Dry Eyes: Symptoms, Causes & Treatment Guide

What Is Dry Eye Syndrome?

Dry eye syndrome (keratoconjunctivitis sicca) is a multifactorial disease of the ocular surface characterized by loss of tear film homeostasis. This leads to eye discomfort, visual disturbance, and potential damage to the ocular surface. The condition affects between 5-50% of people globally, with higher rates in women, older adults, and those who use digital screens extensively.

The tear film that covers your eyes is a complex, three-layered structure essential for eye health, comfort, and clear vision. It consists of an outer lipid (oil) layer produced by meibomian glands that prevents evaporation, a middle aqueous (water) layer produced by lacrimal glands that provides nutrients and washes away debris, and an inner mucin layer that helps tears spread evenly across the cornea. When any component of this delicate system is disrupted, dry eye syndrome develops.

The tear film performs several critical functions beyond simply keeping the eye moist. It provides oxygen and nutrients to the avascular cornea, acts as a protective barrier against pathogens and foreign particles, contributes significantly to the eye's refractive power, and contains antibodies and antimicrobial proteins that protect against infection. Understanding this complexity helps explain why dry eye symptoms can be so varied and why treatment often requires addressing multiple factors.

Research from the Tear Film and Ocular Surface Society (TFOS) DEWS II report has revolutionized our understanding of dry eye disease. The condition is now recognized as a chronic, progressive disorder that, if left untreated, can lead to corneal damage and vision impairment. This shift in understanding has led to more proactive treatment approaches focusing on breaking the vicious cycle of inflammation that perpetuates the condition.

Two Main Types of Dry Eye

Ophthalmologists classify dry eye into two primary categories based on the underlying mechanism, though many patients have features of both types, known as mixed dry eye. Understanding which type predominates helps guide treatment selection.

Aqueous Deficient Dry Eye (ADDE) accounts for approximately 10-15% of cases and results from insufficient tear production by the lacrimal glands. This can occur due to age-related gland atrophy, autoimmune conditions like Sjögren's syndrome, medications that reduce tear production, or damage to the lacrimal glands or nerves that stimulate them. Patients with aqueous deficient dry eye typically have very low Schirmer test scores and may benefit particularly from punctal plugs that help retain the limited tears they produce.

Evaporative Dry Eye (EDE) is far more common, representing up to 86% of dry eye cases. In this type, tears evaporate too quickly from the eye surface, usually due to meibomian gland dysfunction (MGD). The meibomian glands, located in the eyelids, produce the oil layer that prevents tear evaporation. When these glands become blocked or dysfunctional, tear stability decreases dramatically. Risk factors include prolonged screen use, contact lens wear, eyelid inflammation (blepharitis), and environmental factors like low humidity.

What Are the Symptoms of Dry Eyes?

Dry eye symptoms include stinging or burning sensations, gritty or sandy feeling in the eyes, eye fatigue, sensitivity to light, blurred vision that clears with blinking, excessive tearing (reflex tears), difficulty wearing contact lenses, and eye redness. Symptoms typically worsen throughout the day, in dry environments, and during prolonged visual tasks.

The symptoms of dry eye disease can vary significantly from person to person, both in type and severity. Some individuals experience constant discomfort, while others have symptoms that fluctuate based on environmental conditions, activities, or time of day. Understanding the full range of symptoms helps patients recognize the condition and seek appropriate treatment.

Eye irritation is the hallmark symptom and can manifest in several ways. Many patients describe a stinging, burning, or scratchy sensation, often likening it to having something foreign in their eye. This sensation results from the corneal surface becoming exposed when the tear film breaks down. The cornea has one of the highest concentrations of nerve endings in the body, making even minor surface irregularities quite uncomfortable.

A gritty or sandy feeling, medically termed foreign body sensation, is equally common. This occurs because without adequate lubrication, the eyelids create friction against the ocular surface with each blink. Over time, this friction can lead to small erosions on the corneal surface, exacerbating the discomfort and creating a cycle of inflammation.

