Evaporative Dry Eye: What You Need to Know

As an optometrist, Lauren Gormley provides comprehensive eye care to patients at Wilmer Eye Institute’s Green Spring Station location, but she also specializes in a condition that is getting increasing attention these days: evaporative dry eye. We spoke with Gormley to learn more about the condition, its causes and treatments.

What is evaporative dry eye?

Evaporative dry eye means that you don't have enough oil in the tears. When most people think about dry eye, they think about not having enough water in their tears, which is an aqueous deficiency dry eye, but evaporative dry eye is actually more prevalent.

What causes evaporative dry eye?

The most common cause is meibomian gland dysfunction.  These glands, located in the eyelids, are responsible for secreting oils into the tear film. Meibomian gland dysfunction is associated with two changes. One is keratinization, causing obstruction of the opening of the gland leading to the oil, or meibum, not being able to be excreted into the tears. The other is a change to the meibum itself, where the oil becomes thickened and cannot be properly excreted from the glands. Normal testosterone levels help regulate both processes.

Who is most likely to get evaporative dry eye?

It affects predominantly women, especially as they approach menopause and then after menopause. Testosterone is a key regulator of the meibomian glands. Women have their highest levels of testosterone when they are in their 20s. By the time they’re in their 40s, it has decreased by 50%, and by another 25% by the time they’re in their 50s. Men's testosterone also starts to decrease in their 40s, but on average, it only goes down by about 1% per year, so it's a much slower decline. Most men don't end up in a place where they're considered to have low testosterone and are therefore less likely to encounter evaporative dry eye.

Are there other factors that can influence the development of evaporative dry eye?

All women go through these hormone changes, but there are also external factors that can make this worse, including anything that would disrupt blinking. You need to blink in order to spread the oils that are excreted from the meibomian glands into the tear film. Anything that decreases blink rate, like looking at a computer screen all day, will exacerbate the evaporative dry eye. Contact lens usage can also exacerbate dry eye in general.

What symptoms might suggest a diagnosis of evaporative dry eye?

The classic symptom is when you wake up, your eyes feel dry. You're not “doing anything” with your eyes, you're just sleeping, but if you don't have that healthy oil layer protecting the water layer of your tears, when you wake up in the morning your eyes can feel irritated, they can be red. It can feel almost like your eyelids are stuck to your eyeballs, and when you try to open them, it can range from uncomfortable to extremely painful.

What can people who are experiencing these symptoms do, and at what point should they see their eye doctor?

If you’re having symptoms such as dryness, irritation, extra tearing and burning when you open the eyes, you should have a dry eye evaluation, but ideally, you should be having a comprehensive eye exam every one to two years. The doctor may start to see the signs of dry eye even before a patient is symptomatic, so by having a regular exam, these things can be caught and can start to be addressed early on.

What does treatment involve?

Treatment for evaporative dry eye focuses on ensuring that the meibomian glands, which open onto the eyelid margin, can let the oils out. There are over-the-counter lid hygiene products that can help balance the natural bacteria that live by the eyelashes and clear away any debris that builds up through the day. In addition, applying warm compresses will help open the glands and loosen those oils so they can be released from the glands. You can also supplement the oil layer of the tears by taking omega three fatty acids. Some studies have shown a benefit, and I see a lot of benefit from omega 3’s anecdotally with my patients in the clinic. There are also specific artificial tears that supplement both the water layer and the oil layer of your tears.

If you're doing those things and not making progress, or if your symptoms are severe, then you should see a doctor who specializes in evaporative dry eye. In the clinic, I can do a more intense cleaning of the eyelids, or I can help to clear the oils if they're clogged in the glands. There are also devices to help with inflammation of the eyelid, which is a key factor in dry eye and evaporative dry eye.

Can having dry eye damage your eyes?

Untreated, dry eye can lead to permanent tissue changes of the cornea and chronic inflammation of the eyes. If the meibomian glands aren't able to work for long enough, the glands will atrophy, and it's difficult for those glands to function again. That’s why in a perfect world, you would diagnose and manage dry eye early so that you don't end up with any of those end-stage consequences.

Is there research underway to help further our understanding of the condition or help identify preventive measures and treatments?

There have been a few studies trying to utilize hormones to directly impact meibomian gland dysfunction, and it has been shown to improve the oil layer of the tear film and the function of the glands. There is not yet a standard of care about exactly how to put that into practice, but the evidence is starting to build that it could be an effective strategy.

Is there anything women can do to be proactive about these changes?

One of the conversations I have with my female patients who are pre-menopausal or menopausal is to try to find a practitioner who specializes in caring for women who are in their post-reproductive years. There are some great programs at Hopkins that are addressing the needs of these patients. One is the Women's Wellness Healthy Aging Program, which provides expert, collaborative care to support women in the aging process.

There's also an annual seminar called A Woman's Journey, which brings women together with clinicians who can educate them on topics of interest to them regarding perimenopause, menopause and post-reproductive life. I think these foundation programs that Hopkins is running are so valuable. They can give expert, evidence-based information and help clarify some of the things that have been published in the media.

Perimenopause, menopause and the post-reproductive years represent a third of most women's lives. There's no reason to give up on that goal of living your best life because you’re in these post-reproductive years. They're wonderful years, and you really want to be living your life to its fullest potential.