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What is Dry Eye Disease

9 min read

Jovi Boparai MD Profile Picture
Written byJovi Boparai, MD
Reviewed by Brandon Ayres, 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.

Brandon Ayres, MD
Brandon Ayres, MDOphthalmic SurgeonPhiladelphia, PA

Bio

Dr. Ayres is a fellowship trained cornea specialist who is a leading authority in ophthalmology. By combining clinical and surgical expertise, Dr. Ayres delivers personalized eye care to each individual patient. He is an expert in dry eye disease, and has spoken at various international conferences, forums and panels. He personally treats hundreds of thousands of patients, and understands firsthand just how difficult dry eye disease can be. He believes that an effective regimen merges treatments with lifestyle changes to provide lasting relief for the patient.

Get to know Dr. Ayres a little better!

Hobby: cycling
Favorite food: scallops
Superhero: Iron Man
Guilty pleasure: country music
Greatest weakness: snickers bars
Secret power: I can talk to animals

Training:

Medical school: Rutgers Robert Wood Johnson
Ophthalmology residency: University of Medicine and Dentistry of New Jersey (now part of Rutgers New Jersey Medical School)
Cornea fellowship: Wills Eye Hospital

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

What is dry eye disease

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Table of Contents

Key Points

  • Dry eye disease is a chronic condition that afflicts 30 million Americans and 300 million people worldwide.
  • In addition to debilitating symptoms, dry eye disease can affect your physical and mental wellbeing.
  • Dry eye disease is chronic, but treatable.

Keywords

Artificial tears, dry eye disease (DED), meibomian gland dysfunction, tear film

Taking the First Step

If you’re reading this article, either you or someone you know has dry eye disease (DED). It is a chronic condition that affects millions of people worldwide, and can impact you on multiple levels. In addition to your eye health, DED can influence your physical and mental wellbeing. Once you have DED, your symptoms may come and go, but you will typically have it for the rest of your life. We know this seems daunting, but with a good treatment plan you can take control of your DED!

What is Dry Eye Disease

Dry eye disease (DED) is also known as dry eye syndrome, keratoconjunctivitis sicca and ocular surface disease. DED is a chronic condition caused by unstable tears and inflammation, and leads to symptoms such as redness, burning, irritation, gritty sensation and blurry vision. Our goal in this article is to briefly review the different components of DED.

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    The Tear Film & Ocular Surface Society Dry Eye Workshop II defines DED as “a symptomatic disease, characterized by a vicious cycle of tear film instability and hyperosmolarity, which leads to increased ocular surface inflammation, damage and neurosensory abnormalities.”1

    So let’s break this down into readable and relatable language. Your tear film coats the front part of your eye, called the cornea, and it plays a crucial role in protecting the eyes, making your eyes feel comfortable, and in helping you see clearly. In DED, your tear film malfunctions, which sets off a cascade of inflammation, leading to symptoms.

    Who Gets Dry Eye Disease

    Literally everyone. If you’re reading this, chances are that you or someone you know has DED. Approximately 30 million Americans, and over 300 million people worldwide are affected by it.1 But the actual number is probably much higher. In fact, one in every three eye care clinic visits is related to symptoms of dry eyes.2 Think about it, anyone looking at a computer or phone screen (basically all of us these days!), or doing tasks that require long focus without blinking, or driving, or living in high pollution and low humidity areas, will invariably get dry eye symptoms. When these symptoms become persistent and get in the way of your life, that’s when you have DED.

    Dry eye disease effects more than 30 million people

    The Impact of Dry Eye Disease

    We get it. DED is tough for everyone involved. While it does not cause blindness, DED puts you at risk for vision-threatening complications, such as corneal infections and scarring. DED has a significant impact on a person’s life, leading to social, emotional and economic burdens.3 Most people with DED suffer from symptoms for months, try several different over-the-counter treatments, and spend a considerable amount of time, energy and money before seeking professional help. 

