Dry Eye

Dry eye syndrome is the most common eye disorder in Britain, affecting approximately 20% of people in the UK. Dry eye is common as we get older, and is exacerbated by time spent in front of computer screens and in centrally heated or air conditioned environments. 1 in every 3 people over the age of 65 experiences problems with dry eyes.

Dry eye disease occurs when either

  1. the eyes do not make enough tears, or
  2. the tears evaporate too quickly. 

Tear evaporation due to dysfunction of the Meibomian oil glands is the commonest cause of dry eye.



What makes tears?

Tears are made of 3 main components:

Mucous innermost layer of tears.

Mucus tears are produced by mucus cells in the conjunctiva (the transparent lining over the white of the eye). Mucus tear production is healthy in most people. In rare conditions where there is scarring of the conjunctiva, e.g. chemical burns or ocular cicatricial pemphigoid (OCP), production of mucus tears is compromised.

Aqueous (watery) middle layer of tears

Aqueous tears are mainly produced by the lacrimal gland (the tear gland) via openings in the upper eyelid. As we get older, particularly in women after menopause, the lacrimal gland produces less aqueous tears.

Oily outer layer of tears

Oily tears are produced by Meibomian oil glands in the eyelids, which have their openings just behind the eyelashes on both the upper and lower eyelids. This smooth oily layer of tears acts like a waterproof barrier. It stops the aqueous tears from evaporating.

Every time we blink, our eyelids create a new tear film over the front of our eyes. REMEMBER TO BLINK!


Why are tears important for sharp vision?
A uniform smooth layer of tears is essential for sharp vision. When light first hits the eye, it hits the tear film, not the cornea. If the tear film is not a smooth, uniform layer, but instead has patchy areas where it evaporates quickly and dries out, the light gets scattered and does not focus clearly on the back of the eye. Vision fluctuates.

Typical symptoms are that the vision is better just after blinking (when a new smooth layer of tears has been laid over the cornea again, by the eyelids closing), but quickly deteriorates when the layer of tears evaporates e.g. when watching a computer screen in the afternoon.

Laser eye surgery and tears
LASIK can cause dry eye. Multifocal implants give best vision when the tear film is uniform and healthy. Difficulty tolerating contact lenses is most commonly due to dry eye.

Careful evaluation by an expert in both dry eye and laser eye surgery like Miss Saw will optimise the condition of your eyes prior to surgery, and ensure that you have an outstanding outcome after laser or implant surgery.

Why compromise on anything less? Your eyesight is precious. There are many laser eye surgeons but few who have years of expertise and experience in both dry eye and laser eye surgery like Miss Saw.

What are the symptoms of dry eye?

  • Heavy tired feeling of the eyes
  • Decreased tolerance of reading, and working on the computer, and blurriness of vision during these activities.
  • Excessive watering of the eyes (when they are very dry and the brain reflex to make tears is stimulated)
  • Discomfort when wearing contact lenses
  • Stinging or burning of the eyes
  • A sandy or gritty feeling as if something is in the eye
  • Pain and redness of the eyes

What causes dry eye?

There are 2 main types of dry eye:

  1. Lack of aqueous (watery) tears, also known as Aqueous Tear Deficiency


  2. Rapid tear evaporation due to lack of oily tears, also known as Evaporative Dry Eye.
  3. Other causes of dry eye include poor closure of the eyelids e.g in thyroid eye disease or after cosmetic surgery.

Common causes of Aqueous Tear Deficiency

  • The commonest cause of lack of aqueous tears is ageing. The lacrimal gland produces less tears as we get older. As we get older our eyelids are also less effective at spreading the tears each time we blink. 
  • Menopause 
  • Medications like anti-depressants, oral anti-histamines, oral contraceptives
  • Auto-immune diseases like Sjogren’s syndrome, rheumatoid arthritis, lupus
  • Long term contact lens wear causing loss of sensation in the cornea, which reduces the brain reflex that makes tears.
  • LASIK causes a temporary loss of sensation in the cornea, which regenerates after 6-9 months.

Common causes of Evaporative Dry Eye

  • Meibomian gland dysfunction, and blepharitis 
  • Infrequent blinking, associated with staring at computer or video screens or Parkinson’s disease. REMEMBER TO BLINK!

How is dry eye treated?


The following information is provided as a guide only. Careful assessment and treatment by an eye specialist (ophthalmologist) who has the expert training and experience to accurately determine your diagnosis and best treatment approach is important.

