Good Hope Eye Clinic

Sore or dry eyes

David Kinshuck

Introduction

If your eyes feel tired, sore or gritty or sandy, you may have 'dry eyes', or 'blepharitis', or both. Dry eyes  is a common problem as people get older, and in diabetes. The eyes may feel scratchy or gritty, as though there is something in them (foreign body sensation). They also be a little itchy, and they may be red. They may feel as though they are burning, with crusting .

The lashes may crust up and your eyes may stick, although these problems are more likely to be due to blepharitis: Dry eyes and blepharitis often occur together. The eyes feel worse when using the eyes contantly, such as reading or using a computer, when the blink rate reduces.

Sore eyes may be due to blepharitis,  This causes sore eyes by preventing tears spreading evenly. Sore eyes are much commoner in diabetes, perhaps because of all the tablets. Sore eye are very common if a person is taking lots of medications

 

Where are tears made?

Tears are made in a gland near the top of the eyeball, and spread over the front of the eyeball into tear ducts, and then down into the nose. 'Dry eyes' occur when there are not enough tears to keep your eyes lubricated, or the tears that are produced do not spread evenly across the eyes.

tear flow from lacrimal gland

Tears are normally made in the lacrimal gland, and flow over the surface of the eye. They run down tiny tear ducts into the nose. See animation.

 

healthy tear film, side view

Front view

healthy tear film, front view

Side view

Normal tears cover your eye with a thin layer of tears

 

What are dry eyes?

Normally eyes are covered with a thin invisible film of tears; the tears are the lubricating 'oil' of the eye surface. Dry eyes occur when the lacrimal gland that makes the tears dries up. This often happens as you get older, or if you are on certain drugs, or occasionally you may have inflamation of the lacrimal gland.

Sometimes even if the eyes are dry they may feel as though they 'water'; this is due to poorly spreading tears. The eyes then become sore and this makes them water.

Similarly, if your tears do not spread properly, they may feel watery. There are fewer tears at night, so your eye may be sore and a little sticky in the morning. Having a slightly dry eye does not damage your eye in anyway, but only makes them feel uncomfortable. See animation.

 

Poorly spreading tears

As you get older your tears may stop spreading properly, and this causes the same problems as 'dry eyes'. If you have poorly spreading tears the tears do not spread evenly over the eyes' surface, and your eyes feels sore and irritable, as though there is something in them. This is the same feeling as if they were dry. Tears may stop spreading properly if you have blepharitis or are on medication, adding to natural aging problems. See animation

dry eyes, side viewdry eyes, front view

Side view                                Front view

Dry eyes or poorly spreading tears

 

'Causes' of sore dry eyes

Dry eyes

This is a common condtion, and there is not usuually an inderlying cuase inless the eyes are extremely dry. The lacrimal gland dries up.

 

Medical problems

Medical condtions such as thyroid problems and polycystic ovary syndrome may contribute.

There may be an auto-immune component (Arch 11). (This is important: many auto-immune diseases are 400% worse in smokers, so this may be the case in smokers. )  Some patients have Sjogrens disease. AJO 2006   Eye 2008  Acta 2003   K 2005 Patients may be depressed BJO 2013

 

Smoking

This contributes to dry eyes. All dry eye patients should stop smoking right away; smoking contriubutes to all autoimmune diseases.

 

Medications

Many drugs make your eyes dry, or at least feel dry. These include losec, zoton, frusemide, diuretics, anti-hypertensives, and anti-depressants. These drugs do not harm your eye in any way, but if you are using these drugs and have sore eyes at least you will know why! Proton pump inhibitors often contribute and their dose can be reduced.

Most people using lots of medications will have irritable eyes.

 

Allergies & viruses

Some people develop dry eyes after an attack or allergic or infective conjuctivitis. Indeed, if you had one of these conditions and were given lots of drops, the drops themselves may cause (temporarily) dry eyes. This gets better, but it may take several months. (Survey of Ophth Supp 2001).

 

Eye drops...the drug itself

Eye drops may make matters worse. sometimes this is a toxic effect of the drug, such as Maxitrol. Avoid 'Maxitrol' drops after cataract surgery if you have dry eyes or conjunctival disease. It can cause very severe corneal problems (Midland Ophth Meeting, 2005).