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    Even after seeking help, a patient commonly sees multiple eye specialists (ophthalmologists and optometrists) because they feel that their eye specialist is not taking them seriously, or not spending enough time listening to them. This is not the eye doctor’s fault. Taking care of DED requires more time with the patient, which is not always feasible in a busy practice with overhead expenses. As you can imagine, this leads to frustration, hopelessness and treatment failure.4 You can learn more about the impact of DED here.

    DED is chronic, but it is manageable and treatable, just like other chronic conditions that affect the body, such as diabetes and high blood pressure. That’s what we are here for! To get you the best treatment and support from the start as soon as you have symptoms. All we do here at CorneaCare is DED and we have honed our craft and our workflow so we can spend the much-needed time to listen, support, and provide you personalized eye care.

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    Having DED should not prevent you from doing anything you love or need to do. In fact, we’re here to tell you that with consistent effort on your part and support from us, you can protect and preserve your eyes, and live a healthy, fun and prosperous life. 

    What Are the Symptoms of Dry Eye

    Everyone experiences dry eye symptoms differently. Your own experience with DED is very important to us, but the typical symptoms are:5

    • Redness
    • Pain
    • Irritation
    • Gritty sensation, or foreign body sensation
    • Dryness
    • Blurred vision
    • Tearing or watery eyes
    • Burning sensation or stinging of the eyes
    • Light sensitivity
    • Eye fatigue

    Key symptoms of dry eye disease

    What Are the Causes of Dry Eye Disease

    Let us start by saying that DED is not your fault! The best way to think about what causes DED is to divide it up into decreased production of tears (aqueous deficient) or rapid evaporation of tears (evaporative).1 

    What causes dry eye disease?

    Your natural tears are produced by the lacrimal gland. Infection and inflammation may cause the lacrimal gland to malfunction, leading to decreased tear production.

    One cause of inflammation of the lacrimal gland is Sjögren’s syndrome, an autoimmune condition, which is typically associated with severe dry eyes. Another cause of decreased tear production is a disruption in the link between the cornea and the lacrimal gland. When the cornea is dry, it naturally alerts the lacrimal gland to produce more tears. If this feedback loop is disrupted, tear production may decrease. This is commonly seen in people who have had eye injuries, infections or surgeries that decrease the sensitivity of the cornea.

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    In addition to decreased tear production, you could have increased tear evaporation, which also leads to dry eyes.

    Your tear film is made up of three layers: the mucin layer, the aqueous layer and the lipid layer. The mucin layer is made up of molecules that allow it to bind to the surface of the cornea. The aqueous layer then sits on top of the mucin layer, and the lipid layer sits on top of the aqueous layer.

    What is dry eye tear film?

    All three of these layers work collectively to stabilize the tear film, and prevent tear evaporation.

    So you can imagine if the surface of the cornea is damaged, it may not bind to the mucin layer well. Or if there is a decrease in the oil production for the lipid layer, such as in meibomian gland dysfunction, your tear film may not be stable. 

    Contact lens use is another common cause of DED. This is because contact lenses may directly lead to changes on the cornea or decrease the sensitivity of the cornea, predisposing it to symptoms of chronic dry eye. Eye surgery, specifically refractive surgery (LASIK), and preexisting eye conditions, such as corneal diseases and glaucoma, are other risk factors for DED. Some systemic risk factors (with examples in parenthesis) are listed here for your reference: age (>50 years old), female gender, systemic medication side effects (oral antihistamines, antidepressants, decongestants, diuretics or birth control pills), hormonal changes (menopause), autoimmune diseases (thyroid eye disease and rheumatoid arthritis), medical conditions (cancer and diabetes), poor nutrition (low vitamin A), environmental factors (low humidity), and occupational factors (computer screens).6 

    You can learn more about the different causes of DED here.

