Dry Eye

What is Dry Eye?

A dry eye is a chronic and progressive condition that occurs when there are not enough quality tears available to properly moisturize the front of the eye. The dry eye ranges from mild to severe and symptoms can occur either occasionally or continuously.

When we blink, our tears spread across the front surface of our eye and excess tears drain into our nose through small ducts in the corners of our eyelids called puncta. Our tears are responsible for maintaining good ocular surface health, providing clear and stable vision, and reducing the risk of eye infection and irritation by washing away foreign particles like dust.

Our tears are much more complex than you may realize. They are composed of three distinct layers that work together to help anchor tears to the surface of the eye, prevent evaporation, and increase lubrication:

  1. Lipid Layer: The outermost layer is oil-based which helps to prevent the evaporation of our tears. This layer is produced by meibomian glands within our eyelids.

  2. Aqueous Layer: The middle layer is water based which helps lubricate the front of the eye and wash away unwanted particles to help prevent infection. This layer is produced by the lacrimal gland, located above the outside corners of our eyes.

  3. Mucin Layer: The innermost layer is mucin based which helps the tears anchor to the surface of the eye and helps the aqueous layer spread evenly across the eye to keep it moisturized. This layer is produced by special cells found in the conjunctiva (the white part of the eye).

Dry eye occurs when tear production and drainage are not properly balanced. This can be either because we do not have enough tears or because the tears we do have are of poor quality.

There are many reasons why we may not make enough tears. Tear production can diminish with age or as a result of certain medical conditions or medications. Exposure to windy and dry conditions may also reduce tear production.

Poor-quality tears result from one of the three tear layers being out of balance. Each of these layers serves a critical purpose, and a problem with any one of these can create tear film instability. This results in either the tears not spreading evenly across the eye (which creates dry spots), or the tears evaporating too quickly to properly moisturize the eye.

The two main types of dry eye are evaporative (not enough oil) and aqueous deficiency (not enough water). The most common type is evaporative, in which the meibomian glands of the lids are not producing enough oil, which causes the tears to evaporate too quickly.

Aqueous deficient dry eye results when the lacrimal gland doesn’t produce enough of the water layer of our tears. This type is much rarer and can be found in patients who have Sjogren’s syndrome. Occasionally, patients may also have a mix of both types of dry eye.

Who is at risk for Dry Eye?

Over 16 million Americans have been clinically diagnosed with dry eye, but the actual number of dry eye sufferers is likely much higher. Certain factors increase your risk of dry eye syndrome, some of which you might find surprising:

Age: Risk increases with age, especially for those over the age of 50.

Gender: Women are more likely to develop dry eye due to hormonal changes related to pregnancy and menopause, as well as the use of oral contraceptives.

Medical conditions: Sjogren’s, rheumatoid arthritis, diabetes, thyroid disorders, lupus, rosacea, and the use of a C-PAP machine can all cause dry eye symptoms.

Medications: Antihistamines, antidepressants, birth control pills, blood pressure medications, and decongestants are all known to have dryness as a side effect.

Environmental conditions: Living or working in dusty, windy, or dry climates, or exposure to smoke, air conditioning, heating, car vents, or hair dryers can all worsen symptoms of dry eye.

Lifestyle conditions: Insufficient blinking (such as during extensive reading or device use), long-term contact lens wear (especially if the history of overwear), or a history of eye surgery such as LASIK or cataract surgery can all reduce tear production and worsen symptoms of dry eye.

What are the symptoms of dry eye?

You might be surprised to learn that one of the most common first symptoms of dry eye is excessive tearing. As a protective response, your eyes will try to self-soothe their dryness by overproducing tears. Although these tears provide temporary relief, they are ineffective at treating dryness long term because they are not made of the correct composition of lipid, aqueous, and mucin.

Additional symptoms that you may experience are:

  • Burning

  • Redness

  • Itching

  • Sandy/gritty feeling

  • Light sensitivity

  • Eyes that feel fatigued, sore, or heavy

  • Feeling as if you have something in your eye

  • Fluctuating vision that improves with blinking or eye rubbing

  • Difficulty wearing contact lenses comfortably

  • A stinging pain that only lasts for a moment and causes tearing

If you are experiencing any of these symptoms, please contact us to schedule an appointment! Our doctors can make the best treatment recommendations based on your exam findings.

