Dry Eye

Overview

Dry Eye disease is very common amongst any age of patient. However, there are certain ‘at risk’ groups. The tear film is made of three layers, a thick mucin layer at the bottom coats the surface of the eye, on top of this sits the aqueous part of the tear film which is produced by the lacrimal gland and on top of this sits a lipid layer, which stops evaporation, produced by the meibomian glands on the eyelids. 

Dry eye can develop due to a problem in any layer of the tear film or reduced function of the eyelids. Chemical burns, previous Stevens Johnson syndrome or other scarring disease can lead to mucin deficiency. The classic cause of reduced aqueous production is autoimmune disease (Sjogren’s; Rheumatoid arthritis; thyroid problems etc.) However, there are numerous other causes such as postmenopause, drug induced, corneal anaesthesia, irradiation and more. The lipid layer is classically deficient in blepharitis. Poor blink function can be due to lid malposition, lid laxity, surface abnormality (eg pingeculae, pterygium, reduced sensation (such as from previous herpes)) contact lens wear or reduced blink frequency in visually demanding tasks (driving, reading, watching TV). 

Often however, there is often no single identifying cause in every patient, and it is multifactorial. 

Symptoms are variable and include:

• Dry eye feeling
• Reflex watering
• Burning sensation
• Blurred or fluctuating vision (often improves with blinking)
• Redness
• Itching
• Discharge/mucus
• Eye Strain
• Symptoms are usually worse during visually demanding tasks (driving, reading, watching TV)

Who to refer

Outpatient referral can be made for patients with ongoing symptoms despite treatment.

Occasionally dry eye can be particularly severe and cause sight-threatening disease. These patients should be referred to the BEH Emergency Department. See Red Flags section.

Red Flags

Please consider referral to the Bristol Eye Hospital’s Emergency Department if any of the following: 

• Significant Light Sensitivity (As this indicates corneal involvement)
• Reduced Vision
• Increasing Pain
• Suspected infection

Before referral

Please also see Prescribing Guidelines for Dry Eye in the Formulary section of Remedy.

Treatment is multifactorial, 

Conservative Treatments

Environmental causes of dry eye can have a big effect on patient’s dry eye symptoms. Avoiding excessive heating or air conditioning (especially in the car), if the patient wears contact lenses consider a ‘contact lens holiday’ for several weeks may give their eyes a chance to recover. The strategic use of lubricants during visually demanding tasks such as VDU use, reading and driving can make a big difference. 

Contributing factors

With all patients suggest they undertake four to six weeks of good blepharitis hygiene (see Blepharitis Section). This will help eliminate blepharitis as a contributing cause and optimise the tear film.

Consider switching any existing eye drops to preservative-free preparations.

Review the patient’s medications for any drugs which can contribute to dry eye which may be easy to switch to alternatives (such as diuretics, beta-blockers, antimuscarinics, antihistamines, nasal decongestants). The impact of this is often small.

There is some evidence that supplementation of omega-3 may help symptoms, however this is not routinely offered to patients. 

Tear Substitutes

Mild                 g. Hypromellose (preserved) 3-4 times a day

Moderate        g. Hypromellose 0.3% eye drops, Carbomer 980 0.2% gel or Carmellose 0.5% (both unpreserved) up to two-hourly.

Please see December 2023 NPSA alert regarding the potential contamination of some carbomer – containing lubricating eye products with Burkholderia cenocepacia. As a precautionary measure, while further testing is conducted, avoid use of all carbomer-containing lubricating eye products for patients in the following groups:

• individuals with cystic fibrosis
• patients being cared for in critical care settings (e.g., adult, paediatric and neonatal ICU)
• severely immunocompromised
• patients awaiting lung transplantation.

Severe             hyaluronate drops up to hourly (brands include VIZhyal) 

Consider a thick ointment at night, especially when there is thought to be some lid laxity or incomplete closure of eyelids. Thick ointments can be occ VitA-Pos or occ Xailin night.

Referral

If referral is required please submit to Ophthalmology via eRS requesting Cornea clinic.

Resources

These guidelines have been written by Rhys Harrison, consultant ophthalmologist at Bristol Eye Hospital, with thanks to the patients who have kindly given consent to use their photos.

For full ophthalmology guidelines see: Primary Care Ophthalmology Guidance Document

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.