What you always wanted to know about DRY EYE DISEASE ... and never dared to ask !
MORE INFORMATION ABOUT DRY EYE DISEASE
Patients with dry eye disease have many questions
Patients with a so-called dry eye and corresponding complaints have many questions. These questions will be answered in the following so that patients can better understand their disease and the possibilities for detection and treatment.
What is dry eye disease ?
What is keratoconjunctivitis sicca ?
What is the sicca syndrome ?
What is Sjögren´s syndrome ?
How common is dry eye disease ?
Why are tear film disorders so harmful to the eye ?
Are there any risk factors for a dry eye?
In modern office work environments, many risk factors combine to form a condition termed ' Office Eye '
Why does Dry Eye Disease tend to worsen without adequate treatment?
WHAT IS DRY EYE DISEASE ?
It is typically triggered by a lack of the tear film on the eye.
This causes irritation and redness of the eye and complaints such as a sensation of grains of sand, burning, pain, sticky eyes or even wet eyes with tear dripping/epiphora over the cheeks.
What is keratoconjunctivitis sicca ?
The ophthalmologist also refers to dry eye disease as keratoconjunctivitis sicca. 'Sicca' means 'dry' and keratoconjunctivitis indicates inflammation, here of the cornea and conjunctiva. Keratoconjunctivitis sicca thus means "dryness inflammation of the cornea and conjunctiva".
This term is sometimes misleading, as many dry eye patients first have a wet eye with tears over their cheeks. The irritated eye tries to wash away the stimulus by strong tear production, as often works in a foreign body - but unfortunately not in a chronic irritation of the eye itself. However, it has been scientifically proven in recent years that actually often an inflammation develops, and the illness and the discomfort for the patient thus get worse and worse.
What is the Sicca syndrome?
Sicca syndrome is another medical term for the dry eye or for the disease of the dry eye. Again, the term sicca focuses on the dryness of the eye - which is not always true. Many patients, especially the elderly, and at least initially, have a wet eye. The term 'syndrome' describes that it comes to a bunch of different typical symptoms in the patient. These various complaints may at first glance seem incoherent.
THERAPY : => Timely and adequate treatment of dry eye disease is important to avoid permanent damage to vision.
The good news is that every patient can do a great deal of self-improvement to relieve dry eye symptoms.
Dry Eye Disease is very common and can have many different causes
Dry Eye Disease is the most common disease in ophthalmology:
About 1/6 of the population is affected on average in Central Europe and North America
with about 1/3 of the population, the frequency in Asia is about twice as high
with about 2/3 of the population, the frequency of Meibomian Gland Dysfunction (MGD) in the eyelids is again about twice as high - this is the most common cause of the dry eye, which does not always directly lead to complaints
The frequency is increased , eg.
in women and
in advanced age
... this indicates an influence of hormones and aging processes.
Not every dry eye is recognized correctly , because the symptoms are often uncharacteristic at first and the onset is often creeping.
What are the symptoms of dry eye disease ? - How do I recognize a dry eye ?
Symptoms can be very different und thus relatively unspecific. Most dry eye complaints are due to irritation of the eye and disturbance of the tear film:
Irritation and pain in Dry Eye Disease can be different:
feeling of dryness
Irritation and foreign body sensation
´Wet eye´ with tears dripping over the lid margin
this leads to “tired eyes”, "heavy eyelids" or "sticky eyes"
Dry eye Irritation and pain can occur in different regions:
on the surface of the eye itself, but it often occurs
also in the periphery of the eye
in the eye lids or
is even felt behind the eye.
Pain and Chronic Pain Syndromes
The very different complaints that can be felt in different regions of the eye indicate that a complicated irritation of the nervous system can occur in the dry eye.
Persistent eye irritation can lead to pain and chronic pain can lead to pain syndromes. Chronic pain syndromes are a distinct disease factor in dry eye disease and this is often difficult to treat.
Collaboration with pain medicine, psychosomatics and neurology can be helpful here if there are strong subjective symptoms of a dry eye without significant clinically evident damage and if there are other functional disorders from the psychosomatic spectrum (such as e.g irritable bowel syndrome, unclear spinal syndromes, tinnitus, unclear dizziness etc).
In Dry Eye Disease, the homogeneous thin tear film, that is important for a good visual acuity, is disturbed. Therefore, many patients have vision problems like
fluctuating visual acuity or
glare sensitivity and photophobia
THERAPY => Visual disturbances in a dry eye typically improve, or even disappear temporarily, after one or several forceful eyelid blinks, that spread a new and stable tear film. - This is also a good test of whether visual disturbances are due to a tear film disorder.
Wet Eye and Tearing
Initially, the irritation of the ocular surface can lead to an increased flow of tears (as a protective reaction) ... with an overflow of tears (epiphora) over the margin of the lid. It is of course confusing when the disease of the " dry " eye leads to tear dripping and wet eye.
Other reasons for a wet eye and tears over the edge of the lid can be:
when the eyelid is altered, in its shape or position, the tear film can no longer be properly formed or can not be held on the eye ... or ...
when the outflow of tears into the nose no longer works normally either because the eyelid margin it tilted slightly away from the eye, or because of obstruction in the draining lacrimal ducts.
THERAPY => Here, a close examination by the ophthalmologist and maybe a small surgery may be useful.
What is the cause of a Dry Eye? - How does Dry Eye Disease arise ?
Typically, ocular surface irritation is triggered by Tear Film deficiency and eventually by the Disruption of the Tear Film
What is the Tear Film ?
What does the tear film consist of ? - Of the secretions from the Ocular Glands !
from the secretions of the 3 types of glands on the ocular surface, that produce mainly water but also oil and slime/ mucus.
How is the tear film made ? - The Eyelids spread the Tear Film !
the thin, even layer of tears on the eye in the opened eyelid fissure
is pulled out thinly by the blink of the eyelids
from the tear fluid on the eye.
The tear film is only stable for a short time and
must be renewed again and again by a new eyelid strike.
Where does the tear film go to ? - The tears are drained into the nose !
with each new blink of the eyelids, the 'used' tears, after bathing the anterior eye, are sucked through the lacrimal punctum on the nasal side of each eyelid and are led to the nose.
What is the function of the tear film on the ocular surface ?
it keeps the tissue moist,
it contributes to nutrition, regulation and health
it 'smears' the sliding movement of the eyelids over the eyeball and ...
it is important for a sharp vision.
A tear film deficiency can be caused by a defect in:
the amount of tear production by the glands ... or ...
the composition and quality of tears
... of particular importance are apparently the Meibomian glands inside the eyelids
Only rarely a tissue disorder occurs first and later disturbs the tear film, as occurs e.g. in:
Chronic inflammatory disease such as in rheumatic diseases or in the immune response after bone marrow transplantation (graft-versus-host disease, GvHD).
Aqueous deficiency ... in the tear film
A lack of water is often thought be caused by a reduced production of watery tears through the lacrimal gland. However, a primary lack of water due to a disturbance of the lacrimal gland is very rare.
Much more common is (secondary) water loss due to increased evaporation of the tear water on the ocular surface. This occurs in case of oil deficiency and is made worse by desiccating environmental influences.
Tear film deficiency causes tissue damage to the ocular surface, whether caused by increased evaporation or by primary low lacrimal gland production
THERAPY => Aqueous eye drops, with or without added oil, are a useful therapy.
... They should be used as needed and often enough, up to 1x per hour. An even more frequent use of aqueous eye drops is usually not useful, as this can reduce the effect of your own (residual) tears and thereby the irritation of the eye can be worse.
Oil deficiency ... in the tear film is usually caused by dysfunction of the meibomian glands inside the eyelids
Most often, not the water of tears is missing first, but the superficial layer of oil on the tear film, which reduces the evaporation of the water.
Lack of oil is usually caused by disorders of the meibomian glands in the eyelids . When the glands clog, oil is missing and the watery tears evaporate faster, leaving the eye dry. Meibomian gland disorders are very common and increase with age .
THERAPY => Eye drops that contain oil or a lipid spray can help here ... but ...
