Rose-colored sunsets, white sandy beaches, forests of fall foliage — there’s a lot of beauty to see in this world, but it’s hard to enjoy it when you’re dealing with dry eye. This painful eye condition happens when there isn’t enough lubrication in the eyes. Dry eye generally occurs because of one or more of the following factors:
- Inadequate production of tears
- Excess evaporation of tears
- Production of “poor quality” tears, which don’t have the right balance of water, fatty oils, and mucus
Ironically, you may even experience tears streaming down your face because your body is trying to overcompensate for the dryness — but these tears likely don’t have enough lubrication, which can be quite frustrating.
Dry eye disease can happen to anyone, but it’s more common among people with certain autoimmune diseases, including Sjögren’s syndrome, rheumatoid arthritis, lupus, and scleroderma. In these conditions, the same immune system antibodies that attack other parts of the body — such as the joints, connective tissue, and skin — also attack cells in the eyes that disrupt normal tear production. Read more here about how different kinds of arthritis can affect your eyes.
“One of the hallmarks of Sjögren’s syndrome is dry eye, so most patients with Sjögren’s syndrome are aware of their dry eye,” says Danielle Trief, MD, ophthalmologist and assistant professor at the Edward S. Harkness Eye Institute at Columbia University Medical Center in New York City. “However, many patients with arthritis, especially autoimmune arthritis like rheumatoid arthritis, have dry eye but aren’t aware of that connection.”
Not only can having dry eye make everyday activities, such as reading or driving, more difficult, but it can cause serious long-term eye damage, including infection and scarring. This makes it all the more important to treat dry eye and prevent recurring bouts.
Read on for more information about dry eye symptoms, treatment, and prevention.
Symptoms of Dry Eye
Symptoms of dry eye may include any or all of the following, according to the Mayo Clinic:
- A scratching or burning feeling in your eyes
- Red eyes
- Sensitivity to light
- Feeling like something is stuck in your eye (grittiness)
- Stringy mucus around your eye
- Discomfort or inability to wear contact lenses
- Trouble driving at night
- Blurred vision
- Watery eyes
People who have dry eye due to Sjögren’s syndrome are more apt to experience dryness elsewhere, such as dry mouth and vaginal dryness. They may also start experiencing dry eye at a younger age.
Causes of Dry Eye
Many different factors can contribute to dry eye. These include:
- Normal aging (the body naturally produces fewer tears with age)
- Hormonal changes during menopause
- Taking certain medications, such as antihistamines, decongestants, antidepressants, and drugs for high blood pressure
- Everyday habits such as looking at a computer screen for too long
- Medical conditions, including certain autoimmune diseases, especially those in the arthritis family
Types of Arthritis and Related Diseases Linked with Dry Eye
Sjögren’s syndrome is a chronic inflammatory autoimmune disease in which the body’s mucous membranes, especially those in the eyes and the mouth, become extremely dry. Immune system cells are attacking the lacrimal glands in the eye, which is what makes tears, explains Dr. Trief.
Primary Sjögren’s occurs without any other diseases; secondary Sjögren’s occurs along with other autoimmune diseases such as lupus or rheumatoid arthritis. About half of people with Sjögren’s have these other conditions, according to the American College of Rheumatology. A Sjögren’s Syndrome Foundation survey revealed that dry eye symptoms were the most bothersome and activity-limiting aspect of Sjögren’s.
Rheumatoid arthritis is a chronic inflammatory autoimmune disease in which the body’s immune system starts attacking the joints, causing telltale inflammation, pain, and stiffness, often first in the small joints of the hands and feet. Many people with rheumatoid arthritis also have Sjögren’s or other eye-related issues. One study published in the journal Investigative Ophthalmology & Visual Science found that 44 percent of RA patients surveyed had a diagnosis of dry eye disease. According to the American Academy of Ophthalmology, dry eye syndrome is the most common “ocular manifestation” of rheumatoid arthritis.
