Dry Eye – The Rough Truth About Corneal Dryness

Dry Eye Management and Treatment Options

Anyone who has experienced it can tell you that something as simple as dry eyes can make the simplest daily tasks difficult to accomplish. Dry eye can affect eye comfort, clarity of vision and can create secondary issues like blepharitis. Serious cases of dry eye can cause degenerative corneal problems that often times lead to the need for corneal transplants. But whether it is due to seasonal dryness, contact lens wear or systemic tear film deficiencies, temporary and chronic dryness can be a pain in the eye.

What Is Dry Eye?

Dry eye happens when an eye does not produce enough tear film, or when it does not produce enough good quality tear film. There are three layers of tear film that combine together to keep eyes lubricated:

  • Lipid Layer – The lipid layer is the outermost layer produced by the meibomian glands. This layer keeps the surface smooth and stops the tear film from evaporating too quickly.
  • Aqueous Layer – The aqueous or water based layer is the middle layer of the tear film that is produced by the lacrimal glands in the eye lids. This layer makes up the majority of our tear film and helps to rinse away dirt, dust and debris from the eye surface.
  • Mucous Layer – The mucous layer is the innermost layer which is produced by the conjunctiva. Without this layer the other layers would not stick to the eye surface to do their job of keeping the eye moist.

Our eyes produce these tear film layers continually to keep the eye moist and the vision clear. The eye will increase the production when it is irritated, or when we cry. But unfortunately sometimes our eyes don’t produce enough of these layers or something affects the tear film production, resulting in dry eyes.

Dry Eye Symptoms:

How do you know if you have dry eye? Some of the symptoms seem pretty clear and obvious, others seem to indicate overproduction of tears! How can you tell if what you are experiencing is a symptom of dry eye or not?

  • Stinging or burning sensation in the eyes
  • Redness or Irritation – especially in wind or around smoke
  • Blurred vision – especially later in the day, when reading or using the computer for extended periods of time
  • Scratchy, gritty or foreign body sensation in the eye
  • Strings of mucus in or around the eye – in the morning or even throughout the day
  • Blurred vision or discomfort with contact lens wear
  • Excessive watering (wait…what?)

How can my eyes be dry if they water all the time? We get asked this question all of the time, and although it seems counterintuitive, excessive watering is a symptom of dry eyes, and here’s why…

When the surface of the eye becomes dry the tissue goes from smooth to being rough and irregular. When we blink our eye lids notice the rough surface and it stimulates the lacrimal glands to increase the tear film to re-lubricate the eye’s surface. Since the corneal tissue can only absorb so much of the new tear film created to lubricate the surface, the excess spills over and the eyes begin to “water”. This is where artificial tears come into play. (Did you just get a confused look again? If my eyes are watering, why on earth would I add MORE liquid to them? We’re getting there, don’t worry…)

Dry Eye Causes:

Being an ophthalmology practice based in New England we can tell you that winter is hands down our busiest dry eye season, followed by summer (yes summer). Coupled with spring and fall allergy symptoms and you can see how we keep busy all year round. But dry eyes can happen for several different reasons, including:

  • Autoimmune Diseases: Sjogren’s, Rheumatoid Arthritis, Lupus and Thyroid Disease
  • Contact Lens Wear: Contacts absorb tear film and can cause an imbalance in corneal exposure to your eyes natural tears
  • Computer Vision Syndrome: Reading, Computer or Electronic use for a prolonged period of time reduces the frequency in which we blink, which is how tear film is dispersed across the corneal tissue
  • Medications: Thousands of medications have dry eye side effects – Read your pharmacy inserts, ask your pharmacist and prescribing doctor for more information and tell your eye doctor about all of the medications you take
  • Refractive Corneal Surgery: LASIK, ASA, PRK can make dry eye symptoms worse. Be sure to have dry eye testing done BEFORE you have laser vision correction
  • Environment: Dry air due to heat or air conditioning, excessive wind, exposure to smoke or allergens can exacerbate dry eye symptoms
  • Lid Disorders: Blepharitis (redness, dryness, irritation and swelling of lids), Ectropion or Entropion – malposition of the eyelids (turning inward or outward) can effect tear production and absorption of tear film


Any of this sound familiar? Want to know what you can do to treat your dry eye symptoms? We have several options for treating dry eye in it’s varying degrees of severity. Keep in mind that every “body” is different and consultation and treatment directed by your eye doctor will give you the best results. Diagnosis through Schrimer’s tests, tear breakup time (T-But) and corneal staining with fluorescein are just a few ways for ophthalmologists and optometrists diagnose and document dry eye in patients. Note: these tests are often required if over the counter treatments are unsuccessful and prescription treatments are necessary. Traditional treatment for dry eye can include:

  • Artificial Tears: Using artificial tears on a regular basis, before the eyes begin to water, can help to combat dry eye symptoms. (We like to use the example of dry hands in the winter.  One application of hand lotion to dry, chapped hands will provide temporary relief – and often sting since it is touching tissue that usually doesn’t receive exposure, but regular use will heal the skin and cause the tissue to smooth over and not sting with exposure anymore.  Your corneal tissue works essentially the same way). There are several brands and preparations out there for varying severities. Tears can be used up to 4 times a day, if used more frequently it is recommended that you use a preservative free drop. Thicker drops in gel form are available as well and although they stay in the eye longer, they can blur vision. Gels and ointments are usually recommended for night time usage.
  • Punctal Plugs: Your eye doctor may recommend inserting a small plug in the lower (and sometimes upper) punctal openings in your eye lids. This stops the tears from draining out and away from the eye, therefore staying on the eye surface to keep it lubricated. There are temporary and permanent plugs, and in some cases surgical closure of these punctal openings is recommended.
  • Lid Hygiene: Blockage of oil glands, dry skin on eyelids and inflammation of lid tissue can create and cause dry eye symptoms or even make them worse. Using warm compresses, lid massage and keeping lids and lashes clean with daily lid scrubs can help combat blepharitis, which is common in patients suffering from dry eye.
  • Treat from the Inside: Increasing water intake and even use of non-prescription Omega3 oral supplements is recommended by some eye doctors. Always consult your primary care physician before beginning any new medication or over the counter supplement.
  • External Factors: Use a humidifier to increase moisture in the air around you (especially in the winter when the heat is on which dries out the air quicker), wear sunglasses with more curvature and wrap to the front of them to block wind and debris when outside
  • Prescription Eye Drops: If over the counter treatments and lifestyle changes prove to be ineffective in making your dry eye symptoms decrease, your optometrist or ophthalmologist may elect to start prescribed dry eye therapies. Restasis and Xiidra are two prescription medications that eye doctors use in conjunction with traditional dry eye treatments to improve corneal health and reduce symptoms over time. Usually these require documentation of failure off of OTC alternatives alone, dry eye testing results and a prior authorization for use from your health insurance company. They are also not an alternative to artificial tears, but rather intended to be used in conjunction with artificial tears and traditional therapies mentioned above. The tears keep the eye lubricated, but the prescription medications help your eyes to create their own, better quality tears or reduce inflammation due to dry eye disease.
  • Corneal Transplant: If dry eye becomes severe enough and damages corneal tissue, corneal transplants or keratoplasty may be the final option. Visit out Corneal Transplant page for more information about this process.

So if dry eye symptoms are plaguing you, there are treatments to help. Call the office today to schedule a dry eye evaluation and start on your path to clearer vision and better daily comfort.