... above all, it is important to improve the function of the oil-producing meibomian glands in the eyelids again ! This is done by a physical lid therapy (with warming, massage, cleansing), which the patient himself performs regularly at home to improve the blockage and damage to the glands.
Eyelid and Blinking Deficiency ... prevent the tear film
The regular eyelid strike, termed as the ´BLINK´, is performed by the action of the internal eyelid muscles, and is necessary:
to spread the tears into the thin tear film on the eye ... and ...
to squeeze out a small droplet of oil from the meibomian glands to inhibit water evaporation and make the tear film more stable
Rare blinking and incomplete blinking are common causes of a tear film deficiency.
With rare blinking the tear film is renewed too rarely - it then breaks open and the underlying tissue of the eye becomes dry.
In case of incomplete blinking (" nervous blinking of the eye") the eye is not completely closed and thus only the upper part of the tear film is renewed - the lower part of the eye surface remains dry, therefore the first and the most frequent tissue damage is located in the lower half of the cornea and conjunctiva.
"Office Eye"combines many disruptive factors for ocular moisture
The Office Eye / Office Eye is a fast-growing form of dry eye in "modern" office work environments . This can add up several harmful effects and thus lead faster to a dry eye. This form of dry eye not only affects the elderly but also occurs more frequently in younger people .
Concentrated visual work (eg computer, television, driving) is accompanied by rare blinking and therefore easily leads to a dry eye .
The danger of a dry eye is getting bigger:
in a dry environment (air conditioners) and / or
in draft (fans) and / or
dust particles or smoke in the air as well
stress and maybe in addition
too low drinking volume
In addition to an unstable tear film still drying environmental factors and perhaps negative internal influences on the tear production are added.
THERAPY => My observation and, if necessary, change of the eyelid are important here, for a sufficiently frequent and complete eyelid strike. Furthermore, deliberate Blink exercises at work can be useful - there are even computer apps to remember. Furthermore, avoidance to dry working environments, sufficient breaks and sufficient drinking volume are helpful.
What are the Risk Factors for Dry Eye Disease ?
Most complaints in the Dry Eye Disease are explained by the irritation of the eye and the disturbance of the tear film :
Possible Risk Factors for a dry eye include, for example:
Internal Risk Factors, such as e.g.:
Chronic eyelid inflammation (blepharitis) and
various skin diseases (rosacea, atopic dermatitis etc.) as well
inflammatory rheumatic diseases and other systemic diseases
Dysfunction of regulatory systems (endocrine hormonal / immune / nervous system)
various drugs that are put on the eye as drops or systemically, for example as tablets
External Risk Factors such as e.g.:
Tears Disorder/ Tear Deficiency
A tear disorder induces or exacerbates the irritation of the ocular surface.
Irritation / Tissue Damage
An irritated ocular surface, in turn, worsens the stability of the tear film on the damaged ocular surface.
Tear Deficiency and and Ocular Surface Tissue Damage are obviously linked by a so-called "Vicious circle" where the dysfunction of one makes the other worse - which then reinforces the starting event ... and so on.
Therefore, dry eye disease has a tendency to aggravate itself if not treated adequately.
THERAPY => An interruption of the harmful self-aggravation (Vicious Circles) can be done by:
Replacement of tear fluid with aqueous eye drops (tear substitute), with and without oil
nourishing gels or ointments overnight
Avoidance or limitation of triggering stimuli
Eyelid therapy / treatment of the eyelids to improve the meibomian gland function
If the ocular surface is permanently irritated, as is typical in the dry eye, then this can trigger an inflammatory reaction. The inflammation is actually the defense of the eye. But if the inflammation occurs permanently, then it can increase the self-aggravation of the dry eye.
THERAPY => here an anti-inflammatory therapy by the ophthalmologist may be useful.
The ophthalmologist you trust and, for severe cases, even in specialized Sicca centers, there are even more therapy options available.
=> continue to ...
... that makes everything easier to understand!
. . . that makes everything easier to understand ... for everybody
GRITTY EYES - DRY EYES - WATERING EYES - ITCHY EYES - EYE REDNESS - OBSTRUCTED GLANDS - TIRED EYES - HEAVY LIDS - BLURRED VISION - UNSTABLE VISUAL ACUITY ... AND MANY MORE ..
All these different and partly contradictory appearing complaints ... can be symptoms of an Eye Irritation that occurs due to a Damage of the Ocular Surface Tissue
This happens typically following a Deficiency of the Tear Film in front of the eye. It can then no longer keep the delicate tissue sufficiently moist ... with the consequence that the Tissue dries out - This is the reason behind the term "DRY EYE"
The so-called ´DRY´ EYE DISEASE is a very wide-spread condition ... and it represents the most frequent diagnosis in clinical practice.
In contrast to the term "Dry" the occurring irritation of the ocular surface tissue may also lead to episodes of excessive tearing and watering eyes. This occurs particularly in the initial stage of this condition and is often difficult to understand for the patient.
DOCTOR, MY EYES ARE WATERY ... HOW CAN THAT BE ´DRY´ EYE DISEASE ???
An increased tear flow in case of watering eyes can indicate a (still) intact protective tearing reflex.
This reflex is generally triggered by irritation of many kinds such as e.g. wind and fans, or foreign bodies etc.
Such irritating incidences make the tears flow to remove the stimulus.
When the damage to the ocular surface proceeds, this protective reflex will unluckily also become dysfunctional and disappears.
Another reason for watering eyes with tear overflow over the eyelid border, medically termed as ´epiphora´, can occur due to eyelid deformations. Because eyes with eyelid deformations cannot form a normal tear film or cannot hold it on the ocular surface these conditions also lead to Dry Eye Disease with ocular irritation.
Frequent eyelid deformations are e.g. an inward or outward twist of the eyelid margin (ectropion or entropion) that typically occurs with tissue changes in advancing age.
DRY EYE DISEASE can be a ´tricky´ condition of the Ocular Surface
These few contemplations already indicate, that the so-called ´DRY EYE´ Disease can be an unexpectedly tricky issue.
´Tricky´ is not only the fact, that an eye in ´Dry Eye Disease´ can be watering.
Tricky is also the fact that... surprisingly ... most patients with ´Dry´ Eye Disease do not have a primary lack of water but they have a primary lack of oil in the tear film.
The oil on the surface of the tear film has the function to slow down the evaporation of tear water ... similar to a lid on a pot with warm water.
The healthy function of the Ocular Surface depends on a large number of factors that are inter-related and inter-dependent.
The functional and structural network at the Ocular Surface may probably be compared to a house of cards - it appears stable ... but as soon as only one card is moved ...
Science is working on the resolution of ocular surface disease - of which Dry Eye Disease is the most frequent one - for quite a while ... and researchers world-wide have made considerable advancements of knowledge.
This has translated into benefit for the daily lives of hundreds of millions of patients world-wide who suffer from Dry Eye Disease .
But even deeper insight into the disease process and thus continued scientific advancements are necessary to offer more effective strategies for therapy in the future.
IMPORTANT for the patient is to UNDERSTAND his/her CONDITION ... in order to understand the many ways to influence the condition in a beneficial way.
IF you are interested in more stunning news from the ocular surface ... you are IN THE RIGHT PLACE ... HERE ...
... at the INFORMATION PLATFORM on the OCULAR SURFACE and DRY EYE DISEASE of the OCULAR SURFACE CENTER BERLIN (OSCB) - A non-profit Science Institute for the advancement of knowledge on the Ocular Surface and Dry Eye Disease that is set up and run by experienced scientists in the field.
Choose your PAGE of Interest - or simply read along ... which may be most instructive:
Some things of interest
for a first impression
... easy to understand
Choose your CHAPTER of Interest - or simply read along ... which may be most instructive
The Ocular Surface
The Ocular Surface ... is the moist anterior part of the eye
The shining of the Ocular Surface comes from the Tear Film ...
... that maintains the permanent Moisture of the Ocular Surface.
Moisture is necessary for the health of the ocular surface tissue and moisture is also important for perfectly clear vision.
Without sufficient moisture the vision becomes blurry, the tissue is increasingly damaged, and sensations of discomfort occur.
The OCULAR SURFACE performs the first steps of VISION
The OCULAR SURFACE is that part of the eye that permits the entrance of Light.
