Sore or dry eyes David Kinshuck |
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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. They also be a little itchy, and they may be red. They may feel as though they are burning, with crustng, as though there is something in them (foreign body sensation). Your 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. Blepharitis is described on a different page of this web site in more detail. It causes sore eyes by stopping tears spreading evenly. Sore eyes are much commoner in diabetes. |
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. |
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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. |
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Side view |
Front 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. |
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. |
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Side view |
Front view |
Dry eyes or poorly spreading tears |
'Causes': drugs, allergies, conjunctivitis, and dry eyes |
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Blepharitis |
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. |
Blocked glands (above) cause poorly spreading tears as below |
What makes dry eyes more uncomfortable? |
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 |
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A healthy diet & not smoking |
It may seem strange but a healthy diet helps prevent dry eyes and blepharitis.
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Tests for dry eyes |
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. |
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A treatment plan for 'dry eyes' or poorly spreading tears |
A treatment plan for dry eyes: start according to how dry your eyes are |
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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. |
Tear drop preparations-in bottles |
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. 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. |
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Eye gel preparations |
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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 |
These products are much thicker and greasier than eye drops. They
stay in the eye much longer; try using them last thing at night. |
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Very dry eyes ....tear drop preparations without preservatives |
Old..not used so much now | |
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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 |
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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
Others |
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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. 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. |
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. 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. |
Cyclosporine |
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. |
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. Our order or preference in terms of safety, April 2005, is
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 |
In addition to the treatment above (including frequent preservative-free
drops and gel tears), the tear drainage ducts can be blocked with
temporary plugs 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.
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Plug shown in red |
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.
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. |
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Sjogrens Syndrome |
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. 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 tel: 0121 455 6532
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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'. Try the different products out. Your doctor can prescribe the products, and they can also be bought at pharmacies without a prescription. |
Leaflet download |
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, |
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Text book online etc |
For professionals
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The address of this site ('org' changing to 'nhs') is changing from http://www.goodhope.org.uk/departments/eyedept/ to http://www.goodhope.nhs.uk/departments/eyedept/ |
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