The first step is to evaluate which type of dry eye is present: either lack of aqueous (watery) tears and/or lack of oily tears leading to rapid tear evaporation.

The second step is to identify and treat or reverse any underlying cause e.g. stop antidepressant or antihistamine medications, use a different type of contact lens or reduce the number of hours you wear contact lenses,treat Sjogren’s syndrome with a rheumatologist.


The next step is to correct each type of dry eye in turn.

Correction of aqueous tear deficient dry eye (lack of watery tears)


Treatment of aqueous tear deficiency involves treatment along a stepladder of therapy:


Artificial tears, gels and ointments

Replacement of aqueous (watery) tears with artificial tears, gels or ointments is the first treatment in aqueous tear deficiency. See our guide to “How to put in eye drops, gels and ointments”.

There are many different types of artificial tears, made by different companies. Some people find one brand works better for them than another, although no one knows why. It is usually best to try one type for at least one month, until you find the one that works best for you. If you find you need to use the drops more than 4x/day, or if you would like to use them with contact lenses, it is best to use preservative-free eye drops. 

Artificial eye gels are thicker than eye drops. They last longer on the eye and need to be put in less frequently, but they can blur the vision, usually only for a few seconds, which can be helped by blinking. 

Artificial eye ointments are usually used at bedtime because they are thick and cause blurry vision. They help stop the eyes drying out overnight so that they feel more comfortable in the morning. Some thinner ointments can be used during the daytime as well, for long lasting comfort.

Steroid eye drops

Steroid eye drops may be needed if the dry eye condition has led to inflammation of the surface of the eye. Acetylcysteine eye drops clear the mucus in the tear film and improve comfort and vision.

Punctal plugs

Punctal plugs stop tears from draining away, to help them stay on the surface of your eyes for longer. Punctal plugs are made of soft silicone or collagen. They cannot usually be felt when they are in place. They can be removed if the eye is too watery. If the plugs are helping your symptoms of dry eye, it is usually recommended to leave them in. 

The plugs can sometimes fall out on their own. An optometrist or ophthalmologist with appropriate equipment can check if the plug is still in place. If the plugs definitely help your eyes, but they keep falling out, it is best to consider having punctal cautery. Punctal cautery is where the opening of the tear drainage tube is permanently sealed off by a simple procedure carried out under local anaesthetic. 


Topical ciclosporin

Topical ciclosporin is an anti-inflammatory medication which has been shown to increase tear production. Restasis (Ciclosporin 0.05%) has been available in the US and approved by the FDA since 2003. Unfortunately Restasis has never been available in Europe or the UK. Since July 2015 a licensed version of topical ciclosporin, Ikervis (Ciclosporin 0.1%) is now available for dry eye disease. Topical ciclosporin has a slow onset of action. It can take 3-6 months for the medication to work. 

For the majority of people steps 1-4 are sufficient to manage their Aqueous (watery) Tear Deficient dry eye. Steps 5-8 are listed below. 

Oral pilocarpine (Salagen)

Oral pilocarpine can help patients with severe dry eye and dry mouth, for example Sjogren’s syndrome patients. It stimulates the nerves that produce tears from the lacrimal gland and the salivary glands. However it can cause side effects including sweating, a racing heart, nausea and diarrhoea.

Autologous serum eye drops

Autologous serum eye drops may be required in patients who have tried all previous therapies without improvement. Natural tears contain growth factors, proteins and vitamins to support the health of the cornea and surface of the eye. Artificial tear supplements lack these growth factors and proteins. Serum derived from clotted blood has a large variety of nutritious growth factors, vitamins, and proteins, some in higher concentrations than in natural tears. 

In the UK, autologous serum eye drops can only be obtained via the NHS blood and transplant service. These eye drops are prepared from the patient’s own blood, which is processed to separate out the serum after the blood has clotted. The serum is diluted with saline, dispensed into dropper bottles and frozen. The frozen drops are delivered to the patient, and one bottle is used each day. If the patient is not able to have their own blood taken (for example if they are anaemic or very elderly) then allogeneic serum drops, made of pooled donor blood product, is also available. 


Tarsorrhaphy is a small surgical procedure to make the opening between the eyelids smaller, usually at the outer corners of the eyes. This may be necessary in some severe cases of dry eye, to reduce the surface area of the eye exposed.

Systemic immunosuppressive therapy

Systemic immunosuppressive therapy (to suppress the immune system) may be needed in autoimmune diseases like Sjogren’s syndrome and rheumatoid arthritis.