Only after passing the Ocular Surface
... can this light elicit responses of the Retina in the back of the eye
... that later allow the ´curious´ Brain to construct an image of the outside world on the screen of consciousness.
Without a healthy and functioning Ocular Surface, all other steps of the Vision Process that happen later and further ´behind´ ... are basically meaningless.
The OCULAR SURFACE must be permanently MOIST
Our Ocular Surface has the biological requirement that it must be permanently moist - ´always and everywhere´ - to keep the transparent window of the cornea indeed clear.
Since we are living in a dry environment with an air atmosphere, it is actually quite laborious to preserve this little artificial moist ´ecological niche´ of the Ocular Surface - ´always and everywhere´ !
PS: * except for moistening the Ocular Surface, Tears are also of use to give the emotional signal to our fellow human beings that we are exceptionally sad ... or probably exceptionally happy by shedding ´tears of joy´
The moisture of the tears comes from the Ocular GLANDS
The Tear Fluid is produced by several Ocular Glands.
There are three different types of glands needed, because the tear film on the eye consists of three different types of substances.
- Water ... is the main part of the tears and comes from the lacrimal gland behind the upper eyelid. Several small accessory glands contribute minor amounts of fluid.
- Oil ... from the Meibomian lipid glands, that form elongated strands inside the eyelids, can reduce the evaporation of the water. Oil therefore forms a thin layer on the surface of the tear film.
- Mucus/ Slime ... comes from individual small goblet cells in the mucous membrane of the conjunctival sac. They can be seen as little dots in the microscope. The Slime is needed to connect the water of the tears to the cell surface.
TEARS flow along the Ocular Surface
Tears are produced by the various Glands at the Ocular Surface.
The bulk volume consists of water and comes from the lacrimal gland that is located upstream in the upper lateral side of the bony orbit.
From there the tears enter the conjunctival sac. They are flowing over the visible anterior part of the eye and thus constantly bathe this area.
At the nasal side the ´used tears´ are sucked up by two narrow lacrimal puncta, one at each nasal end of the upper and lower eyelid.
Through the lacrimal drainage system the tears enter the nose. When tears go there in larger quantities, e.g. in emotional crying, they may flow backwards into the pharynx where we can sense their salty taste.
The Meibomian Glands are of particular importance for the Ocular Surface
Meibomian oil protects the tear water from evaporation.
The Meibomian glands produce lipids that are liquid at body temperature and thus form an oil.
The glands are of particular importance for the health of the ocular surface because their oil retards the evaporation of the tear water from the lacrimal glands.
In the dry environment that we live in, even a copious secretion of tear water would rapidly evaporate from the ocular surface if it was not protected by the superficial Meibomian oil layer on the tear film.
The Meibomian glands form individual long bodies that fill the tarsal plates of our eyelids. About 25-30 glands can be found in every healthy eyelid and the little orifice is close onto the posterior lid margin ... as can be seen in an ordinary mirror, by everybody who is interested.
With every blink of the eyelids a little drop of oil is expressed by the lid muscle. It gets from the gland onto the eyelid margin and the tear film. where it protects the aqueous tear film from too rapid evaporation.
Opening the eye lids for the entrance of light ... puts the Ocular Surface in some kind of a DILEMMA
The requirement of Moisture - ´always and everywhere´ - confronts the ocular surface with a problem or, more positively thinking, this gives it the change to deal with a Challenge:
Light can only enter the eye when the eyelids are opened ...
... on the other hand, opening of the eyelids would at the same time immediately deprive the Ocular Surface tissue of its moisture and it would start to dry out.
To solve this Dilemma, the Ocular Surface has to apply a ´Trick´: A very narrow layer of fluid is formed from the tears - this is for obvious reasons termed as the Tear Film.
The Tear Film is thick enough to preserve the moisture for the underlying cells of the tissue but not too thick in order not to harm the transmission of light.
The Ocular Surface in fact manages to be even more ingenious, because it solves the dilemma by even improving the passage of light through the presence of the Tear Film. The Tear Film fills in all subtle inequalities of the ocular surface and thereby provides a perfectly Smooth Surface layer for perfect refraction of the incoming light that allows for perfect Visual Acuity.
The TEAR FILM is the SOLUTION for all requirements of the Ocular Surface ... and for VISION
The BLINK movement of the eyelids distributes the tears into the tear FILM
The Tears are transformed into the thin, homogeneous Tear Film ... through the coordinated Movement of the Eye Lids - the BLINK.
During the blink mainly the upper eye lid wipes over the anterior surface of the eyeball and thus distributes the tears into the very narrow Tear Film.
During the down-phase of the blink the old tear film is removed by the upper eyelid and during the up-phase the upper eyelid draws out a new intact homogeneous tear film.
Dysfunction of the Eyelids and of Blinking is an important factor for Dry Eye Disease
It becomes obvious that any disruption of the EyeLid and of their normal Blink movement and speed is an important factor for the onset on a Dry Eye condition . This is termed as ´Eyelid and Blinking Disfunction´ (abbreviated as LBD).
The TEAR FILM
Only through the coordinated blink movement of the eyelids, together with the very special composition of the Tears , is it possible to form a TEAR FILM that is extremely thin (only about one hundreds of a millimeter).
At the same time this very narrow tear film must still be stable to allow the curious brain to achieve a sufficiently sharply focused image of the outside world.
The Tear Film must be stable for at least 10 seconds on average until it eventually breaks up and triggers a stimulus that induces a new blink that forms a new tear film.
Having said this ... all major things are basically named ... The basic functional pre-condition at the ocular surface for vision is a Stable Tear Film. This is achieved by the Basic Functional Complexes of Tear Secretion/ Production by the ocular glands and of the physical Tear Film Formation by the blink movement of the eyelids.
Different Influence Factors can impair the Tear FILM
The formation and preservation of the Tear FILM is very laborious in the dry environment that we live in, and is thus very vulnerable.
The Tear Film depends on a multitude of very different Influence Factors, that can, in one or the other way, have a positive or negative influence.
All negative influence factors are Risk-Factors - they can, sooner or later, lead to a Dry Eye condition - particularly when they become chronic.
The large number of influence factors that may appear unrelated at first glance can let Dry Eye Disease appear as a ´Tricky Condition´ - even though it basically straightforward.
Deficiency of the Tear Film leads to Cell Destruction, IRRITATION, Inflammation and PAIN
The Tear Film has the function to prevent Drying of the Ocular Surface Tissue. Therefore the most immediate consequence of a Dry Eye condition is typically the Drying and thus Destruction of the Ocular Surface Tissue.
The eye lids can then often be sealed by sticky mucus and encrustations.
This results in a ´downstream´ irritation of nerve fibers They transmit ocular irritation of various degrees and can lead to pain that is often described on and around, occasionally behind, the eye. Inflammatory reactions can reinforce the whole process, eventually leading to severe tissue destruction and to a chronic pain syndrome.
... and the Visual Acuity is diminished, which typically leads to BLURRED VISION
Since the Tear Film also has an important function for the refraction of light and thus for the provision of visual acuity, it is no surprise, that visual disturbance is frequently reported in Dry Eye Disease, typically in terms of unstable visual acuity and blurred vision
A lack of OIL is the main starting point in most patients with Dry Eye Symptoms
According to the present scientific knowledge, the vast majority, i.e. four of five patients with a Dry Eye Condition, does NOT have a primary lack of water but instead a PRIMARY LACK OF OIL in the tear film.
This leads to increased water evaporation and decreased tear film stability .... with a secondary water loss.
Therefore, in most patients, it does not seem to make much sense nowadays to use products that do not contain lipids in one or the other way.
It may be possible to replace the effect of lipids on the tear film by other compounds, or to simply use lipids only, e.g. as a liposomal spray. ... In other words, LIPIDS or respective compounds should nowadays be a component of a typical Tear Supplementation Therapy.
The lack of oil is typically due to Meibomian Gland Dysfunction (MGD) inside the Eyelids
The lack of oil on the ocular surface is typically due to Meibomian Gland Dysfunction (MGD), a mostly obstructive condition of the Oil-producing little glands inside the eye lids.
