Clinical

When the eyes are dry

An algorithm approach and management
in general practice

Chirag Patel, Devaraj Supramaniam DRY EYE DISEASE (DED), also known as DED symptom.8 This is likely to be much
‘keratoconjunctivitis sicca’, is a common higher now, with a significant increase
disorder that negatively affects the in prevalence in older patients and the
Background
Dry eye disease (DED) is a common
quality of life of hundreds of millions of presumption that DED is underdiagnosed.
condition frequently encountered yet people around the world.1,2 In the USA,
underdiagnosed in primary care. It can the average cost of managing DED is
lead to significant morbidity, affecting estimated to be $55.4 billion.3 DED, in Anatomy and physiology
quality of life. The causes are numerous, most cases, is not curable and involves The ocular surface is composed of an
while treatment is continually changing. mainly symptomatic management, even epithelium layer lining the cornea, anterior
Objective when ophthalmologist referral is indicated. globe and the tarsi.9 This surface forms
This article provides essential information It is one of the most frequent causes of part of the lacrimal functional unit,
on DED for the general practitioner. visits to the optician or ophthalmologist.4 which also includes the lacrimal glands,
While the concept of DED can appear However, general practitioners (GPs) are in eyelids and meibomian glands.10 Moisture
to be simple, several issues need to be an excellent position to confidently assess and hydration of the ocular surface are
considered before arriving at the
and manage this often underdiagnosed maintained by an ordered layer of tear film
diagnosis and initiating treatment. This
article discusses the approach to DED condition.5,6 that is part of a homeostatic process that
based on pathophysiology, symptoms and In 2017, the Tear Film and Ocular aims to keep the eye lubricated.
examination, leading to appropriate and Surface (TFOS) Society established a The tear film has a volume of
effective treatment. TFOS DEWS II definition, expanding approximately 7–10 µL10 and drains
on the prior definition.1 The executive via the inferior and superior lacrimal
Discussion
While DED appears to be summary stated: punctum into the lacrimal canaliculi,
underdiagnosed, there has been an which subsequently flows into the
increased effort to provide validated Dry eye is a multifactorial disease of superior lacrimal sac component of the
symptom questionnaires, such as the the ocular surface characterised by a nasolacrimal duct, and it finally drains
ocular surface disease index and five- loss of homeostasis of the tear film and into the nose. The tear film is composed
item dry-eye questionnaire, to aid in
accompanied by ocular symptoms in which of three layers, starting from superficial
diagnosing and grading the severity of
DED. This has helped with deciding on
tear film instability and hyperosmolarity, to deep: lipid, aqueous and mucin.4,11
best management and appropriate ocular surface inflammation and damage,
treatment options for the patient. and neurosensory abnormalities play
etiological roles.1 Pathophysiology and subtypes
of dry eye disease
One study showed the prevalence of DED Any alterations in the lacrimal functional
is approximately 7.4% in Australia in the unit can lead to DED, more so with the
adult population,7 and the Blue Mountains presence of risk factors that contribute
Eye Study (reported in 2003) showed that to the development of DED (Figure 1).
57.1% of the older population had one Usually, the constant drying of the open

© The Royal Australian College of General Practitioners 2021 Reprinted from AJGP Vol. 50, No. 6, June 2021   369
Clinical When the eyes are dry: An algorithm approach and management in general practice

eye is offset by homeostatic mechanisms these processes is a hyperosmotic and damage.14 It is frequently associated
that regulate tear secretions and desiccating environment that stimulates with other conditions such as seborrheic
distribution.9 innate inflammatory events1 that dermatitis, acne and rosacea. It can
DED is now universally accepted contribute to an impairment of ocular anatomically be divided into anterior
as either evaporative dry eye (EDE) or surface homeostasis.12 and posterior blepharitis, which can
aqueous deficient dry eye (ADDE).1 The leading cause of EDE is meibomian often co-exist.12,14 Anterior blepharitis is
ADDE is as a result of increased tear gland dysfunction (MGD),9 which can inflammation of the anterior eyelid margin
film osmolarity due to hyposecretion include inflammation, hypersecretion involving the eyelid skin and lashes.9 It
of the lacrimal gland.9 EDE is also a and abnormal excreta of the meibomian can cause burning and grittiness in both
result of increased tear film osmolarity, glands.1,13 ‘Blepharitis’ is a broad term eyes. Posterior blepharitis is often referred
which occurs as a result of excessive referring to inflammation of the eyelid. It is to as MGD that is commonly associated
water evaporation with normal lacrimal thought to involve staphylococcal enzymes with rosacea.14 Signs include redness of
secretory function.12 The result of and toxins, causing immune-mediated eyelid margin with blocked meibomian