Correction of evaporative dry eye (lack of oily tears)


Lack of oily tears due to Meibomian oil gland dysfunction is the commonest cause of dry eye. When severe, Meibomian oil gland dysfunction leads to blepharitis, or development of cysts (chalazion) on the eyelids. See Blepharitis.





Meibomian oil glands are like other sebaceous oily (pimple, acne) glands. Meibomian oil glands do not work well when we are stressed, or have not had enough sleep. When they are dysfunctional, rather than producing clear oil to keep the surface of the eyes moist and keep the vision smooth and clear, they become blocked and filled with a waxy whitish substance. Dysfunction of the Meibomian oil glands in the eyelid can be associated with a skin condition called rosacea. 

Hot eyelid massage on a daily basis

When carried out correctly, hot eyelid massage helps restore Meibomian oil gland function, to express natural oily tears onto the surface of the eye. Expressing natural oily tears onto the surface of your eyes can mean that you don’t have to put in as many artificial tear drops.

The simplest (and often the best) way to correct Meibomian oil gland dysfunction is to hold a small thin folded hot towel or flannel over your eyelids to melt the thickened waxy oil in the Meibomian oil glands, and gently push backwards on your eyelids through the towel, near where the eyelashes come out, to express the natural oil from the gland openings near the eyelashes. Make the towel hot with running tap water which is quite hot (but not so hot that you can’t tolerate it). After counting for 10 seconds whilst pushing backwards towards the upper eyelashes, make the towel hot again, then put the hot towel over the lower eyelids on both sides and count for 10 seconds whilst pushing backwards near where the lower eyelashes come out. You can repeat this for another cycle, making it 10 seconds x 2 on the top eyelid and 10 seconds x 2 on the bottom eyelid. 

This should not take up more than 40 seconds of your day. Make it part of your daily hygiene routine, either in the morning after coming out of the shower, or in the evening after brushing your teeth. 

The main purpose of using hot running tap water, and re-heating the towel every 10 seconds, is to maintain a relatively constant and hot temperature of the hot towel. Avoid letting tap water get into your eyes. Do not wear contact lenses when carrying out hot eyelid massage. Contact lenses must never be worn in the shower or when swimming. The best towels to use are small, thin baby face towels. It is best to do the hot towel massage out of the shower, so that the water can be hot enough. 

It is not recommended to roll a cotton bud downwards or upwards on the eyelid as this stretches the delicate thin eyelid skin and can lead to bags around the eyes.  

[ video or picture of hot towel massage]

If the skin on your eyelids is dry or affected by eczema, the hot towel can make the skin feel more dry. If this is the case, eye masks which are heated in the microwave are available, or other masks containing hot beads. It is important to try to maintain a constant hot temperature (but not burn the skin on the eyelids), and to gently massage by pushing backwards on your eyelids, to express the oil from the Meibomian oil glands. 

Mascara and eyeliner can block the openings of the Meibomian oil glands. It is best to remove mascara and eyeliner with a good quality, plain make up remover each night, and carry out hot eyelid massage to open up the glands. Try to have at least 1 or 2 make-up free days per week.

In some cases where it has not been possible to open the Meibomian oil glands with hot towel massage or other methods, gland expression treatments are available e.g. Lipiflow, MiBoFlo. Following these treatments, it is often necessary to maintain the improvement by daily hot towel eyelid massage.

Oral Low Dose Antibiotics

When the blockage of the Meibomian glands is severe and longstanding, and has caused chronic inflammation and damage to the eyelid margins and eyelashes or is causing recurrent chalazia (cysts), it is often helpful to take a course of oral antibiotics: Doxycycline 100mg/day or Lymecycline 408mg/day. These antibiotics are used in a similar way that dermatologists treat acne.  The onset of action is slow and the course of treatment is at least 6 -12 weeks. The oral antibiotics will also clear up facial acne. The antibiotics must not be taken by women intending to fall pregnant. They should be taken in the morning with food, milk or probiotic yoghurt, and must never be taken at bedtime. Oral Azithromycin is an alternative which has been reported to be effective in Meibomian gland dysfunction.

Omega 3 fatty acids

Omega 3 fatty acids are thought to help with dry eye and Meibomian gland dysfunction. Eating oily fish like salmon and sardines can help. There is no large scale evidence that taking omega 3 supplements helps but it has been reported to be effective in some studies.

Other Treatments

Other treatments reported to improve Meibomian gland dysfunction include Ciclosporin eye drops and Azithromycin eye drops

What can I do?