The glands are blocked by inspissated secretum and excessive keratinization - therefore inspissated oil accumulates inside the glands.
Muscular force during blinking of the eyelids normally helps to express the oil from the Meibomian glands.
Rare Blinking is thought to be an important factor for a lack of oil on the tear film and possibly a co-factor for onset of gland dysfunction.
Intended forceful blinking is known as a simple way to increase the oil layer on the tear film and thus to improve tear film stability in order to prevent ocular surface dryness.
Some Ideas for THERAPY in Dry Eye Disease
How to TREAT Dry Eye Disease ?
In most cases there is a deficiency of the Tear FILM based on a qualitative or quantitative lack of Tear Components.
- Therefore TEAR SUPPLEMENTATION, i.e. the addition of missing tear components - in the form of eye drops or of a spray - is the most frequently used therapy option.
- Sometimes this is termed Tear ´Replacement´ - but, since the (full) Tears with all ingredients can (unluckily) not be replaced at present and in the foreseeable future, the term ´Supplementation´ appears more appropriate.
- All different sorts of eye drops based on aqueous solutions with a lot of different additional ingredients are available, mostly as prescription free over the counter products.
Physical EYELID Therapy
PHYSICAL EYELID THERAPY is reported to restore the function of the Meibomian glands in the Eyelids ... and thus improves Dry Eye Disease
Physical Eyelid Therapy options refer to the fact that the improvement of Eyelid and Meibomian Gland Disease is based on simple but effective physical techniques such as Warming and Moistening, as well as manual Massage and Expression of the Glands with subsequent Scrubbing and Cleaning of the Eyelid Margin.
It is certainly important to note that before any manipulations are done to the eyelids and the eye a clinician should always be consulted for an educated diagnosis and for therapeutic recommendations !
It appears necessary that Physical Therapy is done as a permanent therapy, at best twice a day - because a chronic disease typically requires a chronic therapy. Only a chronic consequent therapy is able to improve the disease condition - still, there is typically only a slow but steady improvement !
PHYSICAL THERAPY consists of 3 Steps
(1) WARMING of the Eyelids
- WARMING, preferably together with moisture
- for at least 10 minutes
- to reach a temperature of 40°C inside the eyelid and thus within the Meibomian Glands
- serves to re-liquefy the inspissated oil inside the Meibomian glands.
In order to achieve 40°C inside the eyelid a slightly warmer (42-45°C) moist warm compress/ cloth must be rewarmed (e.g. from a larger bowl of hot water) every two minutes as shown by studies.
The additional moisture serves to soften up the cornified epithelial squames and lipid encrustations on the eyelid margin.
Commercially available gel masks or even electrically heated and moistened googles may make the potentially laborious effort of physical therapy, twice a day, considerably easier ...
(2) Subsequent Lid MASSAGE to EXPRESS and relieve the obstructed glands
- when the inspissated oil that is stuck inside the Meibomian glands is sufficiently warmed it will become more liquid again
- a careful eyelid massage can then express the pathologic content from the Meibomian glands onto the lid margin
- massage must always be directed towards the gland orifice on the lid margin, i.e. towards the palpebral fissure (as shown in the animation to the right)
- the upper eyelid is thus massaged downwards
- the lower lid is massaged upwards
- anyway, as mentioned earlier, in a chronic disease, such as Dry Eye Disease, a chronic therapy is necessary to improve the condition. A single treatment can typically not result in any major progress. Therefore even a correct careful eyelid massage does not necessarily result in a noticeable expression of inspissated Meibomian lipids. But consequent therapy will result in steady improvement of the disease condition.
- when the oil is very hard and insufficiently re-liquefied it may be necessary to perform a more vigorous expression of the eyelid , e.g. between two fingers.
- during any procedures applied to the eye by a layman it must therefore alway be safeguarded that no harm and wounding is caused to the eye, eyelids and glands !
(3) Eyelid/ Lid Margin HYGIENE concludes physical therapy
- finally, the eyelid margin together with the base of the eyelashes could be cleaned
- from the expressed pathological oil
- from bacteria and bacterial products that occur on every normal lid margin but increase in disease
- from cornified skin squames that deposit on the lid margin
- Lid Margin Hygiene can be done by a soap-free wiping or ´scrubbing´ of the lid with a cotton-tipped rod or a cosmetic pad in order to remove any debris, encrustations and foam from the lid margin.
- it appears important to avoid any soap, shampoo, or any other detergents, as has previously occasionally been recommend., because that would conceivably harm the tear film lipid layer.
- Oily solutions of any kind appear more suitable for eyelid cleaning.
- Commercial eyelid cleaning kits are available that contain everything necessary in a pre-prepared set and may make eyelid hygiene much easier.
The advantage of such physical therapy options is certainly, that this can mostly be done at home by the patients themselves. It may appear as a disadvantage that physical therapy and in particular lid hygiene has to be done routinely once or twice a day, similar e.g. to tooth brushing, but requires slightly more time.
Please Remember: A Happy Eye Lid typically makes a Happy Dry Eye Patient !
- - -
Various other THERAPY OPTIONS are discussed in other Chapters of the full length English Language Pages of the OSCB Information WebSite.
CONTACT LENSES are a fantastic Optical Tool ... customized to the Ocular Surface
Contact Lenses are a fantastic Optical Tool with some clear optical advantages compared with spectacles.
At the same time they provide greater ´freedom´ for outdoor activities, sports and society events.
Contact Lenses are, as their name indicates, in direct ´contact´ with the Ocular Surface.
Contact Lenses are in fact sitting in the middle of the Ocular Surface Functional Unit - with potential influence on all tissues and on the tear film.
Contact Lenses thus have a somewhat ambiguous role for the Ocular Surface - with Pros and Cons.
Contact Lenses are swimming on the Eye ... and thus have higher requirements for the Tear Film
Contact Lenses can be used for medical purposes such as the optical correction of an irregular corneal shape or for the protection of the eye e.g. in severe cases of Dry Eye Disease.
On the other hand, Contact Lenses have higher ´requirements´ for the amount and/or quality of the tear film.
It may well be, that an individual with a borderline normal tear film, who is still without symptoms, may develop Dry Eye symptoms upon insertion of an ordinary soft hydrogel contact lens.
A typical side effect of Contact Lenses is therefore the onset of Dry Eye symptoms and eventually probably of Dry Eye Disease.
On the other hand an individual with a severe Dry Eye Disease may profit from the application of a special so-called ´Scleral´ Contact Lens that is able to preserve the tear solution underneath the contact lens and in front of the cornea.
HYGIENE is a CRITICAL ISSUE in Contact Lens Wear
Contact Lenses have seen great improvements in the past decades.
This has lead to a reduction in the frequency and severity of side effects.
Insufficient Hygiene can lead to serious and sight-threatening infections in contact lens wear.
This is still an important issue, particularly for inexperienced wearers.
Due to the increasing use of disposable contact lenses for short term wear, particularly daily disposables, the risk of infection can be reduced.
Please find more information below on => Contact Lenses and the Ocular Surface
Choose your CHAPTER of Interest - or simply read along ... which may be most instructive
of the Ocular Surface
The Ocular Surface is a permanently MOIST TISSUE
MOISTURE comes from the Tears and is produced by the Ocular Glands - but it must be spread into a Tear FILM by the BLINK Movement of the Eye Lids ... to make moisture PERMANENT - Everytime and Everywhere !
Basic Functional Complexes
The Glands of the Ocular Surface for the production of the dfferent components of water, oil and slime/mucus together form the tear fluid.
The Tears are the essential medium for the provision of moisture at the Ocular Surface.
The Eye Lids spread the tears into the essential pre-ocular Tear Film.
The Tear Film makes it possible that moisture can even persist on the tissue within the opened palpebral fissure. In addition to moisture the Tear Film aids in allowing a perfect light refraction and thus a perfect vision at the same time.
