Dry Eye Syndrome and Guide to Nighttime Therapy

Jul 15, 2015
14 min read

Dry eye disease is one of the most common ocular morbidities, and a leading cause of visits to eyecare professionals today.1,2

Common signs and symptoms of dry eye syndrome (DES) include:

  • dryness
  • redness
  • stinging
  • foreign body sensation
  • reduced vision
  • excessive tearing

These symptoms can often be exacerbated by environment, medical conditions, medications, prolonged use of electronics, as well as various ocular conditions and anatomy.

It's time to think differently.

“For those considering new ways to manage dry eye syndrome, it might be time to think holistically. A company based out of Temecula, California called Eye Eco, has worked extremely hard to develop various products that can be used during this critical time period. - Dr. Matt Geller”

Here’s a 36 page guide on understanding dry eye and meibomian gland dysfunction. Learn how you can treat MGD using LipiFlow, and how to bring this technology to your practice.

Exposure Keratopathy

Symptoms: Irritation, burning, foreign body sensation (FBS), redness, usually worse in the morning.

Clinical Signs: Inadequate blinking or closure of eyelids leading to corneal desiccation. Punctate epithelial defects in the lower third of the cornea, commonly as a horizontal band. Conjunctival injection, chemosis or eyelid deformity.


Image Source: University of Iowa Health Care

Potential Etiologies: CN VII palsy,  Bells palsy, Eyelid deformity, Nocturnal Lagophthalmos, Proptosis.

Workup: Case history. Evaluate eyelid closure and corneal exposure. Check corneal sensation. Look at tear film and corneal integrity with flourescein dye.

Product Recommendation - Onyix™/ Quartz™ Shield

  • Suggested Treatment Duration: overnight, beginning before bed and finishing upon waking up


  • Dr. Geller's Notes: I utilize the Onyix™ and Quartz™ shields particularly for patients with exposure keratopathy because of their ability to create a moisture chamber to halt tear evaporation. I use the Eye Eco Onyix™ shield, which is black for patients who prefer a dark sleep mask, and the Quartz™ shield for patients who'd rather be able to see out of the shield. They just released a new hand made head strap designed specifically for use with a C-PAP machine used for sleep apnea. My patients report that the shield shelters eyes from excess tear evaporation, while also fogging up, creating a moisture rich environment for the eyes. The new strap features a soft cotton/Lycra fabric covering sewn over elastic, so it stays in place and provides great comfort. The mask is nice because it rests inside the orbit for a lower profile. These are often preferred by smaller faces and those that want to use it on the airplane. Coincidentally, I am writing this as I am on a flight from San Diego, CA to Jacksonville, FL and my eyes are feeling extremely dry!

Product Recommendation - Tranquileyes™ XL


  • Dr. Geller's Notes: I utilize Tranquileyes™ XL as a first line therapy for my patients with exposure keratopathy. Practicing in California, many of our patients appreciate a holistic remedy for their dry eye, and so Tranquileyes™ is easily adopted. Tranquileyes™ provides maximum coverage for eyes and surrounding tissue, helping to keep lids closed. Coverage not only replenishes moisture to the patient's eyes, but also to the skin around the eyes. I find that most patients with exposure keratopathy have concomitant meibomian gland disease. Tranquileyes™ ensures eyelid closure and also provides the right level of heat and humidity to treat the MGD comfortably and effectively. Tranquileyes™ is the only system on the market that controls heat and humidity beyond 10 minutes, and can sustain required temperatures and humidity up to 25 minutes. No other product on the market can achieve this, and as we know, relative to MGD, humidity helps open the glands and promotes circulation and healing.

Traditional Treatment: Prevention is key. Artificial tears can be used throughout the day, as well as lubricating ointment at night. Eyelid taping or patching at nighttime can also be helpful. Surgical repair of eyelids can also be used as a last resort.

Floppy Eyelid Syndrome

Symptoms: Irritation, redness, mucous discharge, usually upon waking up in the morning.

Clinical Signs: Lids are extremely easily everted, superficial punctate keratitis.


Image Source: Review of Optometry

Potential Etiologies: Some studies suggest an abnormality in collagen or elastin fibers. Lids are believed to spontaneously evert overnight, causing exposure of the ocular surface.3

Workup: Evaluate eyelid closure and ease of eversion. Evaluate for abnormal laxity. Examine corneal integrity and check for papillae on palpebral conjunctiva.

