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If you have been using lubricating drops for months, perhaps many times a day, and your eyes still burn, feel "sandy" or go blurry, you are not alone. This is one of the most common reasons for seeing a dry eye specialist. On this page we explain why drops alone are not always enough, what is checked to understand what is really happening in the eye, and what the next steps are, in order.
When to see a doctor straight away: a sudden drop in vision; severe eye pain; a red eye with strong sensitivity to light; pain and redness in contact lens wearers (take the lenses out and get seen the same day); heavy discharge; an injury or a chemical getting into the eye (rinse immediately with running water and go to the emergency department). In situations like these, do not wait for a planned consultation.
Why are the drops not helping?
Lubricating drops (artificial tears) add fluid to the surface of the eye and dilute irritating substances. They bring relief, but usually only for a short time, and they do not treat the reason the eye is drying out. When the reason remains, the symptoms come back. These are the common reasons the drops "do not work":
The type of dryness is not being addressed
There are two main mechanisms of dry eye, and they often occur together. In evaporative dry eye, the quantity of tears is normal, but the oily layer that covers them is faulty, usually because of meibomian gland dysfunction (MGD; the meibomian glands are tiny oil glands in the eyelid margins). Lubricating drops add water, but do not repair the oily layer, so the drops evaporate quickly too.
In aqueous-deficient dry eye, the lacrimal gland produces too little fluid. When the shortage is significant, drops cannot keep up, and sometimes the natural tears also need help to stay on the eye for longer. Both types are explained in the guide Dry eye: what it is and when you need a specialist.
The drops themselves are irritating
Preservatives in drops, especially benzalkonium chloride (BAK), can damage the cells of the eye surface when used often. People who put in drops many times a day, or who also use glaucoma drops, can reach a point where the drops are part of the problem. More on this on the preservative-free drops page.
Inflammation of the eyelid margins and Demodex
Blepharitis (inflammation of the eyelid margins) causes scales, redness of the eyelid margins and ongoing irritation. In some people the Demodex mite, a tiny parasite that lives in the lash follicles, is involved. Drops do not clean the eyelid margins, so the irritation continues.
Inflammation on the surface of the eye
In dry eye a cycle sometimes develops: concentrated tears irritate the surface of the eye, the irritation triggers inflammation, and the inflammation further damages the stability of the tears. Lubricating drops do not calm the inflammation, so at this stage they bring less and less relief.
Pain that comes from the nerves
Sometimes the symptoms are much stronger than what is seen in the examination. The sensory nerves in the cornea may have become over-sensitive and send burning and pain signals even without significant dryness. In this situation lubricating drops hardly help, and the approach is different. See neuropathic eye pain.
A general condition, medicines or eyelids that do not close
Persistent dryness can be part of a general condition, such as Sjögren's syndrome, rosacea or thyroid disease. It can also come from medicines that cause dryness (do not stop a medicine without talking to the doctor who prescribed it), or from eyelids that do not close fully during sleep, which leaves the cornea exposed all night.
What does the specialist check?
The aim of the examination is to understand which mechanism is the main driver in your case, and often to discover that several factors are at work together. It starts with a conversation: when the symptoms began, what makes them worse, which drops you have tried, how often and for how long, which medicines you take and which general conditions you have.
Then come the tests:
- A validated symptom questionnaire, which records the severity and makes it possible to see improvement at later visits.
- An examination with a slit lamp (a microscope for examining the eye).
- A yellow dye (fluorescein) that shows how long the tear film stays stable (TBUT), and whether there is damage to the cornea and the conjunctiva.
- A Schirmer test, which measures the quantity of tears.
- An assessment of the meibomian glands with gentle pressure on the eyelid.
- An examination of the eyelid margins and the base of the lashes, including a search for signs of Demodex, and also a check of whether the eyelids close fully.
More details are on the dry eye testing page. Once the picture is clear, a treatment directed at the cause can be chosen, rather than yet another drop of the same kind.
The next steps, in order
Professional guidelines suggest moving forward in stages, but in practice treatment is tailored to the findings, and you do not always go through one stage after another.
1. Strengthen the basics
- Switching to preservative-free drops when you use drops often, and, as needed, a thick gel or ointment at night.
- Warm compresses and eyelid cleaning done regularly and correctly, when there is a meibomian gland or blepharitis component.
- Checking with your doctor whether one of your medicines is contributing to the dryness.