The Healthy Ocular Surface is a Pre-Requisite for Vision and without it all later steps of the vision process are meaningless.
for Dry Eye Disease
DRY EYE DISEASE is a ´dog of many names´
DRY EYE DISEASE is medically also addressed as ´Keratoconjunctivitis Sicca´ - which means ´dry inflammation of the cornea and conjunctiva´ or only as the ´Sicca Syndrome´ (bunch of symptoms related to dryness) . This condition has various colloquial names such as simply ´dry´ eyes, ´ocular dryness´, ´itchy eyes´´heavy lids´ or ´tired eyes´ etc.
The Disease MECHANISM is relatively simple and therefore this condition is relatively frequent
DRY EYE DISEASE IS AN ALTERATION OF THE TEAR FILM AND TISSUE
Dry Eye Disease typically shows the two PATHOLOGIES of
- Tear FILM Deficiency with an unstable tear film that shows e.g. early break-up, increased evaporation, low tear meniscus.
- DAMAGE of the ocular surface tissue is the other basic pathology in Dry Eye Disease. It typically results from Tear Film Deficiency of any kind. A deficient, unstable tear film layer can no longer protect the surface tissue. Therefore the very susceptible surface cells will then immediately start to develop drying alterations that damage the tissue.
- Rarely does Surface Damage occur as a first pathology due to a different pathology such as, e.g. in a severe malnutrition with Vitamin A or due to inflammatory local or systemic disease conditions, such as in Graft-versus-Host Disease (GvHD). In less developed regions of the world, however, pathologies such as malnutrition and inflammatory disease can be more frequent. A Dry Eye can thus occur more often due to a primary Tissue Damage which then deteriorates the Tear Film.
THE BASIC CAUSATIVE FACTORS for Dry Eye Disease are a Lack of Tear Secretion and of Film Formation
The basic CAUSATIVE FACTORS for Dry Eye Disease are those that directly lead to the deficiency of the Tear FILM - this is
- a quantitative or qualitative LACK/ Deficiency of Tear SECRETION by the Glands
- and/ or
- any LACK/ Deficiency of Tear FILM FORMATION that occurs by negative influences on the Blink Mechanism of the EyeLids that distribute the Tears into the pre-corneal Tear Film
Basic causative factors lead to Tear FILM Deficiency that induces the primary pathology of Tissue Damage.
Such patho-physiological analysis of the disease process in Dry Eye Disease led to the ´Holistic Dynamic Concept´ of Dry Eye Disease as described in the Dry Eye Chapter of the original full length English language version of the OSCB WebSite.
MAIN SIGNS & SYMPTOMS
of Dry Eye Disease
The main clinical signs of Dry Eye Disease are thus:
INSTABILITY of the pre-corneal Tear FILM:
Instability of the Tear Film is a typical feature of any type of Dry Eye Disease and thus important to be investigated.
- the normal tear film should be stable for at least 10 seconds before a rupture or "break-up" occurs
- this parameter is termed "Tear Film Break-Up Time", typically abbreviated as "BUT"
- it is typically and easiest determined by applying the vital stain fluorescein into the tears.
- The use of fluorescein solution in the test is termed as FBUT. It may already change the tear film to a certain extent ... but if the amount of additional volume is limited and when the procedure is always performed identical the FBUT Test will lead to consistent and meaningful results
- The FBUT Test has therefore been used for decades with great success.
- Meanwhile non-invasive methods (NIBUT) are gaining increased interest where the tear film break-up is detected by changes in its reflection, which is slightly more accurate in principle but requires specific technical equipment.
Vital STAINING of the Ocular Surface Epithelium:
Vital staining is a quick and easy way to verify another important feature of any type of Dry Eye Disease which is alteration, wounding and destruction of the normal epithelial structure
- When the tear film breaks up
- the lubrication between the bulbar surface, including a possible contact lens, and the eyelids is reduced
- this leads to increased friction and thus to increased mechanical damage of the surface cells
- it exposes the underlying ocular surface epithelium to the air atmosphere
- in addition a local thinning of the tear film by evaporation is shown to result in spots of increased osmolarity of the remaining tear fluid and thus in hyper-osmolarity
- this leads to chemical damage of the surface cells
- The air exposure and the mechanical and chemical damage of the surface epithelium results in pathological alterations of the ocular surface with cell destruction
- cell destruction can be marked by stains that are applied in clinics to the living eye - the stains are therefore termed vital stains
- vital stains bind to the altered surface and thus result in little stained spots where damage has occured.
- Ocular surface damage is a typical characteristic of ocular surface disease and in particular of Dry Eye Disease. The degree of vital staining therefore shows the degree of ocular surface damage.
- Surface staining in the temporal part is the inter-palpebral zone is thought to be more characteristic for Dry Eye Disease than a more nasal staining.
What are the SYMPTOMS of DRY EYE DISEASE ?
The pathology of Dry Eye Disease gives rise to some typical subjective SYMPTOMS
Tear Film Deficiency and Surface Damage lead to typical subjective irritative SYMPTOMS of the patient.
Typical Syptoms in Dry Eye Disease are e.g. ocular irritation, dryness and grittiness, often described as ´heavy eye lids´ or ´tired eyes´, together with an unstable visual acuity and episodes of blurred vision, with various degrees of irritation and pain.
Initially the ocular irritation due to tissue alterations can lead to episodes of increased tearing, watery eyes and tear dripping over the lid margin.
Frequent RISK FACTORS
for DRY EYE DISEASE ... and their Self-Perpetuating INTERACTION
A certain Challenge in the understanding of Dry Eye Disease is based on the fact, that it can be initiated and influenced by a large variety of different factors
- REGULATORY SYSTEMS of the body such as the nerve system, the endocrine hormonal system and the immune system have great importance.
- There are additional RISK FACTORS, that have a negative influence on the tear fluid or on the ocular surface tissue and thus increase the likeliness for the onset and progression of disease.
Various MEDICATIONS can promote Dry Eye Disease
An often underestimated Risk Factor for the promotion of Dry Eye Disease is various types of medication. This is true in addition to the potential negative influence on ocular heath that may come from the presence of systemic disease as such, that may require the medication.
Pharmacological therapy may promote the onset or progression of Dry Eye Disease when they change the internal milieu of the body in a way that has a negative influence on the production of tear components. Another issue occurs when they have a direct negative influence on the health, vitality and integrity of the ocular surface. The latter can occur e.g. in malnutrition of e.g Vitamin A, and in chronic inflammatory ocular surface disease as e,g, in Graft versus Host disease (GvHD) that as typically observed after bone marrow transplantation.
The medicine-related and often pharmacological negative influence on the health of the ocular surface and on the promotion of Dry Eye Disease was in the recent (2017) TFOS DEWS II Report designated an own type of disease, the ´Iatrogenic Dry Eye´.
Many classes of pharmacologicals affect the ocular surface
Many classes of pharmacologicals are known or supposed to promote Dry Eye Disease. This includes, e.g.
- Beta-Blockers against high blood pressure
- some anticholinergics as
- antihistamines for allergies,
- various antiarrhythmics in heart disease,
- various bronchodilators for airway therapy in asthma and in chronic obstructive lung disease,
- various antidepressants
- some anti-Parkinson medications, etc.
- some painkillers (e.g. canabis, opioids, etc)
The potential promotion of dry eye disease depends, however, on the actual medication and on the dosage. An intended necessary positive drug effect on the disease in question certainly has to be weighed against a potential unwanted side effect in order not to endanger the health of a patient. Generally, a medical therapy that is advised by a doctor should not be changed of removed by a patient without better knowledge !
Preservatives damage the Ocular Surface
A direct damage of the ocular surface occurs in particular by the chemicals that are added to eye drops as a preservative in order to prolong the shelf-life and their time of usage by the patient.
This is a problem in particular when the eye drops have to be applied frequently or regularly as in tear supplementation therapy and topical glaucoma therapy.
Frequent application of preservatives often leads to a considerable damage of the fine structure of the ocular surface and thus to decreased wetting of the tissue and to instability of the tear film.
Luckily many eye drops are available today in a preservative free form either in small Single Dose Containers or in sterile drop dispensing bottles. Whenever possible such preservative free medication should be preferred.
