Dry Eye Syndrome in Cape Coral, FL

Dry eye syndrome or dry eye disease is the most common eye disease that eye doctors see in their office with as many as 30 to 40 million Americans effected by dry eyes. You have nearly a 10% chance of developing or having dry eye syndrome. The numbers are increasing significantly as people are spending more time starring at a variety of flat screen devices. These include smart phones, computer screens, iPads, and/or TVs. This is the result of them starring at these screens and diminishing their blinking which leads to their eyes drying out as they are not spreading their tears across their eyes. Teenagers are now developing dry eyes as many are spending hours starring at games on their flat screen device. As much as 3 billion dollars is spent on treating dry eye disease a year in the United States. 5 billion dollar a year loss in work productivity in the United States secondary to dry eye disease is becoming a significant problem.

What is Dry Eye, Dry Eye Syndrome or Dry Eye Disease?

There are more terms that are used for dry eye disease such as aqueous deficiency, evaporative tear deficiency, Keratoconjunctivitis sicca (KCS), dysfunctional tear syndrome, neurotropic epitheliopathy, and lacrimal keratoconjunctivitis. Dry eye disease in simple terms is the loss or reduction of the tear film that covers over the surface of the eye. The tissues that compose the surface of the eye require a specific amount of moisture or tear film for the tissue or cells on the surface of the eye to be healthy. A good or normal tear film is necessary for clear vision. If the level of the tear film present is insufficient, the outer surface tissues become sick, inflamed, irritated, and can eventually die. A normal tear film surface is necessary for clear vision as stated before as this is the first thing that light passes through on its way to be focused onto the retina in the back of the eye.

The Three Layers That Make Up the Tear Film

First Layer: Mucous Layer

The inner tear film layer contains mucin or mucous-like substance. This layer is produced by goblet cells which are located on the surface of the eye. This mucin or mucous-like material provides the base of the tear film on the eye, providing a hydrophilic layer, and it promotes the smooth and even distribution of the tear film.

Second Layer: Aqueous Layer

The tear film layer that rests on top of the mucous layer contains water, enzymes, chemicals, minerals, and proteins. The water layer is produced by the lacrimal gland. Most people have the false impression that this is the only component of their tears or that their tear film is just water.

Third Layer: Lipid Layer

The outer layer contains oil or lipids produced by the Meibomian glands which are located in the eyelids. There are approximately 24 to 25 glands in each eyelid that produce the lipids. The Meibomian glands secrete their oil from small openings on the edge of the eyelid onto the tear film. The oily layer floats on top of the liquid layer and provides a barrier to keep the middle liquid layer from evaporating from the eye. This oil is also helps with lubrication.

How to Diagnose Dry Eye Syndrome

This is one of the most important initial steps in treating dry eye syndrome correctly. In order to treat dry eye syndrome correctly, the first thing to know is what kind of dry eye syndrome is causing your problem. It is also important to know the severity of the dry eye syndrome. Your eye needs to have the proper amount of each of the three layers of the tear film.

Medical and Eye History

The staff or the eye doctor will take a history at the beginning of your visit. There are many diseases that are associated with dry eye syndrome and it is important to know if any of those are present. If you give a history of any of the symptoms associated with dry eye syndrome, many eye doctors’ offices will have you fill out a SPEED™ form or Standard Patient Evaluation of Eye Dryness or dry eye syndrome questionnaire. How high a person scores on the form can indicate the severity of the dry eye syndrome.

A portion of a complete eye exam includes the eye doctor examining the eyes with a slit lamp microscope to evaluate and examine the eye with high magnification. Several dyes that stain damaged cell walls on the surface of the eye can be used by the doctor to determine if or how much the cells on the surface of the eyes have been damaged and to what extent have they been damaged. As stated before, the cells on the surface of the eye need to have a normal tear film to be healthy. If the tear film diminished and/or abnormal the cells will become unhealthy and can die.

Tear Osmolarity or Salt or Sodium or Na Level in Tear Film

Our bodies are composed of mostly water with the addition chemicals and minerals. The body will maintain the normal level of these substances under normal circumstances. If there is an illness or disease present, it can alter the level these chemicals and/minerals. The tear film also contains these chemicals, enzymes, minerals, and proteins. The TearLab Corporation makes an instrument that can measure the salt or sodium (Na) level in the tear film similar to a blood test that measures the levels in the body. The levels found in the tear film are not directly related to the levels in the body. The tear film is exposed to the air and environment. The levels in the tear film can be dramatically different from the body tissue levels. When there is an increased level of salt in the tear film, it indicates a decrease in the amount of the liquid layer in the tear film and dry eyes. The decreased liquid layer is unable to normalize the normal levels present in the ocular tissues. The tear film osmolarity is a very useful test to follow or monitor the condition of the dry eye syndrome and treatment progress.