 

Eye drops...the preservative

Sometimes the soreness is a toxic effect of the preservative..too much preservative can make some eyes sore.

 

Computer use

This reduces blinking AJO13.

 

 

Blepharitis

blocked glands in blepharitis

Blocked glands (above) cause poorly spreading tears as below

poorly spreading tears in blepharitis, side view

In this condition there is a problem with the eyelids ..... the glands in the eyelids block and become slightly inflamed. These tiny glands normally make chemicals that help the tears to spread evenly across the surface of the eye.

But when the glands block they do not produce these chemicals, and so the tears do not spread evenly. This makes the eyes sore. It is usually not at all serious, and various treatments may help. It is explained in more detail on the Blepharitis page.

See animation.

 

What makes dry eyes more uncomfortable?

Staring at a computer screen can make eyes feel sore, tired, and gritty: imageenvision.com

Your eyes may feel more sore in the wind, or any dry hot atmosphere. Contact lenses, or anything that reduces blinking may make 'dry eyes' more uncomfortable, such as watching TV or a computer screen, or sewing. 

If you have sore eyes using a computer screen you should take regular breaks whilst using the computer...eg 5 minutes away from the screen every 30 minutes, with a longer rest every 2 hours and a longer lunch break.

With regular breaks your eyes should be less dry and more comfortable. Everyone is allowed a break of about 5 minutes every 30 minutes if their job involves using a computer all the time. This is a legal requirement in the UK.

 

A healthy diet & not smoking

It may seem strange but a healthy diet helps prevent dry eyes and blepharitis.

  • treatment for high blood pressure appears to make the eyes feel dry. A high blood pressure is harmful, and the effect of the drugs (the irritable dry eye) is not harmful, so it is safer to use the drugs. But if you could lower your blood pressure by increasing exercise, reducing alcohol and salt, this would be preferable.
  • omega 3 fats such as those in fish reduce 'dry eyes' by 30-60%. This healthy diet is discussed here. A Mediterranean is likely to help. Antioxidants improve symptoms (vegetables, fruit, etc).
  • peptic ulcers and hiatus hernias may necessitate proton-pump inhibitor treatment, and these probably make the eyes feel more irritable (my observation)
  • similarly smoking puts blood pressure up and increases peptic ulcers and hiatus hernias...and the drugs treating these seem to make eyes dry and sore
  • a healthy lifestyle is discussed in more detail here
  • smoking may make the condition worse ...it certainly affects the tear film

 

Tests for dry eyes

schirmers tear test (Uic.edu)

The main test is the 'schirmers tear' test. A filter paper strip measures the amount of tears made in 5 minutes. The test time can be reduced to 1 minute, see.

Your doctor may examine your eyes with a slit lamp (an eye microscope) to see the tear film. There are probably 3 tear layers. Next, a drop of 'fluorescein', a yellow dye, may be droped onto your eye, and this shows how well the tears spread (this is very difficult to photograph). The dye is attracted to dry patches on the surface of the cornea, so it shows them up.

 

 

A treatment plan for 'dry eyes' or poorly spreading tears

 

slightly dry .....drops in bottles or gels (healthy diet, not smoking, etc, as above)
moderately dry ......gels (Gel tears, viscotears, liquivisc, or any of the drops below..these are 'carbpmer' gels)
severely dry

Old..not used so much now

the best...
hyaluronidase drops

  • Hyloforte
  • Hylocare
  • Vismed ampoules & gel
  • Clinitas Soothe
  • Hyabak
  • & many others
  • for arthritis sufferers (when bottles are hard to use) Celluvisc or Vismed preservative free ampoules

In addition

extremely dry .....Expert help

Notes

  • This page tells you how to use eye drops.
  • This page for eye ointments.
  • It is often better to try these treatments in stages, starting with drops in bottles or gels.
  • If your eyes are really dry you will need to experiment to see which treament helps you.
  • For severely dry eyes, gels, celluvisc or vismed drops, and ointments will need to be used in combination.
  • If your eyes are very dry, avoid drops with preservatives at the beginning of treatment. (Preservatives can cause problems in people with very dry eyes.) For example, a typical patient with Sjogrens disease and very dry eyes may need punctal occlusion, occasional gel tears, possibly 1-2 hourly celluvisc or vismed, and possibly ointments at night to keep comfortable.
  • Anyone with sore eyes should ideally not use more tham 4 eye drops containing preservative a day in an eye. Anyone needing more drops should use preservative free drops.
  • Steroid drops may be helpful, but these must be supervised by ophthalmologists, especially if used long-term. Inflammation plays a role in dry eyes, and steroid drops can help to make the eyes more comfortable more quickly. If the condition is severe or if the steroids drops are needed for a prolonged period (which is not ideal as they may cause very severe glaucoma), preservative free drops are ideal.

