Dry Eye, Tearing &Blepharitis

Department of Ophthalmology
Kaiser, San Rafael1DEDICATIONThis class and handout are dedicated to you, our patients, whose
well-being is of utmost importance to us and for whom, we areconstantly striving to provide the best health care possible.
No matter how knowledgeable, attentive, and well-intentioned ahealth care practitioner may be, there will never be an advocate foryour health that is as effective as you. This is because only you know
the intimate details of your life and activities: what you eat, how you
sleep, how you spend the day, what the environment is like in yourhome and community.
We hope that you find in this material a series of tools that will
empower you to become a more active participant in your own healthcare.
We are confident that if you take the 15 minutes required to review
this handout and implement the recommendations that seem most
relevant, you will find a significant improvement in the comfort of youreyes, the quality of your vision, and the quality of your life. That to us
seems like a worthy investment!
Happy Reading!
The Department of Ophthalmology
Kaiser- San Rafael2

TABLE OF CONTENTS
Summary of Treatment Recommendations

4

What is Dry Eye and How Does It Work

5

Tearing and Dry Eye

5Things that make Dry Eye Worse

6

Medications that make Dry Eye Worse

7

Blepharitis and Styes

8

Principles of Treatment

9

Lifestyle Changes

10Warm Compresses

11

Lid Scrubs

12

Artificial Tears

13

Flaxseed Oil

15

Further Interventions

16

Other Resources

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SUMMARY OF TREATMENT RECOMMENDATIONS
Please note: 90% of patients will achieve resolution of their Dry Eye
symptoms by implementing the relevant lifestyle changes andfollowing these daily treatment recommendations.
Lifestyle Changes• Sleep 8 hrs per day• Drink 2 liters of water per day• Blink more often and completely• Use a humidifier• Stop smoking• Remove makeup at night• Try wrap-around glasses• Decrease use of allergy and redness relieving eye drops
Daily Treatments• Use warm compresses twice daily• Do lid scrubs when you wash your face
• Use preservative-free artificial tears 4 to 6 times per day and a
few extra drops before reading, watching TV, or using thecomputer• Take Flaxseed Oil
If doing the above is not enough, ask your physician about:• Punctal Plugs or Cautery• Restasis• Steroid and Antibiotic Eye Drops• Oral Antibiotics

4What is Dry Eye?
Dry Eye is a condition in which the tear film that protects your eyes is inadequate
for the health and comfort of your eyes. It is a very common condition andaffects 15% of the population in the United States and approximately 5 million
people over the age of 50.
Dry Eye is not a deadly or life-threatening condition but it is a chronic condition
which can significantly impact one’s quality of life by affecting vision and making
the eyes uncomfortable. The good news is that Dry Eye is treatable! However,since it is a chronic condition and never completely goes away, treatment
requires daily intervention to maintain the health and comfort of your eyes.

What are the symptoms of Dry Eye?
••

Fluctuating vision which is often worse first thing in the morning or towards
the end of the day
Tearing, burning, itching, irritation, foreign body sensation, redness, pain

How does Dry Eye work?
Your tear film is made up of three main layers:•••

A water layer which is produced by your lacrimal gland. The lacrimal
gland sits just underneath the upper outer part of your eye socket.
An oil layer which is produced by your oil glands. The oil glands run allalong the inside of your upper and lower eyelids.
A mucus layer which is produced by cells on your conjunctiva. Your
conjunctiva is the white part of your eye.

If any of these layers is not functioning correctly, your eyes will feel dry. For
example, if you do not produce enough of a water layer, your eyes will feel dry.
The oil layer protects the water layer so if you do not produce enough of an oil
layer, the water layer will evaporate and your eyes will feel dry. These are two of
the main causes of Dry Eye.