Unluckily, Dry Eye Disease has a certain inherent tendency to self-enforce and perpetuate itself, if not timely diagnosis and effective therapy is performed
The two typical pathologies
in Dry Eye Disease are
- Tear FILM DEFICIENCY and
- Surface TISSUE DAMAGE
Tear Film Deficiency and Surface Damage influence each other negatively and are therefore linked by several self-enforcing vicious circles that lead to worsening of the condition.
are a typical component of Dry Eye Disease because inflammation represent a basic protective mechanism of wounded tissue - and this is also true for the Ocular Surface.
When the wounding becomes chronic the inflammatory answers of the tissue also become chronic and more severe.
Inflammatory pathways are thus an important disease mechanism for worsening of the condition in chronic ocular surface disease.
An occasional ´Dry´ Eye condition can certainly happen also in healthy individuals under certain conditions - however, when this becomes chronic, it can develop into a disease
Occasional ocular DRYNESS can certainly occur once in a while also in healthy individuals. Such dryness typically depends on adverse environmental factors, is short-lived and disappears quickly after some vigorous eye blinks or when the negative factors are removed. When the condition becomes chronic, however, an occasional ocular dryness can turn into a manifest permanent Dry Eye DISEASE.
CONTACT LENSES and the Ocular Surface
CONTACT LENSES are a fantastic Optical Tool - with pros and cons
Contact Lenses are a fantastic Optical Tool that has long been desired by many individuals with refractive disorders.
They became eventually widely usable only in the second half of the 20th century and have seen great.improvements since then.
CONTACT LENSES correct refraction directly on the Cornea ... with clear optical advantages
Contact Lenses can correct refractive errors directly on the cornea and therefore, they have some principal optical advantages compared to spectacles.
Contact Lenses certainly provide greater ´freedom´ for the user in a lot of sporting, outdoor and society activities.
There are different basic types of Contact Lenses. Soft hydrogel Contact Lenses are the most widely used type.
Soft lenses can typically be worn without distinct irritation and thus often require no adaptation time for the wearer to get used to a lens.
This may be a reason why most Contact Lenses are of the ´Soft´ type and are not worn for medical but for esthetic/ cosmetic reasons.
CONTACT LENSES are swimming in the Tear Film and have influence on its stability and evaporation rate
The fact that Contact Lenses are sitting in the middle of the Ocular Surface has some pros and cons.
They certainly have some clear optical advantages ...
... but contact lenses still represent a ´foreign body´ for the Ocular Surface Tissues and Tear Film.
Even though contact lenses are typically ´swimming´ in the tear film it is still inevitable, that they are in mechanical contact with the ocular surface tissues.
A typical side effect of contact lenses therefore is the occurrence of increased frictional forces to the ocular surface tissues.
CONTACT LENSES can have negative influence on the Ocular Surface Fine Structure
Although fitting principles usually try to avoid too much physical ´touch´, contact lenses are still, inevitably, in contact with the ocular surface - just as their name suggests.
Contact lenses can thus have mechanical, physicochemical and chemical impacts on the Ocular Surface to varying degrees. Even though such contact lens impacts on the ocular surface may not necessarily be pathologic, they may still contribute to that is known as ´Contact Lens Discomfort´ (CLD). CLD refers to a vague irritative discomfort by sensing the presence of a contact lens on the eye and CLD was the topic and title of the 2013 TFOS report on such Contact Lens impacts on the Eye.
This concerns particularly the interference of the contact lens with the very sensitive central cornea and the similarly sensitive posterior lid border.
The conjunctival areas on the eyeball and on the back side of the lids are less sensitive, but are also in touch with the contact lens and are thus exposed to potential negative influences.
It is known for decades that chronic friction by a contact lens may negatively influence e.g. the fine structure of the conjunctival surface and thus reduce the wettability of the ocular surface. A typical side-effect in long-term contact lens wear is the potential development of Dry Eye symptoms of varying degrees.
It is shown that the structure of the bulbar conjunctiva changes in contact lens wear. This occurs in the zone where the margin of the contact lens is in touch with the surface and rubs over it upon every movement of the eye. The type of epithelium changes, termed as squamous metaplasia, and the number of goblet cells that produce the important mucus for the wetting of the surface, decrease in number. These alterations deteriorate the wetting of the Ocular Surface and promote the onset or worsening of Dry Eye Disease.
The Fitting of a Contact Lens determines its impact on the Ocular Surface:
- in flat fitting the Contact Lens exerts a certain pressure particularly on the center of the cornea
- in steep fitting the margin of a Contact Lens is rubbing particularly on the bulbar conjunctiva
- in every type of fitting a mechanical interaction of the Contact Lens margin with the very sensitive posterior lid border is inevitable due to the blink movement of the upper eyelid
Speciality Contact Lenses can serve as a medical tool
Apart from the fact that Contact Lenses can exert unwanted side effects on the ocular surface and tears Contact Lenses can also be used as a medical tool in selected cases.
The easiest case is probably when a soft Contact Lens is used as a clinical bandage lens to promote healing after surgery or in cases of recurrent corneal defects (erosions)
Several types of Speciality Contact Lenses exist that can be used as medical tools in selected medical conditions for patients who are in continuous clinical control.
This refers to ´Rigid´ Contact Lenses that can correct higher degrees of corneal shape distortion (as occurs in higher astigmatism and in keratoconus) where the visual acuity can not be sufficiently corrected by spectacles.
´Rigid´ Contact lenses can also be used for intended changes of the corneal shape, termed as ´Orthokeratology´ in order to avoid day time wear of spectacles - which certainly needs close clinical monitoring.
SCLERAL Contact Lenses
Even though contact lenses lead to alterations of the ocular surface fine structure with occurrence of dry eye symptoms ...
... Speciality Contact Lenses (Scleral Lenses) can be used as a medical tool in patients with severe Dry Eye Disease.
Scleral Contact Lenses provide a protecting translucent cover over the sensitive cornea and constitute a moist chamber that preserves the patient´s few own tears under the vault of the contact lens against evaporation. This can typically restore ocular surface healing and visual acuity.
When basic rules of hygienic contact lens wear are not respected this can still result in dangerous ocular infections that may endanger vision.
Even with application of the most advanced medical therapy, a severe contact lens related corneal infection may eventually and tragically lead to a loss of the eye.
Bacteria are typically introduced through the handling of the contact lens by the wearer and/or by use of contaminated tap water. Bacteria accumulate in the contact lens containers or in difficult to remove deposits on the contact lens itself.
The occurrence of infection is further promoted by the inevitable occurrence of tissue microtrauma of different kind in contact lens wear. This provides a route of entry through the normally almost impenetrable ocular surface barrier.
Particularly inexperienced Contact Lens wearers are at risk for serious ocular infections. Furthermore patient groups with a reduced level of immune defense such as children and elderly people are particularly susceptible to ocular surface infections.
The increased use of daily disposable contact lenses contributes to a decrease in ocular infections. because the critical steps of cleaning and storage of a worn lens become obsolete.
Deeper INSIGHT ...
... into the function of the Ocular Surface and the development of Dry Eye Disease
... something like a little Glossary on some important issues
Choose your CHAPTER of Interest - or simply read along ... which may be most instructive
The Ocular Surface
The OCULAR SURFACE must be constantly moist to provide its health and thus perfect vision.
What IS the Ocular Surface ?
=> The moist tissue at the anterior side of the eye ball !
The CONJUNCTIVA is a maintenance organ for the cornea that contributes to the health of the cornea. It covers the front side of the eye ball and the back side of the eye lids and thus forms the conjunctival sac that is open to the outside only at the palpebral fissure where the tissue is covered by a film of tears - the tear film. (The width of the conjunctival sac and tear film are greatly exaggerated in the schematic drawing for didactic reasons - normally the eye lids basically touch the globe and transform the ´real´ conjunctival sac into a mere moist slit between the eye lids and the eye ball and the tear film is very thin.).
Why is the Ocular Surface Moist ?
=> To preserve its health and integrity !
Only a moist cornea can stay transparent
The Ocular Surface is a moist mucosal tissue to keep the Cornea transparent.
It must be kept constantly MOIST – everywhere and every time – to remain healthy and intact and the Ocular Surface is thus constantly bathed in the tear fluid.
The vehicle for moisture are the TEARS that are produced by the ocular glands and disposed by the lacrimal drainage system into the nose.