Risk factors
• Wind
Sjögren’s • Primary Sjögren’s syndrome affecting the lacrimal and • Dry air
syndrome salivary glands
• Pollution and tobacco
• Secondary Sjögren’s syndrome: eg rheumatoid arthritis,
smoke
systemic lupus erythematosus
• Hormonal status such
as androgen deficiency,
menopause, hormone
replacement therapy
Non-Sjögren’s • Lacrimal duct obstruction from chronic conjunctival
syndrome inflammation: eg trachoma, erythema multiforme, chemical • Medications such as
burns isotretinoin, β-blockers,
diuretics, antihistamines,
ADDE • Lacrimal gland insufficiency – Primary: eg age related,
antidepressants and anti-
congenital alacrimia
Parkinson medication
• Lacrimal gland Insufficiency – Secondary: eg lacrimal gland
infiltration, lacrimal gland ablation, lacrimal gland denervation • Contact lens wear
• Reflex hyposecretion – Sensory block: eg corneal • Occupational factors such
surgery, diabetes, infection (herpes simplex keratitis, zoster as prolonged computer
ophthalmicus), neurotropic keratitis from cranial nerve V exposure
compression • Nutritional factors such
• Reflex hyposecretion – Motor block: eg cranial VII damage as low omega-3 fatty acid,
from skin cancer surgery, anticholinergic medications vitamin A
• Laser surgery such as
LASIK
• Systemic disease such as
thyroid and diabetes
Ocular surface eg Allergic conjunctivitis
disorders

Blink disorders eg Infrequent blinking

EDE
Eyelid disorders eg Exophthalmos, poor lid apposition, entropion/ectropion

Meibomian gland eg Meibomian gland dysfunction from local disease/systemic

dysfunction dermatoses (such as psoriasis, rosacea and seborrheic
dermatitis), congenital aplasia, distichiasis

Figure 1. A diagrammatic representation of how ADDE and EDE can be divided, with associated common risk factors
ADDE, aqueous deficient dry eye; EDE, evaporative dry eye

370   Reprinted from AJGP Vol. 50, No. 6, June 2021 © The Royal Australian College of General Practitioners 2021
When the eyes are dry: An algorithm approach and management in general practice Clinical

glands and a frothy discharge along the provides a more detailed overview of the exacerbating factors and ocular history.15
eyelid margins.14 different conditions associated with DED. The common symptoms of DED are
While the categories of DED exist, detailed in Box 1.9 Symptoms tend
often distinguishing between them to be worse on waking16 and can be
can be difficult due to an overlap of the History exacerbated by factors that are listed
mechanisms involved (eg in Sjögren’s Diagnosis begins with a thorough in Figure 2.
syndrome). While it is recognised as history, which gathers symptoms, Scores of symptom severity can be
ADDE, the effect on the meibomian severity and risk factors. It is essential assessed with questionnaires, such as
gland can lead to EDE as well.1,5 Figure 2 to ask about the symptoms, duration, the five-item dry-eye questionnaire

Psoriasis Rheumatoid arthritis

Salmon coloured/erythematous Persistent symmetrical polyarthritis affecting the
scaly macules, papules or plaques; hands and feet; systemic features such as fever,
dystrophic and pitting nails that may malaise and weakness; stiffness, tenderness and
resemble onychomycosis; joint pains swelling especially of metacarpophalangeal, wrist
that could indicate psoriatic arthritis. and metatarsophalangeal joints.

Acne rosacea Investigations: Full blood examination (FBE), erythrocyte sedimentation

Variable erythema and telangiectasia over the cheeks and rate (ESR), C-reactive protein (CRP), rheumatoid factor and anticyclic
forehead; presence of inflammatory papules and pustules over citrullinated peptide and antinuclear antibody (ANA).
the nose, forehead and cheeks; rhinophyma.
Sjögren’s syndrome
Seborrheic dermatitis Dry skin; dry mouth; dry food sticking to roof of mouth; difficulty
Greasy scaling over red, inflamed skin in areas of the scalp, speaking for long periods; dental caries; periodontal disease; oral
forehead, eyebrows, eyelash and neck. candida and angular cheilitis; recurrent bilateral parotitis; red dry
tongue; arthritis symptoms; systemic features such as fever, malaise
and weakness.