• Stinging or burning: Sharp, uncomfortable sensation especially in dry or windy environments
• Gritty sensation: Feeling like sand or debris is stuck in your eyes
• Eye fatigue: Tired, heavy-feeling eyes, particularly after reading or screen use
• Blurred vision: Temporary blurring that improves with blinking
• Excessive tearing: Watery eyes as body attempts to compensate
• Light sensitivity: Discomfort or squinting in bright light
• Redness: Bloodshot appearance due to irritation
• Contact lens intolerance: Difficulty wearing lenses comfortably

Why Do Dry Eyes Cause Watery Eyes?

One of the most confusing symptoms for patients is excessive tearing, which seems counterintuitive for a condition called "dry eye." This phenomenon, known as reflex tearing, occurs because the body senses the eye surface is inadequately protected and triggers the lacrimal glands to produce a flood of tears. However, these reflex tears are primarily watery and lack the proper balance of lipids and mucins needed to effectively lubricate the eye. They wash over the eye surface and spill over onto the cheeks rather than providing lasting relief.

This explains why many patients report both dry, uncomfortable eyes and tears running down their face, sometimes at the same time. The key distinction is that reflex tears provide temporary flooding without addressing the underlying tear film instability. Effective treatment focuses on improving the quality and stability of the baseline tear film rather than simply adding more liquid.

When Symptoms Are Worst

Visual fatigue is particularly pronounced after prolonged activities requiring concentration, such as reading, computer work, or driving. During these tasks, our blink rate drops by 60-70%, reducing tear film replenishment. Additionally, the tear film typically becomes more unstable toward the end of the day as the meibomian glands produce less oil after repeated blinking throughout waking hours. This explains why many patients report symptoms worsening in the evening.

Environmental factors significantly impact symptom severity. Air conditioning, central heating, airplane cabins, and windy outdoor conditions all accelerate tear evaporation. Many patients notice symptoms worsen during winter months when indoor heating reduces humidity, or during summer when air conditioning creates similar dry conditions. Geographic location matters too, with dry climates and high-altitude areas associated with higher dry eye prevalence.

What Causes Dry Eyes?

Dry eyes are caused by decreased tear production, excessive tear evaporation, or poor tear quality. Common causes include aging, hormonal changes (especially menopause), prolonged screen use, dry environments, medications (antihistamines, antidepressants, blood pressure medications), contact lens wear, and underlying conditions like Sjögren's syndrome, diabetes, or thyroid disorders.

Understanding the causes of dry eye is essential for effective treatment, as addressing underlying factors often provides more lasting relief than simply treating symptoms. The causes can be broadly categorized into those affecting tear production, those affecting tear evaporation, and those affecting tear composition.

Age-Related Changes

Aging is the most significant risk factor for dry eye disease. Tear production decreases naturally with age, with studies showing a reduction of approximately 60% in tear volume between ages 18 and 65. The meibomian glands also undergo atrophy, producing less of the lipid layer that prevents evaporation. By age 65, approximately 75% of people experience some symptoms of dry eye. These changes occur gradually, which explains why many older adults consider dry eyes a normal part of aging rather than a treatable condition.

Hormonal Factors

Hormonal changes significantly impact tear production, which is why dry eye affects women more frequently than men, particularly after menopause. Estrogen and androgen receptors are present in the lacrimal and meibomian glands, and declining hormone levels reduce gland function. Women taking hormone replacement therapy may experience varying effects, with some studies showing improvement and others showing worsening of symptoms. Pregnancy, breastfeeding, and oral contraceptive use can also influence dry eye symptoms.

Environmental and Lifestyle Factors

Screen use has become one of the leading contributors to dry eye in modern society. When we concentrate on digital devices, our blink rate drops from the normal 15-20 blinks per minute to as few as 3-4 blinks per minute. This dramatic reduction allows the tear film to evaporate between blinks. Additionally, incomplete blinks—where the upper lid doesn't fully meet the lower lid—become more common during screen use. The phenomenon is so prevalent that "computer vision syndrome" or "digital eye strain" now affects an estimated 50-90% of computer workers.

