent regimen of artificial tears and eyelid hygiene. I switched from monthly contact lenses to daily contact lenses. I started taking scheduled breaks from looking at a computer. I ate a healthier diet focused on anti-inflammatory/antioxidants foods, and I bought a humidifier for my room. In the beginning doing all this seemed impossible, but over time it became part of my usual routine. Not only did my eyes feel better, but I was overall healthier and happier! Turns out what is good for my eyes, was also good for my mind and body. I carried this lesson with me as I started my career to become an ophthalmologist and ophthalmic surgeon.

Because of my personal journey and professional training, I believe dry eye treatment starts by listening to and empowering the patient. I listen for the struggles and cue in on their strengths, while picking up on their lifestyle. Only then do we together start building a treatment plan that incorporates good eye hygiene with small, but impactful lifestyle changes. Our sight is our most important sense, and it is intimately linked to our very being. I want dry eye patients to not only get their dry eyes under control, but to also enjoy good mental and physical health, and live a fulfilling life. What is good for the eyes should also strengthen the mind and fortify the body!

Get to know me a little better!

Hobby: vintage watches
Food: peanut butter
Superhero: Superman
Guilty pleasure: desserts
Secret power: has never had a headache

Training:

Undergraduate: University of Pittsburgh Honors College
Medical school: Weill Cornell Medicine
Ophthalmology residency: Wills Eye Hospital.

Edward Lai, MD
Edward Lai, MDOphthalmic SurgeonNew York, NY

Bio

Dr. Lai is a fellowship trained cornea specialist with wide ranging expertise in ophthalmology. Through combining cutting-edge technology with clinical and surgical skills, Dr. Lai is able to deliver excellent care to his patients. Dr. Lai has a specific interest in dry eye disease and how it can impact patients physically and emotionally. He has published on the importance of dry eye treatment in patients undergoing eye surgeries, such as cataract and LASIK. Dr. Lai advocates for building dry eye treatment plans that address the eyes, but also incorporate general health, lifestyle and environment.

Get to know Dr. Lai a little better!

Hobby: boxing
Favorite food: lasagna
Superhero: Spiderman
Guilty pleasure: 90s RnB
Greatest weakness: ice cream
Secret power: cooking

Training:

Medical school: Tufts University
Ophthalmology residency: Manhattan Eye, Ear and Throat Hospital
Cornea fellowship: Weill Cornell Medicine

Amanda C. Kahn, MD
Amanda C. Kahn, MDPrimary Care PhysicianPhiladelphia, PA

Bio

Dr. Kahn is a primary care physician who is passionate about delivering comprehensive, personalized care to her patients. Being at the frontline of healthcare, Dr. Kahn takes care of a diverse patient population. Many of her patients endorse dry eye symptoms, and simply telling them to use artificial tears does not solve the problem. Dr. Kahn has come to appreciate the multifaceted nature of dry eye disease, and how a treatment plan needs to address eye hygiene, along with lifestyle modifications. As a primary care physician, she believes that what is good for the eyes should also be good for the mind and body.

Get to know Dr. Kahn a little better!

Hobby: swimming
Favorite food: brie
Superhero: Jean Grey
Guilty pleasure: dark chocolate
Greatest weakness: Instagram
Secret power: cooking

Training:

Undergraduate: Columbia University
Medical school: Weill Cornell Medicine
Primary care residency: Thomas Jefferson University Hospital

different type of dry eye disease

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Table of Contents

In this article, you will learn the types of dry eye disease and its many causes. Our hope is that once you know the types and causes of dry eye disease (DED), we can collectively develop a dry eye treatment plan to help you take control of your DED! 

Key Points

  • There are two main types of dry eye disease: aqueous deficient and evaporative. In reality, most forms of dry eye disease are a mix of the two types.
  • Aqueous deficient means your body is not making enough tears. Evaporative means your body is making tears, but they evaporate too quickly.
  • The environment, work life and numerous eye and medical diseases can all contribute to dry eye disease.
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Taking the First Step

First, let us start by saying that dry eye disease (DED) is not your fault. We know it is easy to blame yourself, especially when nothing seems to be helping with your symptoms.