Bell’s palsy Investigations: FBE, ESR, CRP, ANA especially anti-Ro and anti-La.
Acute onset of upper and lower Ankylosing spondylitis
facial paralysis; taste disturbance;
Insidious onset of inflammatory low back pain; unilateral/alternating
hyperacusis; epiphora;
lagophthalmos; brow droop; buttock pain; onset of symptoms before age 40 years; peripheral
corneal exposure. enthesitis and arthritis; tender sacroiliac joints; loss of lumbar lordosis,
and accentuated thoracic kyphosis.
Parkinson’s disease Investigations: FBE, ESR, CRP, liver function tests, human leukocyte
Resting tremor; decreased arm swing on side involved; soft voice; antigen B27.
decreased facial expression, rigidity and bradykinesia.
Scleroderma
Raynaud phenomenon; sclerodactyly; telangiectasia of face, fingers
Hypothyroidism and chest; skin thickening with puffy swollen fingers early on,
Fatigue; weight gain; cold particularly affecting hands, forearms, arms, face and trunk; late signs
intolerance; dry skin; hair are firm and tight skin leading to flexion contractures in the hands;
loss; depression; constipation; visceral involvement particularly gastrointestinal system (eg anaemia,
goitre; myxedema; bradycardia; gastroesophageal reflux disease, dysphagia, constipation and diarrhoea).
hyporeflexia. Investigations: FBE, biochemistry, CRP, ESR, ANA and extractable
Investigations: thyroid stimulating hormone (TSH), thyroxine nuclear antigen (ENA, anti-SCL 70 antibody).
(T4; if raised TSH), thyroid peroxidase antibody (TPO).
Systemic lupus erythematosus
Hyperthyroidism Classic triad of fever, joint pain and rash; constitutional symptoms;
Fatigue; palpitations; heat intolerance; hyperdefaecation; weight malar rash; discoid lupus; pericarditis symptoms; pleurisy; arthralgia
loss; tremor; tachycardia; irregular pulse (in atrial fibrillation); and myalgia
brisk reflexes; exophthalmos; diplopia. Investigations: FBE, biochemistry, CRP, ESR, ANA, ENA, anti-dsDNA,
Investigations: TSH, triiodothyronine (T3) and T4, TSH receptor anticardiolipin antibodies, lupus anticoagulant, anti-β2 glycoprotein 1
antibodies. and complement levels.

Figure 2. Overview of systemic conditions that can be associated with dry eye disease
Images reproduced with permission from EyeRounds.org University of Iowa and Science X https://medicalxpress.com/news/2012-08-standards-diagnosis-
Sjögren’s-syndrome.html

© The Royal Australian College of General Practitioners 2021 Reprinted from AJGP Vol. 50, No. 6, June 2021   371
Clinical When the eyes are dry: An algorithm approach and management in general practice

(DEQ-5),17 or the ocular surface disease disorders associated with DED. Examination
index (OSDI).16 The DEQ-5 elicits the Constitutional symptoms such as The first step is to perform an external
presence of dry eye symptoms, their fatigue, weight loss and loss of appetite examination with a focus on skin, eyelids,
frequency, severity and the time of day may be reported. Eliciting history by a adnexa, proptosis and any visible cranial
when they are most severe.17 A positive systems review can guide in determining nerve deficits (mainly looking for 3rd,
result for DEQ-5 is a score of ≥6. a possible cause for DED (Figure 1).15,19 5th and 7th nerve deficits, which may
The OSDI is a 12-item questionnaire When undertaking a social history, it is affect lid closure and blink rate). Check for
used to assess the symptoms of ocular good practice to ask about smoking, as any eyelid deformity such as ectropion/
irritation in DED and how they affect this may associate with the risk of DED entropion as well as incomplete closure
functioning related to vision. The three in the general population.19,20 Medication and infrequent blinking. Look for any
areas that are screened are ocular history is essential, as clinicians are erythema, thickening of the eyelid
symptoms, vision-related function and mainly looking for risk factors that may margins and the presence of discharge as
environmental triggers. The OSDI is cause dry eye, as listed in Figure 2. well as dandruff-like scales (indicating
assessed on a scale of 0–100, with higher
scores representing greater disability:
13–22 represents mild DED, 23–32
represents moderate DED, and ≥33
represents severe DED.16
Past medical history can guide the
clinician as to the cause. Ask about
corneal refractive surgery, contact
lens wear and ocular surface diseases
such as allergic conjunctivitis, varicella
zoster, herpes infections and previous
transplants, which can lead to graft
versus host disease (where donor A B