 

The treatment itself

tear drop preparations-in bottles

sno tear drops

systane drops

These are simple salt solutions with added ingredients which help them spread across the eye. They make the eye more comfortable by lubricating the surface, but the effect does not last all that long. There are many types: different drops may suit different eyes, so try different types. They are not very effective over night, and the eyes may be uncomfortable when you wake up. They are generally best used four times a day or less. If your eyes remain sore, try drops without preservative as below. Examples include 'Liquifilm', 'Tears naturale', 'Hypromellose', and 'Sno-tears'. Systane is very helpful for people with moderately dry eyes. Systane bottles last 6 months, with polyquod as preservative.

There are also Systane preservative free vials.

 

 

Eye gel preparations

gel tears/viscotears

There are two types: 'Gel tears' and 'Viscotears'.  They last longer than drops, do not cause misty vision, and can be used at bedtime as they last partly through the night. There are carbomer tears, and there are many cheap tyes available Liquivisc is another gel drop in a bottle.

 

 

Eye ointments

simple eye ointment & lacrilube ointment

These products are much thicker and greasier than eye drops. They stay in the eye much longer; try using them last thing at night. During the day they may cause misty vision. Examples include 'Simple' eye ointment, and 'Lacrilube'.

Very dry eyes ....tear drop preparations without preservatives

minims artificial tears

Artificial tear minims Old..not used so much now

 

 

 

 

These are artificial tear 'Minims'. They are particularly useful for people with very dry eyes. Because they have no preservative they can be used more often, even every half-hour, without damaging your eyes. 'Minims' tears are in ampoules (mini-bottles) which contain about 14 drops, and may last a day with practice. You are often advised to use the ampoule once and throw it away, but this is probably unnecessary.

The ampoule can be safely used again on the same day until the drops run out. It is probably unwise to use the ampoule a second day after it has been opened as it may get contaminated with bacteria. These are less popular than the new drops with hyaluronic acid such as Hyloforte and Clinitas Soothe etc as below

 

Refresh / Celluvisc Eye Drops

celluvisc preservative free eye drops

 

 

 

 

There are several types of these, but the polyvinyl alcohol preservative free drops can be very helpful for people with very dry eyes. The can be used frequently, and there are several drops in each ampoule. You only need one drop each time. Sometimes they more effective than minims above.

The container is easier to use than 'minims' for people with arthritis of their fingers. The top can be replaced. Try and use each ampoule a few times (but it be thrown away if it is open more than 24 hours).

Refresh is the 'contact lens' version (but the same product as Celluvisc 0.5%). Dry eyes may be more comfortable with Celluvisc 1%....try them to see which is best. Optive is a new version of celluvisc in a bottle that lasts 6 months once opened. It is becoming very popular.

 

Our favourites: sodium hyaluronate ....very popular

Our favourites: sodium hyaluronate ....very popular
Others

Drops containing hyaluronate seem to be the most effective. Many doctors are now recommending these for people with very dry eyes or very poor tear spread. If your eyes are very dry, these should be well worth a try for a 4 week period. Again, you may need a drop every hour or two. There are several types of these, and these two are preservative free: Vismed and Aquify. Your GP may prescribe these. Remember, these are only needed for patients with severely dry eyes. They are expensive.

 

 

 

 

 

 

 

Vismed

Vismed is in single dose units Vismed 0.18% Ampoules and are extremely effective. These ampoules can be resealed and used during the day. These are the best lubricants available. A fresh ampoule should be opened the next day.

There is also Vismed Gel which lasts even longer than the drops.

There are a number of similar drops below. Some people will find a specific drop the most helpful, after trying different drops in turn. Other people find most of the drops helpful.