Environmental conditions play a crucial role in tear film stability. Low humidity environments, whether from air conditioning, central heating, or geographic climate, accelerate tear evaporation. Wind exposure, common during outdoor activities or from fans and vents, similarly increases evaporation. High altitudes, airplane travel, and living in arid climates all increase dry eye risk. Even indoor factors like ceiling fan use or positioning near air vents can significantly impact symptoms.

Medications That Cause Dry Eyes

Medications are a frequently overlooked cause of dry eye symptoms. Many common drug classes reduce tear production as a side effect. Antihistamines, designed to reduce allergic responses, also reduce tear secretion. Antidepressants, particularly tricyclics and SSRIs, have anticholinergic effects that decrease tear production. Blood pressure medications including beta-blockers and diuretics can contribute to dry eyes. Other culprits include acne treatments like isotretinoin, hormone replacement therapy in some patients, and decongestants.

Medical Conditions

Sjögren's syndrome deserves special mention as a leading cause of severe aqueous deficient dry eye. This autoimmune condition attacks the moisture-producing glands throughout the body, causing dry eyes and dry mouth as primary symptoms. It can occur alone (primary Sjögren's) or alongside other autoimmune conditions like rheumatoid arthritis or lupus (secondary Sjögren's). Patients with severe or treatment-resistant dry eye should be evaluated for Sjögren's syndrome, as early diagnosis allows for systemic management.

Other medical conditions associated with dry eye include diabetes (which can affect nerve function and tear production), thyroid disorders (particularly Graves' disease, which can cause eye exposure), rheumatoid arthritis, lupus, and rosacea. Eyelid conditions like blepharitis (inflammation) and lagophthalmos (incomplete lid closure) also contribute significantly to dry eye by affecting tear distribution and evaporation.

How Can I Treat Dry Eyes at Home?

Home treatments for dry eyes include using preservative-free artificial tears 4-6 times daily, applying warm compresses for 10 minutes to improve oil gland function, taking regular breaks from screens using the 20-20-20 rule, using a humidifier, positioning screens below eye level, increasing water intake, and adding omega-3 fatty acids through diet or supplements.

Many mild to moderate cases of dry eye can be effectively managed with over-the-counter treatments and lifestyle modifications. These approaches address the fundamental causes of symptoms and can provide significant relief. Consistency is key—most of these interventions work best when incorporated into a daily routine rather than used only when symptoms are severe.

Artificial Tears

Artificial tears (lubricating eye drops) are the cornerstone of dry eye treatment and remain the first-line therapy recommended by ophthalmologists worldwide. They work by supplementing the natural tear film, providing immediate relief and protecting the ocular surface. For best results, use drops prophylactically to prevent symptoms rather than waiting until discomfort is severe.

Choosing the right artificial tears matters significantly. Preservative-free formulations are strongly recommended, especially for those who need to use drops more than four times daily. Preservatives, while extending shelf life, can irritate the eye surface and exacerbate dry eye symptoms with repeated use. Preservative-free drops come in single-use vials that should be discarded after each use to prevent contamination.

Different artificial tear formulations address different types of dry eye. Thinner, watery drops are comfortable and don't blur vision, making them suitable for mild symptoms and daytime use. Thicker gel drops and ointments provide longer-lasting relief but may temporarily blur vision, making them better suited for nighttime use or severe symptoms. Some newer formulations contain lipid components that specifically address evaporative dry eye by supplementing the oil layer.

Warm Compresses and Lid Hygiene

Warm compresses are particularly effective for evaporative dry eye caused by meibomian gland dysfunction. The warmth melts solidified oils in the meibomian glands, allowing them to flow more freely and improve the lipid layer of the tear film. For maximum benefit, apply a warm compress (around 40-45°C) for 10 minutes, followed by gentle massage of the eyelids to express the oil. Consistency is crucial—daily application produces better results than occasional use.

