Dry Eye Syndrome


Many people experience inadequate tear supply or eye discomfort some time in their lives, perhaps on an airplane, in a dry, overheated room or in a dusty workplace.  But upwards of 10 million Americans suffer from a significant dry eye condition of consequence. 

The classic “Sjogren’s-associated” dry eye affects up to two percent of the population and presents with a characteristic triad of symptoms–dry eye, dry mouth and arthritis. However, only about 10-20% of dry eye patients have Sjogrens.

Other causes of dry eyes include medication, dehydration, inflammation of the eyelids and/or skin, previous eye surgery, systemic diseases such as rheumatoid arthritis, thyroid disease, lupus, sarcoidosis and even poor blinking habits (such as staring at a computer).  Additional issues include autoimmune conditions or reactions related to foreign chemicals such as bromine or prescription medications. Your eye doctor can tell you if you are suffering from Sjogren’s syndrome or other specific diseases that are known to be causative.

However, there are significant numbers of patients who “try everything” (both Western and alternative) and still cannot find a good solution. In most cases this is due to underlying causes that must be figured out by a qualified practitioner – failure to fully identify issues such as digestion, liver function, immune function, thryoid function, relatively unknown system relationships know to TCM and Ayurvedic doctors etc. can be the reason for lack of success. 

Tears are not just made up of water.  They have three separate components:

1.  Oil (from the Meibomian oil glands in the eyelids)
2.  Mucus secretions (from the goblet cells deep inside the eyelid)
3.  Watery tears (the “aqueous” tears from the lachrymal gland and accessory lachrymal glands located in the conjunctiva of the eyelids). 

The innermost layer of tears in direct contact with the eye is the mucus layer, which is also call mucin.  The mucin coats the surface of the cornea.  The watery tears comprise the middle layer, sticking to the mucin and keeping the eye moist.  The outer tear layer is composed of oil from the Meibomian glands; it is deposited like an oil slick on the outside of the watery tears to slow their evaporation from the surface of the eye.  Every time you blink you sweep the tears across the cornea and into the drainage ducts called puncta.

Symptoms of dry eye syndrome include irritation, burning, redness, mucous accumulations, itching, light sensitivity and even tearing.  In fact, when cells fall off the cornea it can be downright painful.  Mild eye muscle problems or inadequate reading glasses may make the symptoms worse.  A routine eye examination can exclude other causes of irritation such as conjunctivitis, faulty glasses or contact lens trouble.

Caffery notes that “The effect of diet on tear function is illustrated clearly by malnutrition-induced xerophthalmia.  Dietary habits in well nourished North American society have been implicated as a cause of some tear dysfunction.  A review of the ocular literature suggests that sufficient dietary protein, vitamins A, B6 and C, potassium, and zinc may be necessary for normal tear function.  Excesses of dietary fats, salt, cholesterol, alcohol, protein, and sucrose have been associated with or suggested as causes of tear dysfunction.” (Caffery, 1991).  The essential fatty acid, gamma-linolenic acid (GLA), has been shown beneficial in Sjogren’s-associated dry eye (Brown et al, 1998).

Standard allopathic treatment consists of wetting drops and plugging therapy.  This is valuable, but ultimately is symptomatic and does not address the deeper issues.  Natural medicine therapy is directed at reducing inflammation, improving your environment, evaluating your drugs and diet, and using herbs and nutrients that directly or indirectly nourish and moisten.  As you read the following suggestions, remember the three components of tears, and that:

• Vitamin A and carotenoids aid epithelial tissue and goblet cells in production of mucin (Driot and Bonne, 1992).
• The watery component of tears requires that you drink water to hydrate your system.
• The oily component of tears is dependent upon adequate essential fatty acids.
• Treating all of the above three represents holistic nourishment therapy, but removal of causes is equally important.

Recommendations

• Use artificial tears.  These are available in non-preserved (sometimes expensive and inconvenient); minimally preserved or fully preserved varieties.  There are some new types of artificial tears that offer patients more options.  Ointments at bedtime are often helpful in reducing morning symptoms.  Refer to the Dry Eye chapter in The Eye Care Revolution for more details.  

• Try punctal plugs.  These reduce tear loss.  Every time you blink, tears exit through the little holes (puncta) in the inner corner of your eyelids.  By plugging the exit route, the tears you make or supply with eye drops, will remain in place longer.  Many companies make removable plugs that can be tried for either short or long periods.