RPS InflammaDry Detector

InflammaDry detects the presence of matrix metallo-protease 9 or MMP-9 on the surface of the eye. InflammaDry is an easy to administer in office test that gives results in about 10 minutes. The sample is taken from the conjunctival lining inside the lower eyelid. MMP-9 is an excellent marker for the presence of inflammation of the eye associated with dry eye disease. Many times inflammation may be present before any clinical signs of dry eye syndrome. An increase of MMP-9 or inflammation causes several issues on the ocular surface including disruption of the corneal epithelial barrier, damage to the cell walls, increased cell turnover, and increased ocular surface irregularity. InflammaDry is very accurate with 85% sensitivity and 94% specificity. It is not expensive and covered by Medicare and most insurance companies.

LipiView – Measures Lipid Layer, Images, and Blinking Evaluation

The LipiView instrument is designed to measure the thickness of the outer oily or lipid layer of the tear film. The LipiView contains a high-resolution movie camera and interferometer which is used to examine the tear film.

The instrument produces a high-resolution movie and images of the tear film and surrounding ocular tissue. The motion picture camera in LipiView also evaluates your blinking during the test. The LipiView counts each blink and evaluates each blink during the testing period. During a normal blinking, the upper eyelid comes all the way down and makes contact with the lower eyelid. Secondary to gravity, the tears drop down and pool on the edge of the lower eyelid and the eye. During normal blinking, the upper eyelid makes contact with the lower eyelid where the pooling tears or tear lake reside on the lower eyelid.

The upper eyelid lifts back up smoothing and spreading the tears back across the surface of the eye. This spreads the tears across the eye which smooths out the tear film like a windshield wiper clearing the rain off a windshield to provide clear vision. If the blinks are partial or incomplete, the eyelid fails to spread the tears back across the eye which leads to a breakdown in the tear film. The instrument counts how many times the eyes blink and what number of the blinks are partial.

The camera in the LipiView is able to capture 3D like images of the Meibomian glands. This allows the eye doctor to evaluate the health of the Meibomian glands and number of glands present in the eyelids. In summary, the LipiView provides the eye doctor with the thickness of the lipid layer, number of partial blinks, and images of the Meibomian glands.

Keratograph® 5M

Keratograph 5M is an ocular instrument that images and measures many different characteristics of the tear film and the surrounding ocular structures.

Meibomian Gland 3D Imaging

The instrument images the Meibomian glands in the eyelids which allows the eye doctor to evaluate health of the Meibomian glands, size, and number of glands in the eyelids which secrete the lipid layer of the tear film.

Tear Film Break-Up Time

The Keratograph 5M times, measures, and evaluates the stability and quality of the tear film. The patient is asked not to blink during this test. The instrument times and measures the breakdown or breakup of the tear film without blinking. The tear film breakdowns faster in people with dry eyes or poor tear films than people with a normal tear film. A tear breakup time of less than 12 seconds is abnormal.

Tear Meniscus or Tear Lake Height

Gravity causes the tears pool on the junction between the lower eyelid and the eye between blinks. The instrument measures the amount or height of the tear film that rests on the lower eyelid. This gives the eye doctor information about the quantity of tears present on the surface of the eye.

Tear Film Dynamics

The Keratograph 5M captures the tear film particle flow characteristics on the surface of the eye and tear film viscosity which evaluates the quality of the tear film.

Advanced Tear Diagnostics (ATD)

ATD manufactures the TearScan 270 MicroAssay System which measures Lactoferrin and IgE in the tear film. Lactoferrin is a protein secreted by the lacrimal gland. Lactoferrin levels are reduced in patients with dry eye syndrome. If IgE levels are increased in the tear film, ocular irritation could also be related to allergies and would need to be addressed. The levels of lactoferrin has a 95% specificity and nearly 75% sensitivity in the tear film. These tests are useful in the diagnosis and monitoring of the dry eye disease and ocular allergies.

Schirmer’s Test

The Schirmer’s test has been around for many years and some eye doctors still use the test. New technologies are now available and it is not performed as often as in the past. The test is also known as:

The test is performed after the instillation of an anesthetic or numbing eye drop. A special strip of special paper is placed on the edge of each eyelid and is left is place for 5 minutes. The strip of paper is removed and the length of how far along the strip the tears wet the paper is measured. Ten millimeters or more of wetting is normal and anything less is considered abnormal.

Risk Factors for Dry Eye Syndrome

Aging

As we age most things in our bodies slow down and it is no different with tear production.

Contact Lens Wear

People who have worn contact lenses for many years are at much higher risk of developing dry eyes secondary to the loss of sensation in the cornea and low-grade inflammation caused by wearing contacts contribute to the development of dry eyes.

Auto-immune Diseases

Rheumatoid arthritis is the most often related disease to dry eye syndrome. Other diseases are lupus, scleroderma, and other immune diseases. Sjogren’s syndrome is the triad of dry eyes, dry mouth, and rheumatoid arthritis.

