If you are an eye doctor, you know these generalized break downs are way too simplistic, and usually a person has multiple causative dry eye factors.  Evaporative dry eye is typically associated with issues with the oil glands of the eye, called Meibomian Gland Dysfunction. Every time you blink, these meibomian glands that lie in the eyelid secrete the oily top coat of the tear film that keeps tears on the eye. Studies suggest that as much as 60% of dry eye sufferers have Meibomian Gland Dysfunction as a major cause of their symptoms.  This means that when I am checking your eyes for dryness, I look even more closely at your eyelid, where these meibomian tear glands are.  What exactly am I looking for?  Well, luckily I have a few patient pictures to illustrate:

A clogged, or inspissated, meibomian gland is a very common finding.  In many cases, I will find one or two on the eyelids, but the patient will only have mild complaints associated with dryness.  They will describe some itching along their lid margin, maybe some end of day dryness or intermittent blurry  vision between blinks.  They may have a history of styes (clogged meibomian glands that get infected with bacteria).  I have even had some patient tell me that they see these in the mirror (great eyesight) and try to pop them!  The best way to fight clogged meibomian glands is to use a warm cloth massage or eyelid cleansing product like Ocusoft eyelid pads or foam nightly before bed.  This will open up the gland and let all of that nice tear film flow freely onto the eye again!

This is obviously a bit more advanced.  Not only is there significant blockage of every meibomian gland on this person's eyelid, but there is a ton of inflammation!  Blepharitis is a common word in eyecare that translates in layman's terms to eyelid inflammation.  All that redness?  That's inflammation.  This person is going to complain about sore or even puffy and swollen eyelids, and typically has some significant complaints with dryness, burning, and redness.  Warm massages and lid cleansers are still used in this patient, but typically an anti-inflammatory treatment like steroid drops or ointments, or oral doxycycline would also be used at this point.

Compared to the preceding photo, this person also has redness, but there is a pretty big difference here.  This is a patient with ocular rosacea, a condition associated with chronic dryness and inflammation.  Typically there are other facial areas of rosacea as well.  The big give away?  Those squiggly blood vessels on the eyelid margin are called telangiectasia, a hallmark of rosacea.  This patient will typically have chronic, persistent dry eye complaints but get little relief from lid massages and warm compreses in my experience.  Anti-inflammatory treatments like steroids or Restasis are typically the preferred treatment route, and oral treatments like doxycylcine are especially popular because they also improve facial patches of rosacea.

This is a great example of how a patient with chronic inflammation and meibomian gland issues looks.  This eye has hallmarks of old inflammation (notice the faint telangiectasia by the lash roots), but no acute inflammation at the moment.  The inflammation has subsided, but the meibomian glands still fail to function ideally.  How can I tell? The glands towards the middle of the picture have a hardened, white center.  If the patient blinks, or I put pressure on the lid at that area, there will likely be NO tear film coming out.  This patient will still have dryness, because the glands aren't functioning like they should!  At this point in the patient's treatment plan, we are turning to more chronic therapies.  The inflammatory cycle has been broken so steroids and doxycycline will give less results, but the glands still aren't normalized.  Sometimes treatment like Restasis that helps the body make more tear film, or new treatments like Lipiflow that pumps the meibomian glands open may be effective, but there is no permanent cure.  This person will have a lifetime of battling their dry eye due to their poorly active meibomian glands.  Once the glands have been damaged, their function may never be restored. That's why treating dry eye early and aggressively is so important!  

There is no cure for dry eye or meibomian gland dysfunction, but new treatments to combat these signs and symptoms are being developed every day.  Talk to your doctor if you have any of the symptoms of dry eye.  Ask if they have external photography that can show you what factors are causing your dryness (or if they can describe what they see if they don't have a camera)!  Your doctor is an eye specialist, trained to treat these conditions and educate you on your personal cause factors.  External photographs like the ones featured here are a great way of tracking progress with treatments, and to educate patients about their personal culprit causing their dry eye symptoms. Keep in mind that not all insurances cover these photographs, unfortunately-- only medical insurances and NOT vision insurances will cover medical treatment or diagnosis of dry eye.  By working with your doctor and trying different treatment plans geared toward your dry eye root cause(s), there is a way to manage these symptoms and achieve relief.

Look closely at your eyelids;  if they are red or you notice clogged glands, you need to see your doctor to combat these issues early.  The earlier we treat the causes of dry eye syndrome, the less likely you are to have permanently damaged meibomian glands (and permanent dry eye symptoms!).

How do you know if you have ocular rosacea or just regular old meibomian gland dysfunction?  I guess the important take home message is that it might not matter.  Treatment is generally the same except for the exacerbating factors (like heat!) that need to avoided in rosacea.  One thing to remember is that if you have been diagnosed with rosacea, you will definitely be more at risk for dry eye, so make sure you tell your eye care provider about this diagnosis and any medications or gels you may be using!  

then Meibomian Gland Dysfunction (or also called blepharitis!) is likely the culprit.  Let's take a closer look at the anatomy of the lid to understand what is going on.

The meibomian glands are sebaceous (or oily secretion) glands that run vertically through the eyelids.  Their opening is just inner to the eyelashes.  The function of these  glands is to secrete the oily "top coat" of the tears, that helps prevent the tears from evaporating off the eye.  When the oily secretion is clogged inside the gland, the tear film is missing proper components and thus dries up very quickly, causing dry eye symptoms.  If the glands are actually clogged and capped, their yellow dome-like contents may be visible along your lids when you look in the mirror.  

CAUSES: Meiboiman gland dysfunction or blepharitis (inflammation along the eyelids) can be caused by dry skin or crusting along the lashline, poor gland secretion (typical with rosacea), staph bacteria (that normally is on our skin but can sometimes flare up), or hormone changes that affect the make-up of the glands and their secretions.

BLEPHARITIS: Scaly, crusty debris called "collarettes" hook onto the eyelashes, causing irritation, inflammation, a spike in staph bacteria count, and clogged meibomian glands!  You wouldn't be able to see it in the mirror, so make sure when you clean your lids, you massage or gently rub along the lashes to get rid of this debris!