A guide to understanding dry eye disease – by an optometrist

Medical

Dry eyes are something that most of us have experienced at some point. After a day of staring at screens, or the morning after a late night, our eyes can feel scratchy, and uncomfortable as though they’d rather be closed. 

Yet, there is a difference between the occasional dry eyes and chronic dry eye disease. While the first will go away after a break from screens and a good night’s sleep, the latter can severely impact your quality of life.

Affecting between 5% to 34% of people around the world, dry eye disease is one of the most common conditions seen in eye clinics. It’s also one of the most misunderstood. In this guide, Dina Sonpal, an optometrist at Midland Eye, explains what dry eye disease is, the symptoms to watch out for and what treatment is available.

What is dry eye disease?

A stable tear film is essential for both comfort and clear vision, as it provides a smooth optical surface and protects the eye. But tears evaporate. To limit the evaporation, tears contain lipids (oils) which work to create a film over the eye. 

With dry eye disease, the glands in your eyes either don’t produce enough tears (aqueous deficient dry eye) or produce tears that don’t contain enough lipids and which evaporate too quickly to keep the surface of your eye properly lubricated (evaporative dry eye).

In both cases, the eye quickly becomes dry and cannot keep up with the lubrication requirements, leading to dry, sore eyes.

What are the symptoms of dry eye disease?

Some symptoms of dry eye disease are fairly obvious, such as a gritty or sandy sensation, redness, irritation, a burning feeling. These symptoms are, however, common for a lot of eye issues and are often mistaken for allergies or conjunctivitis. 

Dry eye disease can also exhibit a few symptoms you may not expect.

Watery eyes are perhaps the most counterintuitive. Just like in healthy eyes, the lack of moisture triggers the release of more tears. Unfortunately, these emergency tears don’t solve the underlying problem but simply overflow your eyes and cause them to stream.

Fluctuating or blurred vision is another symptom that can be ambiguous. People will usually assume they need new glasses, but sometimes blurred vision can be a problem with tear film quality. Since a uniform layer of tear film is essential for clear vision, any instability or lack of uniformity can cause vision to shift in and out of focus.

Likewise, light sensitivity can be a result of the tear film. An irregular film surface over the eye ends up scattering incoming light rather than focusing it cleanly, causing glare. For some patients, this reaction to light can be intense and even painful. 

Ultimately, almost all dry eye symptoms overlap with other eye issues. Rather than hoping for the best while treating the symptoms, the most effective course of action is always to get a proper consultation with an eye specialist. 

What are the causes of dry eye disease?

The most common causes of dry eye disease are ageing and prolonged screen use. Looking at screens for long periods of time, including when gaming, reduces our blink rate which means tears evaporate before they’re replenished. Ageing, meanwhile, reduces tear production and changes the composition of the tear film.

But there are several causes that patients frequently haven’t considered. Some medications, such as antidepressants, antihistamines, blood pressure medications, and some hormonal contraceptives, can reduce tear production as a side effect. Unfortunately, patients often aren’t warned that their eyes might be affected by these medications. 

Some environmental factors, such as air conditioning, central heating, wind, and smoke, can also cause eyes to dry out over time and negatively impact tear film quality and production. Contact lenses are another common cause, disrupting the tear film over time.

One of the most significant and most overlooked drivers of dry eye is Meibomian Gland Dysfunction, or MGD. The Meibomian glands, located in the eyelids, produce the oily layer of the tear film that prevents evaporation. When these glands become blocked or inflamed, they are unable to produce the right mix of oil for the tear film. As a result, the protective film breaks down, and tears evaporate far too quickly. MGD is frequently associated with rosacea and is thought to be responsible for the majority of evaporative dry eye cases.

Hormonal changes, particularly around menopause, have been found to play a far more significant role than was previously recognised. Research suggests that between 50% and 70% of post-menopausal women experience dry eye symptoms. It is thought that declining hormone levels can lead to reduced Meibomian gland activity and, as a result, evaporative dry eye disease. Often, women in this group attribute their dry eyes to general symptoms of ageing and don’t realise that there are specific treatments for dry eye disease.

It’s also worth knowing that dry eye can occasionally be an early sign of an underlying systemic condition. Autoimmune conditions such as Sjögren’s syndrome, rheumatoid arthritis, and lupus can all present with dry eye symptoms, as can thyroid disease. This is one of the reasons it’s so important to get an informed professional assessment as soon as possible.

How does dry eye disease impact your daily life?

Dry eye disease can have a significant impact on daily life, sometimes in ways that aren’t always immediately obvious. And, because symptoms fluctuate and aren’t always visible to others, the impact is often underestimated.

The effects show up across a whole range of daily activities. Screen intolerance affects concentration and productivity at work, reading becomes difficult and frustrating, and night driving is much harder when there’s lots of unexpected glare. 

Outdoor activities can trigger excessive watering due to the wind, while contact lens wearers sometimes find their lenses become intolerable altogether – occasionally having to give up the sports or hobbies they originally wore them for.

Over time, the emotional toll can be considerable. Chronic discomfort has real effects on mood, and patients living with persistent dry eyes often experience irritability, low mood, or anxiety – particularly when symptoms are not improving or feel difficult to explain to others. Clinicians working in this area regularly see patients who have quietly scaled back activities they love, rarely connecting the retreat from those hobbies to a manageable eye condition.

There is also a tendency to minimise or normalise the condition. Patients assume that they’re just tired or they’ve been staring at screens for too long and reach for over-the-counter eye drops. While drops can help, they can also mask the issue in the short term, delaying proper diagnosis and treatment.