My eyes are always tearing, how can they be dry?
Excess tearing from dry eyes may sound illogical but it isn’t. When your eyes are
dry, they become irritated. When your eyes are irritated, your lacrimal glandproduces lots and lots of tears to try and soothe or eradicate the irritation. The
large amount of tears that are produced by this reflex tearing mechanism
overwhelm the tear drainage system and overflow from your eyes causing
tearing.

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What are some things that make the condition of Dry Eyeworse?
•

Age: Tear production decreases as we get older. At age 65, the eye
produces 60% fewer tears than it did at age 18.

•

Menopause: After menopause, there is a decrease in the production of
hormones called androgens. Androgens are critical to the production ofwater by the lacrimal gland and oil by the oil glands both of which
contribute to a healthy tear film.

•

Lack of sleep•

Not drinking enough water•Not blinking enough: The normal blink rate is approximately 15 times
per minute. However, our blink rate decreases to 5 times per minutewhen we are doing an activity that requires concentration such as reading,watching TV, or working on the computer. Not blinking enough leads toan increase in the evaporation of the tear film•

Incomplete blink: 80% of our blinking is incomplete. An incomplete blink
also leads to an increase in the evaporation of the tear film.

•

Environment: A dry or windy environment can make your eyes dry.
Many people notice that they have more symptoms of dry eye in thewinter. This is because the heater is running in the house and makes the
air very dry.

•Smoking•

Heavy makeup: The use of heavy makeup around the eyes can lead toclogging of the oil glands which results in an inadequate oil layer to protect
the water layer of the tear film. This problem can get worse over time ifyou do not thoroughly remove your makeup at night before going to sleep.

•

Contact lens use•

Prior eye surgery such as LASIK or eyelid surgery•

Autoimmune diseases such as Rheumatoid Arthritis, Sjogren’s
Syndrome, or Thyroid Disease•

Medications

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What are some medications that can make Dry Eye worse?
Many eye drops such as those taken for allergy, inflammation, or redness havepreservatives in them. These preservatives can be irritating to the eyes andmake the symptoms worse. Often, just stopping these medications and usingpreservative free artificial tears will lead to an improvement in your symptoms.
There are several medications taken by mouth that can make Dry Eye worse by
decreasing tear production. The most common ones are:
•
•
•
•
•
•
•
•
•

Anti-histamines
Decongestants
Anti-depressantsAnti-anxiety meds
Sleeping pills
Sedatives
Pain relievers
Anti-hypertension meds such as beta-blockers, alpha-blockers anddiuretics
Birth control pills

If you are on any of these medications, it does not mean that you have to stopthem. You can discuss their use with the prescribing physician and see if there
are reasonable alternatives.
Sometimes just knowing that you are on a medication that may be contributing to
your Dry Eye can be helpful as you formulate a plan of treatment.

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What is Blepharitis?
Blepharitis is one of the most common, if not the most common, causes of Dry
Eye. Blepharitis means inflammation of the eyelids. Over time the oil glands on
your lids get clogged with dirt, oil, debris from make-up etc. Once they are
clogged, bacteria tend to accumulate and shed toxins which cause inflammationand irritation which affects the tear film.

What is a stye and why does it occur?
Blepharitis is the most common reason that people develop “styes” or“chalazion”.
A stye is a group of oil glands that have become blocked. Internally, the oilglands keep on secreting oil and bacteria in the oil glands cause inflammation.
This results in the development of an elevated and inflamed bump on the eyelid.

How do I treat a stye?
Styes are not contagious and will resolve with conservative measures to unclog
the glands.
The most effective intervention is the use of warm compresses twice a day for 510 minutes for 4-6 wks.
More than 90% of styles will resolve with the use of warm compresses.
If the stye does not resolve with warm compresses, you can see your doctor
about surgical excision or steroid injection. However, surgical excision has therisk of scarring or notching of the eyelid and steroid injections have a risk of skindepigmentation.
If the stye interferes with your vision, gets worse despite your treatment, or if theinflammation spreads to involve the entire lid, you should call your doctor.

