Caring for your Dry Eyes

About Tears:
Tears are made up of several components:
• Water

•  Mucin (a sticky substance which sticks the tears onto the surface of the eye producing a thin, even lubricating layer). This smooth layer is important for clear vision.

• Oils- secreted by the Meibomian glands in the eyelids. The oil in tears sits on the outer layer of the tears moisturising the eye by holding the mucin and water layers onto the eye and slowing their evaporation.

• Enzymes called lysosomes (these destroy most bacteria and viruses they come in contact with) and Immunoglobulins which protect against infection.

• Oxygen and nutrients dissolved in tears provide nutrition for maintaining a healthy cornea (the clear part of the eye which sits on top of the pupil). The tears also prevent damage to the eye surface from dust particles in the air by washing the surface of the eye each time there is a blink. In Sjogren’s syndrome, due to inflammation and destruction of the tear producing glands, there is a marked deficiency in tear production and the tear film is abnormal in composition. The tears contain less mucin and enzymes so they break down quickly on the surface of the eye which causes the cornea to dry and vision is often blurred.
 
In Sjogren’s syndrome the eyes feel dry, gritty and painful.  Sometimes the eyes feel tired and sensitive to light.  The eye is prone to frequent infections and the cornea prone to damage.

It is important to lubricate your dry eyes when ever they are uncomfortable or feel dry/gritty or painful as if they continue to dry out the eye becomes increasingly damaged.
 If simple lubricating measures fail to relieve your discomfort and you develop blurring of your vision  you should consult an eye specialist as  keratitis is a more severe inflammation of the deeper layers of the outside of the eye which  can occur in auto immune diseases such as Sjogren’s Syndrome

Treating your dry eyes

• Artificial tears are the main treatment in dry eye. It is important that you use  preservative free eye drops if you require drops  more than four times per day, or one with special disappearing preservatives that evaporate on the eye surface (vistil forte is an example of this type of drop and is now funded in NZ).
 
Some brands of preservative free drops which are available in NZ are: Theratears drops, Refresh drops; Bion Tears; Systane Preservative Free. Gels are thicker drops, providing longer relief-often particularly useful for overnight. Gels available in NZ are Genteal Gel and Poly Gel.   As the different brands have different compositions it is important to try several brands to find one that suits you best. If the artificial tears you are using are beneficial but the symptoms are quick to return then try using an artificial tea or gel that is thicker or more viscous.
 
Lubricating Eye Ointment – applied each night helps prevents eyes drying overnight- also may be used in the day for very dry eye though will cause blurring of vision for a short time due to the thickness of the ointment. Some people find it is useful to put artificial tears into the eye then apply a layer of ointment.  There are several brands of non preservative ointment available fully funded on prescription in NZ. Two commonly prescribed are: Lacrilube and Polyvisc eye ointment. As with artificial tears, they differ in their composition so patients may prefer one brand better than another. It appears while one preparation my suit one person it may not bee the most suitable for another so we recommend you keep trying brands till you find drops and/or ointment that suits you best.

• Eye protection – Such as wrap around sunglasses to shield eyes from the drying effects of wind and sun and may be useful when in situations with air-conditioning such as on airline flights.

• Humidifying devices – Some people find vaporizers and humidification masks useful at night to moisturise the air in the room and decrease drying or the eyes nose and mouth.

• Warm compresses and eyelid massage-may be useful to encourage secretion of lubricating oils from the Meibomian glands.

• Tear Duct (Punctal) Occlusion- This can be very effective in helping to retain your own natural tears a bit longer – there are temporary dissolving plugs available which are useful as a trial – these are inserted by an eye specialist (ophthalmologist) into the tear ducts (which drain tears from the eye) to slow the drainage of any tears and drops from the eye. They are worth a try and if you have a good result then the next step is permanent Punctal Occlusion with insertion of silicone plugs (non dissolving) or punctual cautery which is a simple quick procedure performed under local anaesthetic. Punctal cautery involves passing an electric current along a tiny wire which has been inserted into the tear drainage holes. This causes a small burn to the ducts which then scar up and close.  It is mostly painless and can markedly reduce eye discomfort and reduce the need for drops.

• Pilocarpine is a medication that increases saliva and tear production – some people find it very useful. It is fully funded on prescription.  Try 2.5ml of Pilocarpine solution 1mg/1ml Oral Solution (chemists mix this oral solution from Pilocarpine eye drops). There are some conditions where Pilocarpine should be avoided for example if you have uncontrolled high blood pressure or heart failure.

• Autologous lubricating drops.  In rare cases where not enough relief has been gained by the above treatments then a specialist eye department can organise to prepare eye drops made from your own serum.  These are apparently very soothing but complicated to make requiring a collection of your blood for each batch.

• Antibiotic eye ointments/drops- Are sometimes required as without a normal tear film with its protective properties eye infections are common.  Keep the use of these to a minimum as the drops contain preservatives.  Sometimes early infection can be treated with more frequent use of artificial tears.

• Nutritional supplements:  Many people are finding taking daily omega oil supplements useful to decrease dry eye symptoms. These are taken as capsules containing fish oil and/or flaxseed oil.  Omega 3 has many health benefits including protective effects against heart disease, bowel cancer, and some studies show improve concentration and mood. People with arthritis may also find it helpful.

Dry eye is made worse by:

• Low humidity conditions such as air conditioning
• Windy conditions, fans.
• Dusty/smoky environments
• Drugs which cause dryness- for example: tricyclic anti-depressants; some blood pressure medications (diuretics in particular); nausea medications; antihistamines.

Contact lenses are generally not used in dry eye as they tend to aggravate the condition. 

If your eye discomfort gets worse for no apparent reason there could be a complication needing attention such as:
• Corneal abrasion (a scratch on the cornea- usually from a foreign body damaging the eye) or

• Conjunctivitis- which is an infection of the outer layer of the eye, and is much more common in people with dry eye.  This is generally associated with a discharge of pus and increase in eye discomfort. If you find this occurs frequently your doctor may give you a prescription for some antibiotic ointment to have on hand.  Antibiotic ointment is preferable to drops as it is moisturising as drops contain preservative.

• Blepharitis- Inflammation of the eyelids due to Meibomian gland dysfunction. Causes swelling and redness of the eyelids. This may be due to a low grade infection or sometimes due to the irritating effects of preservatives in artificial tears or ointments. Treatment for blepharitis includes massage of the lids after hot flannels have been applied and cleaning the eyelids with “baby shampoo” or a special product called “Lidcare”.

• Keratitis- Inflammation of the cornea which sometimes occurs as a complication of autoimmune disease- this is extremely painful and if suspected it is recommended to see a specialist ophthalmologist for confirmation and treatment.