tissue sets off an overactive systemic

inflammatory response, leading to the
destruction of host tissue, such as in the
eye).18 Facial surgery (eg in skin cancer
management) can cause trigeminal
nerve or facial nerve damage, which
can result in neurotrophic keratitis
and corneal exposure keratopathy,
respectively – both of which increase
the severity of DED.1
There may be underlying systemic
medical conditions and dermatological C D

Box 1. Symptoms of dry eye disease

• Dry and gritty sensation

• Foreign body sensation
• Soreness in the eye Inadequate tears (<10 mm)
• Stinging or burning Suspect low tears (10–14 mm)
• Photophobia Normal range (15–25 mm)
E
• Intermittent blurry vision
• Excessive tearing (due to reflex tear
from corneal irritation) Figure 3. Images portraying information that can lead to a diagnosis of dry eye disease
• Eye fatigue a. Blepharitis of the eye; b. A normal tear film height; c,d. Tear break-up time, which is abnormal
• Fluctuating diurnal vision if dry spot/hole is seen at less than 10 seconds; e. The Schirmer test
• Soreness Figures 3A, 3C and 3D reproduced with permission from EyeRounds.org University of Iowa
Figure 3B reproduced with permission from The College of Optometrists29
• Itching (consider allergic conjunctivitis)

372   Reprinted from AJGP Vol. 50, No. 6, June 2021 © The Royal Australian College of General Practitioners 2021
When the eyes are dry: An algorithm approach and management in general practice Clinical