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PRINCIPLES OF TREATMENT
The most important thing to understand regarding the treatment of Dry Eye isthat it is a chronic condition and will never go away completely. You cannot“cure” Dry Eye but you can treat it so that your eyes remain comfortable.
Treating your Dry Eye is like brushing your teeth or washing your face, youhave to do it everyday in order for it to be effective!
For more than 90% of patients with Dry Eye, minor behavioral changes,
modifications in the environment, and a daily maintenance regimen using
conservative measures will result in the eyes being quite comfortable and asignificant improvement in their quality of life.
In this handout, you will find a thorough review of treatment recommendations
going from more conservative measures to less conservative measures. You
should experiment with them to see which are most relevant and effective foryou.

9Lifestyle Changes•

Sleep: Most people do very well when they get 8 hours of sleep per night.
An adequate amount of sleep gives your eyes time to rest in the moist
environment produced by eyelid closure and gives your tear production
system a much needed rest.

•

Water: Most people should drink 2 liters of water per day or 8 glasses perday (64 oz). You need to be well hydrated to produce enough tears.

•

Blink: Most people do not blink completely and when doing activities
which require concentration, tend to blink less often. Making a conscious
effort to blink more often and completely and/or take breaks when doing
such activities can be helpful.

•

Extra artificial tears: It may also be helpful to use a few drops of artificial
tears in each eye just before you sit down to read, watch TV, use thecomputer or do something else which requires prolonged concentration.

•

Humidifier: Keeping a humidifier in your bedroom or other rooms inwhich you spend a great deal of time can be helpful This is especially truein the winter when using the heater tends to dry out the air.

•Stop smoking: Cigarette smoke is very irritating to the eyes and canmake the symptoms of Dry Eye much worse.

•

Clean your makeup thoroughly: Makeup can clog the oil glands. Doinga thorough clean up every night, especially of the makeup used aroundthe eyes, will allow your oil glands to flow freely.

•

Wrap-around glasses: Wearing glasses tends to protect the tear film
from evaporating as quickly, especially outdoors or in a car where
ventilation causes drying of the eyes. Using wrap-around glasses protects
the eyes from drying out to a greater extent than regular glasses. You can
ask your optician for suggestions on frames that have a wrap-aroundstyle.

•

Use fewer eye drops: Many eye drops such as anti-allergy drops or“redness reliever” drops have preservatives in them that are irritating to
the eyes. It is not unusual for patients to get caught in a vicious cycle ofusing more and more drops to treat the side effects caused by other drops
and actually making their symptoms worse. Often, just stopping these
medications and using preservative free artificial tears will lead to an
improvement in your symptoms

10Warm Compresses
Warm compresses are the most effective means of treating Dry Eye. The key totreatment is that it is done regularly. Warm compresses should be used twice a
day for 5 to 10 minutes each time. With regular and daily use, you may be able
to decrease the treatment time even further.
Warm Compresses work because heat results in the opening of the oil glands
and the softening of the oils that have become hard and are clogging the glands.
This allows the oil to flow more freely and prevent the water layer of your tear film
from evaporating.
There are several ways to apply warm compresses:
Washcloth• Take a clean washcloth and wet it with warm water. The water should not
be scalding hot. Place the washcloth over your closed eyelids for 5 to 10
minutes. Rewet as necessary to maintain the desired temperature.
Rice in a sock
• Fill a cotton sock with uncooked rice and tie a knot so the rice does not fallout. Do not use polyester as it can melt. Place the rice-filled sock in the
microwave for approximately 30 seconds. Warming time may varydepending on your microwave but again, the sock should be warm notscalding hot. Some people feel that this method holds heat better than awashcloth.
Facial Steamer• You can buy a facial steamer at a department store or online. They cost
between $20 and $40. You fill the tank of the steamer with water and plug
it in. It will turn the water into steam and funnel it through a cone close towhich you place your face. The nice thing about this method is that theheat opens up your oil glands and the moisture adds to the water layer ofyour tear film.
•

Many people like this method because it has many other advantages. The
steam is excellent for your skin and it is like getting a mini-facial twice aday. The steam also helps clear your nasal passages, throat, andsinuses.