Product Recommendation - Tranquileyes™ Original

  • Suggested Treatment Duration: 10-20 min of moist heat, daily
  • Clinical Science: Humidity is at roughly 80-96%. This stabilizes the tear film and hydrates eyelid skin, promoting circulation and healing while leaving the eyes and skin hydrated.
  • Dr. Geller's Notes: Floppy eyelid syndrome is one of the most under diagnosed conditions I see in my office. The name quite bluntly means that the patient's eyelids have lost their tensity and therefore droop. This causes chapped and raw eyelids, incomplete lid closure, abnormal tear evaporation and poor ability to spread tears across the eye. Doctors seem to always prescribe artificial tears, but really these patients need a physical mask over their eyes to keep light and comfortable pressure on the eyelids. For moderate cases, I utilize Tranquileyes™ Original at night. This is a smaller mask that puts the right amount of pressure, moisture and heat on the eyelids. It re-hydrates them, and keeps them from drooping. Also, it acts as a physical barrier against rubbing the eyes on pillows, blankets, or sharp objects that cause corneal abrasions. In addition, the Onyix™ or Quartz™ shield will work well. I recommend both, as these patients often need the hydration of Tranquileyes™, but want the slimness and comfort of sleeping with a thinner mask. The original Tranquileyes™ uses soft black sponges, that come with the goggle for sleep instead of needing to put in the beads or instant warm compress.

Traditional Treatment: Artificial tears can be used throughout the day, as well as lubricating ointment at night. Eyelid taping or patching at nighttime can also be helpful. Surgical tightening of eyelids is also an option. Nighttime ointment can be a good solution for some patients; however, that also has its limitations. Many patients will complain of blurred vision from nighttime ointment, matting of the lids in the morning, and overall lack of lubricity several hours after falling asleep.

Sleep Apnea CPAP/APAP Induced Dry Eye

Symptoms: Irritation, redness, mucous discharge, usually upon waking up in the morning.

Clinical Signs: Lid laxity, superficial punctate keratitis.


Image Source: University of Iowa Health Care

Potential Etiologies: Air leakage from the mask can enter the eye and cause dryness. Air from the exhaust may be directed towards the patient's face.4 These issues are exacerbated if the patient suffers from incomplete lid closure.

Concomitant disease: It is important to be aware that there is a strong association between sleep apnea and floppy eyelid syndrome.3 There is also a strong association between sleep apnea and glaucoma.6,7,8 Studies suggest these patients possess almost twice the risk of developing glaucoma over a five year period.9

Workup: Evaluate eyelid closure and ease of eversion. Evaluate for abnormal laxity. Examine corneal integrity. Have patient check proper fit of mask, and rule out any leaks.

Product Recommendation - Eyeseals™ for C-PAP

  • Suggested Treatment Duration: All nights spent with C-PAP, for duration of sleep
  • Dr. Geller's Notes: Over 18 million Americans have sleep apnea and the majority use a C-PAP at night to avoid apnea and keep a normal breathing pattern. These patients undergo various sleep studies, time and energy to get the mask right, but still encounter air leaks that cause tear evaporation. I prescribe Eyeseals™ because they alleviate this nighttime annoyance and restore the tear film to a more manageable point. This is similar to sitting directly in front of a fan, or the blasting air conditioner at work. Your tear film instantly evaporates, leaving your cornea exposed, but Eyeseals™ prevent this. The Eyeseals™ are extremely soft and shelter eyes while increasing relative humidity around the eyes. The shape of the Eyeseals™ are fantastic, molding to the right face shape for the C-PAP to fit comfortably over the mask. I also like them because they are hypoallergenic and do not contain latex. Keeping patients compliant with C-PAP treatment is also beneficial in reducing the risk of developing glaucoma,7,8 yet another benefit of utilizing  Eyeseals™. These patients need to be carefully and closely monitored.


  • Remember, these are foamless shields, made from food grade thermal plastic, and they rest over the orbital bones. They prevent lashes from hitting when the patient blinks at night, and best of all, fog up at night creating a moisture chamber for night use. The original Eyeseals™ have a little lip above the eyebrow and over the nose to work with specific types of C-PAPs. They are designed to rest nicely between the brow to keep things stable.

Traditional Treatment: Ensure eyes are protected with nighttime lubricants.

Recurrent Corneal Erosion

Symptoms: Acute pain, photophobia, foreign body sensation, and tearing. Usually occurs upon awakening in the morning or during sleep when the eyelids are opened or rubbed.