blepharitis; Figure 3A).5 The discharge to evaluate aqueous tear production.19 If be multifactorial, which is why treatment
should be a transparent liquid oil, while you do not have access to these tests, then should focus on optimising function as
thick or discoloured meibum indicates referring to a local optometrist is an option. well as address any underlying diseases
dysfunction.5 Expression of the meibomian It is not expected that GPs carry out involved. The Royal Australia and New
gland with gentle pressure to the lid margin TBUT tests in the office, as specific Zealand College of Ophthalmologists has
from a cotton bud can determine whether equipment is required. The test uses a a patient information publication on DED
the leading cause of EDE – MGD – is fluorescein strip dipped in preservative- that can be accessed on its website.23
playing a role .1 It is also a validated way free normal saline solution.16,22 If there is Before considering pharmacological
of unblocking the glands if this is an issue. scope to implement this in your practice, options, it is essential to modify any
Checking visual acuity is an integral the procedure is performed as follows: The external factors that contribute to DED.
part of the examination, as worse visual strip is placed in the cul-de-sac with the dye Give the following advice to patients:1,6
acuity drives vision-related symptoms in allowed to spread on blinking.19 While the • learn about the natural history, chronic
dry eye.21 Examining the adnexa may give patient is looking straight ahead without nature and outcome expectation
evidence of lacrimal gland enlargement. blinking, the film is viewed with cobalt blue (ie symptom relief rather than cure)
If there is suspected trigeminal nerve light and the time between the appearance • reduce computer use (or lower
dysfunction, then corneal sensation of a first dry spot or hole and the last blink computer screen height, which reduces
should be assessed with a cotton wisp. is confirmed as the TBUT19 (Figure 3C). lid aperture)
If a slit lamp is available, then While there is variability in the times of • increase frequency of eye rest
biomicroscopy evaluation is useful. healthy patients, it is agreed that a cut-off • avoid allergens and irritants – especially
The focus should be on the tear film, the of less than 10 seconds is abnormal and any eye drops that have preservatives
eyelashes, the eyelid margins, puncta, relatively specific in screening for dry eyes.1 • humidify home and work
conjunctiva and cornea.12 If a slit-lamp Ocular staining can be assessed with • minimise air conditioners/heaters
biomicroscopy is not available, then an a dye such as fluorescein. The staining • avoid rubbing the eyes
ophthalmoscope with a high plus lens patterns that could indicate damage are • cease smoking and avoid second-hand
will give a better resolution than the observed over the cornea and conjunctival smoke
ophthalmoscope alone. surface. The criteria of abnormality are >5 • reduce alcohol consumption
The normal tear film height is 0.3 mm corneal spots, >9 conjunctival spots, or lid • ensure that contact lenses are inserted
(Figure 3B); while this is being assessed, margin epitheliopathy of ≥2 mm length and used correctly
the viscosity and presence of debris and and ≥25% width.1 • wear sunglasses or tinted glasses;
mucous strands should be noted. A low tear The Schirmer test is performed by wrap-around frames should be used in
film height of <0.2 mm suggests ADDE.1 placing a filter paper over the lower lid windy conditions
On viewing the lashes, note any ingrown, margin contacting the ocular surface • increase omega-3 fatty acids.
extra and missing lashes. It is useful to (Figure 3D). The eyes are closed, and There is evidence to show that a diet
check the conjunctiva, which includes the after five minutes, the paper is checked rich in omega-3 fatty acids (from fish
inferior fornix and tarsal, as well as the to see the amount of wetting. There is and plant oils) can improve symptoms.
four quadrants of the bulbar. Staining with no universal cut-off but tear wetting of A meta-analysis concluded that due to
fluorescein will help assess the cornea for <10 mm in five minutes is considered the anti-inflammatory effect of omega-3
ulceration, neovascularisation, infiltrates abnormal.9 Its use is variable in practice supplementation on the ocular surface,
and scarring.19 The presence of cells and due to its specificity and sensitivity. it could help with DED.24
flare in the anterior chamber is indicative of Nonetheless, the executive summary from Many pharmacological treatment
intraocular inflammation, which suggests DEWS concluded that this test without options are available. For mild disease,
uveitis, a condition that is linked with anaesthesia is a well-standardised test it may be enough to use ocular lubricants
systemic autoimmune diseases.15 This will for providing an estimation of stimulated such as drops, gels or ointments (Table 1).
need discussion with an ophthalmologist reflex tear flow.1 Generally, the dose is one to two drops, or
on the day. Blood tests are usually not required in one application, three to four times a day
An examination to look for clinical diagnosing DED; if there is suspicion for as required. Some patients may need to
associations of other systemic conditions, underlying systemic illness such as those apply them more frequently. Gels provide
such as those listed in Figure 1, is useful to listed in Figure 3, then specific tests for more extended relief than drops but
determine the treatment pathway. those conditions will be required as shown. can blur vision (less so with ointments).
Ointments can be used at night if dry
eye affects sleep or occurs on waking.
Investigation Treatment Preservative-free lubricants are preferred
Office tests that can be done include tear Treatment aims to improve symptoms for severe dry eye as preservatives can
break-up time (TBUT) and ocular surface and effectively improve any related vision worsen DED and cause epithelium
staining.1,22 The Schirmer test can be used disturbance. The aetiology of DED can toxicity.25 Adding a lipid-stabilising

© The Royal Australian College of General Practitioners 2021 Reprinted from AJGP Vol. 50, No. 6, June 2021   373
Clinical When the eyes are dry: An algorithm approach and management in general practice

agent is useful as this can mimic the of anterior blepharitis if eyelid hygiene is an underlying autoimmune cause), as
composition of the natural tear film, which measures do not suffice.14 Additionally, they will require further investigation and
can improve lipid tear film structure and doxycycline 100 mg daily for two to four a trial of treatments, which will need close
overall stability.26 weeks can be used for posterior blepharitis monitoring as well as compounding (refer
MGD can be optimised with several if eyelid hygiene is inadequately to Figure 4 for indications for referral).
non-pharmacological methods such as controlling symptoms.14 Recently, Anti-inflammatories such as topical
lid massage several times a day, in the manuka honey drops have been tried steroids are occasionally prescribed by
direction of meibomian gland opening, for blepharitis associated DED, and was an ophthalmologist; if used long term,
warm compresses applied to the eyelids found to be a useful adjunct.27 However, it they increase the risk of glaucoma
(with eyes closed) for two to five minutes to may irritate the surface (especially those and early cataracts.12 Ciclosporin is an
soften the crusts, and gentle scrubbing of with DED), which may affect the patient’s immune-modulating medication with
the lashes with eyelid solutions or wipes.14 adherence.27 anti-inflammatory properties that has
There is some evidence to suggest that More severe and refractory cases need shown to reduce symptoms and corneal
applying chloramphenicol 1% ointment more aggressive interventions – usually surface damage.28 This, along with punctal
topically to the eyelid margin twice daily managed by the ophthalmologist (in plugs, may help severe ADDE.5,9,15 Other
for one to two weeks can improve cases conjunction with a rheumatologist if there treatments include testosterone eye

