Dry Eye Disease: More Than Just Dryness — and Why Early Evaluation Matters

Dry eye disease affects an estimated 16 million adults in the United States and is one of the most underdiagnosed and undertreated conditions in eye care.¹ It is also widely misunderstood. Most patients who live with dry eye for years do so believing it is a minor inconvenience managed adequately with over-the-counter artificial tears — unaware that the underlying cause of their symptoms may be actively progressing in a way that drops alone cannot address.

Your Annual Exam Is About More Than Your Prescription

Glasses and contacts are important — but they are only part of what we do at your annual wellness exam. Getting your prescription right improves your quality of life every day. Evaluating the health of your ocular surface and meibomian glands protects both your comfort and your long-term visual function in ways that a prescription update alone cannot.

During every routine visit, we assess for signs of dry eye disease — including meibomian gland structure and lid margin health — as part of our standard examination. If findings suggest a more structured evaluation is warranted, we schedule a dedicated dry eye workup to characterize your disease, identify the underlying cause, and build a treatment plan accordingly.

What Dry Eye Disease Actually Is

Dry eye is not simply a lack of tears. It is a multifactorial disease of the ocular surface in which the tear film — a complex, layered structure — becomes unstable, leading to inflammation, surface damage, and symptoms ranging from irritation and fluctuating vision to significant discomfort.² There are two primary forms, and most patients have elements of both.

Evaporative dry eye, driven by meibomian gland dysfunction (MGD), accounts for the majority of cases — estimated at roughly 85% of dry eye presentations.³ The meibomian glands line the upper and lower eyelids and secrete the lipid layer of the tear film, which prevents rapid tear evaporation. When these glands become obstructed or atrophied, the lipid layer thins, tears evaporate too quickly, and the ocular surface is left exposed and inflamed. MGD is progressive and structural — meaning the glands can permanently atrophy if the condition goes unaddressed long enough.

Aqueous deficient dry eye occurs when the lacrimal gland produces insufficient tear volume. This form is less common but can be more severe, and is associated with autoimmune conditions such as Sjögren's syndrome, certain medications, and hormonal changes — particularly in post-menopausal women.

The Most Common Misconception — and Why It Matters

Most patients who present with dry eye have been managing symptoms with artificial tears for months or years. Drops provide temporary symptom relief — but they do not address the underlying cause. In evaporative dry eye, the meibomian glands continue to degrade during that time. By the time many patients are evaluated, gland atrophy is already measurable and partially irreversible. Earlier intervention consistently produces better long-term outcomes.⁴ If your symptoms have been present for more than a few months, or if drops are no longer providing adequate relief, a dedicated evaluation is the appropriate next step.

How We Evaluate Dry Eye

Meibography allows us to image the meibomian glands directly and assess their structural integrity — identifying dropout, truncation, or distortion that indicates progressive gland loss. This is part of our routine examination for all patients, not reserved exclusively for symptomatic ones, because structural changes often precede significant symptoms.

Lid Margin Assessment and Telangiectasia Grading evaluates the health of the lid margin and the presence of abnormal blood vessel growth — a clinical marker of chronic inflammation and MGD severity. This is also incorporated into the routine exam.

Tear Prism Height and Tear Break-Up Time (TBUT) assess tear volume and tear film stability respectively. A shortened

TBUT — the time between a blink and the first appearance of a dry spot — is one of the most reliable indicators of an unstable tear film.

Meibomian Gland Expression assesses both the ease of gland expression and the quality of the secreted meibum. Healthy glands produce clear, fluid lipid; dysfunctional glands produce turbid, thickened, or absent secretions.

Fluorescein Staining reveals damage to the corneal and conjunctival epithelium caused by tear film instability and desiccating stress. The pattern and distribution of staining helps us characterize disease severity and monitor treatment response.

Treatment: Individualized by Disease Type and Severity

All patients begin with lid hygiene — twice-daily lid preparation and warm compresses — as the foundation of meibomian gland maintenance. From there, treatment is personalized based on disease type, severity, and individual presentation.

For evaporative dry eye, Intense Pulsed Light (IPL) targets the abnormal lid margin vasculature that perpetuates MGD-related inflammation and has strong clinical evidence supporting its efficacy.⁷Radiofrequency (RF) therapy complements IPL by improving gland function through controlled periorbital thermal stimulation. Both are available in our office.

For aqueous deficient or inflammatory presentations, prescription drops — including cyclosporine (Restasis) and lifitegrast (Xiidra) — address the underlying inflammatory cycle driving tear insufficiency.⁶Omega-3 supplementation supports meibum quality and reduces ocular surface inflammation.⁵Punctal plugs and Lacrifill conserve existing tear volume for patients with reduced aqueous production.

For more advanced or refractory cases, amniotic membrane therapy promotes ocular surface healing and reduces inflammation. Serum tears — a personalized supplement derived from the patient's own blood — are an emerging option for complex presentations that we are in the process of making available in our office.

Who Is Most at Risk

Dry eye disease disproportionately affects women — particularly post-menopausal women, in whom hormonal changes significantly alter tear production and meibomian gland function.⁸ Contact lens wearers, individuals with high daily screen time, and patients on antihistamines, antidepressants, or antihypertensive medications also carry elevated risk. If you fall into any of these categories and have not had a dry eye evaluation, it is worth raising at your next visit.

The Bottom Line

Dry eye disease is progressive when left unmanaged, but highly treatable when identified early. OTC drops are not a long-term solution for most patients — they are a bridge, not a treatment. If your symptoms are persistent, worsening, or no longer responding to drops, contact us to schedule a comprehensive dry eye evaluation.

For educational purposes only. Not a substitute for individualized medical care.

Dry Eye Disease

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https://doi.org/10.1016/j.jcrs.2017.03.035

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8. Sullivan DA, et al. Sex, sex steroid hormones, and dry eye disease. Int Ophthalmol Clin. 2017;57(2):111–118. https://doi.org/10.1097/IIO.0000000000000170