  • Drink lots of water. This improves tear production.
  • Don’t smoke. This makes eyes more dry.
  • Get enough sleep, try not to have a stressful lifestyle
  • Be diligent about hot eyelid massage every day, as part of your hygiene routine, to express natural oily tears into your eyes.
  • Remember to BLINK when you are looking at computer screens or reading.
  • Alcohol and chilli/curries can worsen Meibomian gland dysfunction and rosacea so avoid them for short periods if your eyes are flaring up.
When can I stop doing the dry eye treatment?

Dry eye is a long term chronic condition. It is not possible to be cured of dry eye. Dry eye is more common as we get older. By doing effective daily hot eyelid massage, depending on how severe your dry eye condition is, it can be possible to minimise the amount of lubricating eye drops you need to put during the daytime, and mainly only need to put ointment at bedtime.

Will my eyes become “dependent” on artificial tears if I use them? Should I stop using them, so that the eye will start to make tears again?

Your eyes will not become “dependent” on artificial tears. Using artificial tears/gel/ointment when your eyes are dry is like putting moisturising cream onto dry skin. Artificial tears will stop the dryness from damaging the cornea and will improve comfort and vision. Stopping artificial tears in eyes that are dry will not encourage the eye to make tears again; instead, the eyes could become more dry and could develop complications such as a corneal ulcer.

For more information:

Tear Film & Ocular Surface Society (TFOS) www.tearfilm.org/

BritshSjögren’s Syndrome Association www.bssa.uk.net

The Dry Eye Zone is a resource centre for people with severe or chronic dry eye. www.dryeyezone.com

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  • I highly recommend undertaking laser surgery with Valerie. I had a very high prescription (-8) and was wearing spectacles and then contact lenses since I was 5 years old. I was a bit apprehensive at the start but Valerie was very reassuring from the beginning. I received all the information I wanted allowing me to make my choice. The surgery (in May 2016) didn’t take long at all and the discomfort only lasted a couple of hours. I was provided with a range of drops including anesthetics drops against the pain which were very efficient. After a few hours, I was seeing and my vision settled very quickly after then. I was driving my son to school after 48h. Valerie gave me her mobile number allowing me to call her, anytime (even during the weekend) if I had any concerns. This was really reassuring. She is making herself available for her patients and is very caring. My vision is now perfect, which is an amazing and crazy feeling! Whenever friends mention laser surgery, I encourage them to see Valerie as I know they will be in very safe hands. The clinic facilities at AVC are very clean and modern, as you would expect for private facilities. You are very well looked after all way through.

    Lauren A.
  • Had my surgery over a year ago. Currently still no issues and have better than 6/6 or 20/20 vision. Miss Saw was very thorough and that gave me the confidence to go ahead with the surgery. She also explained that if I had any issues after surgery to contact her immediately. That alone gave me confidence I was in good hands. The surgery was quicker than I expected. Before long I suddenly could see with a lot of detail. Also to note Miss Saw is very gentle as well. Best thing I have ever done and better still with such an excellent surgeon.

    Sarah Datson
  • Lens replacement surgery in November 2016.
    Not needing reading glasses is amazing!

    Rick B.
  • I have always considered having laser eye surgery. After using contact lenses and glasses for over 10 years, I decided to go ahead with it. After going online to look at reviews on Moorfields website Ms V Saw had very good feedback. Having had a consultation which was brilliant and answered all my questions, I then decided to proceed with surgery. Obviously going in for the surgery can seem quite daunting but everyone, especially Miss Saw, put me at ease and told me what was happening throughout the procedure. It has been the best thing I have ever done and would do it all over again! Miss Saw was fantastic. I would recommend her to anyone considering Lasik Surgery. Thank you!

    Elizabeth Godfrey
  • Ms Saw and her team are very friendly and professional – they made sure I understood everything beforehand and explained exactly how the procedure would go so I knew what to expect. Ms Saw’s manner is calm and reassuring and I am thrilled with the results.

    Kit Roberts
  • The service provided by Valerie and her team was fantastic and I am very pleased with the results. I would not hesitate to recommend her to any of my friends or family.

    Caolan Gardner
  • I wish I’d had the treatment years ago. It’s transformed my life, stripping out a whole layer of stress, anxiety and upset. I was terrified of the procedure and the recovery process for PRK. It was over in moments and in retrospect, neither the treatment or recovery felt like a big deal. I can’t recommend Valerie Saw highly enough. She took time to answer my numerous questions in-depth, face-to-face during consultations as well as over the phone and via email. She put me at ease and she has changed my life for the better, and for this I am eternally grateful.