 

Hylofort and Hylocare

hyloforte: preservative free eyedrops

Hyloforte. This are proving very popular for our patients..currently the most popular (Vismed is probably just as comfortable).

Hylocare is very effective if the eye gets very dry.

 

 

 

Clinitas Soothe

Available on prescription, well worth a try. The ampoules can be resealed ..the opened ampoule will be safe for one day's use. There are enough tears for one day in one ampoule for average use. Clinitas.

 

Cyclosporine

This is a drug, not a lubricant...all the other products on this page are harmless lubricants.. Restasis and here (topical cyclosporine) may be effective...we await more results. Cyclosporine drops are available now from the NHS and can be very helpful. However Restasis is used in the US but is not available on he NHS and is very expensive. The Moorfields product is stronger than Restasis, and is not as well tolerated (it can make the eyes feel sore).

 

Using contact lenses if you have dry eyes

These are not ideal in dry eye patients. However, if you take precautions, that is remove your lenses immediately if your eye becomes red, try and use preservative free tear drops whilst your contact lenses are in place, they can often be worn safely for short periods. They should not be used if your eyes are very dry. Generally you should discuss this with your optometrist or ophthalmologist...and not wear them if your eyes are very dry or you are having lots of problems.

For instance, a patient with slightly dry eyes and blepharitis should be able to safely wear such lenses in the evenings for special occasions.

 

Plugs

canalicular plug for dry eyesPlug shown in red

In addition to the treatment above (including frequent preservative-free drops and gel tears), the tear drainage ducts can be blocked with temporary plugs see.

This saves the tears draining away, and makes the eyes a little more comfortable. If the plugs work, permanent plugs can be inserted.

Ask your ophthalmologist.

 

 

 

Extremely severe dry eyes

This is a more serious condition, and an ophthalmologist should give you specific advice. The eye is prone to develop ulcers and infections. Punctal occlusion is essential, but scarring may cause this naturally. Some patients with severe filamentary keratitis need plugs and special contact lenses, see.   

Eyes which are very dry indeed such as those with pemphigoid may need drops prepared form the patients own serum. These must be given after the advice of an ophthalmologist expert in this area. See. Autologous serum eye drops can now be prepared for individual patients by the NHS Blood Transfusion Service. Each person has to make their own donation. This should be considered in patients with severe ocular pemphigoid or alkali burns etc. Contact jean.harrison at nbs.nhs.uk.  for autologous serum for extremely dry eyes

 

Sjogrens Syndrome

Contact
British Sjogrens Syndrome Association
BSSA PO Box 10867
Birmingham B16 0ZW
tel: 0121 455 6532 kate@bssa.uk.net

Very dry eyes, especially if the mouth is dry as well, may be part of 'Sjogrens' syndrome: a dry mouth can lead to tooth decay. Sjogrens patients may also have joint problems.

If your GP, specialist, or dentist, suggest you may have either Sjogrens disease or syndrome, the British Sjogrens Syndrome Association can advise. This is a self-help organisation for people with Sjogrens Syndrome. It aims to spread information about the disease and how to alleviate it's symptoms. Its quarterly newsletter provides a regular updating of information on current research and a forum for the exchange of views on how best to cope with the problems of living with Sjogren's syndrome.

Pilocarpine tablets (and other newer medications) can be used to treat very dry eyes in Sjogrens patients.

Sjogrens is diagnosed blood tests (positive anti-ro and anti-la antibodies), mouth mucous membrane biopsy, and expert dentists and rheumatologists. In Birmingham, this is at the Dental Hospital. BMJ 2012

 

Summary of dry eye treatment

To make your eyes comfortable you need to replenish the natural tear film that protects the surface of your eyes. There is no magic 'cure'. Different types of products are available, and nearly all are harmless: they do not contain any drugs, merely 'oiling' the surface of the eye. If you have very dry eyes, you need drops without preservatives, and may need plugs.

Try the different products out. Your doctor can prescribe the products, and they can also be bought at pharmacies without a prescription.

 

Leaflet download

leaflet for dry eye patients

If you are a health professional and want to have a leaflet to give to give to patients, instead of this web page, see 200k Adobe PDF.

Alternatively, here is a Microsoft Publisher document click here,

 

 

Text book online etc

 

For professionals