How is dry eye disease diagnosed?

A professional dry eye assessment is much more involved and in-depth than most patients expect. It begins with a detailed history and symptom review, followed by an external examination of the eye and eyelids using a slit lamp. 

Professional clinicians will then assess the Meibomian glands and evaluate the tear film using ocular surface staining – a technique that reveals areas of damage or instability on the eye’s surface that would otherwise be invisible.

Advanced clinics can take testing even further. Meibography, for instance, uses imaging to assess the structure of the Meibomian glands directly, while tear osmolarity testing and inflammatory marker analysis provide additional layers of diagnostic precision. 

At Midland Eye, this process is supported by the Topcon TERA – a computer-assisted multi-test dry eye imaging system that helps assess and grade each component to reliably inform a personalised treatment plan.

All of these assessments are quick and painless but, together, they paint a complete picture. Since dry eye disease is not a single condition with a single cause and a single treatment, it requires careful analysis to establish what’s actually going on. 

What are the treatment options for dry eye disease?

The good news is that there are now far more treatment options for dry eye disease than in the past. Treatment is also now highly personalised and is shaped by whether a patient has aqueous deficient, evaporative, or mixed dry eye.

Some simple adjustments are almost always recommended in the treatment of dry eye disease, including: 

• Environmental changes, such as avoiding air conditioning directed at the face, wearing wraparound sunglasses outdoors, reducing exposure to heating vents. 
• The 20-20-20 rule: every 20 minutes of screen time, look at something 20 feet away for 20 seconds to help with issues associated with screen use. 
• Eyelid hygiene, consisting of a daily routine of warm compresses followed by a gentle eyelid scrub to ensure that the eyes stay clean and healthy. This is particularly important for patients with MGD, as it helps to keep the Meibomian glands clear and functioning. 
• Dietary supplements, particularly omega-3 fatty acids and vitamin D, can also support tear film health.
• Over-the-counter lubricating drops – look for preservative-free artificial tears for general use and lipid-containing drops if you suffer from evaporative dry eyes.

What are the clinical treatment options for dry eye disease?

For more persistent or severe cases, there are several clinical interventions that can help dry eye sufferers.

• Anti-inflammatories, such as ciclosporin, or short courses of corticosteroids can address the inflammatory component of dry eye disease. 
• Punctal plugs are tiny devices inserted into the tear ducts that help retain moisture on the surface of the eye by reducing drainage. 
• Intense Pulsed Light (IPL) therapy has become an increasingly recognised treatment for MGD, reducing inflammation and improving gland function. 
• BlephEx is a professional eyelid cleaning procedure which reduces bacterial build-up on the lid margins that can contribute to gland dysfunction. 
• For the most severe cases, autologous serum tears (eye drops made from a patient’s own blood serum) or amniotic membrane treatment may be considered.

Dry eye disease is, for most patients, a manageable condition but it does require the right plan, so it’s always important to get a professional diagnosis and personalised treatment.

What to expect during and after treatment

It is important to understand that dry eye treatment isn’t going to provide an immediate cure. Improvement is gradual and small changes build up over time. Dry eye disease is a chronic condition, and some fluctuation in symptoms early in treatment is normal and doesn’t mean it isn’t working.

Patients who see the best outcomes are those who maintain their treatment routine consistently. 

The most common mistakes patients make are using lubricant drops reactively when eyes feel bad, rather than regularly as directed, and giving up on eyelid hygiene once symptoms start to improve. Treating dry eye disease is about making a small effort every day, even when you don’t experience any symptoms.

It’s also essential to maintain ongoing screen habits and environmental changes. Even patients who are keeping on top of their treatment plan can undermine their progress by ignoring screen time, the 20-20-20 rule, and returning to the same windy, dry environments.

Unfortunately, dry eye disease is not something that we can currently cure. The goal of treatment is to control it effectively to reduce irritation and discomfort. For patients who engage properly with diagnosis and treatment, the outcome is very optimistic. You can live a relatively normal life and engage in all the activities you previously enjoyed, such as driving, sports, and reading.

Future diagnosis and treatment for dry eye disease

There is considerable ongoing research into dry eye disease which will hopefully translate into new diagnostic and treatment tools in the near future. 

One such development is biomarker analysis in tear film testing. The aim is to detect and measure specific biological markers in tears, allowing for earlier and more precise diagnosis, potentially identifying dry eye disease before symptoms have even developed and enabling more targeted treatment from the outset. It would also allow clinicians to monitor how a patient is responding to treatment in a far more objective way than is currently possible.

If you experience dry eye symptoms, get a proper assessment

As with all eye conditions, early diagnosis and treatment is always the best course of action. If you’re experiencing any eye discomfort, fluctuating vision, unexpected watering, or sensitivity to light then go to your doctor, optician, or specialist eye clinic for a proper assessment. 

Author: Dina Sonpal is an Optometrist at Midland Eye. Midland Eye was founded by four ophthalmic surgeons who wanted to provide patients with a comprehensive, specialist service for the diagnosis and treatment of all eye conditions. The team are leaders in their field and offer a consultant-only service to all patients requiring eye care or surgery.

Every consultant is qualified to treat common eye conditions such as cataracts but each one also has a particular area of specialisation, ensuring that patients get the best possible outcome, no matter what the diagnosis. Private patients can benefit from access to collaborative care and facilities with the latest and best technology. The clinic’s approach is designed to be convenient for people who lead busy lives and have limited time to seek medical advice and treatment.