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To truly understand the different forms of dry eye disease, you must first understand how the tear film functions. The tear film is composed of three distinct layers, and each layer is important in its own way. The oily lipid layer is produced by your meibomian glands in your eyelids, and this oil is the outermost layer of your tears. In the middle, we have the aqueous (watery) portion of the tears, produced by the lacrimal glands. Lastly, we have the mucin layer which is right up against the eyeball and produced by the conjunctival goblet cells.
If you suffer from aqueous deficient dry eye disease, you’re not producing enough of the watery portion of your tears. The lacrimal gland, near your temporal upper eyelid, produces the aqueous portion of your tear film and, when this gland fails to produce enough tears for the eyes to be comfortable and function properly, extreme dry eyes can result.
Aqueous deficiency is most often due to Sjogren’s syndrome, and it is actually categorized as either Sjogren’s syndrome dry eye or non-Sjogren’s syndrome dry eye. Sjogren’s Syndrome is an autoimmune condition that attacks the salivary and lacrimal glands. Someone with this condition may notice both extreme dry mouth as well as dry eyes. Learn more about Sjogrens’s syndrome here.
For those without Sjogren’s, aqueous deficiency may result from any of the following (not an exhaustive list):
If you’ve been suffering from aqueous deficiency, the lack of watery tears makes the tears hyperosmotic, or salty. This can be measured in your eye doctor’s office, although it is not always done. This hyperosmolarity leads to inflammation over time, which can lead to more advanced issues with dry eye disease and even corneal changes.
No matter what the form of dry eye, management can be complicated. In most cases, the cause is multifactorial which presents an increasing challenge. For the clinician, diagnosing the issue appropriately and figuring out which is the largest factor in a patient’s disease means a better treatment plan will be chosen from the beginning.
It’s also important to keep in mind that dry eye disease is a chronic condition, and this requires a chronic treatment. The majority of the treatments we and your doctors mention should be used long-term instead of expecting short term benefits. Below you’ll find an entire list of treatments to consider for aqueous deficiency, although there are other less common treatments not listed. Many of these overlap with MGD treatment because MGD is so prevalent and it’s important to take care of the entire ocular microbiome and entire system.
Before anything else, a change in diet may be warranted in order to decrease systemic inflammation that could be contributing to dry eye. Consuming processed foods with excess sugar, fried foods, dairy, alcohol, and red meat can increase inflammation in the body. To decrease inflammation, focus on plants. Fruits, vegetables, whole grains, nuts, seeds, and healthy fats are all great choices to decrease inflammation. To make this easy on you, we recommend one simple change; replace your breakfast with a green smoothie. This simple change not only floods your body with hydration, but you’re also consuming tons of antioxidants which can help fight inflammation. For more on green smoothies, including recipes, head here.
No matter what form of dry eye you have, it’s important to make sure you’re getting enough hydration daily. For most people, we recommend drinking half your body weight in ounces of water per day. This means that if you weigh 150 pounds, you should be drinking at least 75 ounces of filtered water each day. Make this easy on yourself by keeping a reusable water bottle with you at all times. If you don’t have a home filtration system or another way to filter your water, we recommend the Big Berkey filtration system. By drinking enough water daily, you can help combat the debilitating dry eye (and dry mouth) that is often common in aqueous deficiency.
Because over 85% of dry eye sufferers also have some form of MGD, we highly recommend removing your makeup (if you wear it) and washing your face nightly. To remove makeup, use a simple oil-based makeup remover which is gentle on the eyes and surrounding skin. For washing your face, try a foaming tea tree face wash. Tea tree essential oil is something that you don’t want to use in large quantities around your eyes, but it can be incredibly beneficial for combating demodex mites and other bacterial microorganisms that can lead to blepharitis and MGD.
Along with washing your face, we recommend cleansing your eyelids and lashes twice daily. This is something everyone can do to prevent eye issues in the future. We love using hypochlorous acid because it is made naturally by the body and is incredibly gentle on the skin of the eyelids as well as the eyes. Simply spray the solution onto your closed eyelids, rub it in with clean fingertips, and let it dry. Doing this twice daily will help prevent inflammation of the eyelids and further dry eye issues.
While we don’t always recommend punctal plugs when there is a lot of inflammation present, they can be a lifesaver for some people with aqueous deficient dry eye. The puncta are the drainage holes in the eyelids where the tears are able to drain out into the nose. Everyone has two puncta on their top eyelids and two on the bottom. By plugging the bottom two punta (and sometimes all four), you’re able to retain more of the tears you make directly on your eyes. If your eyes aren’t making many tears, as is the case with aqueous deficiency, every little bit of tears can make a big difference.
These prescription medications may be prescribed by your doctor because they help the lacrimal glands produce more high quality tears, and this is the main deficiency in those that have aqueous issues. There are currently three medications available; Restasis, Xiidra, and Cequa. Each of these is dosed one drop in each eye, twice per day, and they can be very beneficial for those with aqueous deficiency. However, make sure to discuss expectations with your prescribing doctor, as each one will take a specific time to work (which sometimes requires being patient).
We don’t usually recommend topical steroids for long term use because they do have potential side effects. However, they are sometimes the best option when a patient has incredibly inflamed eyes and/or eyelids. Steroids work by combating inflammation directly, so they are a wonderful resource and they are widely available and affordable. Side effects your doctor will be watching for include increase in intraocular pressure (IOP) and an increased risk of cataracts with long term use. However, with proper monitoring by your physician this is nothing to worry about.
Because these large, rigid lenses completely vault over the cornea on the front of the eye, scleral lenses can be very beneficial for those who have a hard time making enough tears. To insert these lenses, you first fill them with either a non preserved saline solution or preservative free artificial tears. Once they’re on your eyes, your eyes are essentially being bathed in solution all day. This can be very comforting and even healing for people who have aqueous deficient dry eye.
Last on our list are amniotic membranes, and these are amazing for healing corneal issues due to dry eye disease. Patients who suffer from recurrent erosions, ulcers, or excessive dry patches may benefit from these. These amniotic membranes are made from human amniotic membrane or umbilical cord donated by mothers. The tissue retains its full biologic activity which helps the membrane decrease inflammation, reduce scarring, and promote growth of healthy corneal tissue. This is a great option for those with more severe dry eye issues. Membranes are usually worn one eye at a time for one week, until they have dissolved or been removed by your doctor.
We touched on this a bit already, but there is a distinct difference between aqueous deficient dry eye disease and evaporative dry eye disease. Where a deficiency in aqueous stems from issues with the lacrimal gland, evaporative dry eye is caused by issues affecting the meibomian glands. In fact, it’s estimated that over 85% of dry eye sufferers have meibomian gland dysfunction (MGD), which is the main contributor to evaporative dry eye.
The oil portion of the tears is so important because it is what keeps the tears on the eyes, and it helps provide a smooth surface to look through and for your eyelids to blink over. If the meibomian glands are affected in any way, this can drastically reduce the quality and quantity of the oily tear layer, causing the tear film to evaporate much more quickly.
There are many causes of evaporative dry eye, with MGD being the largest culprit. Other contributors include anterior blepharitis, ocular allergies, use of preservatives in eye drops, contact lens wear, and some medications such as retinoids. Even if you’ve been diagnosed with strictly an aqueous issue, it’s likely that your treatment plan will include maintenance for MGD in addition to therapies for aqueous deficiency.
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