Many patients with EMS develop dry eye syndrome. This condition is
characterized by burning, discomfort, irritation and scratchiness in the eye as
if a foreign object might be present. Symptoms can range from very mild to very
severe. Often, blurred vision accompanies these symptoms. Many patients with
this syndrome just have a chronic feeling that their eyes are tired.
This syndrome stems from an inadequate tear film coating the eye. The outer
surface of the eye is a mucous membrane, like the throat and needs to be moist.
If one’s throat is dry, then the throat becomes irritated, scratchy and
uncomfortable. An identical phenomenon occurs when the eye dries and leads to
dry eye syndrome.
The tear film which keeps the eye moist is not actually composed of water but
is more like the oil film which coats the skin and prevents the skin from
drying. Most people with dry skin realize that if they apply water to the skin,
this pulls the natural oil off the skin and dries it even more. An identical
process occurs when patients with a dry eye have excess tearing. If the tear
film is deficient or evaporates, then often patients will have reflex tearing
which is the body’s attempt to relubricate the eye. Unfortunately, these tears
are the watery type of tears similar to that produced when someone cries. These
tears actually make the problem even worse by pulling the oil film off the eye
and drying the eye even more.
The initial treatment for dry eye syndrome involves the use of artificial
tears. These drops are designed to mimic the natural tear film of the eye and
keep the eye better lubricated. Often, by using these drops, patients experience
significant relief of their symptoms. The frequency with which patients need to
apply these drops can vary dramatically. Some patients need to instill a drop
every hour while others may only need to use the drop several times a day. The
drops are not harmful and patients can use them as frequently as they would
The drops are available in any pharmacy as an over-the-counter product.
Patients should use the drops which are labeled as lubricating eye drops.
Solutions designed for itchy eyes, allergic symptoms, or to get the red out,
should not be used since the clearing agents in these drops will often irritate
the eye. Preservative-free drops are also available as an over-the-counter
product. These tend to be more expensive than regular artificial tears and
really are no better than the regular artificial tears unless people are
allergic to the preservative.
In many instances, artificial tears alone fail to completely relieve the dry
eye symptoms. In these cases patients can often achieve dramatic relief with the
use of punctal plugs. In the corner of the lower eyelid is a small opening
called the punctum which leads through a drainage system into the nose. This is
the normal mechanism whereby excess tear and oil film is removed from the eye.
Unfortunately, in patients with a dry eye, as soon as any moisture or
lubrication is made, it tends to run right out the drain. These drains can be
occluded with a small silastic plug. By doing this, as noted above, it will
often make people significantly more comfortable.
These occluding plugs can be placed in each drain through a very brief
procedure done in the physician’s office. No anesthetic is required and there
are no risks, side effects or complications associated with the procedure.
Initially, temporary or dissolvable plugs are placed in the punctum. These
last for approximately five to seven days and allow the patient to experience
what it is like to have the eye better lubricated. The temporary plugs do not
block the punctal drain as well as the permanent plugs. As a result, a temporary
plug is placed both in the drainage hole of the upper and lower lids. This is to
allow the patient to experience the maximal lubrication possible to see if the
plugs will have a good effect.
The more permanent plugs block the drain completely. Eighty percent of the
tears drain out the lower lid while 20% drain out the upper lid. As a result,
the more permanent plug is placed just in the lower lid. This typically achieves
good lubrication for the patient while allowing the excess overflow tears to
drain out the upper lid.
The beauty of the above approach is that the temporary plug allows the
patient to experience the benefit of eye lubrication before moving forward. Even
the permanent plug can be easily removed, if for any reason, the patient feels
this is necessary. Some doctors will treat this condition by using a heat
cautery to seal over the drainage hole. Although this is also a simple procedure
which can be performed in the office, I personally do not favor this approach
because it is much more difficult to reverse if for any reason the patient does
not like it.
My personal recommendation to any patient with EMS and dry eye syndrome would
be to initially try artificial tears on a very frequent basis even up to every
three to four hours to see if this relieves their symptoms. If it did not, I
would encourage them to move ahead with punctal plugs.
Copyright 1996 Richard Tipperman, M.D.
Dr. Tipperman did his residency and was Chief Resident at Wills Eye Hospital. He is on the staff at Wills Eye Hospital and does private practice in Philadelphia. He has special interest in cataract surgery and management of complications of cataract surgery. Each person should seek the advice of their own medical professional for their own situation. The information contained in this article is of a general nature.