When chronic dry eye symptoms are hard to treat with drugs or lifestyle changes alone, other procedures or strategies may be needed. These strategies and procedures may include certain drugs or eye drops, as well as surgical procedures.
It can be helpful to understand the parts of your eyes and the role of your tears. This can help you make informed decisions about procedures that save your natural tears to help manage moderate to severe chronic dry eye.
Your eye
Your eye has special glands and cells that help make and release tears. The lacrimal gland is located under the outside edge of the eyebrow within the orbit of the eye. This gland secretes the watery part of tears, especially in response to dryness or irritation. The glands of Krause and Wolfring also help to secrete the water layer of the tear film.1
The meibomian glands are located on the edge of the eyelids. These glands secrete oil that is part of the tear film and help keep tears from evaporating too quickly.1
Goblet cells are special cells on the surface of the eye. They produce a protein called mucin, which is the building block for the mucus inner layer of the tear film.1
Tears drain into the upper and lower puncta (small openings) on the inside corner of your eyelids. They then flow into the tear duct of the eye.1
The cornea is a thin, clear membrane that covers the surface of the eye. The cornea serves 2 main purposes: protection and bending of light for normal vision.1
How do tears work?
Your eyes are coated with a thin layer of tears every time you blink. This layer is known as a tear film. This film has 3 layers, all with different functions:2
- Oily (lipid) layer – This is the outside layer of the tear film. This layer helps to keep the tears from drying out too quickly. This layer is made by the meibomian glands.
- Watery (aqueous) layer – This is a watery middle layer that makes up most of what we see as tears. Its purpose is to clean, protect, and lubricate the eye.
- Mucus (mucin) layer – This is the inner layer of the tear film, which helps to spread the watery layer evenly over the eye surface. This layer is made up of mucin, which is a protein secreted by goblet cells. It helps keep the eyes moist and free from particles. Without this layer, the tears could not coat the eye properly.
Tear conservation strategies and procedures
Tear conservation strategies and procedures may be an option for treating moderate to severe chronic dry eye. These procedures save your natural tears. Your doctor may take a stepwise approach. This means they will first address the overall quality of your tears, then use methods to save the tears you already have.3
Step 1: Address the quality of the tear film
Inflammation plays a key role in the development of dry eye symptoms. This is why the first step works to stop inflammation, before any surgical options are considered.
Eye drops that decrease inflammation or improve the overall tear film are usually the focus of treatment early in the disease. Your doctor will also look at underlying causes of your dry eye symptoms.3
Step 2: Preserve the tears
In certain cases of chronic dry eye, the body does not make enough tears to coat the ocular surface. Or, your tears may drain or evaporate too quickly. If this is the case, your doctor may consider procedures that increase the amount of time it takes for your tears to drain.3,4
Punctal occlusion is one procedure that can be performed in a doctor’s office. This involves “blocking” the duct that drains your tears, known as the puncta. This can be done by inserting plugs or using cautery. Cautery is a procedure that uses heat to close off part of the tissue.3,4
Punctal plugs may be temporary (dissolving) or semi-permanent, made of special plastic. Punctal plugs may be removed if no longer needed. If you need punctal plugs, your doctor will use drugs that help decrease any discomfort during the procedure.3,4
Risks and side effects of punctal occlusion
Every procedure has its risks. With punctal occlusion, the most common side effect is a scratchy or irritated feeling in the eye. Other side effects may include:4
- Too many tears
- Accidental removal, usually from rubbing the eyes
- Irritation of the eyelid if the plugs are not properly fit
- Irritation of the tear ducts
- Eye infection (rare)
These are not all the possible side effects of punctal occlusion. Talk to your doctor about what to expect or if you experience any changes that concern you during treatment with punctal occlusion.
Before beginning treatment for chronic dry eye, tell your doctor about all your health conditions and any other drugs, vitamins, or supplements you are taking. This includes over-the-counter drugs.