What are the dangers of Dry Eye?

Many people consider dry eye symptoms to simply be a nuisance that is alleviated by using an artificial tear drop. While this may be true for some mild cases, most cases of dry eye are chronic and progressive and require consistent treatment to prevent long-term effects.

The dry eye that goes untreated can progress into chronic inflammation of the eye, corneal abrasions, and even ulcers. All of these can result in pain, sensitivity to light, inability to work or drive, and even long-term vision impairment.

Our goal at Handel Vision Clinic is to help stop the progression of dry eye before it becomes severe or damaging. At the first sign of dryness, our doctors can recommend proper treatment to help prevent long-term issues related to dry eye.

How do you treat Dry Eye?

Similar to glaucoma, dry eye has no cure so the goal of treatment is to slow the disease progression in order to maintain long-term eye health. In the case of dry eye, our goal is also to minimize your symptoms by restoring or maintaining the quantity and quality of your tears by using one or more of the following techniques:

Adding tears: Most mild cases of dry eye can be effectively managed with over-the-counter artificial tear drops or ointments to supplement natural tears. Our doctors can make recommendations as to which brand of tears to use* and how frequently to use them based on your current type and level of dryness. In more severe cases, using artificial tears may not be adequate enough to prevent symptoms.

*Note: There are a wide variety of artificial tears on the market that vary in viscosity, preservatives, and compatibility with contact lens wear. Our doctors will recommend which type is best for you but urge avoiding any type of “redness relief” drops other than Lumify. All other brands are likely to cause rebound redness over time, as well as other adverse effects.

Conserving tears: In order to keep natural tears in the eyes longer, we can block off the tear ducts (the puncta) in order to slow their drainage. This can be accomplished in-office by using tiny collagen or silicone plugs, called punctal plugs. We begin with temporary plugs made of collagen that will dissolve within a few weeks. If this treatment is successful we can then insert silicone plugs which are designed to last for years but can be removed if necessary. We can also refer to an ophthalmologist to have the puncta permanently closed through surgery, if necessary.

Increasing tear production: Prescription eye drops are available to help increase the production of tears. There are a few different types available such as Restasis, Xiidra, or Cequa. Our doctors can help determine if one of these medications is right for you.

Treat existing inflammation: Inflammation of the eyelids or ocular surface is a primary cause of dry eye development. It might be necessary to use prescription drops or ointments, eyelid cleaners, warm compresses, lid scrubs, or nutritional supplements to decrease this inflammation in order to properly treat your symptoms.

Self-care strategies: Depending on the severity of your condition, some of these self-care strategies may also help to minimize or eliminate your symptoms.

  • Direct car vents and fans away from your face

  • Add a humidifier to your bedroom or office

  • Remember to blink regularly when reading, watching TV, or using computers, phones, and other devices

  • Consider adding fish oil (omega-3 fatty acids) and flaxseed oil into your diet through natural sources or supplements

  • Wear good sunglasses to protect your eyes from the sun and wind

  • Use an air filter to remove irritants from the air

  • Clean your lids and lashes using lid cleansers or baby shampoo and warm water each morning and night

  • Frequently use warm compresses or lid-warming eye masks

  • Talk with our doctors if wearing contact lenses worsens your dryness symptoms, as a change in material or solution may help

In-office treatments: We are proud to offer a few in-office tests and procedures to help reduce or eliminate the symptoms of dry eye and prevent progression. After completing your dry eye evaluation, our doctors will be able to use your findings in order to recommend the best course of treatment for you.

Common Dry Eye Misconceptions

Our doctors treat multiple patients with dry eyes every day. Many dry eye sufferers tend to have similar comments, complaints, and confusion about their symptoms and treatment strategies. We have compiled a list of some of the most common statements that we hear from our dry eye patients to help unravel some of the misconceptions about this condition!

  • “I tried using drops before but it never seemed to help so I stopped using them.”

    • Dry eye is a chronic and progressive condition that requires consistent treatment. Many times, people only use artificial tear drops as needed when their eyes feel dry. To properly treat dry eye, these drops should be used multiple times a day to help prevent the symptoms from occurring. If you are already using drops multiple times per day without relief you may need a more aggressive form of treatment.

