Foreign body sensation, burning, dryness, mildly to moderately decreased or fluctuating vision, and tearing. Often exacerbated by smoke, wind, heat, low humidity, or prolonged use of the eye (e.g., when watching television or working on a computer that results in decreased blink rate). Usually bilateral and chronic (although patients sometimes are seen with sudden onset in one eye). Discomfort is often out of proportion to clinical signs.

Critical

• Scanty or irregular tear meniscus seen at the inferior eyelid margin: The normal meniscus should be at least 0.5 mm in height and have a convex shape.

• Decreased tear break-up time (measured from a blink to the appearance of a tear film defect, by using fluorescein stain): Less than 10 seconds indicates tear film instability.

NOTE Tear film defects must be randomly located, as isolated areas of repeated early tear break-up may indicate a focal corneal surface irregularity.

Other

Punctate corneal or conjunctival fluorescein, rose bengal, or lissamine green staining; usually inferiorly or in the interpalpebral area. Excess mucus or debris in the tear film and filaments on the cornea may be found in severe cases. 

See 4.1, Superficial Punctate Keratopathy.

• Idiopathic: Commonly found in menopausal and postmenopausal women.

  • Evaporative: Lipid layer tear deficiency; often associated with blepharitis or meibomian gland dysfunction. Symptoms may be worse in the morning with complaints of visual blurring upon waking.

  • Aqueous deficient: Aqueous layer tear deficiency; aqueous production decreases with age. Symptoms frequently worsen later in the day or after extensive use of the eyes.

  • Combination: Evaporative and aqueous deficiency often occur together. May also include a mucin layer tear deficiency.

• Lifestyle related: Arid climate, allergen exposure, smoking, extended periods of reading/computer work/television viewing.

• Connective tissue diseases (e.g., Sjögren syndrome, rheumatoid arthritis, granulomatosis with polyangiitis [GPA, formerly Wegener granulomatosis], systemic lupus erythematosus).

• Conjunctival scarring (e.g., mucous membrane pemphigoid, Stevens–Johnson syndrome, trachoma, chemical burn).

• Drugs (e.g., oral contraceptives, anticholinergics, antihistamines, antiarrhythmics, antipsychotics, antispasmodics, tricyclic antidepressants, beta blockers, diuretics, retinoids, selective serotonin reuptake inhibitors, chemotherapy).

• Infiltration of the lacrimal glands (e.g., sarcoidosis, tumor).

• Postradiation fibrosis of the lacrimal glands.

• Vitamin A deficiency: Usually from malnutrition, intestinal malabsorption, or bariatric surgery. See 13.7, Vitamin A Deficiency/Xerophthalmia.

• After cataract surgery or corneal refractive surgery such as limbal relaxing incisions, photorefractive keratectomy (PRK), laser in situ keratomileusis (LASIK), and small incision lenticule extraction (SMILE): Likely secondary to disruption of corneal nerves and interference with normal reflex tearing. The size and location of the incision or flap may be correlated to the degree of the patient’s symptoms.

1. History and external examination to detect underlying etiology.

2. Slit-lamp examination with fluorescein stain to evaluate the ocular surface and tear break-up time. May also use rose bengal or lissamine green stain to examine the cornea and conjunctiva. Tear meniscus is best evaluated prior to the instillation of eye drops.

3. Tear secretion testing: Technique: After drying the eyes of excess tears, Schirmer filter paper is placed at the junction of the middle and lateral one-third of the lower eyelid in each eye for 5 minutes. Eyes are to remain open with normal blinking.

   • Unanesthetized: Measures basal and reflex tearing. Normal is wetting of at least 15 mm in 5 minutes.

   • Anesthetized: Measures basal tearing only. Topical anesthetic (e.g., proparacaine) is applied before drying the eye and placing the filter paper. Abnormal is wetting of 5 mm or less in 5 minutes. Less than 10 mm may be considered borderline. We prefer the less irritating anesthetized method.

4. Other potentially helpful in-office tests include measurement of tear osmolarity and level of matrix metalloproteinase-9 (MMP-9); elevation of these factors suggests dryness and inadequate tear film. Tear lactoferrin can also be measured; low levels suggest aqueous deficient dry eye disease.

