Dry eyeBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7533 (Published 15 November 2012) Cite this as: BMJ 2012;345:e7533
- Louis Tong, senior consultant ophthalmologist 1, associate professor2,
- Jeremy Tan, family physician3, lecturer4,
- Julian Thumboo, adjunct professor4, head and senior consultant5,
- Gabriel Seow, family physician6
- 1Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore
- 2Office of Clinical Sciences, Duke-NUS Graduate Medical School, Singapore
- 3Faith Medical Group, 211 Toa Payoh Lorong 8, #01-19, Singapore
- 4Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- 5Department of Rheumatology and Immunology, Singapore General Hospital, Singapore
- 6Woodlands Clinic, Blk 131, Marsiling Rise #01-204, Singapore
- Correspondence to: L Tong, Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751
- Accepted 31 October 2012
A 30 year old woman visits her general practitioner complaining of itchy eyes for six months, aggravated by computer use in her job as a clerk. Dry eye is a common multifactorial condition of the tear and ocular surface. In ambulatory settings it may commonly result from increased tear evaporation (resulting from, for example, blepharitis or contact lens wear); tear hyposecretion (from, for example, age related or anticholinergic drugs); and mucous dysfunction (mucus secreting goblet cells in the conjunctiva may be damaged after previous infectious conjunctivitis). Severe dry eye resulting from systemic diseases is uncommon in primary care but conditions predisposing to dry eye should be documented (box ).
What you should cover
Are the symptoms consistent with dry eye?—Ask about symptoms of dry eye, such as chronic burning, grittiness, and visual fluctuations. Paradoxically, patients may complain of watery eyes owing to eye irritation and reflex tearing. A complaint strongly suggestive of dry eye is worsening of symptoms by prolonged visual tasks, exposure to wind, and air conditioning.
Is the dry eye part of a systemic condition?—Take note of a dry mouth (suggesting Sjögren’s syndrome), and review for common systemic illnesses and drugs that worsen dry eye (box). Ask about history of orbital radiation and any ocular (especially refractive), facial, and intracranial surgery.
Are there any red flags?—Warning signs of more serious conditions include an acute history, persistent or profound visual loss, associated diplopia, and systemic ill health evidenced by loss of weight or fever.
Systemic causes of dry eye
Post-menopausal state* or post-oophorectomy
Mucous membrane pemphigoid
Tricyclic antidepressants (anticholinergic effect)*
Antihistamines (anticholinergic effect)*
Lacrimal gland related
Lymphoma and leukaemia
Primary Sjögren’s syndrome
Secondary Sjögren’s syndrome (that is, associated with systemic lupus erythematosus, rheumatoid arthritis, or other autoimmune diseases)
*The most common systemic causes of dry eye found in general practice
Mild conjunctival redness or a grossly normal eye could indicate dry eye. Dry eye may be confused with allergic and infective conjunctivitis. A series of steps can help doctors to make a probable diagnosis:
Inspect and evert lids. Large subtarsal papillae suggest allergic conjunctivitis, especially in a patient with a history of atopy, asthma, eczema, or contact lens use. Subtarsal petechiae or membranes suggest infective conjunctivitis
Conjunctiva. Look for copious discharge or chemosis suggesting infective conjunctivitis, and sectorial redness suggesting episcleritis
Proptosis and lid lag suggest thyroid eye disease
Red reflex. Irregular pupil suggest uveitis
Visual acuity should not be severely impaired in dry eye, as blinking helps to maintain normal acuity during examination.
The examination should focus on: the skin (acne, eczema, malar rash, target lesions); finger joints (features of rheumatoid arthritis); neck (goitre); Parkinsonian features (in Parkinson’s disease there is reduced blinking, resulting in excessive tear evaporation between blinks).
Schirmer’s testing, fluorescein dye, and slit lamp microscopes are needed for a formal diagnosis of dry eye, and community optometrists have access to these.
What you should do
Reassure the patient if no red flags are present. Dry eye is a chronic condition but does not threaten sight.
Start artificial tears (lubricant eye drops), the mainstay of management. Reassure the patients that preservative-free formulations can be used as often as desired and titrated to visual activities. If initial formulations do not relieve symptoms, consider adding transient gels, or hypo-osmolar eye drops that contain hyaluronate and lipids. Ointments and viscous gels are best used before bedtime as these induce blurring. Some trial and error may be necessary to determine what is most comfortable for each patient.
Consider aggravating factors, such as (a) contact lenses—these should be removed for the day when dry eye symptoms appear, and patients could consider the newer silicon-hydrogel or rigid gas permeable lenses if they need to continue wearing contact lenses; (b) drugs with antimuscarinic side effects—for patients taking tricyclic antidepressants, consider alternatives such as selective serotonin reuptake inhibitors (also, the use of oral antihistamines should not be prolonged unnecessarily).
Manage commonly associated conditions. Ocular irritation will improve if allergic conjunctivitis, blepharitis, and rosacea are treated.
Refer to an ophthalmologist (a) urgently, if the red flags mentioned above are detected; and (b) routinely, if symptoms persist (may need punctal plugs, ciclosporin, and steroids).
Dry Eye Company (www.dryeyezone.com)—US resource for treatment and relief of severe or chronic dry eye conditions
Clinical Knowledge Summaries (www.cks.nhs.uk/dry_eye_syndrome)—Diagnosis and management information about dry eye
Prodigy (http://prodigy.clarity.co.uk/dry_eye_syndrome)—Diagnosis and management information about dry eye
2007 Report of the International Dry Eye WorkShop (DEWS). Ocular Surface 2007(5). www.tearfilm.org/dewsreport/pdfs/TOS-0502-DEWS-noAds.pdf
Cite this as: BMJ 2012;345:e7533
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: LT was supported for the submitted work by the Singapore National Research Foundation under its clinician scientist award NMRC/CSA/013/2009 and administered by the Singapore Ministry of Health’s National Medical Research Council, and by the Singapore Ministry of Health’s National Medical Research Council under its individual research grant NMRC/1206/2009 and centre grant NMRC/CG/SERI/2010. All authors have no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.