Dry eye syndrome is one of the most common conditions seen in ophthalmology clinics — and one of the most frequently dismissed. Patients are often told to 'just use drops', when in fact there is a wide spectrum of underlying causes and a range of targeted treatments that go well beyond over-the-counter lubricants.
What is dry eye syndrome?
The tear film that coats the surface of the eye is a three-layer structure: an outer oily layer produced by the meibomian glands in the eyelids, a middle watery layer from the lacrimal glands, and an inner mucin layer from goblet cells in the conjunctiva. Dry eye occurs when any part of this system fails — either producing too few tears (aqueous deficiency) or tears that evaporate too quickly (evaporative dry eye).
Evaporative dry eye, caused by meibomian gland dysfunction (MGD), accounts for the majority of cases — roughly 85%. The meibomian glands become blocked, the oily layer thins, and tears evaporate faster than they should.
Symptoms
- Grittiness or a foreign body sensation — 'something in the eye'
- Burning or stinging, especially later in the day or after screen use
- Fluctuating or blurred vision that temporarily clears with blinking
- Reflex watering — the eye compensates for dryness by producing excess watery tears
- Red, irritated eyes, particularly in wind, air conditioning or smoke
- Discomfort with contact lens wear
- Difficulty with driving at night due to glare and halos
Risk factors
- Age — tear production and meibomian gland function decline naturally with age
- Female sex — hormonal changes (menopause in particular) affect tear composition
- Screen use — blinking rate drops significantly when using a computer or phone
- Contact lens wear
- Certain medications — antihistamines, antidepressants, diuretics, HRT
- Previous eye surgery — including LASIK refractive surgery or cataract surgery
- Autoimmune conditions — Sjögren's syndrome, rheumatoid arthritis, lupus
- Rosacea and blepharitis (lid margin inflammation)
Treatment: a stepwise approach
Treatment is tailored to the underlying cause and severity.
- Step 1 — Lid hygiene: warm compresses applied to the eyelids for 10 minutes twice daily soften meibomian gland secretions. Follow with gentle lid massage. This is the cornerstone of MGD treatment.
- Step 2 — Lubricating eye drops: preservative-free artificial tears used 4–6 times daily. Gel formulations for more severe symptoms. Hyaluronic acid-based drops are well tolerated.
- Step 3 — Omega-3 supplementation: evidence supports daily omega-3 fatty acids (fish oil or flaxseed) for MGD. Typically 3–6 months before benefit is noted.
- Step 4 — Topical anti-inflammatory therapy: cyclosporine A eye drops (Ikervis) or short-course steroid drops for inflammatory dry eye.
- Step 5 — Punctal plugs: tiny silicone plugs inserted into the tear drainage openings to keep tears on the eye surface longer. A quick, painless in-clinic procedure.
- Step 6 — In-clinic treatments: thermal pulsation (e.g. LipiFlow), intense pulsed light (IPL) therapy, or blephex (mechanical lid cleaning) for resistant MGD.
Frequently Asked Questions
Can dry eye syndrome be cured?
For most patients, dry eye is a chronic condition that is managed rather than cured. However, with the right combination of lid hygiene, lubricants, dietary changes and in some cases in-clinic treatments, symptoms can be very well controlled and quality of life significantly improved.
Why do my eyes water if I have dry eye?
Paradoxically, dry eye commonly causes watery eyes. When the basal tear film is inadequate, the eye triggers reflex tearing from the lacrimal gland. These reflex tears are watery and not as effective as normal tears, so the underlying dryness persists. The key is restoring a stable baseline tear film, not suppressing the watering.
Are preservative-free drops worth paying more for?
Yes, for frequent users. If you use drops more than 4 times a day, preservative-free formulations are strongly recommended. Preservatives such as benzalkonium chloride (BAK) are toxic to the corneal surface epithelium with repeated use and can worsen dry eye over time. Unit-dose preservative-free drops cost a little more but are significantly better for the ocular surface.
Mr Mohamed Mohyudin
MBChB BSc MSc FRCOphth CCT — Consultant Ophthalmic Surgeon, Spire Elland Hospital, Yorkshire. GMC 7039600.
View full credentials →