Q: My eyes are always bothering me! Why are my eyes so dry and what can I do about it?
A: Dry eye. It sounds innocuous, even trivial, but dry eye is much more than just a nuisance. If ignored or mismanaged it can lead to damage of the ocular surface, vision loss, and the inability to wear contact lenses ever again. So what exactly is dry eye? Dry eye is a condition in which there are not enough “quality” tears to lubricate and nourish the eye. There are many different reasons why dry eye can occur. Hormonal fluctuations during the different phases of a woman’s reproductive life (pregnancy, breastfeeding, and menopause) can cause debilitating dry eye, and consequently, I see a disproportionate amount of women with dry eye in my practice. Many medications can also cause dry eye. This time of year many of us take oral antihistamines such as claritin and zyrtec for seasonal allergies, and although they are very effective in drying out our nasal passages they also dry out our eyes. Other causes of dry eye are autoimmune diseases such as Sjogrens Disease (whose major feature is dry eye and dry mouth) as well as Lupus and Rheumatoid Arthritis. Environmental factors also play a big part – dry eye is worse during the winter because of the low humidity and it is further exacerbated by the dry hot air being pumped out by the artificial heating systems. Frequent use of digital devices also contributes to dry eye because staring at a screen for hours on end decreases the blink rate, leading to dryness.
How do we treat dry eye? The first step is to use a quality, over-the-counter artificial tear 3-4 times a day. Not all products are created equal – I like the Systane brand family of drops made by Alcon and Blink tears by Abbott. If drops are needed more than four times a day, it’s time to switch to a preservative free brand, because sometimes, the preservatives themselves can cause irritation. Once someone is using drops that often, though, it’s really time to be more aggressive. The addition of an overnight ointment is very helpful, and in some cases, we consider putting plugs into the tear ducts to limit the tears that drain out of the eyes. Prescription drops, such as Restasis (Allergan) and Xiidra (put out by Shire and pronounced like ‘hydra’), help reduce inflammation in the eye, which is one of the causes of dryness. These drops can take months to take effect, which can be very frustrating. If lid inflammation is a contributing factor, we add a lid hygiene regimen, which includes using a moist heat eye compress, followed by a special lid cleanser. Omega 3 fatty acid supplements have been recommended for dry eyes for years, but last month, the DREAM study debunked their effectiveness, so the actual benefits are unclear. In many cases, borderline dry eye will go unnoticed by many patients until it is diagnosed during an eye exam. I encourage even asymptomatic patients to treat their dry eye with daily drop usage to ensure optimal ocular health.
Contact lens users frequently experience dry and irritated eyes. Contact lenses are very selfish and needy pieces of plastic. They steal about half of your tear film while on the eye, in order to stay moist. This can turn a borderline dry eye patient, or even someone without dry eye, into a very unhappy and uncomfortable patient. There are two types of dry eye in contact lens wearers. One is temporary dry eye, which occurs when patients wear their contacts for too many hours a day, don’t change their lenses frequently enough, or don’t clean their lenses properly. Temporary dry eye can become permanent dry eye if these bad habits continue. Chronic dry eye in contact lens users is due to underlying dry eye disease, as discussed above. I fit almost every new contact lens wearer in my practice into a daily disposable contact lens. Fresh clean lenses every day, combined with the newest hydrating high oxygen lens materials, have dramatically decreased the amount of contact lens dryness and complications in my practice. Some of my favorite brands are J&J’s Acuvue Oasys 1-day with HydraLuxe, as well as Cooper’s Clariti 1 day, or its cousin MyDay. I encourage dry eye patients using frequent replacement lenses to switch to dailies and/or cut down on wearing time. Contact lens solutions themselves can cause dryness and irritation, so a one-use lens is ideal. A lot of my patients are concerned about cost – the average cost of a pair of quality dailies is about $1.64 a day- way less than your daily Starbucks fix.
Anecdotally, dry eye and contact lens intolerance is something I see more in my frum female patients because we tend to have more children spaced closer together and spend a good portion of our twenties and thirties pregnant or lactating. My nursing moms seem to be hit the hardest, and my theory is that the combination of hormones, along with being partially dehydrated from nursing, create a dry and inhospitable tear film. Put a contact lens on that unhappy eyeball and you have an unhappy patient. I have also seen more problems in patients that have been wearing contacts over twelve hours a day, seven days a week for many years. The cornea (front surface of the eye) literally becomes exhausted, and sometimes it takes months of an enforced contact lens vacation and aggressive treatment to get the eye back to normal. Even after treatment, some women can never go back into full-time contact lens use, even after switching to dailies and using eye drops religiously. Perimenopause and menopause cause estrogen levels to plummet, which is also a trigger for dry eye. Women who have been lucky enough to successfully wear contacts up until this point are suddenly unable to tolerate their lenses. Sometimes, successful contact lens wear has to be redefined as being able to wears contacts on a part-time basis only.
Another trigger for dry eye is eye makeup. I don’t care what the makeup artists say, never ever put eyeliner on the waterline (the inner rim where the eyelid meets the eye). There are tiny glands inside that rim that secrete oil, and eyeliner on those glands clogs them up and blocks oil secretion, which is a crucial component of tears. Incomplete tears = dry eye. Makeup with glittery particles in it can fall into the tear film and irritate the eyes or even cause a corneal abrasion. Makeup has to be removed nightly so it doesn’t irritate the delicate skin around the eyes, or seep into the eye, and again, clog those little oil glands. Sleeping in eye makeup on Friday night or Yom Tov is an unavoidable fact, and I recommend waterproof liner and mascara, as well as eyelid primer, so your eyeshadow clings to your lids. Using artificial tears during the day ensures that any makeup that sneaks in gets washed away. If you are a contact lens wearer, put your contacts in first and then apply your makeup. At the end of the day, take out the contacts, clean them thoroughly (if they are not dailies), and then remove your makeup.
Dry eye affects roughly 25 million Americans. Like any other chronic disease, it needs to be dealt with on a daily basis and may require lifestyle changes that are upsetting and annoying. Treatment plans are not one size fits all and should be tailored according to the etiology of the dry eye. New therapies are constantly evolving, as awareness of dry eye as a chronic condition grows. Contact lens technologies are also improving and allowing many chronic dry eye patients to at least wear contacts on a part time basis. Although dry eye may not be curable, it can be managed successfully, allowing patients to experience clear and comfortable vision.