TEARS are the Essence and Medium of Moisture at the Ocular Surface
The Tear FLUID, usually simply termed as ´TEARS´ is produced/ secreted by the Glands of the Ocular Surface.
After their ´usage´ at the Ocular Surface, which refers to the bathing of the cornea and conjunctiva ...
... the tears are discharged from the bulbar surface into the lacrimal drainage system towards the nose.
The continuous production of new tear tears and their flow over the ocular surface is therefore of utmost importance for the health and clarity of the CORNEA and thus for intact VISION.
Also, the regulated disposal of ´used tears´ from the ocular surface is very important because there is very little space on the ocular surface for fluid.
Actually not even one drop of extra fluid, e.g. of eye drops, can typically be accommodated and thus most of it typically flows away over the lid margin
In contrast to a real DRY Eye, with a definite lack of tears, the increased production of tears as seen in an irritated ´Watery´ Eye ... or, a decreased disposal of tears from the ocular surface, as seen in an abnormal eyelid shape termed as ´ectropion´ can also lead to problems.
Both of these conditions with ´too many tears´ at the ocular surface typically lead to a (continuous) dripping of tears over the lid margin, that is termed ´epiphora´ by the clinician.
So ... we can see that the ocular surface is not too different from our experience in daily life - too much can be equally tiresome as too little.
What is the Tear FILM ... and what is it good for ?
=> it is a fluid film with a certain layered structure
=> It provides Moisture and Vision !
Constant moisture of the cornea and conjunctiva in the opened palpebral fissure is achieved by covering them with a layer of tear fluid – The TEAR FILM.
This is thin and homogeneous enough not to impair vision and at the same time sufficiently stable to avoid desiccation of the tissue at the air atmosphere.
The Tear FILM has three layers constituted by the products of different glands. Mucins from single goblet cells (GC) in the conjunctiva make the surface wettable by the Water from the Lacrimal Gland. Oil from the Meibomian glands inside the eye lids forms the surface - it retards evaporation of the tear water and provides stability of the tear film.
What is the role of the Eyelids?
=> They spread the essential pre-ocular Tear FILM !
The wiping movement of the upper eyelid during the blink spreads the tears into the thin and homogeneous Tear FILM.
Of particular importance at the eyelid margin is the posterior lid border because this is the structure that distributes the tears into a very thin film of tears. The posterior lid border acts similar to the wiper blade at the windscreen of car. It is therefore termed the lid wiper.
This blink movement of the Eyelids is not only necessary for keeping the moisture of the tissue in the palpebral fissure ...
The wiping movement of the upper eyelid during the blink spreads the tears into the thin and homogeneous Tear FILM.
This blink movement of the Eyelids is not only necessary for keeping the moisture of the tissue in the palpebral fissure ...
... but, at the same time, the tear film is the main surface for refraction of the light to provide perfect vision.
Another function of the blink is that the force of the lid muscle expresses some oil from Meibomian oil glands inside the Eyelids.
A lack of blinking therefore leads to a lack of oil on the tear film and to its instability.
In conclusion, the necessary prerequisites for a stable Tear Film and thus for ocular surface health and visual acuity are Secretion of tear fluid by the glands and the Formation of the tear film by the blinking action of the eyelids …
... consequently an alteration of Gland function and/ or of Eyelid function may lead to a Dry Eye condition - if this occurs chronically it may result in Dry Eye Disease.
In addition to spreading the Tear Film from the tear fluid, the eyelid action during blinking also contributes to the drainage of the used tear fluid via the lacrimal drainage system into the nose.
WHY is the Ocular Surface so important ?
=> The Healthy Ocular Surface is a Pre-Requisite for Vision !
The healthy Ocular Surface provides the clear window of the eye to see the light from the environment.
Without a healthy ocular surface all later steps of the vision process are meaningless.
Some DETAILS on Dry Eye Disease
DRY EYE DISEASE is an impairment of permanent moisture of the Ocular Surface with subsequent Destruction of the Tissue and a Reduction of Visual Acuity.
What IS DRY EYE DISEASE?
=> An Alteration of the Tear FILM that typically leads to Damage of the Ocular Surface Tissue
Dry Eye Disease is often termed as ´KeratoConjunctivitis Sicca´ (KCS) or simply known as ´Dry Eyes´, Burning Eyes, Itchy Eyes, Heavy Eye Lids, Tired Eyes ... and many other colloquial expressions that refer in one or the other way to ocular irritation.
Dry Eye Disease is a complex dysregulation of the functional anatomy of the ocular surface that impairs the permanent moisture and the integrity of the tissue and thus its health and the intact vision.
It typically goes along with signs and symptoms of ocular dryness, ocular irritation, tissue destruction and pain as well as with visual impairment, mainly in the sense of fluctuating visual acuity. and blurred vision.
WHAT are the CAUSATIVE FACTORS for Dry Eye Disease ?
=> A Deficiency in the Production of Tear Components and/ or a Deficiency in the Formation of a stable Tear Film are the main causative factors that lead to subsequent desiccation and damage of the tissue
Basic CAUSATIVE FACTORS for the pathology are:
(1) a Deficiency of Gland SECRETION/ Tear PRODUCTION by any pathology of the ocular glands that leads to an insufficient quantity and/ or quality of tears and/or
(2) a Deficiency in the FORMATION of a sufficiently stable Tear FILM from the available secretions, by any eye lid or blinking problem (termed as Lid- and Blinking Dysfunction - LBD).
The alterations in the function of the ocular glands and/ or of the blinking mechanism lead to INSTABILITY of the Tear FILM and thus to impairment of permanent ocular surface wetting. Insufficient wetting then results in DAMAGE of the Ocular Surface Tissue !
in Dry Eye Disease
What are typical SYMPTOMS of Dry Eye Disease?
=> Typical subjective SYMPTOMS are various degrees of Ocular Dryness, Blurred Vision, Irritation and Pain !
The basic causative factors of insufficient secretion and/or insufficient tear film formation ...
... lead to the primary pathologies of Tear Film instability and subsequent Drying and Damage of the Tissue
These two pathologies explain the typically SYMPTOMS in Dry Eye Disease::
initially, occasional episodes of increased tear flow and watery eyes can alternate with eye dryness
... this is protective reflectory activation of tear production in order to wash away the irritating stimulus
Irritation of varying degrees up to pain
Grittiness, Foreign body sensation, Burning or stinging
also a feeling of dull pressure around the eye and even behind the eye can occur
such sensations can explain the frequent description of a Dry Eye as:
´Heavy´ eye lids or ´tired´ eyes
Unstable visual acuity/ Blurred Vision
e.g. intermittent blurred vision that comes and goes and becomes better upon enforced blinking - which is good evidence that the symptoms indeed derive from a Dry Eye condition.
Contact lens wear is or becomes uncomfortable or impossible
due to the increased demands for an abundant tear film that contact lenses have, in particular soft hydrogel lenses
eye redness is typically not very intense in mild to moderate Dry Eye Disease
in Dry Eye Disease
What are typical SIGNS of Dry Eye Disease ?
=> Typical objective Clinical SIGNS of Dry Eye Disease are a reduced a reduced tear film stability and/ or tear volume on the ocular surface that reduce the moisture of the tissue and lead to surface damage !
The lack of sufficient tear fluid or a lack of a sufficiently stable Tear Film, that is often caused by a Dysfunction of the Meibomian Glands (MGD), results in the pathological SIGNS of the Dry Eye Disease.