Commercial warming masks designed for eye care maintain heat longer and more evenly than homemade compresses. They can be microwaved or heated according to instructions and molded to fit the contours of the face. For those with significant meibomian gland dysfunction, in-office procedures like LipiFlow provide more intensive thermal pulsation treatment.

Lid hygiene complements warm compresses by removing debris, bacteria, and biofilm from the eyelid margins. This is especially important for patients with blepharitis. Use a gentle, purpose-designed lid cleanser or diluted baby shampoo applied with a clean cotton pad or lint-free cloth. Gently clean along the base of the lashes where debris accumulates. This should be done once or twice daily, preferably after warm compresses when oil glands have been loosened.

The 20-20-20 Rule for Screen Use

For those whose dry eye is related to digital device use, the 20-20-20 rule provides a simple, effective strategy: every 20 minutes, look at something 20 feet away for 20 seconds. This encourages complete blinks and gives the tear film a chance to recover. While seemingly simple, this practice requires conscious effort to implement, as we become absorbed in our work and forget to take breaks.

Additional screen-related modifications include positioning monitors slightly below eye level (which reduces the exposed ocular surface), increasing font sizes to reduce strain, adjusting screen brightness to match ambient lighting, and using matte screen filters to reduce glare. Some patients benefit from specialty computer glasses with blue light filtering or slight magnification.

Environmental Modifications

Humidity control significantly impacts dry eye symptoms. Using a humidifier, especially in bedrooms and home offices, can maintain humidity levels between 40-60%, which is optimal for tear film stability. Desktop humidifiers placed near the work area can help counteract the drying effects of computer use. In winter, whole-house humidifiers attached to heating systems may be worthwhile investments for dry eye sufferers.

Avoiding direct airflow is equally important. This means positioning away from fans, air conditioning vents, and heating ducts. Wearing wraparound glasses or moisture chamber glasses outdoors provides protection from wind. For drivers, directing car vents away from the face and keeping windows closed on dry or windy days helps maintain ocular surface hydration.

Dietary and Supplement Considerations

Omega-3 fatty acids have shown promise in managing dry eye symptoms, though research results are mixed. These essential fatty acids, found in fatty fish (salmon, sardines, mackerel), flaxseed, and walnuts, may help reduce inflammation and improve meibomian gland function. The large DREAM study found modest benefits from omega-3 supplementation compared to placebo, though individual responses vary. A typical recommended dose is 2-3 grams daily of combined EPA and DHA.

Adequate hydration supports overall tear production. While drinking more water won't cure dry eye, dehydration can worsen symptoms. Aim for 8 glasses (about 2 liters) of fluid daily, more in hot weather or during exercise. Limiting alcohol and caffeine, which have diuretic effects, may also help some patients.

When Should You See a Doctor for Dry Eyes?

See a doctor if: dry eye symptoms persist despite several weeks of over-the-counter treatment; you experience significant eye pain, redness, or vision changes; symptoms interfere with daily activities; you need eye drops more than 4-6 times daily; you suspect an underlying medical condition; or you develop signs of eye infection.

While mild dry eye often responds well to self-treatment, certain situations warrant professional evaluation. Eye care providers, including ophthalmologists and optometrists, can perform specialized testing to determine the type and severity of dry eye and recommend targeted treatments not available over the counter.

Persistent symptoms despite consistent use of artificial tears for several weeks suggest the need for evaluation. This may indicate a more severe form of dry eye, an underlying systemic condition, or the need for prescription medications. Similarly, if you find yourself needing to use eye drops very frequently—more than 4-6 times daily—to manage symptoms, professional guidance can help optimize your treatment regimen.

Vision changes associated with dry eye deserve prompt attention. While mild, temporary blurring that improves with blinking is common, persistent vision problems could indicate corneal damage or other complications requiring treatment. Any sudden vision changes should be evaluated urgently.