DED is also known as dry eye syndrome, keratoconjunctivitis sicca and ocular surface disease. DED can be divided up into decreased production of tears (aqueous deficient dry eye) or rapid evaporation of tears (evaporative dry eye).1 This is an oversimplification, but it helps with understanding other concepts, such as, how your natural tears are made, the different layers of your tear film, and the basics of dry eye treatment.

Causes of dry eye disease

Aqueous Deficient Dry Eye: Not Making Enough Tears

Your natural tears come from the lacrimal gland, located in your eye socket deep under the skin. The lacrimal gland produces three different types of tears:2 

  • Basal tears – always there
  • Reflex tears – only when you need them
  • Emotional tears – show up due to emotions

Basal tears are constantly secreted to lubricate the ocular surface. Reflex tears are produced in response to stimulation from the cornea. Emotional tears appear during high emotion situations. 

Since the lacrimal gland produces your tears, anything that causes it to malfunction will decrease tear production.

Sjögren’s syndrome, an autoimmune condition, causes inflammation of the lacrimal gland, and is associated with severe dry eyes.3 In addition, Sjögren’s affects the salivary glands in your mouth, causing mouth dryness. Patients will complain of “dry mouth” or needing to drink water frequently, in addition to dry eye symptoms.

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    Another cause of decreased tear production is disruption of the connection between the cornea and lacrimal gland. When the cornea is dry, it stimulates the lacrimal gland to produce more tears. This critical link between the cornea and lacrimal gland keeps the ocular surface lubricated, comfortable and protected. If this link is disrupted, tear secretion may decrease. This is often seen in people who have eye injuries, corneal scarring or eye surgeries that decrease the sensitivity of the cornea.

    Measuring tear production

    Your eye doctor can measure tear production using the Schirmer’s test. This test involves placing a piece of paper on the inside of the lower eyelid and measuring the volume of tears you produce in 5 minutes. If your DED is primarily due to decreased tear production, lubrication with artificial tears can help supplement low tear volume. Your doctor can also place punctal plugs in your tear drainage system to allow your tears to stay longer in your eyes.

    Learn more about treatments for dry eyes.

    Evaporative Dry Eye: Tears Dry Up Too Fast

    In addition to decreased tear production, you could have increased tear evaporation, also known as evaporative dry eye disease. Your tear film is made up of three layers sitting on top of each other:4 

    • Mucin layer – the glue 
    • Aqueous layer – the water
    • Lipid layer – the oil
    What is dry eye tear film?

    The mucin layer is secreted by cells (especially Goblet cells) located in your conjunctiva. This is the clear film that lines the white part of your eye known as the sclera. The aqueous layer is the largest layer and comes from the lacrimal gland. The lipid layer is made up of oils secreted from your meibomian glands that line the eyelid margin. 

    The mucin layer is attached to the cornea, the aqueous layer sits on top of the mucin layer, and the lipid layer sits on top of the aqueous layer. All three of these layers work collectively to stabilize the tear film and prevent tear evaporation. 

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    Meibomian gland dysfunction

    The most common cause of evaporative DED is meibomian gland dysfunction (MGD). Meibomian glands line your eyelids and secrete oil which makes up the lipid layer in your tear film. These glands sometimes stop working well. Instead of releasing oil into your tear film, the oil can deposit on the eyelids or in the glands themselves. MGD can happen for many reasons, but it’s mostly related to genetics, environment, age and gender.

    When the meibomian glands stop secreting oil, your lipid layer in the tear film becomes deficient. This causes the remaining layers in your tear film to break up and evaporate quickly. Moreover, as the oil builds up on your eyelids or in the meibomian glands, you can get styes and eyelid inflammation, also known as blepharitis. This creates a vicious cycle where MGD directly causes DED, leading to other conditions that worsen dry eye disease.

    Glands and goblet cells

    As we discussed above, if the lacrimal gland malfunctions, you can get decreased tear production. Meaning, your aqueous layer may become deficient, which leads to overall tear film instability and rapid tear evaporation. 

