Your Dry Eye is (Probably) Caused By Your Eyelids!

As a dry eye specialist, I see it all the time.  A new patient presents for a dry eye evaluation and is at his or her wits-end.  They are on countless drops, both prescription and over-the-counter.  They have been to a number of doctors but have found little or no relief.  They’ve been told they have ocular rosacea, sjogren’s syndrome, or a host of other conditions.

​The fact is, nearly 90% (and more by some estimates) of dry eye syndromes can be traced back to eyelid disease.  Our lids contain so many structures that are vital for producing and maintaining a healthy ocular surface environment including accessory lacrimal (tear) glands, meibomian (oil) glands, the lid wiper structure and more.  If any of these structures are inflamed or obstructed, they won’t work properly and this results in a breakdown of the complex structure of the pre-corneal tear film.

What are some of the causes of lid disease?


Demodex Blepharitis: This condition is caused by an over-infestation of the demodex mite in and around our eyelash follicles.  Everyone has demodex mites, but some people have an over-colonization on their eyelids.  This, in my opinion, is the single most common cause of dry eye syndrome because it results in inflammation, reduced basal tear production and meibomian gland dysfunction.  These patients are often mis-diagnosed as having an autoimmune condition or ocular rosacea. 


Ocular Rosacea:  It is my experience that almost all ocular rosacea patients suffer from demodex blepharitis.  In fact, there is strong evidence that rosacea in all forms is strongly linked to the demodex mite.  Rarely, patients can show red and inflamed eyelid margins with no form of infestation, but this is definitely the exception to the rule. 


Bacterial Blepharitis:  We all have trillions of bacteria that live on us and inside of us, referred to as our normal flora.  Sometimes, a few too many of these organisms accumulate along the eyelashes.  The eyelashes offer protection, moisture and oils that all combine to promote microbial growth, making bacterial blepharitis a common culprit of dry eye.  The bacteria promote inflammation, thereby reducing gland function.  They also produce exotoxins and lipase that disrupt our tear film and ocular surface.  This condition can be difficult to treat with traditional therapies because the bacteria will form biofilms along the lid margin, protecting them from soaps and other treatments.  These biofilms also clog tear and oil glands on the lids.


Meibomian Gland Dysfunction:  The meibomian glands line our eyelids and secrete an oil (lipid) layer that coats and protects our tears.  This lipid layer is solely responsible for the stability and even distribution of tears across the ocular surface and also prevents the tears from evaporating between blinks.  Almost all dry eye has some component of meibomian gland dysfunction.  These glands can become clogged for a number of reasons including genetics and all of the conditions listed above.  Extended electronic device use (and the subsequent lack of blinking) is the main cause for the steep rise in this condition in recent years.  Once these gland become significantly clogged, they must be opened through in-office procedures. 




What Can Be Done?
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The first step is getting a proper diagnosis by your eye doctor who specializes in dry eye and lid disease.   Testing for dry eye includes meibomian gland imaging, digital tear film analysis, vital dye corneal staining analysis, blink analysis, tear film osmolarity testing and ocular surface and eyelid examination.   We often epilate (pluck) an eyelash for microscopic examination in the exam room. 


There are a variety of at-home treatment options including prescription drops, eyelid cleaners and heat therapy, but most patients fail to find sufficient relief with these products and exercises.  For the majority of cases, we start with tailored in-office treatments to remove the offending cause of the lid disease and treat the clogged glands.  There are a variety of procedures that can target demodex mites, bacterial blepharitis, eyelid margin inflammation, meibomian gland obstructions, bacterial biofilm and more.  From there, we send the patient home with maintenance therapy products to enhance the in-office treatments. 


Most of these procedures are brand new and not covered by medical or vision insurance.  However, the cost is typically less than the cost of over-the-counter and prescription eyedrops when extrapolated over time… and are far more effective!  The goal of modern dry eye therapy is to greatly reduce or remove the need for eye drops during the day. 


Next time you feel any one of the common symptoms of dry eye (variable vision that changes with the blink, itching, burning, excessive tearing, redness, tired or heavy eyes, reduced contact lens wear time), look at your eyelids!  They’re usually the ones to blame.