Dry eye: diagnosis and management

What is dry eye?

Dry eye, or dry eye disease in the international terminology, has been defined since 2017 by the landmark TFOS DEWS II report as a multifactorial disease of the ocular surface, characterised by a loss of homeostasis of the tear film accompanied by ocular symptoms. Three mechanisms interact: tear film instability, tear hyperosmolarity and ocular surface inflammation, to which neurosensory abnormalities are added.

Clinically, two main forms are distinguished, often intertwined:

• Aqueous-deficient dry eye — tear production is insufficient (less active lacrimal glands, autoimmune disease, drug-induced causes).
• Evaporative dry eye — the lipid layer of the tear film is altered and the tear evaporates too quickly. The most common cause: meibomian gland dysfunction (MGD) along the eyelid margins.

In the majority of cases seen in practice, both mechanisms coexist to varying degrees. This distinction matters because it guides treatment.

Most common symptoms

Symptoms vary considerably from one patient to another. Those most frequently reported in consultation:

• A sensation of sand, grit or a foreign body in the eyes
• Prickling, burning, itching
• Red eyes, heavy eyelids at the end of the day
• Fluctuating vision that improves after repeated blinking
• Visual fatigue while looking at screens, difficulty sustaining prolonged reading
• Photophobia (sensitivity to light), paradoxical watering (the eye reacts with a reflex hypersecretion)
• Intolerance to wearing contact lenses

The intensity of symptoms does not always correlate with the objective severity of the condition. Some very bothered patients have an unremarkable examination; others present with significant corneal involvement and few complaints. This dissociation explains why an objective assessment is essential.

Causes and risk factors

Dry eye is the result of several mechanisms that combine. The main contributing factors identified:

• Age — tear production and film quality gradually decline after the age of 50.
• Female sex and menopause — the drop in oestrogen affects the ocular surface and the meibomian glands.
• Prolonged screen work — the blink rate falls from 15-20 per minute to fewer than 5, promoting evaporation.
• Contact lens wear — even when well tolerated, lenses weaken the ocular surface over the long term.
• Meibomian gland dysfunction (MGD) and chronic blepharitis — the major cause of the evaporative form.
• Prior refractive surgery (LASIK, PRK) — responsible for transient dryness in a majority of patients in the weeks following the procedure; hence the importance of the preoperative assessment.
• Autoimmune diseases — Sjögren’s syndrome first and foremost, rheumatoid arthritis, lupus.
• Medications — antihistamines, antidepressants, beta-blockers, diuretics, hormonal treatments.
• Environment — air conditioning, heating, pollution, exposure to wind.

Diagnosis in the practice

The diagnosis of dry eye rests on the combination of a structured interview and objective tests. Complaints alone are not enough: the assessment makes it possible to quantify the condition, identify the dominant form (aqueous-deficient or evaporative) and guide treatment.

Slit-lamp examination

Examination of the eyelids and eyelid margins to look for blepharitis or meibomian dysfunction (obstruction of the gland orifices, thickened secretions). Examination of the conjunctiva and cornea, looking for hyperaemia, a chalazion, or inflammatory signs.

Measuring tear film break-up time (NIBUT) with the Sirius topographer

At the Cachan practice, I use the Sirius topographer (CSO) to measure the NIBUT (Non-Invasive Breakup Time) — the time it takes for the tear film to break up spontaneously between two blinks. Unlike the conventional fluorescein test, this measurement is non-invasive (no instillation of dye that would disturb the film) and reproducible.

A NIBUT below 10 seconds is considered abnormal; below 5 seconds, the dryness is severe. This measurement is particularly valuable in two situations:

• Preoperative refractive surgery assessment — undetected pre-existing dryness can worsen significantly after LASIK or PRK and delay visual recovery. Screening and treating it before the procedure changes the prognosis.
• Treatment follow-up — comparing NIBUT before and after treatment provides an objective measure of improvement.

Schirmer test and corneal staining

The Schirmer test measures tear production in millimetres on a strip placed in the conjunctival fornix for 5 minutes. A result below 5 mm indicates marked aqueous-deficient dryness.

Fluorescein and lissamine green staining reveals punctate involvement of the cornea and conjunctiva (superficial punctate keratitis), graded according to the Oxford scale. They document the objective severity of the involvement. Epithelial thickness mapping complements this assessment by objectively imaging corneal surface involvement: its diagnostic value in ocular surface disorders was studied in a comparative study co-authored by Dr Tourabaly (Cornea, 2022).

Management in the practice

The treatment of dry eye follows a progressive, stepwise logic, according to the objective severity and the discomfort experienced. The aim is to restore a stable ocular surface, reduce chronic inflammation and improve day-to-day comfort. Treatment is tailored individually after a full assessment.