Lupus is a chronic inflammatory autoimmune disease in which the body’s immune system can attack multiple organs and systems, including the joints, skin, heart and blood vessels, kidneys, lungs, and brain. Eye manifestations of lupus are common; many people with lupus also have Sjögren’s syndrome as well as other eye-related issues. Dry eye is the most common way lupus affects the eyes, according to a study in the journal Rheumatology, affecting about one-third of lupus patients. The study reports that “usually, symptoms are relatively mild (irritation, redness) but severe pain and visual loss may occur.”
Also known as systemic sclerosis, scleroderma is a chronic inflammatory autoimmune disease in which the body’s immune system attacks connective tissue, such as collagen in the skin, causing changes in the skin’s texture and appearance. But scleroderma can also affect other parts of the body, including blood vessels, muscles, and organs such as the heart, lungs, and kidneys. Research shows eye problems are common in people with scleroderma; research indicates it may affect anywhere from 40 to 80 percent of people.
Treatment for Dry Eye from Arthritis and Autoimmune Diseases
First, if you have symptoms of dry eye, it’s important to see an eye doctor and your rheumatologist for a thorough evaluation. It’s not a good idea to attempt to self-treat your symptoms with eye drops because dry eye can cause long-term damage if it is not properly treated. Inflammatory arthritis and other autoimmune diseases can cause other eye problems in addition to dry eye and you need a professional evaluation to figure out what’s behind your symptoms and how to optimally treat them.
Medication, lenses, devices
Over-the-counter eye drops
People with mild symptoms may be able to use over-the-counter eye drops, also known as artificial tears (they come in gel or ointment form as well), which can help lubricate the eyes.
Topical cyclosporine (Restasis) eye drops
This is a very common type of prescription eye drop that helps relieve inflammation in the eye which can, in turn, help boost tear production.
Lifitegrast (Xiidra) eye drops
Lifitegrast also helps reduce inflammation in the eye and is a common prescription for those with an autoimmune disorder and dry eye, says Dr. Trief.
Corticosteroid eye drops
Your doctor may also recommend corticosteroid eye drops. These eye drops, however, should not be used for long periods of time because this can increase the risk of vision-related side effects such as glaucoma and cataracts.
These tiny inserts of the medication hydroxypropyl cellulose (Lacrisert) are like a slow-release version of artificial tears. About the size of a grain of rice, you place them in your eye (between your lower eyelid and eyeball) once a day.
“Sjögren’s is caused by a lack of tear production, so we want to take measures to keep tears around, and punctal plugs help with this,” says Dr. Trief. These are little plugs that doctors put in the eyelids — where the tears drain — to keep those tears around longer, says Dr. Trief. While there are permanent punctal plugs, more commonly doctors use the temporary variety, notes Dr. Trief.
Medication that stimulates tear production
A class of medication called cholingerics help to promote tear production. They are available in eyedrop, pill, or gel form. Names include pilocarpine (Salagen) and cevimeline (Evoxac).
Autologous blood serum drops
If you have very severe dry eye and other treatments aren’t helping, your doctor may recommend this option, which uses components from a sample of your own blood — which has vitamins and growth factors that more closely mimic real tears — with ingredients to make artificial tears. “They are essentially supercharged artificial tears because they have our natural proteins and growth factors to help heal sometimes a very sick ocular surface,” says Dr. Trief.
“There are a few challenges with these — they are expensive, they need to be specially made by drawing blood, they need to be refrigerated, and they expire fairly quickly,” adds Dr. Trief. Because of all of these factors, she usually only recommends blood serum tears when more conservative measures fail.
Moisture chamber spectacles
These are specially outfitted glasses with a gasket, or cup, that rests between the glasses frame and your face to help to slow down the evaporation of tears by acting as a barrier against wind and other drying factors in the environment.
“There are special contact lenses, called scleral lenses, used for people with bad ocular surface disease, for example after chemical injury, burn, or graft-versus-host-disease,” says Dr. Trief. The most famous of these lenses is called a PROSE lens, which vaults over the cornea so that there is a well of fluid always in contact with the eye. “This would not be routinely used for Sjögren’s, except in very severe cases,” says Dr. Trief.
