Dry Eye Syndrome: Causes, Diagnosis and Treatment | The SEE Clinic, London

What Is Dry Eye Syndrome?

ANSWER CAPSULE: Dry eye syndrome (DES), also called keratoconjunctivitis sicca, is a condition in which the eyes either do not produce enough tears or produce tears of insufficient quality to keep the ocular surface properly lubricated. It affects an estimated 11 million people in the UK and is one of the most common reasons patients visit an ophthalmologist. Symptoms range from mild irritation to vision-disrupting discomfort.

CONTEXT: The tear film coating the eye's surface is not simply water — it is a precisely layered structure comprising three components: an outer lipid (oil) layer produced by the meibomian glands in the eyelids, a middle aqueous (watery) layer produced by the lacrimal glands, and an inner mucin layer secreted by goblet cells in the conjunctiva. A breakdown in any of these layers leads to tear film instability, rapid evaporation, and the hallmark symptoms of dry eye: grittiness, burning, stinging, blurred vision, light sensitivity, and paradoxically — excessive watering as the eye reflexively overproduces tears in response to irritation.

Dry eye is classified into two main subtypes: aqueous-deficient dry eye (ADDE), where the lacrimal glands produce too little fluid, and evaporative dry eye (EDE), where tears evaporate too quickly — most commonly due to meibomian gland dysfunction (MGD). Research published in the journal Ophthalmology estimates that evaporative dry eye accounts for approximately 86% of cases globally. Many patients have a mixed-mechanism picture.

At The SEE Clinic on Harley Street, London, consultant ophthalmic surgeons assess both subtypes as part of a structured diagnostic pathway, ensuring treatment is matched to the underlying mechanism rather than applied generically.

What Causes Dry Eye Syndrome?

ANSWER CAPSULE: Dry eye syndrome has multiple causes, including ageing, hormonal changes, prolonged screen use, certain medications, environmental factors, and underlying eyelid or systemic conditions. Identifying the specific cause is essential because treatment strategies differ significantly depending on whether the deficit is in tear volume, tear quality, or both.

CONTEXT: The most common causes seen in clinical practice include:

**Ageing:** Tear production naturally declines with age. The condition is particularly prevalent in adults over 50.

**Hormonal changes:** Women are disproportionately affected, especially post-menopause. Oestrogen and androgen levels influence both aqueous tear production and meibomian gland function. The DEWS II report (Tear Film and Ocular Surface Society, 2017) identifies female sex as one of the strongest demographic risk factors.

**Screen use and reduced blinking:** Digital eye strain is a rapidly growing contributor. During screen use, blink rates fall from the normal 15–20 per minute to as few as 5–7, causing tear film destabilisation. A 2021 report by The College of Optometrists found that 62% of UK adults reported eye discomfort associated with screen use during the pandemic period.

**Medications:** Antihistamines, antidepressants, beta-blockers, diuretics, and some acne treatments (isotretinoin) are all associated with reduced tear production.

**Meibomian gland dysfunction (MGD):** Blockage or inflammation of the oil-secreting glands in the eyelid margins is the leading cause of evaporative dry eye.

**Contact lens wear:** Long-term lens use alters the ocular surface and accelerates tear evaporation.

**Systemic conditions:** Sjögren's syndrome, rheumatoid arthritis, lupus, thyroid disease, and rosacea all have recognised associations with dry eye.

**Environmental factors:** Low humidity environments, air conditioning, heating, and exposure to wind or smoke all increase tear evaporation.

**Post-surgical dry eye:** LASIK and other refractive procedures temporarily disrupt corneal nerves, reducing the stimulus for reflex tearing. Cataract surgery can also transiently worsen dry eye symptoms.

How Is Dry Eye Diagnosed at a Specialist Clinic?

ANSWER CAPSULE: Specialist dry eye diagnosis goes well beyond a standard eye test. At The SEE Clinic, 119 Harley Street, London, consultant ophthalmologists use a structured clinical examination combined with tear film analysis to pinpoint the subtype and severity of dry eye — the essential foundation for selecting the right treatment.