Environmental

Dry eye syndrome occurs secondary to environmental conditions such as dry climates, lifestyles that include outdoors with sun and wind exposure, drafts from heating or air conditioning, ceiling fans, and decreased humidity from air conditioning. Smoking and other chemical irritants can cause dry eye disease.

Hormonal

Scientists have found hormone receptors on the surface of the eye which are related to tear production. It turns out that the largest group of dry eye patients are post-menopausal women. Women who are placed on hormone replacement therapy experience are more likely to have dry eye syndrome. Higher doses of estrogen can be associated with dry eye syndrome. Women that are only taking estrogen are 70% more likely to develop dry eye disease. Women that are taking estrogen and progesterone have a 30% chance of developing dry eye disease.

Exposure of the Eyes

When there is abnormal exposure of the eye, the eye is more exposed to the environment causing dry eyes. Thyroid eye disease can cause the eye to protrude forward exposing more of the eye. Some people may not sleep with their eyes completely closed which exposes the eye during the night. This can also happen after eyelid surgery or to an eyelid abnormality called loose lid syndrome. The upper lid is very loose and allows the eye to open during sleep.

Job Related

A person’s job can have a significant effect on dry eye syndrome. People that work spending their day looking at a computer or other flat screen device decrease their blinking which further exposes the eye to the environment which contributes to dry eyes. Jobs that are in an environment associated with dust, dirt, chemical fumes, cold temperatures with dry air, and others lead to the development of dry eyes. Outdoor jobs contribute to dry eye syndrome such as commercial fishermen, golf pros, farmers, tennis pros, life guards, and other outdoor jobs.

Hobbies or Games

People that stare for long periods of time working on a hobby or playing a video game are at risk of developing dry eye syndrome. In the past, dry eye syndrome was an old person’s problem but now teenagers are now developing dry eyes. Many young people are staring at and playing video games for hours at a time. They are not going to miss one action scene, laser shot, or bomb. Parents need to limit their kid’s times on these flat screens to 30 minutes and then take a break.

Central Nervous System Diseases

There are many central nervous system diseases that can contribute to the development of dry eyes. The more common CNS diseases related to dry eyes are Parkinson’s disease and Alzheimer’s disease. These people have very poor blinking rates leading to dry eyes. The average person blinks their eyes 15 times a minute. A person with CNS disease may only blink their eyes 1 or 2 times a minute leading to severe dry eye problems in many cases.

Medications

There are many medications that can cause dry eye or dry eye syndrome. Some examples are anti-histamines, nasal decongestants, anti-depressants, diuretics, certain blood pressure medications, tranquilizers, birth control pills, and chemotherapy.

Neurotropic Dry Eyes

Normal corneal sensation is very important in maintaining a normal tear film. The loss or reduction of corneal sensation contributes to dry eye syndrome. Patients who have had LASIK or other similar surgeries have a decreased corneal innervation with loss of sensation which disrupts the tear film. This is usually temporary in most cases and the corneal sensation returns in approximately 6 months.

Pregnancy

Pregnant women’s hormones are altered during the pregnancy that can decrease the tear film.

Chemical or Thermal Burns to the Eye

People that suffer injuries to the eye from chemicals or burns to the surface of the eye can suffer enough damage to the tissues or cells producing the tear film that they can develop dry eye syndrome.

Other Eye Diseases

There are many other eye diseases associated with dry eye syndrome such as blepharitis, allergies, Steven’s Johnson Syndrome, and many different skin diseases around the eye. Approximately 50% of people with dry eye syndrome are allergic to 1 or more environmental antigens.

Symptoms of Dry Eye Syndrome

Burning
Itchy eyes
Sandy or gritty sensation
Painful eyes
Eyes stuck together when waking up in the morning
Stinging
Light sensitivity or photophobia

Foreign body sensation
Blurred vision or episodes of blurred vision
Stringy discharge
Heavy eyelids
Unable or difficulty wearing contacts
Unable to cry when emotionally upset

The most common thing that people complain of are that their eyes burn or itch and water. Many people don’t understand at first, how can my eyes water if I have dry eyes. Once it is explained that as your eyes dry out, the salt or Na levels in the liquid part of the tear film increase and this increased salt level causes their burning, irritation, and inflammation in the eye. The eye’s response to this irritation is to cry or water in secondary to the irritation. The salt level decreases as the eye waters and the eye feels better. With time, the eye begins to dry out again and the same process repeats itself over and over. One of the main goals in the treatment dry eye syndrome is to control and maintain a normal salt level in the tear film.

JAMES E. CROLEY III, M.D.

Dr. James E. Croley III is a board-certified ophthalmologist and the founder of the Cataract & Refractive Institute of Florida. He graduated magna cum laude from Cumberland College before attending medical school at the University of Miami and completing his residency at the University of Alabama Eye Foundation Hospital. Additionally, he studied at Stanford University where he gained further education in advanced ophthalmology techniques. Dr. Croley is a member of the American Academy of Ophthalmology and the Florida Society of Ophthalmology.