This is an eyelid surgery that’s done to partially close the eyelid. “While uncommon, we will sometimes do this if the eyelids don’t close properly — like if you have exposure keratopathy,” says Dr. Trief. Exposure keratopathy is damage to the eye that occurs from prolonged exposure to the outside environment.
Use of amniotic membrane
Human amniotic membrane (AM) — in the form of sheets that are placed in the eye or as specialized contact lenses — can help treat severe forms of dry eye. The amniotic membrane has anti-inflammatory properties, however, when it is in place, it blurs the vision. “I usually keep these in for one to two weeks. The benefit is usually not permanent, though if there is a scratch on the cornea from severe Sjögren’s, it can promote healing,” says Dr. Trief.
This is an antibiotic that helps particularly well with meibomian gland dysfunction (when there is a blockage of these glands), which lowers the amount of oil secreted in tear production.
Some patients with Sjögren’s syndrome that is affecting other organs and systems may be prescribed such medications such as:
- Hydroxychloroquine (Plaquenil), an antimalarial drug also used to treat rheumatoid arthritis and lupus; it can help with the joint pain and rashes that some Sjögren’s patients experience
- Oral corticosteroids, such as prednisone
- Other immune-suppressing medications, such as methotrexate, azathioprine, mycophenolate, and cyclophosphamide
- Rituximab, a biologic drug that targets certain immune system pathways to decrease inflammation
While some doctors prescribe omega-3 fatty acids for dry eye, one large study found that when patients took 3,000 mg of omega-3 fatty acids for 12 months, they didn’t show any real benefits compared to people taking a placebo.
Some patients may also be advised to try a liposomal spray. This is an eye spray that helps the outer, lipid layer of your eye to ease the discomfort. Research shows some brands work better than others, so it’s important to talk to your doctor before using them.
People with chronic inflammatory diseases and dry eye disease should see an ophthalmologist regularly to watch for early signs of eye damage and to ensure treatment as soon as possible.
For mild cases of dry eye, lifestyle changes also help you feel better. Even for more severe cases, it’s important to keep up these lifestyle changes — like minimizing that screen time — but you’ll likely need to use medication as well to help ease the discomfort. “Making adjustments to your life, like taking a break from the computer, can be helpful for everyone,” says Dr. Trief.
Take visual breaks
If you’re having trouble doing things like reading a book or writing emails on your computer — anything that requires visual focus, go on a quick eye holiday. Switch up tasks or close your eyes for a minute or two, and blink often, which helps move the tears evenly over your eyes.
Add moisture to your environment
Do you live in a dry home? Especially during the winter, the air in your house can get dry, which isn’t ideal for your eyes. Try moisturizing the inside of your home with a humidifier, suggests Elena Schiopu, MD, a rheumatologist and assistant professor at Michigan Medicine in Ann Arbor.
Keep wind away
Wind in your eyes can exacerbate eye dryness. If possible, do your best to avoid hair dryers pointed toward your eyes and car heating or air conditioning that blasts air toward your face. When outside, wear wrap-around sunglasses to prevent wind from irritating the front and sides of your eyes. On very windy days, consider staying indoors.
You’ve probably heard that exercise can help prevent heart disease and relieve joint pain, but did you know that physical activity helps with dry eye too? “Exercise can help reduce inflammation and maybe alleviate some of the consequences of Sjögren’s,” says Dr. Schiopu. One possible explanation: Movement increases blood flow, which can help encourage the release of oils needed for healthy tears.
Handle your tech wisely
Spending too much time with computer and phone screens can contribute to dry eye. One way to reduce dry eye issues that can be caused by your tech: Position your computer screen so it’s below eye level. When your screen is higher than eye level, you have to open your eyes wider, which can accelerate the evaporation of the tears resting on your eyes.
Try a warm compress
There are little glands on the eyelid called meibomian glands, which provide the oil for tear film, explains Dr. Trief. “These can easily get clogged up, so to keep the oils flowing well you can use a warm compress or heat on your eyelid to open them,” says Dr. Trief.
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Interview with Danielle Trief, MD, Columbia University Medical Center
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