  • “My eyes are only dry when I wear contacts.”

    • The material of contacts can worsen dry eye symptoms, as can the type of solution used, overwearing your lenses as prescribed or sleeping in lenses. If your eyes bother you while wearing your contacts, be sure to talk to our doctors!

  • “My eyes water a lot but it’s just allergies.”

    • There is certainly an overlap of symptoms between dry eye and allergies, and you may even have both simultaneously! Redness, watering, and itching are all classic findings of both conditions but many times we find that patients who believe their allergies are the cause of their symptoms actually have dry eyes! Our doctors can use a microscope to differentiate between the two and recommend proper treatment.

  • “I use Visine (or Clear Eyes) but my eyes are still always red.”

    • Redness relief drops may provide a temporary improvement but most formulations do not treat the underlying dryness and inflammation that is causing the redness to begin with. Additionally, you can develop a tolerance to these drops, causing a rebound effect in which redness worsens in the long run! It is important to properly treat the underlying cause to prevent the worsening of redness over time.

  • “I’ve never had issues with dryness before, so I don’t know why they’d be dry all of a sudden.”

    • Because dryness is a progressive disease, it is not abnormal to suddenly start having symptoms. Age, medications, environmental changes, and allergies are all examples of factors that can increase your symptoms.

  • “I don’t have an issue with dryness, my eyes are always watering!”

    • We hear this all the time! Watering is actually one of the first signs of dry eye syndrome. Your eyes will try to self-soothe dryness by overproducing tears, causing them to water. The more severe your dryness is, the more your eyes will water.

  • “Can’t I just use a rewetting drop when they feel dry?”

    • Only using a rewetting drop when your eyes feel dry is the same as only brushing your teeth when you have bad breath! It might provide some temporary relief, but it won’t work as well as doing it routinely. Plus, frequent treatment helps prevent further damage!

  • “Do I have to use these drops forever?”

    • Occasionally, mild dryness may only need temporary treatment. But in most cases, because dry eye syndrome is a chronic condition, consistent treatment is pivotal to preventing symptoms. If you are unable or unwilling to use eye drops, our doctors can recommend other forms of treatment.

  • “My eyes only feel dry (or only water) at the end of the day when I sit down to watch TV.“

    • Dryness tends to increase throughout the day which makes you more likely to have symptoms in the evening. Plus, when you do things like watch TV, play on your phone, use a computer, or read, you don’t blink as frequently. This worsens your dryness and your eyes will begin to self-soothe by tearing.

  • “I hate using eye drops, is there another way to treat this?”

    • Using over-the-counter artificial tears is a common initial treatment for dry eye, but there are other treatment options available including nutritional supplements, self-care strategies, or in-office procedures. (However, please note that it might be necessary to satisfy insurance requirements for other treatments with a short course of consistent artificial tear use.)

  • “My eyes get dry but it’s really not that bad. Do I really need this treatment?”

  • Please remember that dry eye is truly a symptom of a disease process in your eye. Avoiding treatment due to not having symptoms is a personal choice but not recommended by our doctors. We strive to provide our patients with a lifetime of healthy, comfortable eyes and clear vision, and preventing disease progression is our top priority!

In-Office Testing and Treatments for Dry Eye

Dry Eye Testing

Diagnosis of dry eye can be accomplished through either a comprehensive eye examination or a problem-focused medical visit. Information obtained through patient history and our dry eye questionnaire can help gauge the severity of your symptoms while a microscopic view of your eyes will be used to determine the clinical level of your condition.

Further testing will be performed at your initial dry eye evaluation and monitored at regular visits to ensure improvement of symptoms and ocular health. We begin by performing a tear film osmolarity reading with our TearLab instrument. This painless test helps to quantify the severity of your dry eye and can be used at future visits to monitor the results of your treatment.

Our doctors will evaluate your ocular health, lid structure, and blink dynamics by using a microscope. Specially dyed drops may be used to observe the quantity and quality of your tears and highlight changes made to the surface of the eye caused by poor tear flow or insufficient tears.

Based on the findings, a treatment plan will be created for you and may include the use of over-the-counter or prescription eye drops, lifestyle or contact lens changes, nutritional supplements, and at-home treatments or in-office procedures.