Step 1 — Hygiene measures and tear substitutes

The first step combines simple but effective measures:

• Preservative-free artificial tears — to be instilled several times a day depending on the discomfort, with a composition tailored (sodium hyaluronate, trehalose, carbomer) and chosen according to the dryness profile.
• Daily eyelid hygiene — gentle cleansing of the eyelid margins with specific wipes or dedicated gel, warm compresses to loosen the meibomian secretions in cases of blepharitis.
• Environmental rules — regular screen breaks (the 20-20-20 rule: every 20 minutes, look at something 6 metres away for 20 seconds), humidifying indoor air, protection against wind.
• Omega-3 supplementation — some studies suggest a favourable effect on tear stability, although the data remain heterogeneous.

Step 2 — Eyelid care and anti-inflammatory treatment

When artificial tears are not enough, active management is built around three complementary approaches: daily eyelid care to restore the meibomian glands, a short course of topical azithromycin in cases of posterior blepharitis, and, if inflammation persists, 0.1% ciclosporin eye drops.

Daily eyelid care

For the evaporative form linked to meibomian dysfunction — the most common — local care is essential: 10-minute warm compresses once or twice a day to loosen the meibomian secretions, gentle eyelid massage from the margin towards the centre after the compress to express the obstructed secretions, and cleansing of the eyelid margin morning and evening with dedicated wipes or a fragrance- and alcohol-free gel. Consistency makes the result: neglected care quickly loses its benefit, whereas daily care transforms the quality of the tear film within a few weeks.

Course of azithromycin 1.5% eye drops

In cases of posterior blepharitis or meibomian dysfunction resistant to local care alone, I prescribe a short course of azithromycin 1.5% eye drops, one drop morning and evening for 3 days. This molecule combines a local anti-inflammatory action and a targeted antibacterial effect on the eyelid flora. The course can be repeated monthly as maintenance treatment, depending on the evolution. The study by Foulks et al. (Cornea, 2010, PMID 20489573) demonstrated clinical improvement and the restoration of meibomian lipid properties under topical azithromycin; it studied the 1% formulation, twice daily for two days then once daily for four weeks. The short 1.5% regimen, twice daily for three days, is that of the formulation marketed in Europe and reflects the protocol of my practice: it is neither the concentration nor the duration that this study tested.

Ciclosporin 0.1% eye drops

In persistent inflammatory forms, particularly with associated keratitis or Sjögren’s syndrome, treatment with ciclosporin 0.1% eye drops (one drop in the evening at bedtime) acts on the chronic inflammation of the ocular surface — a central mechanism in persistent dryness according to the recommendations of the TFOS DEWS II Management and Therapy Report (Jones et al., Ocul Surf, 2017).

Practical points to know:

• Gradual clinical effect, generally visible after 4 to 6 weeks — consistency is essential.
• Possible stinging on instillation, especially in the first weeks, which eases over time.
• Instilling in the evening at bedtime limits discomfort during the day.

Step 3 — Punctal plugs (lacrimal occlusion)

Punctal plugs (punctal plugs) are small collagen or silicone devices that I place in the lower lacrimal puncta — sometimes the upper ones — to slow the drainage of tears towards the tear ducts. The tears produced remain in contact with the ocular surface for longer, which improves hydration and comfort.

This technique is useful in confirmed aqueous-deficient forms (low Schirmer, partial response to medical treatments). It is performed in consultation, without anaesthesia, in a few minutes. Collagen plugs are absorbable (a temporary test over 3 to 6 months); silicone plugs are permanent but removable at any time.

This step is only offered after failure of, or an insufficient response to, the preceding steps, and on an objective assessment consistent with aqueous-deficient involvement.

Complementary treatments not performed in the practice

Pulsed light (IPL, Intense Pulsed Light) is an emerging treatment for severe evaporative forms linked to meibomian gland dysfunction, acting on the local inflammatory burden and on the secretion of the meibomian glands. I do not currently perform IPL in the practice; when the indication is confirmed after a full assessment, referral to a specialised centre can be proposed, and follow-up is coordinated between the two facilities.

Patient pathway

The management of dry eye is provided in both of my offices, with dedicated equipment:

• Cachan office (94) — Sirius topographer for NIBUT measurement, particularly indicated for patients concerned by refractive surgery (systematic preoperative assessment). Telephone: +33 1 45 47 08 11.
• Paris 13 office — Diabet’ — diagnosis and follow-up of dry eye as part of general ophthalmology and retina consultations. Telephone: +33 1 89 31 30 60.

Appointments can be booked directly on Doctolib. The first consultation includes the structured interview, the slit-lamp examination, the objective tests (Schirmer, staining) and, at the Cachan office, the NIBUT measurement. A treatment plan is proposed at the end of the assessment, with follow-up at 4 to 6 weeks to evaluate the response.

Frequently asked questions

Sources

1. Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II Definition and Classification Report. Ocul Surf. 2017;15(3):276-283. PMID: 28736335
2. Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628. PMID: 28736343
3. Foulks GN, Borchman D, Yappert M, et al. Topical azithromycin therapy for meibomian gland dysfunction: clinical response and lipid alterations. Cornea. 2010;29(7):781-788. PMID: 20489573

This article is for informational purposes. A personalised ophthalmological opinion remains essential for any treatment decision.