• Modify your environment.  Is your home, bedroom or workplace too dry? Is there sufficient humidity? If you suffer from dry eye symptoms especially in the winter, place a humidifier in your bedroom, or put a pie pan with some water in it over the heating ducts.  Houseplants can help regulate humidity.

• Remember to blink.  Many of us stare at computers and get lost in our work and simply forget to blink.  Other people have weak lower lids, which do not contribute the necessary 20 percent involved in completing a blink.  Your or your eye doctor may notice that the lower lid doesn’t move with a routine blink.  Fortunately, with a forced or voluntary blink, you can close the eye.  Inadequate eye closure while sleeping may also contribute to dry eye symptoms.

• Take a look at your current medications.  Common drugs for intestinal problems, depression, allergy and colds may dehydrate sensitive tissues in your body.  If they are necessary, you may have to compensate for this dehydration by drinking more water.  Ask you pharmacist or doctor if any of your current medications may cause dry eye.

• Take a break from your computer.  Look away and every 20 minutes exercise your eyes.

• Evaluate your diet.  Drink at least six to eight glasses of water per day, and limit sodas, caffeine and alcohol.  Include fish, soy and other legumes, and seeds in your diet.  These provide essential fatty acids to protect cells and stabilize the tear film.  Omega-3 and -6 fatty acids from plant sources (such as flaxseed, evening primrose or borage oils) or from cold-water fish (such as salmon, mackerel, sardines, halibut and cod) are loaded with these good fats.  A good supplement is a gelcap containing about 200-250 mg. of DHA and 150-200 mg of EPA, and an additional 500 mg. gelcap of evening primrose oil.  Take one gelcap of each twice daily with meals. Double or triple the dose if your have significant inflammation.

* Interesting factoid-1. 2,000 years ago TAM (Traditional Ayurvedic Medicine) doctors made a wash out of licorice root, turmeric root, haritaki fruit (Terminalia chebula) and Himalayan cedarwood (Cedrus deodara) ground with goat’s milk to treat dry eyes.  For children, the treatment was mother’s milk applied as drops in the eyes. 

• Interesting factoid-2. You can sometimes get moisture into the eyes simply by squeezing the eyelid with your fingers to milk out fluids.  Another simple method is the eye drops made by rubbing the fingers in water, mentioned above.  

• Use Vitamin A eyedrops.  To my knowledge the only brand available is Viva-drops.  I often add a few drops of an herbal ophthalmic solution called rue-fennel tincture, made by Herb Pharm.   Rue-fennel tincture is also good for conjunctivitis (see below).  By the way, the correct way to use eye drops is not to pull the bottom lid open looking in the mirror.  Lie down on your back, place the dispenser near the inner depression of each eye (closest to the nose), being careful not to touch the skin or eye.  Let one or two drops fall in, and then blink several times to spread the solution over the ocular surface.

Complex Treatments

Complete treatment of dry eyes at our clinic for patients who do not get success from the above standard treatment almost always involves combinations of systemic herbal medicine formulas.  Some patients, especially those over the age of 60, need digestive aids to ensure proper absorption of nutrients.  Beneficial herbs from the digestive group like bromelain, white atractylodes, and ginseng root can be of help. 

Dry eyes are often associated with menopause and Reynaud’s syndrome.  The same herbs and supplements we use to treat these problems (Yin nourishing and blood nourishing herbs) appear to help strengthen other membranes such conjunctiva, mouth, nose and ears. In addition to EFA’s, we often use glucosamine sulfate 750 mg. twice per day in our clinic to treat dry eyes if Sjorgren’s related.

Success with using EFA’s, if sourced from fish, can be tricky, because all the fish today is contaminated with heavy metals like mercury, and must be decontaminated using a process called molecular distillation. This process chemically replaces the glycerol backbone of the oil with ethanol, and severely reduces absorption from 50% to 300%, to the point where for many patients no benefit is seen. Some higher quality manufacturers have methods that overcome this issue. 

Depending upon signs and symptoms, we can make a tonic formula of blood and/or Yin nourishing herbs that moisten, choosing from herbs like alfalfa root, American ginseng root, cooked rehmannia root, dang gui root, shou wu root, shilajatu, white peony root, lycium fruit, wild asparagus root and triphala.  I recommend about 2-4 grams twice per day of the concentrated extracts for long term use.  If successful, there will be a gradual improvement in general health over several months time, and a slow return of moisture to the eyes.

If there are other factors involving the immune system or nutritional deficiencies present, they need to be evaluated and taken care of to get good results.