2. Prescription treatment
When there is inflammation, the eye doctor may prescribe anti-inflammatory drops. These may be steroid drops for a short period and under monitoring (because of the risk of raised eye pressure), or drops that regulate the immune response, such as ciclosporin, for long-term use. When there is marked MGD or rosacea, the doctor may also consider a treatment by mouth from the tetracycline group, given here mainly for its anti-inflammatory effect. Do not start or stop a prescription treatment without a doctor's advice. The prescription eye drops for dry eye page explains what these drops do, how soon they take effect and what the common side effects are.
3. Treatments at the clinic
When the basics and medical treatment are not enough, or when the examination shows a problem that can be treated directly, there are several options. Each one suits a different mechanism, and none suits everyone:
- Meibomian gland expression: after warming, the blocked glands are emptied. It may help some patients with MGD.
- IPL treatment: broad-spectrum pulsed light (not a laser) on the skin below the eyes, usually combined with gland expression. It may bring relief to some patients with MGD, especially when there is also rosacea.
- Eyelid margin cleaning with BlephEx: removal of scales and the bacterial layer from the eyelid margins, when there is blepharitis or Demodex.
- Punctal plugs: they keep the natural tears on the eye for longer. They are suitable mainly for aqueous-deficient dry eye, and are usually considered after the inflammation on the surface of the eye has calmed down.
- Autologous serum eye drops: drops made from the patient's own blood, for severe dryness, for example in Sjögren's or after a bone marrow transplant, or when the surface of the cornea is struggling to heal.
- Bandage contact lens: a soft lens that protects the cornea like a "bandage", in selected cases and under close follow-up because of the risk of infection.
Several treatments are often combined, alongside daily care at home. Treatments at the clinic may bring significant relief to some patients, but not to all, and chronic dry eye usually needs ongoing treatment. All the treatments are gathered on the treatments page.
Before the examination, it is worth writing down which drops you have tried, how often and for how long, and what helped and what did not. You can also bring the bottles themselves. A full preparation checklist is on the preparing for your visit page.
When is it worth seeing a specialist?
It is worth booking an examination if the symptoms last several weeks despite preservative-free drops, compresses and eyelid cleaning, if you need drops many times a day, if the dryness affects your work, driving or sleep, or if you have a general condition linked to dryness. What happens at the visit itself is explained on the dry eye consultation page.
Want a basic explanation first?Want to organise your symptoms before the examination? The symptom questionnaire on the Mitzmutz site
Frequently asked questions
Is it worth trying another brand of drops before getting examined?
If you have not yet tried preservative-free drops, that is a reasonable step. But if the problem lies in the meibomian glands, the eyelid margins or inflammation, switching between similar lubricating drops usually does not change much, and it is better to find out what the cause is.
Do the treatments at the clinic replace the drops?
Usually not completely. The aim of a treatment directed at the cause is to ease the symptoms and sometimes to reduce the need for drops, but for most patients suitable drops remain part of the routine.
My examination is fairly normal, but my eyes still burn. What does that mean?
Sometimes the symptoms are much stronger than what is seen in the examination. This can point to over-sensitivity of the corneal nerves (neuropathic eye pain), which needs a different approach. See neuropathic eye pain.
How soon can I expect an improvement?
It depends on the cause and the treatment. Treatment of the glands, the eyelids and inflammation usually works gradually, over weeks, so it is important to give it time and to come to the follow-up visit.
Home care not enough? We can look into it.
At the dry eye clinic in Haifa we find out what is causing the dryness and build a personal treatment plan.
Sources
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628.
- Wolffsohn JS, Arita R, Chalmers R, et al. TFOS DEWS II Diagnostic Methodology report. Ocul Surf. 2017;15(3):539-574.
- Akpek EK, Amescua G, Farid M, et al. Dry Eye Syndrome Preferred Practice Pattern®. Ophthalmology. 2019;126(1):P286-P334.
- Nichols KK, Foulks GN, Bron AJ, et al. The International Workshop on Meibomian Gland Dysfunction: executive summary. Invest Ophthalmol Vis Sci. 2011;52(4):1922-1929.
- Galor A, Moein HR, Lee C, et al. Neuropathic pain and dry eye. Ocul Surf. 2018;16(1):31-44.
- Baudouin C, Labbé A, Liang H, Pauly A, Brignole-Baudouin F. Preservatives in eyedrops: the good, the bad and the ugly. Prog Retin Eye Res. 2010;29(4):312-334.
The information on this site is general only. It is not medical advice and does not replace an examination by an eye doctor.