Dry eyes is a common medical problem, and is due to a shortage of tears. It occurs as people get older, in diabetes, kidney failure, and as a side effect of drugs.
The eyes may feel scratchy or gritty, as though there is something
in them ('foreign body sensation'). They also be a little itchy, and they may be red. They may
feel as though they are burning, with crusting. If your eyes feel tired, sore or gritty or sandy, you may have either 'dry eyes', or 'blepharitis',
The 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 constantly, such as reading or using a computer, when the blink rate reduces OS 19. The blepharitis causes sore eyes by preventing
tears spreading evenly.
Where are tears
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
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. See animation.
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. This is sometimes termed evapourative dry eye (and is treated similarly to blepharitis).
Similarly, if your tears do not spread
properly, they may feel watery.
There are fewer tears at night, so your eye may be sore and a little sticky
in the morning.
Having a slightly dry eye does not damage your eye in anyway, but only makes
them feel uncomfortable. See animation. Pain from dry eye Eye 15.
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
Side view Front view
Dry eyes or poorly spreading
tears: this is a type of 'superficial punctate keratitis'
'Causes' of sore dry eyes
This is a common condition, and there is not usually an underlying cause unless the eyes are extremely dry. The lacrimal gland dries up.
Poor tear spreading: blepharitis etc
see blepharitis below and elsewhere on this page
There may be an auto-immune component (Arch 11). (This is important: many auto-immune diseases are 400% worse in smokers, so this may be the case in smokers.) Some patients have Sjogrens disease, others have depression BJO 2013 .
Contributory factors BJO 14 :
age, asthma, eczema, the presence of any allergy, cataract surgery, rheumatoid arthritis, osteoarthritis, migraine and stroke. The highest effect sizes were found with depression, pelvic pain, irritable bowel syndrome and chronic widespread pain syndrome.
- Medical conditions such as thyroid problems and polycystic
ovary syndrome may contribute.
- Vitamin a deficiency
- Ocular surface disease index questionnaire complete with patient see
- look at blink rate, lid margin staining, lagophthalmos, tear break up time, floppy lids, sleep apnoea,
- If there are folds of conjunctiva, take a strip off surgically.
- Shirmers no anaesthetic.
- To treat at night consider cling film or shield
- Symblepharon..? pemphigoid
- Mucous fishing syndrome: use lubricants, steroids and no 'fishing'.
- No baby shampoo..just use or blepharaclean wipes, or plain water, hot bathing
- Vitamin D deficiency General health BJO 14
This contributes to dry eyes. All dry eye patients should stop smoking right away; smoking contributes to all autoimmune diseases.
Many drugs make your eyes dry, or at least feel dry. These include proton pump inhibitors such as
losec & zoton, diuretics (eg. frusemide), anti-hypertensives, and anti-depressants. These drugs do not harm your eye in any way, but if you are using
these drugs and have sore eyes at least you will know why! Often the proton pump inhibitors dose can be reduced.
Most people using lots of medications will have irritable eyes.
Allergies & viruses
Some people develop dry eyes after an attack or allergic or infective
conjunctivitis. Indeed, if you had one of these conditions and were
given lots of drops, the drops themselves may cause (temporarily)
dry eyes. This gets better, but it may take several months.
(Survey of Ophth Supp 2001).
Eye drops...the drug itself
Eye drops may make matters worse. sometimes this is a toxic effect of the drug, such as Maxitrol. Use preservative free drops after cataract surgery if you have dry eyes
or conjunctival disease.
Eye drops...the preservative
Sometimes the soreness is a toxic effect of the preservative..too much preservative can make some eyes sore. Glaucoma drops also cause sore eyes, especially the thoese with preservative.
This reduces blinking AJO13.
This commonly contriubutes or causes dyr eyes. See Blepharitis page.
Laser and refractive surgery
These procedures damage the nerves in the cornea, and dry eyes may develop even 20 years later. OS17
Conjunctivochalasis: a fold on conjuctiva (grey) prevents tears spreading (green) making the eyes water and irritable
Redundant inferior conjunctiva. see . Surgery helps. This makes the eyes sore by peventing tear spreading.
Other causes of dry or sore or watery eyes include
- Map dot fingerprint dystrophy
- recurrent erosion syndrome
- lagophthalmos and incomplete lid closure
- sore after lasik...usually to nerve damage
- neuropathic pain, that is dysfunctional nerves...chronic and central sensitisation
- Patients with eye pain often have pain elswhere. OS 19
Blocked glands (above) cause poorly spreading tears
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. Blepharitis treatment NHS
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,
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 BJO 15.
breaks your eyes should be less dry and more comfortable. Everyone is allowed a break of
about 5 minutes every
if their job involves using a computer all the time.
This is a legal
requirement in the UK.
Score your dry eye..the Ocular Surface Disease Index here
diet & not smoking
It may seem strange but a healthy diet helps prevent dry eyes
- treatment for high blood pressure appears to make the eyes
feel dry. A high blood pressure is harmful, and the effect of
the drugs (the irritable dry eye) is not harmful, so it is safer
to use the drugs. But if you could lower your blood pressure
by increasing exercise, reducing alcohol and salt, this would
3 fats such as those in fish reduce 'dry eyes' by 30-60%.
This healthy diet is discussed here.