Commercial Hot Packs• You can buy ready made gel packs, warm compresses, or goggles.
These are available online or at some pharmacies.

11Lid Scrubs
Lid scrubs are helpful because they help get rid of the dirt and debris that collecton the eyelashes and block the oil glands. This treatment is particularly helpful if
you tend to wear makeup on a regular basis. Lid scrubs should be done twice a
day on a daily basis. Lid scrubs can be incorporated into your daily routine ofwashing your face in the morning and before going to sleep at night.
There are several ways of doing lid scrubs:
Washcloth• Take a clean washcloth. Run it under warm water and then put a few
drops of Baby Shampoo on the washcloth. Rub the washcloth together so
it gets foamy. Wrap the washcloth around your fingers and clean along
the base of the eyelashes with your eyes closed for approximately 15
seconds on each eye. You should do this gently and make sure your eyes
are closed so that you don’t rub against the cornea.
Commercial Lid Scrubs• You can buy commercial lid scrubs that are disposable and single use atany pharmacy. They should be used as outlined above.
•

Some examples of commercially available lid scrubs include:o Ocusoft Lid Scrubso Cliradex
o Sterilid by Theratears

12Artificial Tears
The use of artificial tears is one of the cornerstones of the treatment of Dry Eye.
As we get older, our ability to produce tears decreases. By the age of 65, ourtear production is 60% less than what it was at the age of 18. Therefore, it
becomes necessary to supplement our natural tear production with artificial tears.
How often should I use artificial tears?
One of the most important points about using artificial tears is that if you areusing artificial tears when your eyes feel dry, it is already too late. You
should use artificial tears daily with a frequency that prevents your eyes fromfeeling dry. It is like watering your plants. You don’t wait until your plants turnbrown before you water them. Rather, you water them often enough when they
are green to prevent them for turning brown.
It is often useful to start by using artificial tears 4 to 6 times per day. If your eyes
are comfortable at this frequency, you can decrease the frequency to see if youreyes stay comfortable. If your eyes still feel dry at 4-6 times per day, you canincrease the frequency. You should experiment until you find the minimum
frequency that you need to keep your eyes comfortable. It is important that you
not make changes based on just one or two days of experience. Use the same
frequency consistently for a week before you decide if it is working or not working
for you.
Which type of artificial tear should I use?
There are many brands of artificial tears and most of them are safe and effective.
The brand is not important but if you use artificial tears more than 4 times perday, it is best to use a preservative free variety because the preservatives
themselves can contribute to eye irritation. Most brands make a preservativefree variety of artificial tears.
Refesh, Theratears and Genteal are examples of brands that make good quality
products
Can I overdose or hurt my eyes by using artificial tears too much?
If you are using preservative-free artificial tears, you can never use “too much”.
You can use preservative-free artificial tears every hour or more and it will notdamage your eyes.

13Artificial Tears cont.
There are so many types of artificial tears. Some are thicker and others are
more watery. How do I know which is right for me?
The type of artificial tear product that is best is an individualized decision basedon the severity of symptoms and other factors.
The thicker or more viscous tear products are helpful in cases of severe dry eye
but they tend to make the vision blurry. The thinner or more liquid artificial tears
tend not to blur the vision but do not lubricate the eyes as much.
You will have to experiment with different products to find what works best foryou.
Suggested Regimen:
An approach that many patients have found helpful is to use a thick lubricant in
the morning and at night and a thinner product during the day:•

Genteal Gel, Refresh Liquigel, Refresh PM, and Celluvisc are examples ofthick lubricants. You can use them just before going to bed at night andfirst thing in the morning when you wake up.

•

These thicker lubricants tend to have preservatives in them but that is finesince you are not using them multiple times a day.

