• Introduction
• Where are tears made?
• What are dry eyes?
• Poorly spreading tears
• What drugs aggravate dry eyes?
• What makes dry eyes more uncomfortable?
  eg using computers
  
  
• A healthy diet and exercise
• Tests for dry eyes
• Treatment plan
• Drops, gels
• creams,
• Very dry eyes & preservative free drops
• Celluvisc,  Refresh tears
• Our favoutietes :sodium hyaluronate drops, Vismed, Clinitas Soothe, Hylofrte and Hylocare
• Oxyal, Optive,
• Cyclosporine
  
  
• Contact lenses
• Plugs
• Extremely dry eyes
• Sjogrens Syndrome
• Comprehensive web site (for professionals)
• helpful book by Lauren
• For professionals
  

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.

See animation.

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.

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.

• 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.

• 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).

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

• 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).

  • sometimes it is a toxic effect of the preservative..too much preservative can make some eyes sore.

• There is 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. All dry eye patients should stop smoking right away.)  AJO 2006   Eye 2008  Acta 2003   K 2005

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.

Blocked glands (above) cause poorly spreading tears as below

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.

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

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.

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.

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.

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.

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'.

Artificial tear minims

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

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: sdium hyaluronate ....very popular

Our favourtes

• Vismed
• Hyloforte & Hylocare
• Clinitas Soothe,

Others

• Oxyal
• Optive
• Hyabak..preservative free in an easy to use bottle

Vismed

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.

These available in the UK through pharmacies, from the AAH wholesaler, anywhere in the UK, by request from the pharmacy. Your GP may prescribe these. Remember, these are only needed for patients with severely dry eyes. They are expensive.

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. 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

A new product 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.

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).

Cyclosporine is a drug...all the other products on this page are harmless lubricants.

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.

Our order or preference in terms of safety, April 2005, is

1. silicone hydrogel (first choice)
2. hydraclear
3. daily disposable

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

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 page.

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.

Plug shown in red

One patient with severe filamentary keratitis needed 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.

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.

British Sjogrens Syndrome Association

BSSA
PO Box 10867
Birmingham
B16 0ZW

tel: 0121 455 6532
E-Mail: [email protected]

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.

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,

• see
• helpful book by Lauren

• diagnosis Eye 2011
• NPY and other growth factors Archives 11
• look for other conditions such as ocular pemphigoid. Photos