    Eye injuries

    If your conjunctiva gets injured or damaged, the cells in it may not produce the molecules necessary for the mucin layer. Without mucin, the remaining layers of the tear film lose their anchor and become unstable. We can see this in eye injuries, such as blunt trauma and chemical exposure (acids and alkali), where the conjunctiva can get scarred.

    If the surface of the cornea is damaged, the mucin layer may not be able to attach to it. This can happen in the setting of eye injuries, corneal scarring, and eye surgeries. If the mucin layer fails to attach to the surface of the cornea, the aqueous and lipid layers also will not attach well, and as a result, the tear film can become unstable and evaporate quickly. 

    We can measure tear film instability in the clinic by using fluorescein, which is the “yellow” stuff that eye specialists put in your eyes. Fluorescein is a natural dye, and it lights up when we use a special light on our exam machine. With this, we can see how quickly your tear film breaks up (TBUT). A rapid TBUT is an indicator of tear film instability.

    When we see this, we may think about using artificial tears with oil and lipids. We also emphasize eyelid hygiene with warm compresses, cold compresses and eyelid wipes to improve meibomian gland function.

    You can learn more about treatments for dry eyes here.

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    Mixed Forms of Dry Eye Disease

    Most patients do not have a clear aqueous deficient or evaporative type of DED. For example, as we discussed above, decreased tear production from the lacrimal gland can lead to both types of DED. Eye injuries, scars and surgeries can also lead to both. In fact, the most common types of dry eye disease are typically a mix of aqueous deficient and evaporative. Further, there are several contributing factors, such as the environment, workplace, ocular diseases, medical problems and oral medications.

    Environmental Causes of Dry Eye

    Your environment plays a vital role in DED.5 For example, high winds or low humidity may cause your tears to evaporate fast. Poor air quality may cause irritation to your eyes. A high ultraviolet (UV) index (intense sunlight) could be difficult for people who experience light sensitivity because of DED.

    These factors are also important to consider inside your house. Sleeping under a fan or in front of an air conditioner could cause your tears to evaporate rapidly, just like in high wind areas. Other risk factors include low humidity inside your house and stagnant, poor air quality. 

    Environmental Conditions that affect dry eye disease

    With COVID-19, wearing masks has become standard practice. For DED patients, this becomes a problem because airflow is directed upwards toward your eyes, leading to rapid tear evaporation. This causes dry eyes and actually carries the name “mask-associated dry eye disease.”

    You should certainly wear a mask during the pandemic, and if you have DED and live in areas with environmental risk factors, you do not need to pack your bags and move. Your environment should not be your enemy! Instead, you can make small, but impactful changes to improve your dry eye symptoms. For example, using a humidifier, and directing air conditioning away from your eyes can make a big difference. So can wearing sunglasses or eye protection when outside on sunny or windy days. 

    Occupational Causes of Dry Eye

    The average person spends at least half of their waking hours at their job. For most of us, that means looking at a computer screen for hours. When we look at a computer screen, or any screen for that matter, our blinking decreases, and so we do not replenish our tear film, leading to dry eye symptoms.6

    Another important consideration is screen placement. If your computer screen is above eye level, your eyes naturally open more to look upwards at the screen. This exposes more of your ocular surface to the environment. 

    The workplace and dry eye disease

    With COVID-19, we have become even more reliant on our computers for work. Anytime we are using our eyes to focus, our blinking naturally decreases. This includes driving, cooking, knitting, sewing, you name it.

    Most of our daily activities require focusing with our eyes, which is why dry eye disease can be so debilitating.

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    Other Eye Conditions Linked to Dry Eye Disease

    There are several eye conditions and surgeries that can cause or worsen DED.7 For instance, the drops used to lower your eye pressure in glaucoma cause dry eyes.

    Antibiotics used to treat corneal or eye infections can lead to DED if used for too long. Most of these eye drops contain benzalkonium chloride (BAK), a preservative that prolongs the shelf-life of eye drops. This can be toxic to the ocular surface, including both the cornea and conjunctiva. 

    Contact lens wear is another cause of dry eyes. Millions of people worldwide wear contact lenses. Many do not follow good contact lens hygiene, such as not sleeping or showering in contact lenses, or discarding them at the recommended time. Poor contact lens hygiene can directly injure the cornea, leading to DED. Contact lenses may also destabilize your tear film and blunt the connection between the cornea and the lacrimal gland. This leads to decreased tear production. 

