Dry eye disease

A multifactorial ocular surface condition that occurs when tear film homeostasis is disturbed.

Alter tear-film homeostasis with altered composition, reduced production, and rapid evaporation, and ocular surface inflammation lead to discomfort and blurred vision in patients with dry eye disease.

It is characterized by abnormal tear film composition and ocular surface inflammation.

Patients with dry eye disease present with a sensation of a foreign body in their eye and blurred vision.

Precipitating factors include: poor eyelid function, environmental factors, inflammatory processes such as Sjogren syndrome and some ocular or systemic drugs such as antihistamines, retinoids, and selective serotonin reuptake inhibitors.

It is most prevalent in females and older adults.

It is associated with connective tissue disease, contact lens wearing, medication such as diuretics and anti-histamines, and hematopoietic stem cell transplant.

Patients with Sjogren’s syndrome, rheumatoid arthritis, chronic systemic graft versus host disease or at higher risk of moderate to severe dry eye disease.

Patient with a history of bariatric surgery or malnutrition may lead to vitamin a deficiency which can cause dry eye disease.

Bell palsy and other eyelid malposition disorders may result in incomplete lid closure, leading to inadequate distribution of the tear film over the ocular surface and cause excessive tear evaporation.

Medication classes associated with aqueous tear deficiency include diuretics, antihistamines, and anti-depressants.

Isoretinoin is a cause of Meibomian gland dysfunction which can be severe and lead to evaporated dry eye disease.

Prevalence is 5-50% globally and is one of the most frequent ocular conditions.

Negatively impacts the quality of life and functional capacity, such as reading ability.

Prevalence of DED is approximately 5%.

$3.8 billion per year is spent on managing this process.

When productivity loss, physician visits and other costs are considered patient expenditures on dry eye approximate $55.4 billion per year and $11,302 per patient per year, respectively.

Pathophysiology depends on tear film component production from the lacrimal, meibomian, and other accessory glands, goblet cells, the health anatomy of the ocular surface and eyelids, the presence of inflammatory mediators in the tear film, and hormonal shifts and abnormalities.

Categorized into two main groups: aqueous tear deficiency and evaporative dry eye disease.

Many patients have a combination of both types of disease.

Aqueous tear deficiency is due to reduce lachrymal secretion or inadequate tear volume.

Evaporative dry disease is more common and develops in the setting of normal lacrimal secretion, and involves excessive evaporation of the tear film, which may be a result of insufficient lipid layer of the tear film.

Tear film hyper osmolarity stimulates ocular surface inflammation and epithelial and goblet cell damage leading to increased tear film instability and hyperosmolality creating a recurrent cycle for dry eye disease.

Patients with metabolic syndrome and sedentary lifestyles have a higher rate of dry eye disease, thought to be due to oxidative stress and sympathetic nervous system dominance.

The presence of rosacea or atopic dermatologist can be associated with ocular surface inflammation and subsequent disruption of tear film homeostasis and evaporative DED.

Anxiety and depression are associated with dry eye disease.

Aerobic exercise increases tear secretion, and the incorporation of light exercise and diet with low glycemic index foods have an associated improvement in dry eye symptoms.

As a result of ocular surface inflammation, dry disease alters neurologic pathways responsible for blink rate, tearing, and corneal sensation which further contribute to the process.

Artificial tear preparations are available, and should be tried first.

Artificial tears contain some form of cellulose to lubricate the eye, may contain polyethylene glycol or polyvinyl alcohol to prevent evaporation, and may include a preservative.


Diagnosis is based on patient symptoms and objective findings.

Patient symptoms include: foreign body sensation, irritation, pain, blurred or fluctuating vision, and tearing.

It is typically bilateral but may be asymmetric.

Schirmer testing, using filter paper strips to quantify aqueous tear production,  but has low sensitivity of 40 to 50% and reproducibility.

Testing can be done to measure the level of matrix metalloproteinase 9 in the tear film:elevated level suggest the patient may benefit from topical anti-inflammatory medication such as cyclosportiness.

Paradoxical tearing is a response in some patients to ocular surface irritation, triggering a reflex tear production which provides temporary relief.

Lacrisert is a daily insert the gradually releases hydroxypropylcellulose after placement into the inferior conjunctival sac and is approved for moderate to severe dry eye syndromes.

Differential diagnosis: allergic conjunctivitis, toxic conjunctivitis secondary to medication or other agents, superior limbic keratoconjunctivitis: foreign bodies and infection should be excluded, as well.


The goal of treatment is the restoration of tear film homeostasis.

The goal of treatment is the restoration of tear film homeostasis.

Optimal treatment depends on specific causation common multiple treatment modalities may be necessary to disrupt the cycle of dry eye disease.

Lubrication with artificial tears and ointments on the first line management and can provide partial relief of symptoms.

Lubrication with artificial tears and ointments on the first line management and can provide partial relief of symptoms.

Most over the counter treatments should be used no more than 4 to 6 times a day because of the exposure of elevated amounts of preservatives in these agents that may result in similar symptoms to dry eye disease.

Preservative free artificial tears are less irritating and may be used more frequently.

Topical treatments include steroids, cyclosporine, or lifitegrast.

Topical steroids can cause secondary glaucoma, cataract formation, or both.

Oral doxycycline and topical oral azithromycin maybe effective in dry eye disease caused by meibomian gland dysfunction.

Patients with dry eye disease associated with   Sjogren syndrome or chronic ocular graft versus host disease may benefit from autologous tears or platelet rich plasma.

Scleral contact lenses are large diameter rigid lenses that can serve as a temporary reservoir for tears or ophthalmic medications, increasing their contact time with the cornea.

Topical cyclosporine (Restasis) mechanism probably involves immunomodulatory or anti-inflammatory effects.

Topical cyclosporine significantly improves Schirmer tear test results, but may take 4-6 weeks to achieve results.

Serum cyclosporine concentrations are undetectable or negligible.

Topical cyclosporine can cause transient burning and stinging in the treated eye, and the addition of topical corticosteroids in the first month may be helpful.

Lifegrast (Xidra) Ophthalmic solution is a lymphocyte function associated antigen-1 antagonist approved for treatment of dry eye disease: in It is thought to reduce ocular surface inflammation.

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