How Is Dry Eye Syndrome Diagnosed?

Dry eye is diagnosed through a comprehensive eye examination including patient history, tear film assessment using fluorescein dye, Schirmer test measuring tear production, tear breakup time (TBUT) test assessing tear stability, meibomian gland evaluation, and sometimes specialized tests like tear osmolarity or inflammatory marker testing.

A thorough dry eye evaluation begins with a detailed patient history. Your eye care provider will ask about symptom duration, severity, and patterns; environmental factors and screen use habits; medications you're taking; other medical conditions; and previous eye surgeries or treatments. Standardized questionnaires like the OSDI (Ocular Surface Disease Index) or SPEED (Standard Patient Evaluation of Eye Dryness) help quantify symptom severity and track response to treatment.

Clinical Examination

The slit lamp examination allows detailed visualization of the ocular surface, tear film, and eyelids. The examiner looks for signs of tear film instability, corneal and conjunctival damage, eyelid margin abnormalities, and meibomian gland dysfunction. Special dyes may be used to highlight damage:

Fluorescein staining reveals areas where the corneal epithelium has been damaged, appearing as bright green spots under blue light. This corneal staining indicates significant dry eye disease and helps guide treatment intensity. Conjunctival staining with lissamine green or rose bengal provides additional information about ocular surface health.

The Schirmer test measures tear production by placing small paper strips inside the lower eyelids for five minutes and measuring how far the tears travel along the paper. Results below 10mm suggest aqueous deficiency, while results below 5mm indicate severe deficiency. The test can be performed with or without anesthetic drops, testing different aspects of tear production.

Tear breakup time (TBUT) assesses tear film stability. After instilling fluorescein dye, the patient is asked to blink and then keep their eyes open while the examiner counts seconds until the first dry spots appear on the cornea. A TBUT of less than 10 seconds is considered abnormal and suggests tear film instability, often related to meibomian gland dysfunction.

Meibomian Gland Assessment

Given the high prevalence of evaporative dry eye, meibomian gland evaluation is essential. The examiner applies gentle pressure to the eyelids to express meibum (the oil produced by meibomian glands) and assesses its quality—healthy meibum is clear and flows freely, while unhealthy meibum may be cloudy, thick, or absent entirely. Meibography, imaging of the meibomian glands, can reveal gland dropout or atrophy that helps predict treatment response.

Advanced Testing

Several newer diagnostic tests provide additional information for complex cases. Tear osmolarity measurement, using devices like the TearLab system, can detect elevated salt concentration in tears, which correlates with dry eye severity and inflammation. Matrix metalloproteinase-9 (MMP-9) testing, available as a point-of-care test (InflammaDry), detects inflammatory markers in tears, helping identify patients who might benefit from anti-inflammatory treatment.

What Medical Treatments Are Available for Dry Eyes?

Medical treatments for dry eyes include prescription anti-inflammatory drops (cyclosporine, lifitegrast), steroid eye drops for short-term use, punctal plugs to retain tears, in-office procedures like intense pulsed light (IPL) or LipiFlow for meibomian gland dysfunction, and autologous serum tears for severe cases. Treatment is stepped based on severity.

When over-the-counter treatments prove insufficient, prescription therapies offer more potent options. Modern dry eye management follows a stepped approach, with treatment intensity matched to disease severity. The TFOS DEWS II treatment recommendations provide a framework that most eye care providers follow.

Anti-Inflammatory Eye Drops

Cyclosporine ophthalmic emulsion (Restasis, Cequa, Ikervis) is a prescription anti-inflammatory drop that increases tear production in patients whose tear glands are suppressed by inflammation. It works by inhibiting T-cell activation and reducing inflammatory cytokines on the ocular surface. The medication requires consistent use for 3-6 months before maximum benefit is achieved, and patients should be counseled that initial stinging upon instillation is common but typically improves over time.