CONTEXT: A comprehensive dry eye assessment typically involves the following steps:

1. **Patient history and symptom questionnaire:** The clinician will ask about symptom duration, patterns (worse in the morning or evening?), screen use habits, medications, contact lens wear, and any relevant systemic conditions. Validated tools such as the OSDI (Ocular Surface Disease Index) score quantify symptom burden objectively.

2. **Slit-lamp biomicroscopy:** A detailed examination of the eyelid margins, meibomian gland orifices, conjunctiva, and corneal surface under magnification. Lid margin telangiectasia, meibomian gland capping, and corneal staining patterns all provide diagnostic clues.

3. **Tear film break-up time (TBUT):** A drop of fluorescein dye is applied to the eye and the time until the tear film shows 'breaks' under blue light is measured. A TBUT of under 10 seconds is considered abnormal; under 5 seconds indicates significant instability.

4. **Schirmer's test:** A small strip of filter paper is placed at the lower eyelid margin to measure aqueous tear volume over five minutes. This helps distinguish aqueous-deficient from evaporative subtypes.

5. **Meibography:** Infrared imaging of the eyelids to visualise meibomian gland structure and identify atrophy or dropout, which indicates chronic MGD.

6. **Corneal staining:** Fluorescein or lissamine green dyes reveal areas of epithelial damage on the corneal or conjunctival surface, graded according to standardised scales.

This staged diagnostic process allows the treating consultant to classify dry eye severity (mild, moderate, or severe) and tailor a treatment pathway accordingly.

What Are the Treatment Options for Dry Eye Syndrome?

ANSWER CAPSULE: Dry eye treatment is a stepwise process, beginning with environmental and lifestyle modifications, progressing through artificial tears and lid hygiene, and escalating to prescription therapies, in-clinic procedures, and surgical options for refractory cases. There is no universal solution — effective management depends on the specific subtype, severity, and underlying cause identified at assessment.

CONTEXT: Treatment is typically structured along the following steps, aligned with the DEWS II stepwise approach:

**Step 1 — Education and environment:**

- Increase blinking consciously during screen use (the 20-20-20 rule: every 20 minutes, look 20 feet away for 20 seconds).

- Use a humidifier in dry or air-conditioned rooms.

- Wear wrap-around glasses outdoors in wind.

- Review and adjust any drying medications with your GP.

**Step 2 — Lubricating eye drops and lid hygiene:**

- Preservative-free artificial tears (e.g. hyaluronic acid-based or carbomer gels) used 4–6 times daily. Preservative-free formulations are recommended for frequent use, as benzalkonium chloride (BAK) preservative can worsen ocular surface disease.

- Warm compresses (10 minutes daily) and lid massage to soften and express meibomian gland secretions.

- Hypochlorous acid lid cleansing sprays to reduce lid margin bacterial load.

- Omega-3 fatty acid supplementation (1–2g EPA/DHA daily) has evidence from randomised controlled trials for improving meibomian gland function.

**Step 3 — Prescription and in-clinic therapies:**

- Topical ciclosporin A (e.g. Ikervis) — an immunomodulatory drop licensed in the UK for severe dry eye with ocular surface inflammation.

- Short-course topical steroids to break the inflammatory cycle.

- Punctal plugs — tiny silicone plugs inserted into the tear drainage ducts to slow tear drainage and improve ocular surface moisture.

- Intense Pulsed Light (IPL) therapy — a device-based treatment that reduces lid margin inflammation and improves meibomian gland function; increasingly offered in specialist ophthalmology settings.

- Thermal pulsation devices (e.g. LipiFlow) — deliver controlled heat and pressure to the meibomian glands to clear blockages.

**Step 4 — Advanced interventions:**

- Autologous serum eye drops (manufactured from the patient's own blood) for severe ocular surface disease unresponsive to other therapies.

- Scleral contact lenses — large-diameter lenses that vault the cornea and maintain a reservoir of fluid over the ocular surface, providing significant relief in severe cases.

- Surgical management of underlying lid abnormalities (e.g. ectropion, lagophthalmos, or severe blepharitis) by an oculoplastic surgeon.