In-Office Dry Eye Treatments


The iLux is our most advanced piece of equipment for treating meibomian gland dysfunction (MGD) in the office. The meibomian glands lie within the eyelid and release the lipid layer of the tear film. This oil layer (also known as meibum) helps to prevent the tears from evaporating too quickly, resulting in dry eye symptoms.

In healthy eyes, meibum should easily flow out of the meibomian glands like water and onto the surface of the eye. In meibomian gland dysfunction, the glands become clogged with thickened meibum which must be forced out like toothpaste! If this oil is not properly removed, the glands may become infected (causing styes), inflamed (causing a chalazion), or permanently damaged (causing severe and irreversible dryness).

If MGD is left untreated, the meibomian glands can begin to atrophy. Once severe atrophy has taken place, they will no longer function. This results in chronic dry eye symptoms. Since there is currently no treatment available once they reach this stage, obtaining relief becomes very difficult.

Studies show that about 86% of dry eye sufferers have signs of MGD, and these signs can be present in patients who don’t even have symptoms of a dry eye yet! In order to keep the oil flowing freely and the meibomian glands healthy and functional, we need to melt the meibum and unclog the meibomian glands. At-home treatments such as warm compresses and lid scrubs can help, but not as efficiently as the iLux.

The iLux is a handheld instrument that uses thermal pulsations (localized, light-based, heated compressions) to clear any meibomian gland obstructions and melt the meibum so that it flows freely. This helps treat and prevent dry eye symptoms, but more importantly, it works to maintain the integrity of the meibomian glands to protect against future irreversible damage.

The iLux procedure takes about 8-12 minutes to perform and is performed on both upper and lower lids. Its effect usually lasts for over a year but may need to be repeated during the year depending on the severity of your MGD.

Punctal Plugs

In order to keep natural tears in the eyes longer, we can block off the tear ducts (the puncta) in order to slow their drainage. This can be accomplished in-office by using tiny collagen or silicone plugs, called punctal plugs.

If you are a candidate for this procedure, our doctors will begin by inserting temporary plugs made of collagen that will dissolve within a few weeks. If this treatment is successful, we can then insert silicone plugs which are designed to last for years, but can still be removed if necessary. We can also refer to an ophthalmologist to have the puncta permanently closed through surgery, if necessary.

Punctal plugs are easily inserted in-office using a numbing drop, tweezers (or pre-loaded applicator), and the slit lamp (microscope). Patients with severe ocular inflammation may not be a good candidate for this procedure and may require additional treatment prior to, or in place of, punctual plugs.


PROKERA is a biologic bandage contact lens used in patients with moderate to severe dry eye, or other types of corneal disorders. The lens features an amniotic membrane tissue that provides natural anti-inflammatory and anti-scarring properties to promote faster and more effective ocular surface healing than other treatments can provide.

The PROKERA lens is easily inserted in-office and left in place for 5 days. You will then return to the office to have the lens removed and inserted into the fellow eye for another 5 days. Ideally, this will prevent dry eye symptoms from occurring for the next 5-7 months, at which point another PROKERA insertion is recommended (subsequent treatment may require fewer days of wear).

Scleral Lenses

Another lens-based treatment available for dry eye (and other corneal conditions) is a scleral lens. These are custom-designed, rigid contact lenses with a large diameter that vaults over the cornea and rests on the white surface of the eye (the sclera). This creates a small pool of water between the lens surface and the cornea which works to provide moisture and symptom relief.

Prescription Medications

In addition to the above in-office treatments we offer, our doctors are also able to prescribe medications to help increase the production of tears and/or decrease existing inflammation that causes dryness. These medications are incredibly effective and have historically been the gold standard in quickly managing dry eye signs and symptoms.

Depending on the severity of your disease, you may only be prescribed a short-term medication such as Eysuvis, or you may require daily maintenance medications such as Restasis, Xiidra, or Cequa. It might also be necessary to use a combination of other prescription drops or ointments, oral medications, eyelid cleaners, or nutritional supplements to properly maintain your dry eye symptoms.

To find out which of these in-office treatments might work best for your dry eye, call our office to schedule an appointment today!