Lifitegrast (Xiidra) is a newer prescription option that works by blocking T-cell interaction with the ocular surface, reducing inflammation through a different mechanism than cyclosporine. Some patients experience dysgeusia (altered taste sensation) as a side effect. Like cyclosporine, consistent use over several months produces the best results, though some patients notice improvement within weeks.

Corticosteroid eye drops provide powerful anti-inflammatory effects but are typically used short-term (1-2 weeks) to quickly reduce inflammation before transitioning to maintenance therapy with cyclosporine or lifitegrast. Long-term steroid use carries risks including elevated eye pressure and cataract formation, so they're reserved for acute flares or as "pulse" therapy under careful monitoring.

Punctal Plugs

Punctal plugs are tiny devices inserted into the tear drainage channels (puncta) to help retain tears on the eye surface longer. This is particularly useful for aqueous deficient dry eye, where tear production is limited. Plugs come in dissolvable (temporary) and non-dissolvable (semi-permanent) varieties. Temporary plugs allow for a trial period to assess benefit before committing to permanent plugs. The procedure is quick, painless, and performed in the office.

Procedures for Meibomian Gland Dysfunction

For patients with significant meibomian gland dysfunction not adequately controlled with warm compresses, in-office procedures offer more intensive treatment. LipiFlow applies precisely controlled heat and pressure to the inner and outer eyelids, melting blockages and expressing meibum more effectively than manual techniques. A single treatment session can provide months of improvement.

Intense Pulsed Light (IPL) therapy, originally developed for skin conditions, has shown effectiveness for dry eye related to rosacea and meibomian gland dysfunction. The light energy reduces inflammation, destroys abnormal blood vessels around the eyelids, and appears to improve meibomian gland function. Multiple sessions are typically required.

Advanced Treatments for Severe Cases

Patients with severe dry eye unresponsive to standard treatments may benefit from autologous serum tears—eye drops made from the patient's own blood serum. These drops contain growth factors, vitamins, and proteins naturally found in tears but absent from commercial artificial tears. While highly effective for some patients, the requirement for regular blood draws, refrigeration, and limited shelf life makes them logistically challenging.

Other options for severe cases include scleral lenses, large contact lenses that vault over the cornea and maintain a fluid reservoir, providing constant lubrication. Amniotic membrane grafts may be used to promote healing in cases of severe corneal damage.

Can Dry Eyes Cause Complications?

Untreated dry eyes can lead to complications including corneal abrasions and ulcers, increased risk of eye infections, chronic inflammation and scarring, permanent vision impairment, and significant reduction in quality of life. Early, consistent treatment prevents most complications.

While dry eye is often considered more of a nuisance than a serious condition, chronic untreated disease can indeed cause meaningful harm. The tear film serves a protective function, and its disruption leaves the ocular surface vulnerable to damage and infection.

Corneal complications represent the most serious potential consequence of severe dry eye. Without adequate lubrication, the corneal epithelium becomes damaged, leading first to punctate keratitis (small erosions visible on examination) and potentially progressing to filamentary keratitis, recurrent corneal erosions, or frank corneal ulceration. Severe corneal damage can result in scarring that permanently impairs vision. These complications are most common in patients with severe aqueous deficiency or those who cannot close their eyes completely.

Increased infection risk accompanies dry eye because the tear film contains antimicrobial proteins (lysozyme, lactoferrin, secretory IgA) that protect against pathogens. Reduced tear production or poor tear quality diminishes this protection, making the eye more susceptible to bacterial, viral, and even fungal infections. Contact lens wearers with dry eye are at particular risk, as lenses can harbor organisms when not adequately bathed in tears.

Quality of life impacts from dry eye disease should not be underestimated. Studies show that the symptom burden of moderate to severe dry eye equals that of moderate angina or dialysis. Patients may struggle with reading, computer work, driving, and other activities that require sustained visual attention. Sleep disturbance, depression, and anxiety are more common in dry eye patients, highlighting the condition's broader impact on well-being.