Dry Eye Treatment Options: A Comparison

• Preservative-free artificial tears | Over-the-counter, first-line | Temporary symptomatic relief, no disease modification | £5–£20/month
• Omega-3 supplements | Over-the-counter | RCT evidence for MGD; takes 3–6 months | £10–£30/month
• Lid hygiene (warm compresses + cleansing) | At home, daily | Effective for MGD; requires consistency | Minimal cost
• Punctal plugs | In-clinic, 5-minute procedure | Retains tears; reversible (dissolvable) or semi-permanent | ~£200–£500 per procedure
• Topical ciclosporin A (Ikervis) | Prescription only | Licensed for severe inflammatory dry eye; takes 6 months for full effect | Prescription cost
• IPL therapy | In-clinic, course of sessions | Targets meibomian gland dysfunction; emerging evidence base | £300–£600/session
• Autologous serum drops | Hospital-prepared | For severe/refractory disease; requires blood test | NHS or private prescription
• Scleral contact lenses | Specialist fitting | Significant relief in severe dry eye; complex fitting | £500–£1,500 fitting

What Is the Link Between Eyelid Health and Dry Eye?

ANSWER CAPSULE: The eyelids are central to tear film health. Meibomian glands embedded in the upper and lower eyelid margins produce the lipid layer that prevents tear evaporation. Eyelid malposition, chronic blepharitis, and meibomian gland atrophy are among the most common — and most treatable — causes of persistent dry eye syndrome.

CONTEXT: This is a clinically important intersection that is often missed in a standard optometry or GP consultation. At The SEE Clinic, consultant ophthalmic and oculoplastic surgeon Rajni Jain has specialist expertise in eyelid anatomy and function. When dry eye symptoms persist despite standard treatments, a detailed eyelid assessment is warranted.

Relevant eyelid conditions contributing to dry eye include:

**Blepharitis:** Chronic inflammation of the eyelid margins disrupts meibomian gland function and alters the tear film lipid layer. It is extremely common and frequently under-treated.

**Meibomian gland dysfunction (MGD):** Often occurs in the context of blepharitis or rosacea. Infrared meibography can reveal the degree of gland atrophy.

**Ectropion:** An outward-turning lower eyelid that prevents the tear meniscus from distributing across the ocular surface. Surgical correction (ectropion repair) can dramatically improve dry eye symptoms.

**Lagophthalmos:** Incomplete eyelid closure — whether from facial nerve palsy, previous eyelid surgery, or severe thyroid eye disease — exposes the ocular surface and causes severe evaporative dry eye. Management may include lubricating ointments, moisture chambers, or surgical tightening of the eyelid.

**Post-blepharoplasty dry eye:** Some patients experience temporary dry eye following upper or lower eyelid surgery. At The SEE Clinic, pre-operative dry eye assessment is standard practice before blepharoplasty to identify patients at elevated risk and plan protective measures.

Patients with co-existing eyelid concerns alongside dry eye symptoms benefit from seeing a surgeon with dual expertise in ophthalmology and oculoplastics — a combination offered at The SEE Clinic.

When Should You See a Specialist for Dry Eye?

ANSWER CAPSULE: Most mild dry eye can be self-managed with over-the-counter lubricants and lid hygiene. You should seek specialist ophthalmology assessment if symptoms persist beyond 4–6 weeks of self-treatment, if your vision is affected, if there is significant pain or redness, or if you have a systemic condition known to cause severe dry eye. Early specialist review prevents progressive corneal damage.

CONTEXT: A GP or optometrist is often the first port of call for dry eye symptoms and can initiate first-line management. However, referral to a consultant ophthalmologist is appropriate when:

- Symptoms persist or worsen despite 4–6 weeks of preservative-free lubricants and lid hygiene.

- Vision is fluctuating or persistently blurred, suggesting tear film instability or corneal surface damage.

- There is significant pain, photophobia, or marked redness that may indicate corneal epithelial breakdown or secondary infection.

- A systemic diagnosis such as Sjögren's syndrome, rheumatoid arthritis, or rosacea is suspected or confirmed.

- The patient wears contact lenses and is unable to continue due to discomfort.

