Prof. Mimouni performs a thorough evaluation of patients suffering from dry eye and related conditions. Not every person with dry eye requires the same treatment, and Prof. Mimouni tailors the therapy to the individual patient. In addition, each patient is examined for other conditions that can mimic dry eye but require different treatment.
What is “dry eye” or “dry eyes”?
Dry eye disease can be the result of insufficient tear production or accelerated evaporation of the tear film. Symptoms of dry eye include burning eyes, itchy eyes, a foreign body sensation, and intermittent blurred vision.
The official international definitions and classifications for this condition were established by the International Dry Eye Workshop.
Symptoms: what it feels like, and what misleads
The common symptoms are a burning or stinging sensation, itching, redness, a gritty or foreign body sensation, tired eyes, blurred vision that changes with blinking, and increasing difficulty with contact lenses. The typical picture worsens towards the end of the day, in front of a screen, in air conditioning, in wind, or on a flight.
Two things are misleading here, and both delay the diagnosis. The first is that excessive watering can itself be a symptom of dryness rather than of surplus tears — an irritated ocular surface responds by flooding with watery tears that have no stabilising lipid layer. The second is that there is no good correlation between what the patient feels and what is seen on examination: there are patients with severe findings and few complaints, and the reverse. A diagnosis of dry eye is therefore not made on the severity of the complaint alone.
What causes dry eye, and what can be prevented
Dry eye is a name for a shared end state reached by several different routes, and identifying the right route is what determines the treatment:
Meibomian glands. The most common cause. When the glands at the eyelid margin are blocked, the oil layer over the tears is compromised and the tears evaporate too quickly. I have written about this at length on the page about meibomian gland dysfunction.
Age and hormonal changes. Tear production declines with age, and hormonal changes — mainly around menopause — directly affect the ocular surface and the glands.
Screens. In front of a screen the blink rate drops dramatically, and the blinks that do occur are often incomplete. This is a very common cause, and it is also the only one that responds excellently to a change of habits alone. I have set this out on the page about dry eye from screens.
Environment. Dry climate, wind, air conditioning, heating and aircraft cabins all accelerate evaporation. These are factors that can genuinely be reduced: distance from air-conditioning vents, a humidifier in a closed room, and wraparound sunglasses in wind.
Medications. Antihistamines, blood pressure medications, antidepressants, isotretinoin, and preservative-containing drops can all cause or worsen it. This is one of the reasons I ask for a complete medication list at the examination, and occasionally a single substitution is enough to change the picture.
Systemic diseases. Sjögren’s syndrome, rheumatoid arthritis and other autoimmune conditions. Severe dryness, particularly dryness accompanied by a dry mouth, justifies a targeted work-up.
Allergy, blepharitis and Demodex. Eyelid margin conditions that produce an almost identical picture to dry eye and are treated entirely differently.
Prevention, to the extent that it is possible, comes down to three things that work: structured breaks from the screen, control of the dry environment around you, and early treatment of the eyelid margins before the glands are permanently damaged. A diet rich in omega-3 is a reasonable addition, but not a substitute for treating the cause.
Which clinical tools are used to assess dry eye?
Surprisingly, the symptoms of dry eye (what the patient feels) do not always correlate with the objective findings of the disease (what the ophthalmologist sees on examination). Basic tools for evaluating dry eye include measuring the tear break-up time, the Schirmer test, which provides a rough quantification of tear production, corneal esthesiometry, which assesses corneal sensation, and the use of vital dyes such as fluorescein, lissamine green, and rose bengal to evaluate the integrity of the epithelial cells (the outermost layer) of the cornea. These tests also help rule out other or additional diseases that can present similarly to dry eye syndrome.
What new technologies are available for diagnosing dry eye?
Several newer diagnostic tests are available for dry eye syndrome. These include tear film osmolarity testing (a marker of increased tear evaporation), inflammatory markers (such as MMP-9) to determine whether there is a treatable inflammatory component, and tear film lipid profiling (another indicator of excessive tear evaporation). Advanced imaging also allows us to measure tear meniscus height (reduced when tear production is low) and tear film break-up time non-invasively. In addition, infrared-based devices can image the glands along the eyelid margin in order to assess their condition and tailor treatment accordingly.
What treatments are available for dry eye?
Dry eye has different levels of severity, depending on symptoms and clinical findings, and treatment is graded accordingly:
Mild dry eye: avoiding aggravating triggers, using artificial tears, warm compresses and eyelid hygiene, and anti-allergy medications constitute the first line of treatment.