    Eye surgeries can also cause or worsen different types of dry eye disease. Eye surgery can directly injure the ocular surface, and typically involves antiseptics and drops that are not gentle on the cornea.

    Refractive surgery, such as LASIK, can injure the corneal nerves and the Goblet cells (which secrete mucin for your tear film), and change the shape of the cornea, leading to tear film instability and decreased tear production.

    Medical Problems Linked to Dry Eye Disease

    Did you know that your general health can also impact DED?8

    Autoimmune conditions, such as Sjögren’s syndrome or rheumatoid arthritis, are associated with types of dry eyes. Thyroid problems can manifest with thyroid eye disease, which typically causes dry eyes.

    Poor nutritional status (diet with low vitamins A, B, C, D and E, and low omega-3 fatty acids) can contribute to dry eye disease. Cancer, dermatitis, rosacea, diabetes, high blood pressure, and menopause (hormonal changes) are a few of the many medical problems associated with dry eyes. 

    Several oral medications have side effects that can cause dry eye symptoms. These medications include antihistamines, antidepressants, birth control pills, isotretinoin (Accutane), diuretics, decongestants, beta blockers, chemotherapy, and hormone replacement therapy. These medications can either decrease tear production or make your tear film unstable.

    Putting It All Together 

    As we’ve said before, and the above article should convince you, DED is not just about dry eyes; it can affect and be affected by your whole body and mind leading to poor quality of life.

    DED is not your fault!

    While it is important to know the causes and types of dry eyes, remember that most forms of DED are usually multifactorial, with several contributing factors. This is why simple eye lubrication with eye drops or CorneaCare artificial tears, warm compresses and even prescriptions (cyclosporines and lifitegrast) alone are insufficient.

    What is most important is to develop a personalized therapeutic plan, make some important environmental and lifestyle modifications, and stay consistent.

    Want to take care of your dry eyes but not sure where to start?
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    What’s Next

    Let’s learn about why dry eye disease matters! Also read more to learn about the causes dry eye disease.

    Bibliography

    1. Tear Film & Ocular Surface Society. Dry Eye Workshop II Report. Ocular Surface Journal, 2017. TFOS DEWS II Report, http://www.tfosdewsreport.org/.
    2. Mukamal, Reena. “Facts About Tears.” American Academy of Ophthalmology, 2016, https://www.aao.org/eye-health/tips-prevention/facts-about-tears. Accessed 8 July 2021.
    3. Sjogren’s Foundation. “Understanding Sjogren’s.” Sjogren’s Foundation, 2021, https://www.sjogrens.org/understanding-sjogrens. Accessed 15 July 2021.
    4. Foster, C Stephen. “What is the anatomy of tear film relevant to dry eye disease (keratoconjunctivitis sicca)?” Medscape, 2019, https://www.medscape.com/answers/1210417-108241/what-is-the-anatomy-of-tear-film-relevant-to-dry-eye-disease-keratoconjunctivitis-sicca. Accessed 18 August 2021.
    5. Higuera, Valencia. “What Is Dry Eye? Symptoms Causes, Diagnosis, Treatment, and Prevention.” Everyday Health, 2020, https://www.everydayhealth.com/dry-eyes/guide/. Accessed 31 July 2021.
    6. Wheeler, Regina B. “Dry Eye and Screen Use.” WebMD, 2021, https://www.webmd.com/eye-health/dry-eye-screen-use. Accessed 25 August 2021.
    7. Golden, Mark I., et al. “Dry Eye Syndrome.” NCBI: Stat Pearls, 2021, https://www.ncbi.nlm.nih.gov/books/NBK470411/. Accessed 15 July 2021.
    8. Yang, Wan-Ju, et al. “Risk Factors for Dry Eye Syndrome A Retrospective Case-Control Study.” Optometry and Vision Science, vol. 92, no. 9, 2015, pp. e199-e205. Optometry and Vision Science, https://journals.lww.com/optvissci/fulltext/2015/09000/risk_factors_for_dry_eye_syndrome__a_retrospective.11.aspx.

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