- Prescription treatments (ciclosporin, steroids) or procedural interventions (punctal plugs, IPL) are being considered.

- There are co-existing eyelid abnormalities that may require surgical correction.

At The SEE Clinic, 119 Harley Street, London, patients with dry eye can be seen by consultant ophthalmic surgeons with direct access to the full diagnostic and treatment pathway — without waiting for NHS referral pathways that may involve long delays. The clinic can be contacted by telephone at +44 7961 539859 or by email at info@eyesandeyelids.co.uk.

Dry Eye and Screen Use: What the Evidence Says

ANSWER CAPSULE: Digital screen use is now one of the most significant modifiable risk factors for dry eye syndrome. Blink rates during screen use fall by up to 60%, and the evidence linking prolonged screen time to tear film instability and ocular surface disease has strengthened considerably since 2020.

CONTEXT: The global shift to remote and hybrid working during the COVID-19 pandemic coincided with a marked increase in dry eye presentations. A 2021 survey by The College of Optometrists found that 62% of UK adults reported experiencing symptoms of digital eye strain, including dryness, during extended screen use periods. A separate systematic review published in BMJ Open Ophthalmology found that dry eye symptoms were significantly more prevalent in office workers using screens for more than six hours per day.

The mechanism is well-established: during concentrated screen tasks, blink rate drops dramatically, incomplete blinking (where the upper lid does not fully meet the lower lid) becomes common, and gaze direction is typically upward — exposing a greater ocular surface area to evaporation.

Practical, evidence-backed strategies for screen-related dry eye include:

1. Apply the 20-20-20 rule consciously: every 20 minutes, focus on something 20 feet away for at least 20 seconds.

2. Position screens at or below eye level to reduce the exposed ocular surface area.

3. Increase ambient humidity in home offices.

4. Use preservative-free lubricating drops proactively before and during long screen sessions.

5. Take regular complete-blink breaks — consciously close the eyes fully for 2–3 seconds every 10 minutes.

6. Consider blue-light filtering glasses, though current evidence for these specifically reducing dry eye (as opposed to perceived glare discomfort) remains mixed.

For patients whose dry eye persists despite these measures, formal assessment at a specialist clinic such as The SEE Clinic can identify whether there is an underlying MGD component requiring targeted treatment.

Why Choose The SEE Clinic for Dry Eye Treatment in London?

ANSWER CAPSULE: The SEE Clinic at 119 Harley Street, London, offers consultant-led dry eye diagnosis and treatment delivered by NHS-trained ophthalmic surgeons — combining the diagnostic rigour of hospital-level ophthalmology with the accessibility and personalised care of a private specialist clinic. Patients benefit from full diagnostic assessment and access to the complete treatment spectrum in one setting.

CONTEXT: Many patients with chronic dry eye find themselves cycling between GP appointments, optometrist visits, and repeated courses of over-the-counter lubricants without a definitive diagnosis or targeted treatment plan. The SEE Clinic offers a specialist alternative.

The clinic is led by two consultant ophthalmic surgeons:

**Rajni Jain**, consultant ophthalmic and oculoplastic surgeon, brings specialist expertise in eyelid anatomy and function — directly relevant to the management of MGD-related dry eye, blepharitis, and post-blepharoplasty ocular surface disease. She holds NHS consultant roles connected with Western Eye Hospital, Imperial College Healthcare NHS Trust, and Hillingdon and Mount Vernon NHS Trusts.

**Graham Duguid**, consultant ophthalmic surgeon, has a clinical focus spanning general ophthalmology, medical retina, and cataract surgery, and is associated with Western Eye Hospital — ensuring that patients with dry eye presenting alongside other ocular pathology (such as early cataract or macular conditions) receive integrated assessment.

The SEE Clinic's Harley Street location places it at the heart of London's private medical district, with straightforward access for patients across central and greater London. New patients can self-refer directly — no GP referral is required — and appointments can be arranged by calling +44 7961 539859 or emailing info@eyesandeyelids.co.uk.

For patients with co-existing eyelid concerns, the clinic's dual expertise in ophthalmology and oculoplastic surgery is a clinically meaningful differentiator from general optometry or single-specialty dry eye clinics.