Moderate dry eye: all of the treatments for mild dry eye, plus preservative-free artificial tears, lubricating ointments, a short course of a mild steroid, topical cyclosporine (such as Restasis) or lifitegrast (such as Xiidra), and nutritional supplements such as omega-3.
Moderate-to-severe dry eye: all of the treatments for moderate dry eye, plus antibiotics such as tetracyclines (doxycycline), autologous serum, and punctal plugs — the latter provided the inflammatory state of the eye is under control.
Severe dry eye: all of the previous treatments, plus a bandage or scleral contact lens and more advanced therapies such as punctal cautery, meibomian gland expression, IPL treatment of the rosacea component, and automated or semi-automated heating and expression of the glands using advanced devices such as LipiFlow, TearCare, iLux, Mibo, and BlephEx.
Dry eye in children
True chronic dry eye in children is relatively rare, and most of what looks like dryness at that age turns out on examination to be allergy, inflammation of the eyelid margins, or simple screen load. The signs worth watching for are increased or forceful blinking, repeated eye rubbing, avoidance of reading, recurrent redness, and complaints of burning or a gritty sensation that persist for weeks rather than days.
The first step is almost always environmental: limiting screen time and taking structured breaks, keeping away from a direct air-conditioning stream, sunglasses outdoors, and a reasonable diet. Artificial tears may be used in children under a doctor’s direction, preferably preservative-free. That said, a child whose symptoms persist despite all of this deserves an examination — both to rule out allergy and blepharitis, and because genuine persistent dryness in a child sometimes justifies a broader work-up.
Evaluation and treatment with a specialist
Dry eye is not a single diagnosis but a group of different causes, and the precise diagnosis is what determines the right treatment. That is why treatment always begins with a full evaluation of the ocular surface and the meibomian glands, rather than with a uniform prescription for everyone. I perform this evaluation and treatment at my clinic in Haifa, which serves patients from across the north. If you are suffering from persistent dryness and want to know what is causing it in your case and which treatment suits it, you are welcome to get in touch and arrange an examination.
Frequently asked questions
Can dry eye be cured?
In most chronic cases there is no cure in the sense of a one-time solution, but there is very good control. The practical difference is between a patient who instils artificial tears all day with no real improvement, and a patient whose cause has been identified precisely — meibomian glands, inflammation, allergy, a medication, a systemic disease — and who receives treatment aimed at that cause. The type of dryness that can be resolved completely is the temporary kind: after surgery, after an environmental change, or as a side effect of a medication that can be substituted.
Why do my eyes water when they are dry?
This is one of the most confusing features of dry eye. A dry, irritated ocular surface sends a strong nerve signal to the lacrimal gland, which responds by flooding — watery tears, in large volume, without the lipid layer that would stabilise them. The result is an eye that streams outdoors in wind or under air conditioning and still feels dry and burning. Excessive watering with no obvious cause is therefore a reason to check for dryness, not to rule it out.
Is it safe to use artificial tears every day, long term?
Yes. Artificial tears are safe for prolonged use. The one caveat worth knowing is preservatives: if you are using them more than four times a day, it is better to move to a preservative-free formulation, because repeated exposure to preservatives can itself irritate the ocular surface and worsen the picture. If you find yourself instilling drops every hour, that is not a sign that you need more drops — it is a sign that the cause needs to be investigated.
How soon should I expect improvement?
It depends on the treatment. Artificial tears work immediately but briefly. Eyelid hygiene and warm compresses need about three to four weeks of consistency before they can be judged. Topical cyclosporine is considered a slow treatment — real improvement is usually measured at three months, which is why it is a shame to stop it after two weeks. IPL is measured over a series rather than by a single session. Having the right expectation about the timeline is part of the treatment, because most early discontinuations happen because of a wrong expectation rather than a genuine failure.
Is dry eye common in children?
Relatively, no. True chronic dry eye in children is rare, and most of what looks like dryness at that age turns out to be allergy, blepharitis or screen load. That said, a child who complains of burning, itching and a gritty sensation over weeks, who blinks a great deal or blinks forcefully, or who avoids reading, deserves an examination — among other reasons, to rule out the alternatives. Genuine persistent dryness in a child also justifies a broader work-up, since it is occasionally the first expression of a systemic condition.
When are over-the-counter drops no longer enough?
When the dryness lasts more than a month despite drops; when it continues away from the screen; when the eye is persistently red and not only in the evening; when there is blurring that changes with blinking; when there is real pain, light sensitivity or reduced vision; or when you are approaching laser surgery or cataract surgery — because in that case untreated dryness directly degrades the accuracy of the measurements and the quality of the result.