May need punctal plugs, Refer to an

Patient with suspected dry eyes anti-inflammatories and/ ophthalmologist
Artificial tears
or immune-modulating if no improvement
medication in four weeks

Triage questions:
ADDE
How long have symptoms been present?
Are there any triggers present? Presence
of discomfort? Severity? As listed in Figure 3

Is there a dry mouth or swollen glands?

Is vision blurred, and does it clear on blinking? Low tear
volume test
Is there a red eye?
(ie TFH)
Are symptoms monocular or binocular? Assess risk factors and
Are contact lenses worn? manage any modifiable ones
TBUT if able
Is there any itching, discharge or swelling?
Suspect <10s
Is the patient currently taking any medications?
dry eye
Are there any recent viral illnesses? +1 of
Is there any presence of systemic symptoms Administer questionnaire,
such as joint swelling? such as DEQ-5 or OSDI to Ocular surface staining
assess severity if able >5 corneal spots, Signs suggestive
DEQ-5 ≥6 or OSDI >13 >9 conjunctival spots, or of MGD/blepharitis
lid margin (≥2 mm length or conditions listed
Perform a clinical examination and consider and ≥25% width) in Figure 3
differentials based on examination Suspicion
for dry eye

Refer to
ophthalmologist
EDE including MGD/
blepharitis
• If corneal damage is suspected
• If there is an underlying causative diagnosis, such
as autoimmune diseases (eg Sjögren’s syndrome)
• If there are eyelid deformities that need correcting,
Refer to an
such as ectropion Lipid containing lubricants,
ophthalmologist
• If there is deterioration/loss of vision external heat, compresses
if no improvement
• Same-day referral is indicated for acute vision loss, suspected and lid hygiene
in four weeks
acute glaucoma, keratitis and iritis (look for marked redness
of the eye, severe pain/photophobia)

Figure 4. Algorithm approach to dry eye disease

ADDE, aqueous deficient dry eye; DEQ-5, five-item dry-eye questionnaire; EDE, evaporative dry eye; MGD, meibomian gland dysfunction;
OSDI, ocular surface disease index; TBUT, tear break-up time; TFH, tear film height

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When the eyes are dry: An algorithm approach and management in general practice Clinical

Asthma Rep 2004;4(4):314–19. doi: 10.1007/

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lubricant (available with and doi: 10.18773/austprescr.2018.048.
• Carmellose sodium (SU and MU; drops, gel)
without preservatives) 6. Smit DP. Dealing with dry eye disease in general
• Hypromellose (SU and MU; drops, gel) practice. S Afr Fam Pract 2014;54(1):14–18.
doi: 10.1080/20786204.2012.10874168.
• Sodium hyaluronate (SU and MU; drops)
7. Gayton JL. Etiology, prevalence, and treatment of
• Carbomer 980 (SU and MU; gel) dry eye disease. Clin Ophthalmol 2009;3:405–12.
• Polyvinyl alcohol (SU and MU; drops) doi: 10.2147/opth.s5555.
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Lipid tear supplements – • Perfluorohexyloctane (MU; drops) Maroun R, Wang JJ. Prevalence and associations
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9071.2003.00634.x.
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DED is an important condition that Ophthalmology Registrar, Flinders Medical Centre, SA symptom score to discriminate between groups
needs to be recognised in primary Competing interests: None. with varying self-assessed severity. Invest
Ophthalmol Vis Sci 2008;49(13):5851.
care settings. Treatment options are Funding: None.
18. Hovanesian JA, Shah SS, Maloney RK. Symptoms
Provenance and peer review: Not commissioned,
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