5. Consider screening for Sjögren syndrome especially if associated with dry mouth and systemic autoimmune-related symptoms.

Mild Dry Eye

Artificial tears q.i.d., preferably preservative-free.

Moderate Dry Eye

1. Increase the frequency of artificial tear application up to q1–2h; use only preservative-free artificial tears.

2. Add a lubricating gel or ointment q.h.s.

3. Lifestyle modification (e.g., humidifiers and smoking cessation).

4. Cyclosporine 0.05% to 0.1% drops b.i.d. are effective for patients with chronic dry eye and decreased tears secondary to ocular  inflammation. Cyclosporine often burns with application for the first several weeks and takes 1 to 3 months for significant clinical improvement. To hasten improvement and lessen side effects, consider treating patients concomitantly with a mild topical steroid drop (e.g., loteprednol 0.5%, fluorometholone 0.1%, or fluorometholone acetate 0.1%) b.i.d. to q.i.d. for 1 month while beginning cyclosporine therapy.

5. Lifitegrast 5% drops b.i.d. are effective for the signs and symptoms of dry eye disease. Lifitegrast may burn on instillation, may cause blurred vision for several minutes, and may leave a metallic taste in the throat. Symptomatic improvement is often noted within 2 weeks of starting lifitegrast but can take up to 3 months.

6. Perfluorohexyloctane 100% drops q.i.d. have been shown to improve the signs and symptoms of dry eye by 2 weeks with continued improvement at week 8. Patients may experience mild blurring of vision while using perfluorohexyloctane.

7. Varenicline nasal spray 0.03 mg b.i.d. can improve the signs and symptoms of dry eye syndrome. The spray should be directed at the anterior aspect of the nose; it often causes sneezing.

8. If these measures are inadequate or impractical, consider punctal occlusion. Use collagen inserts (temporary) or silicone or acrylic plugs (reversible). Crosslinked hyaluronic acid gel can be used to occlude the punctum for up to 6 months. Ideally, any inflammatory component, including blepharitis, is treated prior to punctal occlusion.

Severe Dry Eye

1. Perfluorohexyloctane, cyclosporine, lifitegrast, and varenicline as described earlier.

2. Punctal occlusion, as described earlier (both lower and upper puncta if necessary), and preservative-free artificial tears up to q1–2h. Consider permanent occlusion by thermal cautery if plugs continually fall out.

3. Increase lubricating gel or ointment to b.i.d. to q.i.d. p.r.n.

4. Moisture chamber (plastic film sealed at orbital rim) or air protection glasses/goggles with lubrication at night.

5. If mucus strands or filaments are present, remove with forceps and consider 10% acetylcysteine q.i.d.

6. Other therapies may include oral flaxseed oil, oral omega-3 fatty acids, autologous serum tears, topical vitamin A, bandage soft contact lens, or a scleral lens.

7. Strongly consider scleral lenses for severe dry eye.

8. Consider a small permanent lateral tarsorrhaphy if all the previous measures fail. A temporary adhesive tape tarsorrhaphy (taping of the lateral one-third of the eyelid closed) can also be used, pending a surgical tarsorrhaphy.

NOTE In addition to treating the dry eye, treatment for contributing disorders (e.g., blepharitis, exposure keratopathy) should be instituted if these conditions are present. Always use preservative-free artificial tears if dosing is more frequent than q.i.d. to prevent preservative toxicity. If the history suggests the presence of a connective tissue disease (e.g., history of joint pain or swelling, dry mouth), consider blood testing for these conditions and/or referral to an internist or rheumatologist for further evaluation.

Several days to months, depending on the severity of symptoms and degree of dryness. Anyone with severe dry eyes caused by an underlying chronic systemic disease (e.g., rheumatoid arthritis, Sjögren syndrome, sarcoidosis, ocular pemphigoid) may need to be monitored more closely.

NOTE Patients with significant dry eye should be discouraged from contact lens wear and corneal refractive surgery such as PRK, LASIK, and SMILE. However, daily-disposable soft contact lenses can be successful if fit loosely and combined with aggressive preservative-free lubrication and plugs, if needed.

Patients with Sjögren syndrome have an increased incidence of lymphoma and mucous membrane problems and may require internal medicine, rheumatologic, dental, and gynecologic follow-up.