If you are using lubricating eye drops several times a day but your eyes still feel dry, gritty, burning, watery or tired, the problem may not simply be that you are “not making enough tears”.
For many patients, the issue is actually the quality of the tears.
Along the edges of your eyelids are tiny oil-producing structures called the meibomian glands. When these glands become blocked or stop producing healthy oil, your tears can evaporate too quickly.
Eye drops may temporarily make the eyes feel better, but if excessive evaporation is part of the problem, the relief may only last a short time.
Dry Eye Is Not Just One Condition
“Dry eye” is an umbrella term covering several different problems.
Broadly, dry eye may involve reduced tear production, excessive tear evaporation, ocular-surface inflammation, eyelid disease – or a combination of these factors.
This is why two people with similar symptoms may require completely different treatment.
Someone with reduced tear production may respond well to regular lubricating drops.
Another patient may be producing enough watery tears but still feel constantly dry because the tears are evaporating too rapidly.
In that situation, repeatedly adding more watery drops may not address the main cause.
What Are the Meibomian Glands?
The meibomian glands sit vertically inside the upper and lower eyelids.
Every time you blink, they should release a thin layer of oil onto the surface of the tears.
This oily layer helps slow evaporation and keeps the tear film stable between blinks.
When the glands are functioning properly, the oil is relatively clear and flows easily.
When they become dysfunctional, the oil may become thicker, cloudy or difficult to express. In some cases the gland openings become obstructed.
This is known as meibomian gland dysfunction, or MGD.
What Does MGD Feel Like?
Patients with meibomian gland dysfunction may experience:
- burning, stinging or grittiness;
- fluctuating or blurry vision;
- watery eyes;
- redness;
- tired or heavy-feeling eyes;
- discomfort with contact lenses;
- sensitivity to air conditioning or wind; or
- frequent dependence on lubricating drops.
One clue is that the vision may temporarily improve after blinking, then become blurry again as the tear film breaks up.
Why Do Lubricating Drops Only Help for a Short Time?
Artificial tears can add moisture and temporarily improve the tear film.
That can be very helpful.
But if the underlying problem is rapid tear evaporation, the added fluid may also disappear relatively quickly.
The issue is not necessarily that the drops are ineffective. It may simply mean they are treating one part of the problem rather than the main driver of the symptoms.
This is why patients sometimes say:
“The drops work, but only for 10 or 20 minutes.”
That pattern can be a reason to look more closely at the eyelids, meibomian glands and tear-film stability.
Why Are My Eyes Watering If They Are Dry?
Watery eyes and dry eye can occur together.
If the ocular surface becomes irritated or unstable, the eyes may respond by producing extra reflex tears.
These tears are mostly watery and may not contain enough of the oily component needed to remain on the eye for long.
As a result, a patient can have tears running down their cheeks while the surface of the eye is still unstable and uncomfortable.
This is one reason why watery eyes do not necessarily rule out dry eye.
What Is the Difference Between Aqueous-Deficient and Evaporative Dry Eye?
In aqueous-deficient dry eye, the eyes do not produce enough of the watery component of the tears.
In evaporative dry eye, the eyes may produce a reasonable amount of fluid, but the tear film evaporates too rapidly.
Many patients have elements of both.
The distinction matters because the treatment approach can be different.
Someone with significant meibomian gland dysfunction may need treatment directed at the eyelids and gland function rather than simply increasing the frequency of lubricating drops.
Why Can Dry-Eye Symptoms and Examination Findings Be So Different?
One of the frustrating aspects of dry eye is that symptoms and clinical findings do not always match perfectly.
Some people have obvious meibomian gland changes but relatively few symptoms.
Others experience substantial burning, irritation or visual discomfort even though the visible changes initially appear mild.
This is why dry-eye assessment should not rely on one test alone.
We consider the patient’s symptoms alongside the tear film, eyelids, ocular surface, blinking, gland function and other contributing factors.
What Does Meibography Show?
Meibography allows us to image the meibomian glands within the eyelids. Healthy glands generally appear as relatively long, organised structures extending through the eyelid.