    Alex Smith
  • Ms Saw is an outstanding surgeon. Very clear information and individual attention as I had long standing conjunctivitis and blepharitis as well as myopia. Felt fully prepared for the surgery and extremely confident in her skill. Delighted to wholeheartedly recommend both the procedure and Ms Saw. Can’t believe I didn’t have this done years ago!

    Emma Hawkes
  • Having a very high prescription most of my life was restricting in everyday life. I waited until I was ready to take the plunge and have the eye surgery (mainly due to confidence and checking to see what would be suitable for my high prescription). Ms Saw has been very helpful and supportive during the whole procedure and we have both been surprised and happy by the results of the surgery

    Deepkamal Bakhshi
  • Brilliant Service. Everyone was kind and helpful. Can now see my golf ball after playing my shot. Highly recommended.

    David Pollicott
  • "Calm and clear. I was particularly grateful for being able to contact Valerie both pre and post-surgery with questions. The teams both in Valerie’s practice and at Moorfields were friendly, reassuring and approachable. Thank you for taking such good care of my sight!"

    O. Robinson
  • I received the highest level of professional care from Valerie Saw and her team. I have a pre-existing condition, (Blepharitis) so was anxious about surgery. However, not only has Miss Saw corrected my vision, she has also greatly improved the Blepharitis symptoms with medication, which previous ophthalmologist, GP’s and opticians had not diagnosed/treated adequately. The surgery was quick, pain free and extremely professional. Thank you!

    Andrea Rees
  • After many years debating whether to have surgery I eventually booked an appointment with Ms Saw. Valerie and her team explained everything fully, addressed my worries and put me at ease. The procedure was easier than I thought it would be and I only wish I had done it sooner. Thanks to Ms Saw I do not need glasses anymore.

    Lynda Parker
  • I went to a number of eye clinics who all failed to spot my cataracts. Valerie was quick to diagnose and treat my various needs and swiftly achieved great results. If you are worried or in need of advice or quality care I would recommend Valerie.

    Nicholas Pollitt
  • The initial examination was thorough beyond all previous experience and her advice complete, informative and very reassuring. Taking the plunge I elected to have lasik surgery and the procedure was duly completed without pain in a calm and comforting environment by a scrupulously professional team led by Valerie. Despite the recent surgery there was an immediate and staggering improvement in my vision and within 12 hours I could read newsprint without the aid spectacles. It is now 4 months since the procedure and having undergone 3 equally thorough post operative checks the result continues to improve. I am now free to pursue my passion for wildlife photography and bird watching without the constant annoyance of spectacles hanging around my neck and the only regret is that I didn't have the procedure carried out years ago! If you are in any doubt forget it, make an appointment to see Valerie, put your trust in her abilities and enjoy a life changing experience. Brilliant!

    Nick Stantiford
  • The surgery itself was quick and (literally) painless. I am 3 months down the line and delighted, not only with the result but with the follow up care I received. I highly recommend Valerie and her whole team. I could not have done this without them!

    Verity Westcott
  • I am extremely glad I went with Valerie and her team, they were friendly, caring, informative and professional. The surgery was so quick, easy and pain free. I was extremely nervous about the procedure, just the thought made my stomach turn. Valerie and her team made me feel extremely relaxed and explained the procedure clearly to me. The nurses on the day were really helpful and explained all the aftercare drops to me. I still can’t believe I went through with it but so glad I did and would recommend it to anyone and would highly recommend going to Moorfields and having Valerie as your surgeon. Her voice is extremely calming whilst the procedure is taking place.

    Sarah Dean
  • Valerie was highly professional and very competent indeed and the Lasik surgery on my left eye went really well. The procedure was explained very clearly in advance and the procedure itself was quick and painless and has resulted in clear long distance vision in the eye. It all went very well and I can strongly recommend Valerie.

    Michael Hart
  • Ms Valerie Saw’s team were very attentive and helpful. I had LASEK surgery which has longer recovery time and is more painful. Ms Saw ensured the pain has kept to a minimum and even came in on a Saturday to check how my eyes were healing! All my questions were answered promptly.

    Jabin Ahmed
  • I was so afraid of this operation but Ms Saw has a calm and gentle manner which is so reassuring to the patient. Her skills are outstanding – I can’t remember being able to see from early childhood, but because of Ms Saw’s abilities a miracle has occurred and I can see when I open my eyes. I am so grateful to her.

    Brenda Garnham