A Mediterranean is
likely to help. Antioxidants improve
symptoms (vegetables, fruit, etc). Vitamin D supplements ECL16
- peptic ulcers and hiatus hernias may necessitate proton-pump
inhibitor treatment, and these probably make the eyes feel more
irritable (my observation)
- similarly smoking puts blood pressure up and increases peptic
ulcers and hiatus hernias...and the drugs treating these seem
to make eyes dry and sore
- a healthy lifestyle is discussed in more detail here
- smoking may
make the condition worse ...it certainly affects the tear film
- live yoghurt preparations may help CT17
BMJ 18 Minimally processed food is prefered (vegetables, fruit, nuts, seeds, beans, vegetables, whole grains, plant oils, live yoghurt): avoid ultraprocessed foods rich in refined starch and sugars, and industrial additives such as trans-fats and salt.
Tests for dry
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.
plan for 'dry eyes' or poorly spreading tears
.....drops in bottles or gels
Viscotears or Xailin Gel 3-4 times a day used 2016.
healthy diet wtih vitamin D, plenty of fish and vegetables, and not smoking
(Gel tears, Viscotears, liquivisc, or any of the drops below) , Xailin Gel 3-4 times a day, VitA-Pos or Xailin Night, either at night
warm compresses with eye bag for 5 minutes/warm compress, and if effective reduce and use as required
- Spectacles increase humidity.
- Carmellose /Celluvisc /Refresh drops
- Hyloforte, Thaloz Duo, Hylocare, Hyabak, Xailin HA, VISUXL
- Vismed ampoules & gel
- Clinitas Multi..bottle or clinitas soothe;
Clinitas (sodium hyaluronate 0.4% preservative-free)
extremely dry .....expert
- a short course of preservative free steroid drops such as prednisolone minims four times a day
- Cyclosporine once day, such as Ikervis once daily Nice 16
- Serum drops for the most severe problems
page tells you how to use eye drops.
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 treatment 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 1/2-2 hourly drops containing hyaluronic acid as above, such Vismed, and possibly ointments at night to keep comfortable, such as VitA-Pos or Xailin Night,
- Anyone with sore eyes should ideally not use more than 4 eye drops
containing preservative a day in an eye. Anyone needing more drops
should use preservative free drops.
- If this does not work, an ophthalmologist should advise.
- 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, and such patients may benefit from Cyclosporine
- Next, Cyclosporine once day, such as Ikervis once daily
The treatment itself: 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.
Different drops may suit different eyes,
so try different types. They are not very effective overnight,
and the eyes may be uncomfortable when you wake up. Hyloforte, Thaloz Duo, Hylocare, Hyabak, Xailin HA, VISUXL. They can be used as often or as little as needed, but every 1-2 hour for the average patient with severe dry eye.
Eye gel preparations
There are several types such as
'Viscotear' , Xaiin Gel & 'Blephagel'; They
last longer than drops, do not cause misty vision, and can be used
at bedtime as they last partly through the night.
These products are much thicker and greasier than eye drops. They
stay in the eye much longer; try using them last thing at night.
During the day they may cause misty vision. VitA-Pos is now our preferred night-time ointment (some prefer Xailin Night, at night)
Very dry eyes
....tear drop preparations without preservatives
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. Most of these contain hyaluronic acid such as Hyloforte , Xailin HA, or Clinitas Soothe etc. Use 1/2- 4 hourly, more often if sore, less often if comfortable.
Our favourites: sodium hyaluronate ....very popular
|Our favourites: sodium hyaluronate ....very popular
Drops containing hyaluronate seem to be the most effective.
Many doctors are now recommending
these for people with very dry eyes or very poor tear spread.
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.
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.
Clinitas 0.4% eye drops 0.5ml unit dose
Available on prescription, well worth a try. The ampoules
can be resealed ..the opened ampoule will be safe for one day's use.
There are enough tears for one day in one ampoule for average use.
This is a drug, not a lubricant...all the other products on this page are harmless
lubricants. This drug us considered safe without the risks of long term steroid drops.
- Cyclosporine one drop at night 'Ikervis': Nice guidance 2016
- a short course of preservative free steroid drops such as prednisolone minims four times a day may b e best to use first, and if there is some benefit, then long term Ikervis may help. Ikervis irritates the eye at first, and it takes time to get used to.
Tiny filaments accumulate on the cornea, and stain green with fluorescein.
- acetylcysteine, perf ere ably preservative free; Ilube contains acetylcysteine but has preservative
- acetylcysteine in my experience can make the eye more sore, but is recommend by experts
- lots of lubricants, preservative free, such as Hyloforte hourly or Vismed
- ?low dose steroid drops preservative free if eye very red ?prednisolone minims
- punctal plugs
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
For instance, a patient with slightly dry eyes and blepharitis
should be able to safely wear such lenses in the evenings for special
Plug shown in red
In addition to the treatment above (including frequent preservative-free
drops and gel tears), the tear drainage ducts can be blocked with
temporary plugs see.
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.
Extremely severe dry eyes
see (serum drops)
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.
This is a self-help organisation for people with Sjogrens Syndrome.
It aims to spread information about the disease and how to alleviate
it's symptoms. Its quarterly newsletter provides a regular updating
of information on current research and a forum for the exchange of
views on how best to cope with the problems of living with Sjogren's
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.
After laser for refractive surgery
Needs lots of lubricants and steroid drops. An SPK-like keratitis develops.
Graft versus host disease dry eye
Summary of dry eye
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'.
Different types of products are available, and nearly all are harmless:
they do not contain any drugs, merely 'oiling' the surface of the
eye. If you have very dry eyes, you need drops without preservatives,
and may need plugs.
Try the different products out. Your doctor can prescribe the products,
and they can also be bought at pharmacies without a prescription.
book online etc