Xerophthalmia - Dry eyes
Main causes
| Category | Main causes | Mechanism |
|---|---|---|
| Primary or secondary Sjögren's syndrome | Primary Sjögren + Secondary Sjögren (lupus + RA + scleroderma + polymyositis) + anti-SSA (Ro) + anti-SSB (La) antibodies | Lymphocytic infiltration of the lacrimal and salivary glands → progressive destruction → dry eyes (xerophthalmia) + mouth (xerostomia) → keratoconjunctivitis sicca |
| Meibomian gland dysfunction (MGD - most common) | Rosacea + seborrheic dermatitis + chronic blepharitis + contact lens wear + aging + andropause + menopause | Obstruction of the Meibomian glands → deficit in the lipid layer of the tear film → increased evaporation → film instability + inflammation |
| Medicines | H1 antihistamines + tricyclic antidepressants + antipsychotics + diuretics + systemic beta-blockers + isotretinoin + oral contraceptives + chemotherapy + beta-blocker eye drops | Anticholinergic effect → reduction in lacrimal secretion + or direct effects on the lacrimal glands |
| Eye surgery (LASIK + cataract) | Section of sensory corneal nerves during surgery → reduced lacrimal reflex + neurotrophic dysfunction | Frequent post-LASIK dry eyes (30-60 % of patients) + usually transient (3-12 months) + sometimes chronic |
| Environmental and behavioral | Prolonged exposure to screens (reduced blinking) + air conditioning + heating + dry air + wearing contact lenses + exposure to wind + smoke | Increased evaporation of tear film + reduction in palpebral blinking (from 15/min to 5/min in front of a screen) |
| Vitamin A deficiency | Undernutrition (developing countries) + lipid malabsorption + bariatric surgery | Retinol deficiency → squamous metaplasia of the conjunctiva → loss of caliciform cells → mucin deficiency → Bitot spots + keratomalacia if severe |
| Ocular inflammatory diseases | Scarring conjunctivitis (mucous membrane pemphigoid + Stevens-Johnson syndrome + trachoma) + chemical burns | Destruction of accessory lacrimal glands + caliciform cells + conjunctival scars |
Diagnosis
- Symptoms (OSDI - Ocular Surface Disease Index) : burning + tingling + sensation of sand or foreign body + photophobia + paradoxical lacrimation (compensatory reflex) + fluctuating blurred vision (improves after blinking) + aggravation by reading + screens + wind + smoke + heating
- Schirmer test: blotting paper strip placed in the lower conjunctival cul-de-sac × 5 minutes → measures the quantity of tears produced → 10 mm = normal → useful for quantifying the deficient aqueous component
- Break-Up Time (BUT) : instillation of fluorescein + slit-lamp observation → time to appearance of first dry area on cornea → 10 sec = normal → measures tear film instability
- Staining with fluorescein and rose Bengal : visualization of altered corneal and conjunctival epithelium → superficial punctate keratitis → scoring of epithelial lesion severity
- Sjögren's test if hyposecretion is severe: anti-SSA (Ro) + anti-SSB (La) + ANA + FR + CBC + VS + CRP + biopsy of accessory salivary glands (lower lip) if diagnosis uncertain
Treatment - steps according to severity
- General measures : reduced screen time + 20-20-20 rule (every 20 min of screen time → look at 20 feet for 20 sec) + humidifier + wind protection + stop smoking + protective glasses + reduce aggravating medication if possible
- Preservative-free artificial tears (1st line) : sodium carmelose (sodium carboxymethylcellulose) + hyaluronic acid + polyethylene glycol → instillation 4-8×/d depending on symptoms → prefer preservative-free formulations (benzalkonium chloride aggravates inflammation and film instability) + lubricating gel at night (Lacri-Lube® + Refresh PM®) if nocturnal symptoms
- Treatment of meibomian dysfunction: warm compresses × 5-10 min + palpebral massage morning and evening → liquefaction of meibomian secretions + improvement of lipid layer + eyelid cleansing (Blephagel® pre-moistened wipes + or diluted baby shampoo solution)
- Topical cyclosporine (Restasis® 0.05 % + Cequa® 0.09 %) : topical immunomodulator → reduces ocular surface inflammation + increases tear secretion → 1 drop × 2/d + 3-6 months before maximum effect + indication: moderate to severe dryness insufficiently controlled by artificial tears alone
- Lifitégrast (Xiidra® 5 %) : LFA-1 integrin antagonist → blocks T lymphocyte-epithelial cell interaction → reduces inflammation → 1 drop × 2/d + Health Canada approval + effect as early as 2-4 weeks + alternative or combination to cyclosporine
- Punctal plugs : occlusion of the upper and/or lower lacrimal points → retention of tears in the cul-de-sac → for severe hyposecretory forms refractory to topical treatments
- Autologous serum : eye drops prepared from the patient's own serum (centrifuged + diluted 20 % + refrigerated) → contains growth factors + vitamins + IgA → for severe refractory forms + neurotrophic keratitis + Stevens-Johnson syndrome
Consult an ophthalmologist if dry eyes are accompanied by decreased vision + intense photophobia + eye pain + or visible corneal lesions - these signs may indicate severe keratitis requiring urgent treatment. Consult a physician for a Sjögren's work-up if dry eyes are accompanied by severe dry mouth + joint pain + or other systemic signs. For prescription of adapted artificial tears + topical cyclosporine and referral to ophthalmology, Clinique Omicron offers medical consultations at its points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's specialized physicians and nurse practitioners (IPS) assess dry eyes (OSDI symptoms + Schirmer test if indicated), look for treatable causes (aggravating medications + vitamin A deficiency + Sjögren's), recommend preservative-free artificial tears adapted to the type of dryness, prescribe topical cyclosporine (Restasis®) or lifitégrast (Xiidra®) for moderate to severe forms, prescribe immunological testing if Sjögren's is suspected, and refer to ophthalmology for severe keratitis + tear plugs + autologous serum. Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The contents of this page are provided for information purposes only and do not replace the advice of an ophthalmologist. Eye drops containing benzalkonium chloride as a preservative may aggravate dry eyes over the long term - prefer preservative-free formulations (single-dose) for frequent use. Cyclosporine and lifitégrast take several weeks to months to produce their full effect - do not stop them prematurely.
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