•You can complement the use of the thick lubricant with a preservative-free
artificial tear product which you can use multiple times throughout the day.

•With this approach, you are giving your eyes an intensive amount of
lubrication but also avoiding having your vision be blurred throughout the
day.

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Flaxseed Oil
What is flaxseed oil?
Flaxseed oil is a polyunsaturated plant oil that carries vitamins A, D, E, and K. It
is the most concentrated vegetarian source of Omega 3 fatty acids in nature.
Flaxseed oil helps suppress inflammation and keeps your oil glands healthy. It
can take a few months to work after incorporating it into your diet so you will haveto be patient.
Flaxseed oil also contributes to smoother skin, better hormonal balance, lessstress, improved cholesterol levels, reduced arthritic symptoms, improved
immune function, better wound healing, improved digestion, increased energy,
healthy blood tissue as well as anti-cancer properties.
How much flaxseed oil should I take?
There is no consensus on how much flaxseed oil you should take but many
experts recommend 1-2 grams per day or 1 tablespoon per day.
What is the best way to take flaxseed oil?
You can buy ground flaxseed or flaxseed oil at the grocery store. It has a nutty
flavor and goes well with many dishes. You can stir it into yogurt, sprinkle it onsalads, cereal, smoothies or soups. You can also add it to your favorite salad
dressing or drizzle it onto stir fry, steamed vegetables, rice or pasta. You should
not cook with flaxseed oil because the high heat can turn this healthy fat into aharmful one. It is better to add flaxseed oil after cooking.
You can also buy capsules that can be taken as a nutritional supplement. This is
more expensive than ground flaxseed or flaxseed oil but may be moreconvenient.
Are there any medications that I may be using that I should discuss withmy doctor before I start to use flaxseed oil?
Flaxseed oil can affect the clotting of your blood. You should talk to your doctor if
you are using Coumadin, Warfarin, Plavix or other blood thinners prior to starting
flaxseed oil. It is fine to use aspirin.
Are there any side effects to the use of flaxseed oil?
Flaxseed oil is generally pretty well tolerated and does not have a lot of side
effects. One common side effect is an increase in intestinal gas symptoms.

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FURTHER INTERVENTIONS
Most people will do very well with the recommendations we have alreadymentioned. However, if your eyes are still uncomfortable after trying these moreconservative measures, please see your doctor to discuss further interventions
that may be helpful. Options for further intervention include:
Punctal Plugs or Cautery• Your doctor can place small plugs into the puncta or use cautery to close
the puncta. The puncta are where tears drain and are located on thenasal aspect of your eyelids. Closing them with plugs or cautery results inthe tears staying on the surface longer and making your eyes feel less dry.
The placement of punctal plugs and cautery to close the puncta are
relatively straightforward procedures that can be done in the office. The
placement of punctal plugs is reversible but cautery is not.
Some people complain of excessive tearing after the placement of plugs
or cautery because their tears are not draining as effectively and overflow
from their lids.
Restasis• Restasis is a prescription medication that is a very dilute form of
cyclosporine which is an immune suppressant. It is used twice a day andhelps reduce inflammation and also increases tear production. It must be
used for at least 3 months before you know whether or not it is reallyworking.
Some people complain that Restasis stings when you use it.
Steroid and Antibiotic Eye Drops or Oral Antibiotics• Steroid and antibiotic eye drops or oral antibiotics can provide temporary
relief from the symptoms of Dry Eye. However, they cannot be used longterm because of side effects.
Long term use of steroid eye drops can cause cataract and glaucoma.
Long term use of antibiotic eye drops or oral antibiotics can cause thebuild up of resistant bacteria in your body and in the community.

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OTHER RESOURCES
Kaiser Health Encyclopedia:
https://members.kaiserpermanente.org/kpweb/healthency/entrypage.do
Mayo Clinic Website:www.mayoclinic.com/health/dry-eyes

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