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Surface Matters | Nov/Dec '18

Generations of Dry Eye

Presentation, examination, and treatment differ among age groups.

Ocular surface disease (OSD) is complex: It takes many forms, reaches various degrees of severity, and can be influenced by systemic diseases, medications, and environmental challenges. Some trends in dry eye disease (DED) occur at different stages of patients’ lives. Specifically, young, middle-aged, and older patients tend to have varying symptoms, structural changes, and red flags for differential diagnoses.

It is not mandatory to have a plethora of expensive diagnostic equipment to accurately diagnose and treat dry eye patients, young and old. In my practice, we start with obtaining a thorough patient history using targeted yes-or-no questions, such as “Have you noticed it often feels like something is in your eye or that it hurts to blink?”

From there, our diagnostic tests and observations include tear breakup time, staining patterns, delayed tear clearance, and a look at the quality of meibomian gland excrescences. It is also helpful for diagnosis and patient education to include testing for the inflammatory factor matrix metalloproteinase-9 (MMP-9; InflammaDry, Quidel) and meibography (LipiScan, Johnson & Johnson Vision). The following examples highlight common findings in patients of different ages and specialized strategies for addressing their DED.


A 30-year-old patient with dry eye often uses a computer frequently and may have a history of contact lens wear. Patients in this age group often complain about gritty eyes, fluctuating vision, and decreased contact lens wear time (or a desire for LASIK). This is often an early form of aqueous-deficient DED. In this scenario, I might suggest artificial tears and remind the patient to take frequent breaks in screen time according to the 20-20-20 rule (taking a 20-second break to view something 20 feet away every 20 minutes).

We must also heed the red flag raised by the presence of inflammatory OSD in a young, otherwise healthy-appearing patient. I look for signs of Sjögren syndrome, such as dry speech pattern or dental decay, as well as dermatologic findings of eczema, psoriasis, rosacea, or the malar rash of lupus. Appropriate testing for underlying systemic problems is advisable as well. I use the Sjö test (Bausch + Lomb), which detects Sjögren syndrome years earlier than older tests—a major advantage for this age group. I also test for antinuclear antibodies; rheumatoid factor; Ro- and La-antibodies (SS-A and SS-B); angiotensin-converting enzyme; lysozyme; T3, T4, TSH, and thyroglobulin antibodies; and double-stranded DNA.


A 50-year-old patient with DED often complains of fluctuating vision that interferes with work and frustratingly sandy, watery eyes that over-the-counter artificial tears do not alleviate. Many patients in this age group have evaporative DED caused by meibomian gland dysfunction (MGD). In this setting, the examination should include assessing the meibomian glands and checking for MGD sequelae, such as Salzmann nodular degeneration and other problems resulting from years of circulating proteases and chronic inflammation, including basement membrane disorders and recurrent erosion syndrome. Ocular rosacea may be present, and ophthalmologists should also be on alert for facial rosacea and systemic diseases such as Sjögren syndrome, rheumatoid arthritis, Hashimoto disease, and other autoimmune disorders.

Treatment decisions depend on many factors, but we always need to address the source of the inflammation as soon as possible to prevent progression to problems such as conjunctivochalasis, recurrent erosion, or Salzmann nodular degeneration. As first-line therapies, I consider immunomodulators such as cyclosporine (Restasis, Allergan) and lifitegrast (Xiidra, Shire). Punctal plugs can keep more tears on the ocular surface. (MMP-9 testing can be used to determine if inflammatory mediators have resolved sufficiently before plugs are placed.)

Patients with more advanced MGD also benefit from the synergistic combination of thermal pulsation therapy (LipiFlow, Johnson & Johnson Vision) and intense pulsed light therapy (M22 OPT, Lumenis). Thermal pulsation therapy melts the abnormal secretions and express the glands, and intense pulsed light therapy treats lid margin telangiectasias and posterior blepharitis, thus reducing a common underlying source of inflammation.


It is common for DED patients in their 60s and 70s to complain of near-constant foreign body sensation and watery eyes, rather than dry eyes. In some cases of late-stage DED, the cornea can become neurotrophic, making symptomatic complaints less reliable factors in diagnosis, but the visual symptoms remain. I often see patients who think they need cataract surgery, but the examination reveals that part or all of their visual problems result from chronic DED or overt keratitis. These patients may have had DED for decades and tried artificial tears and prescription medication to no avail.

When examining older patients, I look for all the same problems seen in younger patients, but I also check for mechanical problems such as conjunctivochalasis. Additionally, I look at the history of patients in their 60s and older to see if any medications or underlying systemic conditions could be contributing factors.

Prescription dry eye medications are good options for older patients. Treatment with a combination of intense pulsed light therapy and thermal pulsation therapy is often beneficial for treating the underlying disease and restoring some meibomian gland function.


Even for patients in their 70s and older with advanced disease, DED treatment can be effective and can improve vision, comfort, and quality of life. If we are vigilant with patients of all ages, we can not only produce those benefits but also prevent the damage seen in advanced disease. Further, we can seize the opportunities to diagnose underlying health problems throughout our patients’ lives.

Neel R. Desai, MD
  • Director of Cornea, Cataract, and Refractive Services, The Eye Institute of West Florida
  • Medical Director, Lions Eye Institute for Transplant Research
  • President and CEO, Clarity Visionary Consulting
  • desaivision@hotmail.com
  • Financial disclosure: Consultant (Johnson & Johnson Vision, Lumenis, TearLab)