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Dry Eyes – Are you Dry, Droopy, or Dysfunctional?

Posted // Tuesday, July 30, 2013
By: Dr. Christian Hester

Millions of Americans are affected by dry eye disease. While a person may have mild dry eyes with little bother, another person may have a severe form that can cause blindness. Most patients with dry eye diseases can be divided into one of three categories: dry, droopy or dysfunctional. So when I evaluate a patient with dry eyes, I ask myself, “Is my patient dry, droopy, or dysfunctional?”

Here is how I can tell if a person’s eyes are dry, droopy or dysfunctional and the common treatments to fix the problem.


In the dry category, people have dry eye disease because they don’t produce enough aqueous (watery) component for tears.

First-line treatments include minimizing environmental irritants, lubricating eyes with over-the-counter artificial tears up to four times a day, and/or placing plugs in the opening of the tear drainage duct so that tears stay longer. Common environmental factors include increased screen time and fans. When we look at a computer or TV screen for hours, our blink rates decrease. Every now and then you should look away and blink several times. While fans keep us cool during the summer, the circulating air can dry the eyes’ surface. If you need to use a fan and have dry eyes, make sure that it is not blowing toward the eyes.

Second-line treatments include prescription medicines such as Restasis (cyclosporine) and increasing the frequency of artificial tears. Restasis is thought to increase tear production by decreasing inflammation. If you use artificial tears more than four times a day, you should use preservative-free artificial tears (they come in clear individual vials) since excessive amounts of preservatives can damage to the eye’s surface.

Third-line treatments include serum tears and the PROSE lens. For serum tears, a patient’s blood is drawn, processed, and stored in small tubes. Serum tears contain growth factors, fibronectin, and other components produced by our bodies that promote healing of the eye’s surface. The PROSE (Prosthetis Replacement of the Ocular Surface Ecosystem) lens is a customized prosthetic device that maintains a reservoir of fluid over the eye’s surface. This treatment is a viable option when all other treatments have failed.


Gravity and age have a way of conspiring against us and unfortunately, eyes are not immune either. An under-recognized cause of dryness on the eye’s surface is a condition called conjunctivochalasis. In this condition, the transparent membrane that overlies the white of the eye becomes droopy. As a result, tears get trapped in the tissue folds and cannot properly distribute across the eye’s surface. This condition can be corrected with an in-office “nip-tuck” procedure.


When it comes to dysfunctional eyes, meibomian gland dysfunction is most common. We have approximately 75 tiny glands that reside just behind our eyelashes. Dysfunction of these glands commonly results in an imbalance in the tear-film and damages the eye’s surface through inflammation. First-line treatments include warm compresses several times a day, lid scrubs with baby shampoo or commercial cleaning cloths, and increasing the amount of omega-3 fatty acids in your diet through changes in eating habits and over-the-counter supplements. I particularly like the HydroEye supplement since it contains GLA, which has been shown to be helpful in treating dry eyes. Second-line treatments include the use of steroid eye drops and oral or topical tetracyclines in order to reduce inflammation and improve the quality of the glands’ secretions. Finally, the glands’ function may be improved by mechanical expression of the clogged glands.

A less common but difficult dysfunction to treat is a dysfunctional blink that traumatizes the eye’s surface. After traditional treatments have failed, the eye’s surface can be restored to normal health by injecting Botox into the eyelid muscles to weaken the muscles responsible for blinking. This intervention results in decreased blink frequency, blink force and eyelid pressure on the eye’s surface.

Dry eye disease can be a complicated eye condition to treat. In order to determine the best treatment plan, a patient should undergo a specialized dry eye evaluation. If you think you might be suffering from dry eyes or would like to learn more, contact us to schedule a quick appointment.

About the Author:  Dr. Christian Hester is fellowship-trained in cornea and refractive (e.g., LASIK) surgery. As part of his fellowship training, he worked with Dr. Stephen Pflugfelder, one of the world’s experts in dry eye disease.