Example meibography showing a relatively healthy meibomian gland pattern compared with gland shortening and dropout.It can help us assess the overall gland structure and identify areas where glands have become shortened, distorted or lost.
This can be useful when trying to understand whether meibomian gland dysfunction is contributing to persistent symptoms.
However, meibography is only one part of the assessment.
A patient may have visible gland changes without severe symptoms, while another may have significant obstruction or poor-quality secretions despite relatively preserved gland structure.
The images therefore need to be interpreted together with the rest of the examination.
What Else Do We Look At?
A dry-eye assessment may include evaluation of:
- tear-film stability;
- the quality of the meibomian gland secretions;
- the eyelid margins;
- incomplete or inefficient blinking;
- corneal and conjunctival staining;
- inflammation;
- contact-lens wear;
- medications;
- screen use; and
- environmental factors.
The aim is to understand why the tear film is unstable, rather than simply confirming that the patient has dry-eye symptoms.
Can Incomplete Blinking Cause Meibomian Gland Problems?
It can contribute.
A complete blink helps spread the tears across the eye and assists the meibomian glands in expressing oil.
During prolonged computer or phone use, people often blink less frequently and may perform more incomplete blinks.
Over time, this can contribute to an unstable tear film and may worsen symptoms in susceptible patients.
For some people, improving blink habits and addressing screen-related behaviour forms an important part of treatment.
How Are Blocked Meibomian Glands Treated?
Treatment depends on what we find.
For some patients, relatively simple measures such as appropriate lubricants, warm compresses, eyelid care and improved blinking may be enough.
Other patients may require more targeted treatment of the meibomian glands or associated inflammation.
Options can include meibomian gland expression, prescription therapy, treatment of blepharitis or ocular-surface inflammation, and in-office treatments such as IPL when appropriate.
The treatment plan should be matched to the patient rather than applying the same protocol to everyone.
Does Everyone With Dry Eye Need IPL?
No.
Intense Pulsed Light (IPL) can be useful in selected patients, particularly when meibomian gland dysfunction and eyelid inflammation are important contributors.
But dry eye has many possible causes.
If the main problem is reduced tear production, medication-related dryness, incomplete blinking or another ocular-surface condition, IPL may not be the most important treatment.
At Westmead Eyes, we assess the tear film, eyelids and meibomian glands first and then determine whether IPL is appropriate.
The aim is not to perform IPL simply because somebody has dry-eye symptoms.
What If I Have Already Tried Several Different Eye Drops?
That is often when a more detailed assessment becomes useful.
If you have already tried multiple artificial tears but continue to experience symptoms, questions worth investigating include:
Are your tears evaporating too quickly? Is the oil layer inadequate? Are the meibomian glands blocked? Is blinking incomplete? Is there ocular-surface inflammation? Could your medication, contact lenses or environment be contributing?
Sometimes changing the type of lubricant is helpful.
Other times, the reason the drops have not solved the problem is that the main issue lies elsewhere.
When Should I Have My Dry Eyes Assessed?
Consider a more detailed dry-eye assessment if symptoms are persistent, particularly if you are repeatedly using lubricating drops without satisfactory relief.
It may also be worthwhile if you experience fluctuating vision, contact-lens intolerance, significant burning or grittiness, frequent watery eyes or symptoms that worsen with screens, air conditioning or prolonged visual concentration.
Dry Eye and Meibomian Gland Assessment in Sydney
At Westmead Eyes, our dry-eye assessments look beyond simply recommending another bottle of artificial tears.
We assess the tear film, ocular surface, eyelids, blinking and meibomian glands to determine which factors are contributing to your symptoms.
Treatment can then be individualised according to the findings.
→ Learn more about Dry Eye Treatment
If you are not sure how significant your symptoms are, you can also complete our Dry Eye Symptom Questionnaire.
→ Take the Dry Eye Symptom Test
If your symptoms are persistent despite using eye drops, you can book a Dry Eye Assessment to investigate the underlying cause.