Keratoconjunctivitis Sicca (Dry Eye Syndrome)

Keratoconjunctivitis sicca, also known as dry eye syndrome, is a common dysfunction of the eyes. It occurs when the eyes cannot produce tears or produce insufficient quantities of tears, or when there is an imbalance in the amount of oil, water and mucus in the tear fluid.

The condition is a common cause of ocular irritation, typically resulting in a feeling of grittiness in the eyes, redness and blurred vision, among other symptoms. 1 While there are numerous potential underlying causes of dry eye syndrome, some of the most common include long periods spent in front of TV or computer screens, aging and certain medical conditions, including Sjögren syndrome, allergic conjunctivitis and rheumatoid arthritis. 2

Keratoconjunctivitis sicca can generally be effectively managed, with the choice of treatment method dependent on the underlying cause, the symptoms and the severity of the condition. Mild cases may respond well to simple environmental changes or over-the-counter eye drops, while more severe cases may require treatment methods such as anti-inflammatory medication or surgery. 1

The symptoms of keratoconjunctivitis sicca are mild in most instances, but can nevertheless be highly troublesome for the affected person.

Symptoms typically affect both eyes and may include: 2 3

• Irritation and redness
• Dryness and grittiness
• A discharge of mucus
• Temporarily blurred vision
• Itching
• Sensitivity to light
• The sensation of a foreign-body in the eye
• Excessive tear production

Symptoms tend to be at their worst at the end of the day or after protracted use of the eyes; after driving, for example. 3 People experiencing possible symptoms of keratoconjunctivitis sicca can use the free Ada app to carry out a symptom assessment.

If any of the symptoms of dry eye syndrome persist or cause serious pain, medical attention should be sought.

Tears are composed of a mixture of oil, water and mucus, a combination that ensures the surface of the eyes remains smooth and clear, as well as protecting the eyes from infection. 4

Dry eye syndrome generally occurs for one of three reasons:

• The glands of the eyes are unable to create an adequate amount of tears
• The tears evaporate too rapidly
• There is an imbalance in the composition of the tears

One common cause of dry eye syndrome is an inability of the glands in the eyes to produce enough tears to keep them moist. Typical reasons for this include: 1

• Underlying medical conditions, including Sjögren syndrome, diabetes, rheumatoid arthritis, scleroderma, systemic lupus erythematosus, thyroid disorders and vitamin A deficiency
• Aging
• Certain medications including decongestants, antihistamines, hormone replacement therapy and antidepressants; medications used to treat high blood pressure, acne and Parkinson’s disease, as well as birth control drugs
• Laser eye surgery
• Damage to the tear glands from inflammation or radiation

Another common cause of dry eye syndrome is the evaporation of tears at an increased rate. Causes of this can include:

• Dry, windy, smoky or air-conditioned environments
• Blinking less often, typically when reading, driving, watching TV or using a computer
• Problems with the eyelids, such as ectropion, an out-turning of the eyelids, or entropion, an in-turning of the eyelids

The tear film that coats the eyes is composed of three substances, each with a different role within the eye: 4

• Lipid: The oily outer layer produced by the meibomian glands. Prevents tears from evaporating too quickly.
• Aqueous: The watery middle layer produced by the tear glands. Helps to nourish the cornea and the conjunctiva.
• Mucus: The inner layer produced by goblet cells. Aids in binding water to the eyes, helping them to stay moist.

Keratoconjunctivitis sicca can result from problems with any one of these layers. For example, the meibomian glands can become blocked, resulting in decreased production of oils or the production of lower-quality oils. 5

People experiencing any of the symptoms of keratoconjunctivitis sicca should visit a doctor or ophthalmologist, an eye specialist, as soon as possible. In addition, a symptom assessment using the free Ada app can be carried out.

Doctors may run a number of tests to identify the cause of the condition. These may include: 6

• Fluorescein eye test: Fluorescent eye drops are used to highlight the tears in the eyes, enabling a specialist to monitor how tears are being produced and how quickly they are evaporating. The drops may also show any damage to the surface of the eye.
• Schirmer’s test: Blotting paper is placed over the lower eyelids and left for five minutes. The wetness of the paper determines the diagnosis, with less than 10 mm indicating the presence of dry eye syndrome.
• Lissamine green test: A strip of paper containing a special dye is placed over the surface of the eyes, allowing specialists to identify any damage to the surface of the eye.

After being diagnosed with keratoconjunctivitis sicca, a specialist will recommend a treatment route appropriate to the underlying cause, the specific symptoms and the severity of the condition. There is no cure for dry eye syndrome, but it can be effectively managed.

Treatment may involve:

For people who experience keratoconjunctivitis sicca as a reaction to a certain medication, treatment may involve their doctor prescribing an alternative medication that is not associated with dry eyes.

Even if there is a suspicion that a certain type of medication is causing keratoconjunctivitis sicca, never stop taking medication without first consulting a doctor.