The typical signs of Dry Eye Disease are important to known and are useful for the Diagnosis:
the tear film ruptures quickly and has a short ´break up time´ (BUT)
this is typically evaluated by staining the tear film with a green stain (fluorescein) observed in blue light in order to make break-up of the tear film visible
the animated schematic diagram to the right illustrates a highly pathologic tear film that is stable for only one single second - whereas a normal value should be at least ten seconds or longer (until the tear film ruptures and triggers another blink to reform a new tear film).
initially, occasional episodes of increased tear flow and watery eyes can alternate with eye dryness
there is a Low tear volume on the Ocular Surface
due to either increased evaporation of tear water due to a deficiency of oil secretion (this is the main primary reason - termed evaporative dry eye)
or due to decreased secretion of aqueous tears from the lacrimal gland (termed primary aqueous deficient dry eye)
Deficient/ thin oil layer on the tear film
typical consequence of Meibomian Gland Dysfunction (MGD) - the main primary cause of Dry Eye Disease
Lid Margin Alterations, such as:
Meibomian gland orifices with pouting or plugging by inspissated material
increased redness and increased blood vessels (teleangiektasia)
foam and debris on the lid margin
rounding and irregularity of the posterior lid border
Defects of the epithelial tissue that covers the Ocular Surface (Epithelial Vital Staining)
of the Cornea and Conjunctiva
of the Lid Margin as Lid Wiper Epitheliopathy (LWE)
Elevated levels of inflammatory mediators in the tears and tissue
inflammatory cytokines, chemokines
downstream activation of tissue degrading enzymes
Lid-Parallel Conjunctival Folds (LIPCOF) along the lid margin
as a sign of tissue destruction due to activation of tissue degrading Matrix-Metalloproteinase (mainly MMP9) enzymes
Disappearance of Meibomian gland tissue (Gland Drop-Out)
occurs in visualization of the glands by specific techniques (Meibography)
in Dry Eye Disease
WHY are the subjective SYMPTOMS and the clinical SIGNS in Dry Eye Disease often disparate?
=> ... this is not completely clear as yet and still an issue of ongoing scientific investigations 1!
In Dry EYE DISEASE there is often a Disparity between subjective Symptoms of the Patient and the objective clinical Signs points to some considerations on the neurobiology.
Stimulus, Irritation and Perception
The processing of signals from the Ocular Surface is complex and is influenced on different levels of the nervous system. Therefore, the outcome depends on many variables and may very well be different in different individuals. This fits well with the observations from our daily lives, that different people tend to have different ´nerve costumes´ and may react differently to the same stimuli.
Another issue is, that there is a principal difference between a ´perception´ e.g. of touch in a peripheral organ, such as the cornea, and the allocations that subcortical centers add to it in order to produce something that we call pain.
PAIN is not a mere perception but is basically more of a feeling, i.e. a construction of the brain, because it contains an emotional aspect that the brain allocates to an incoming afferent impulse from the periphery.
The emotional aspect that the brain allocates to the stimulus is based on very individual things like previous experiences, recent emotions, or future expectations ... in order to name just a few factors. Therefore the actual feeling that is generated in the brain can vary to a large degree in different individuals. This may point to a neuro-biological explanation of the disparity of signs and symptoms in Dry Eye Disease.
However, for the respective individual, the two different neurobiological authorities of "perception´ and of ´pain´ are not always clearly discernible ... and it is not always clear which of the authorities is more ´real´ and thus trustworthy.
Pain has the biological sense to alert us in order to avoid dangers that may threaten our health or our life. Under certain conditions when a pain becomes chronic and when it leads to a damage of the nervous system itself, it can develop into a chronic PAIN SYNDROME. Pain has then lost its biological function and becomes a disease of its own. In such cases where chronic pain persists without an identifiable tissue damage it may be useful to seek the help of a pain specialist.
Subjective emotional rating
The subjective emotional rating of a sensation may very well dominate over the pure perception ... or reverse. In some cases intense subjective symptoms are causing a severe suffering of the patient whereas the clinical investigation may only observe few minor manifest alterations or even now pathology - this may probably point to a potential chronic pain syndrome.
On the other hand there may be a patient who in fact has severe objective alterations of the normal structure and function but does not suffer from any severe symptoms or may probably have no symptoms at all. Such a patient may then have only a limited interest in therapeutic interventions even though these may be very advisable from a clinical perspective.
Psychosomatic Influence on a disease process and on its self-perception by the patient are an established and well recognized part of medicine for a long term. Apart from e.g. back pain, cardiovaculatory dysfunction, and intestinal dysfunction, a psychosomatic component can play an important role also in Dry Eye Disease, as confirmed by many studies. When the disease becomes the main concern in daily life this may suggest that it could be useful to seek the help of psychosomatics.
How do we GET Dry Eye ?
=> Dry Eye Disease is strongly influenced by Regulatory Systems and Risk Factors
Several factors influence the function of the Ocular Surface.
An impairment of positive factors and the occurrence of negative factors both decreases the normal function of the tissue and thus increase the likeliness and severity of a potential Dry Eye Disease.
The complex dysregulation of the functional anatomy of the ocular surface in Dry Eye Disease with a deficiency of the basic functional complexes for permanent moisture is influenced by different factors:
Failure of regulation
Failure of mainly the Nervous System, Endocrine Hormonal System, and the Immune System deteriorates the function of the Ocular Surface. Age and female Sex, related to a predominating estrogen action with relative lack of androgens, appear as the main predisposing factors for a higher risk of Dry Eye Disease
Negative external influence factors represent RISK factors for disease. They influence the tears on the surface and can override the normal functional capacity. They mainly occur in desiccating environments, contact lens wear, visual tasks with low blinking frequency. Many occur combined in typical office work environments and may lead to a Dry Eye Condition termed "Office Eye".
Alteration of organ Health
Negative internal influence Factors represent RISK factors of the onset of disease. They act on the tissues that produce the tear fluid and can deteriorate the normal function. These are e.g. chronic diseases, chronic medication, age, sex, nutrition or hydration etc.
=> Tear Film Deficiency with decreased wetting of the tissue and Tissue Damage negatively influence each other in self enforcing vicious circles and lead to progression of disease !
Self enforcing Vicious Circles
The complex pathologic events in Dry Eye Disease tend to influence each other negatively and thus form self enforcing VICIOUS CIRCLES of Disease Progression.
This does often lead to a worsening of disease without a timely diagnosis and an effective therapy.
Inflammation is an important mechanism
Inflammation is an important mechanism for worsening of Dry Eye Disease.
Inflammation is a basic protective mechanism of cells and tissues against wounding and destruction, as typically occurs in Dry Eye Disease due to tear film instability and increased friction. Inflammation initiates destructive mechanism in order to overcome the ´destructor´ and is later followed by tissue repair.
When inflammation becomes chronic, however, it transforms into a negative and destructive process because the initial destruction can not be followed by a sufficient repair.
In chronic diseases like Dry Eye Disease, the chronic tissue wounding may lead to a chronic inflammation that drives some vicious circles and can thus greatly enhance the disease process.
Dry Eye Therapy to interrupt the vicious circles in Dry Eye Disease may then include an anti-inflammatory therapy for a limited time in addition to a sufficient Tear Supplementation and Eyelid Therapy .
For more detailed information on THERAPY in Dry Eye Disease please see the Full Length English Language Pages of the OSCB
When is a Dry Eye a ...DISEASE ?
WHEN does a "Dry" Eye turn into Dry Eye DISEASE ?
=> When ´Dry Eyes´ become chronic an occasional condition of ocular dryness can turn into a disease !
AN OCCASIONAL “DRY” EYE IS NOT YET A DISEASE
Most of us have probably already had an occasional sensation of a “dry” eye, e.g. when we are exposed to an unusually dry and desiccating environment, characterized by Low humidity, hot temperatures, high wind speeds and/ or by Low blinking frequency due to intensely concentrated visual tasks as e.g. in screen work
Such a “dry” eye is is typically a short-lived condition that disappears as soon as we become aware of it and remove the described desiccating stimulus.
WHEN “DRYNESS” BECOMES CHRONIC THE CONDITION TURNS INTO A DISEASE
Only when the feeling of “Dryness” remains constantly and cannot be removed or sufficiently improved by avoiding desiccating environmental stimuli and/or by improving blinking
… then the conditions becomes chronic and an occasional “Dry” Eye may develop into Dry Eye DISEASE.
This is typically related to an increase in duration and intensity of symptoms and by increasing severity of clinical findings/ signs due to increasing alteration and wounding of the ocular surface tissue
Several Different and Interacting self-enforcing VICIOUS CIRCLES of disease aggravation and worsening occur in chronic Dry Eye Disease and can lead to the full blown clinical picture with a progressive tissue destruction and a loss of function of the ocular surface.
=> For more detailed information please consult the original full-length English Language Version