    How to Diagnose Dry Eye Disease

    There are several ways to diagnose DED, but it all starts with listening to you, the patient.6 In fact, there are instances in DED when a patient has classic symptoms without any abnormal exam findings.7

    Several questionnaires can be used to assess the patient’s symptoms. For example, the Ocular Surface Disease Index (OSDI), the Standard Patient Evaluation of Dry Eye Questionnaire (SPEED), or the Dry Eye Questionnaire (DEQ). These questionnaires attempt to capture the patient’s subjective experience with dry eye disease as objective, measurable data.8

    Next is the exam, where we want to look at the skin around your eye, eyelids, eyelashes, how you blink, the surface of the cornea, the tear film, and the conjunctiva (a thin membrane that lines the inner part of your eyelids and covers the white part of your eye, the sclera). We look at several key exam findings. For example, if the skin around your eye is red, it cues us that you may have rosacea and so we are on the lookout for blepharitis (inflammation of the eyelids). On your eyelids, we look at your eyelid margin to see if you have meibomian gland dysfunction. We also pay attention to your blinking. If you close your eyes, and part of your eye is still exposed to the environment (incomplete blink), we worry about eyelid function. 

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    On the surface of the cornea, the common things we check are corneal sensation, corneal staining, tear film break-up time (TBUT), and tear production over 5 minutes. Corneal sensation is typically checked with a cotton tip application (q-tip), and you know from above that a decrease in corneal sensation can lead to decreased tear production. Remember that yellow stuff your eye specialists put in your eyes? Well, that stuff is called fluorescein, and it can stain the surface of your cornea and conjunctiva, highlighting areas where the surface is loose, not as strong, or broken off, which are signs of DED. Fluorescein also helps us measure TBUT, which is an indicator of tear film stability. The faster your tear film breaks up, the quicker your tears evaporate. Finally, we may perform the Schirmer’s test, where we use a strip, placed gently on the inside of your eyelid, and we measure how many tears you produce over 5 minutes.

    Key exam findings for dry eye disease

    There are other molecular tests, such as detecting matrix metalloproteinases-9 (MMP-9), which is a marker of inflammation, and tear osmolarity measurement, which tells us the concentration of various molecules in your tears. High-quality imaging of the eye also allows for measuring the height of the tear meniscus, an indicator of your tear production. Novel imaging methods can also assess tear film quality and thickness of the lipid layer, something called tear film interferometry. More on all of this later!

    How to Treat Dry Eye Disease

    And so we get to the question you care most about! Unlike what you may have heard, dry eye treatment is not as simple as putting in eye drops. Remember DED is chronic, and therefore treating DED requires continued effort on your part.9 But no worries, we’re here to support you at each step! Treatment options for DED can be divided into five components: 

    1. Education, implementation, and consistency
    2. Tear replacement
    3. Prevent tear evaporation
    4. Reduce inflammation
    5. Promote healthy nerve function and growth 

    By far, the most important aspect of treatment, and one that often goes unaddressed, is learning about DED and then implementing a treatment plan and staying consistent. Knowledge is power, and learning about DED is the first step to mastering your DED. Once you have a treatment plan, you have to implement it so that it integrates into your daily routine, and becomes habitual. Lastly, you have to stay consistent. You can have the best treatment, but if you do not adhere to it consistently, it will not work.10

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    To treat the aqueous deficient type of DED (not making enough tears), we can replace the deficiency with artificial tears to improve lubrication on the surface of the eye. There are over 50 different types of artificial tears. They can contain preservatives or be preservative-free, with different viscosities (thickness) and come in bottles or individual vials. You can also do tear replacement therapy with gels and ointments, which are typically used at bedtime. 

    To treat the evaporative type of DED, we can prevent tear evaporation. To accomplish this, we implement an eyelid hygiene routine with warm compresses and eyelid massages or scrubs. The goal of this is to optimize meibomian gland function, and produce a good lipid layer to prevent your tears from evaporating. There are many in-office procedures that heat and massage the meibomian glands. Other in-office procedures deal with the tear ducts, such as punctal plugs, which block the tear ducts to allow tears to stay in your eyes longer. Several prescription eye drops are coming to market that address the eyelid hygiene component.

    Most individuals typically will have features of both aqueous deficient and evaporative DED. Therefore, a treatment regimen often consists of lubrication and eyelid hygiene.

    What are the best treatments for dry eye disease?