Mild cases of keratoconjunctivitis sicca may respond well to simple environmental and lifestyle changes. These may include: 1 4

• Taking regular breaks from time spent in front of TV, computer or phone screens.
• Taking steps to reduce dryness in the environment. This may involve using a humidifier, reducing the heating or hanging up a damp cloth.
• Wearing glasses or goggles when exposed to dry, dusty or windy environments.
• In some cases, warm eye compresses and scrubs may be useful.
• In some cases, stopping smoking or reducing exposure to secondhand smoke may be useful.

Lubricant treatments, sometimes called artificial tears, include eye drops, ointments and gels. They are often effective in mild to moderate cases of keratoconjunctivitis sicca, and most are available from pharmacists without a prescription. 8 At first, lubricant treatments may need to be used frequently – every hour, for example. Once symptoms begin to improve, they may be necessary less often. 1 Artificial tears containing preservatives should be avoided.

In severe or persistent cases, certain kinds of anti-inflammatory medications may be prescribed by a doctor. Generally, these medications will only be recommended if the condition does not respond to lubricants.

Anti-inflammatory medications include: 8

• Corticosteroid eye drops and ointments
• Oral tetracyclines, such as doxycycline, lymecycline and oxytetracycline
• Ciclosporin eye drops

In severe cases and depending on the case, surgery may be recommended as a treatment method for keratoconjunctivitis sicca.

A punctal occlusion is the most common type of surgery used for this purpose. The procedure involves inserting small plugs into the tear ducts, blocking the drainage route of tears and keeping the surface of the eyes moist as a result. Temporary plugs may be inserted at first to test the efficacy of the procedure. Later, more permanent plugs may be inserted.

More rarely, a procedure known as a salivary gland autotransplantation may be carried out. This procedure involves transplanting glands responsible for the production of saliva from the lower lip to the area around the eyes. The saliva is then used as a substitute for tears. 8

In very rare cases, when all alternative treatment methods have proven ineffective, serum eye drops may be recommended.

Serum eye drops are created by removing the blood cells from the blood of the affected person or that of a donor, leaving just the serum, which is then combined with a diluent and contained in a dropper bottle. 8 Due to the complexity of the process, serum eye drops can take several months to produce.

Q: Are there any home remedies for keratoconjunctivitis sicca?
A: Yes, there are a number of home remedies for dry eye syndrome, including:

• Warm compresses: In some cases, irritation can be reduced and the meibomian glands unclogged through the application of a warm compress. To do this, wet a clean cloth with warm water, place it over the eyes and gently dab the corners of the eyes. This may be necessary every day.
• Hygiene: Keeping the eyelids and areas surrounding the eyes clean, including the lashes,can help prevent dry eyes. A small amount of mild cleanser or shampoo can be used to clean this area. Avoiding excessive touching of the eyes can also help keep the eyes clean.
• Hydration: A person can stay hydrated by drinking sufficient amounts of water, roughly 8 to 10 glasses daily. This can help the eyes to stay moist.
• Environmental and lifestyle changes: Measures such as avoiding overly-dry environments and taking regular breaks from activities, such as watching TV and using the computer can be effective in managing dry eyes.

Q: Should I be worried about blurred vision as a result of keratoconjunctivitis sicca?
A: Temporarily blurred vision can be a symptom of keratoconjunctivitis sicca. Although an inconvenience, it can usually be managed through treatment. However, those who experience blurred vision should seek medical attention, as, in rare cases, it can be a symptom of a more serious condition.

Q: What can I do when my eyes feel dry?
A: If your eyes begin to feel dry during activities such as driving, reading or using a computer, it is a good idea to take frequent breaks to allow the tear film to refresh. You should also remember to blink frequently. Laying a clean damp cloth over your eyes may also be effective in re-moisturising the eyes. Hanging up a damp cloth may also be effective in reducing the dryness in the environment.

Q: Is there a surgical method of treatment for keratoconjunctivitis sicca?
A: Yes, a minor, non-invasive surgical procedure to insert punctal plugs can be used to treat dry eye syndrome. These tiny plugs are placed into the opening of the tear ducts in the eyes. They work by blocking the drainage of tears from the eyes, keeping them lubricated. Surgery will generally only be recommended in some patients after other treatment methods have proven unsuccessful.

Q: What is the relationship between keratoconjunctivitis sicca and meibomian gland dysfunction (MGD)?
A: Meibomian gland dysfunction (MGD) is among the leading causes of keratoconjunctivitis sicca. The condition occurs when the glands responsible for the oily component in tears cease to function, preventing the oily component from being released and causing the watery component to dry out more quickly. 10

Q: What is the relationship between dry eye syndrome and Sjögren syndrome?
A: Sjögren syndrome is an autoimmune disorder. Its principal symptom is dryness of the eyes and mouth. As such, Sjögren syndrome is one of the leading causes of dry eye syndrome.