    We know inflammation plays a vital role in DED pathology. Therefore, reducing inflammation is an important part of treatment. We typically do this with anti-inflammatory prescription eye drops, such as steroids, cyclosporine (Restasis and Cequa) and lifitegrast (Xiidra). Another approach is to eat food rich in anti-inflammatory compounds and antioxidants, such as Omega-3 fatty acids.

    Here at CorneaCare, we really stress the importance of your diet, because eating a well-balanced diet, with anti-inflammatory and antioxidant properties, is not only good for your eyes, but also foundational for your mind and body.    

    Promoting healthy nerve function and nerve growth in the cornea is not well understood, but we know it is important. The nerves in your cornea help with sensation (temperature, touch, pressure and pain), and also help in stimulating your lacrimal gland to produce tears. Inflammation and changes in tear osmolarity (concentration) can cause damage to the nerves in the cornea. If the nerves get damaged, they may not be able to communicate with the lacrimal gland, and alert it to produce tears. Alternatively, the nerves can become hypersensitive, causing them to activate randomly, or become overactive to mild stimuli. Meaning that a patient with seemingly “normal” eyes during an exam may still experience severe symptoms because the corneal nerves are hypersensitive.

    Remember what we said – your experience with DED is just as important as the clinical exam. You can learn more about the treatment options for DED here.

    Putting It All Together

    CorneaCare is here to give you a voice and listen to you. DED is physically and emotionally exhausting, and we know you have been through difficult times searching for answers and trying to find treatments that work. We do not believe in creating one-sided physician-to-patient treatment plans, because that would just perpetuate what is already wrong with DED treatment. These are your eyes we are talking about, and you should be in the driver’s seat for making treatment decisions, with our support. We want to empower you to take control of your DED.

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      What’s Next:

      Let’s dive into the different types of DED.

      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. Farrand, Kimberly, et al. “Prevalence of Diagnosed Dry Eye Disease in the United States Among Adults Aged 18 Years and Older.” American Journal of Ophthalmology, vol. 182, no. 1, 2017, pp. 90-98. American Journal of Ophthalmology, https://www.ajo.com/article/S0002-9394(17)30290-8/fulltext#%20.
      3. Barber, Laurie, et al. “Dry eye symptoms and impact on vision-related function across International Task Force guidelines severity levels in the United States.” BMC Ophthalmology, vol. 18, no. 1, 2018, p. 260. BMC Ophthalmology, https://bmcophthalmol.biomedcentral.com/articles/10.1186/s12886-018-0919-7.
      4. Medeiros, Susanne. “Dry Eye Can Affect More Than the Eye.” American Academy of Ophthalmology, 2018, https://www.aao.org/eye-health/news/dry-eye-can-affect-more-than-eye. Accessed 30 August 2021.
      5. Mayo Clinic. “Dry Eyes.” Mayo Clinic, 2020, https://www.mayoclinic.org/diseases-conditions/dry-eyes/symptoms-causes/syc-20371863. Accessed 30 August 2021.
      6. Hutton, David. “Dry eye patients reveal misconceptions about condition in new survey.” Ophthalmology Times, 2021, https://www.ophthalmologytimes.com/view/patients-with-dry-eye-reveal-misconceptions-about-condition-in-new-survey. Accessed 03 September 2021.
      7. American Optometric Association. “Dry eye.” American Optometric Association, 2020, https://www.aoa.org/healthy-eyes/eye-and-vision-conditions/dry-eye?sso=y. Accessed 15 August 2021.
      8. McMonnies, Charles. “Why the symptoms and objective signs of dry eye disease may not correlate.” Journal of Optometry, vol. 14, no. 1, 2021, pp. 3-10. ScienceDirect, https://www.sciencedirect.com/science/article/pii/S1888429620301151?via%3Dihub#!
      9. Recchioni, Alberto, et al. “A systematic review assessing the quality of patient reported outcomes measures in dry eye diseases.” PLOS ONE, vol. 16, no. 8, 2021, p. e0253857. PLOS ONE, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253857.
      10. Heiting, Gary. “Dry eyes: Causes, symptoms and treatments.” All About Vision, 2019, https://www.allaboutvision.com/conditions/dryeye.htm. Accessed 15 August 2021.

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