Clinical Signs: Corneal abrasion, epithelial defects, map dot dystrophy.


Image Source : Review of Optometry

Potential Etiologies: Anterior corneal dystrophies. Previous corneal abrasion secondary to trauma.

Workup: Case history. Examine corneal integrity with fluorescein.

Product Recommendation - Onyix™ / Quartz™ Shield

  • Suggested Treatment Duration: during the acute phase of corneal erosions
  • Dr. Geller's Notes: Several times, I have encountered patients who "self inflict" healing problems with their corneal erosions. Patients will present with a corneal erosion, which I will debride, and then prescribe ointments and antibiotic coverage; however, if the patient returns again with complaints of pain upon awakening, or demonstrates poor healing, I immediately ask about sleep patterns. After careful questioning, I often uncover that my patients are rubbing their eyes, rubbing their face on their pillow, or have aggressive sleep patterns like tossing and turning. That is when I will prescribe the Onyix™ or Quartz™ shield (depending on their preference). It's not that the shield completely creates a barrier, but it gives them positive feedback NOT to rub, scratch, or touch their eyes. It keeps them more aware of their face when they are sleeping as well. This can go a very long way for patients who are "self-inflicting" poor recovery of a corneal erosion. The Eye Eco mask basically tells the patient "listen, give your eyes a break, let them heal, resist the temptation to be rough on them." While putting ointment in is one option for some, many people don’t even realize their eyes are getting completely trashed at night, and how great they feel when they are able to shelter the eyes in a moisture rich environment at night.

Traditional Treatment: Treat as corneal abrasion initially. Can use Muro 128 ointment in addition to antibiotics. After defect is healed, artificial tears throughout the day and nighttime lubrication is critical to prevent recurrence. Debridement and stromal puncture can be used for non-responsive cases.

Meibomian Gland Dysfunction

Symptoms: Irritation, redness, burning, foreign body sensation, blurred vision throughout the day.

Clinical Signs: Capped or dysfunctional meibomian glands.

Potential Etiologies: MGD is believed to be the most common cause of evaporative dry eye, and may even be related to aqueous deficient dry eye. Meibomian oil deficiency causes increased evaporation of the tear film.5


Image Source: Review of Ophthalmology

Workup: Evaluate lids and quality of meibum upon expression of glands. Assess tears and TBUT.

Product Recommendation - Tranquileyes™ XL

  • Suggested Treatment Duration: 10-20 min of moist heat, daily
  • Clinical Science: Tranquileyes™ follows the guidelines from The International Workshop on Meibomian Gland Dysfunction, keeping moist heat in the range of; 101–110°F/38.33-43.33°C
  • Dr. Geller's Notes: I utilize Tranquileyes™ XL as a first line therapy for my patients with Meibomian Gland Dysfunction. Nothing speaks better to the patient than the idea that "we are going to start holistic, basic, and non-invasive treatment." Even if the disease process is far along, I still typically prescribe Tranquileyes™ and Omega-3's and let the patient know that steroids, antibiotics, and other treatments will come later. I do this because dry eye is a chronic disease and without the patient being part of our treatment plan, we cannot succeed. Tranquileyes™ XL helps me set the stage for what is to come in the future. The 101–110°F moist heat really does the trick when it comes to breaking up and melting clogged miebum in the upper and lower lids.

Traditional Treatment: Washcloth based warm compress, omega-3 supplementation, baby shampoo, Avenova lid hygiene, Cliradex lid wipes for demodex, doxycycline oral antibiotic, loteprednol gel, and LipiFlow treatment.

Concluding Comments

No matter what treatment you choose, it is important that you treat patients with a purpose. Understanding the disease process of ocular conditions that exacerbate dry eye syndrome, will better help you recommend treatment to your patients. It is important that we treat the ocular condition and ailment during the day and night, which is why developing a treatment modality encompassing and addressing both is important.

Checkout EyeEco.com for more information on their product line up.


  1. O’Brien PD, Collum LM. Dry eye: diagnosis and current treatment strategies. Curr Allergy Asthma Rep.2004;4:314–319

2. Gayton JL. Etiology, prevalence, and treatment of dry eye disease. Clinical Ophthalmology. Auckland, N.Z. 2009;3:405-412.

3. Daniel G. Ezra, Michèle Beaconsfield, Mano Sira, Catey Bunce, Richard Wormald, Richard Collin. The Associations of Floppy Eyelid Syndrome: A Case Control Study. Ophthalmology, 2010; 117 (4): 831 DOI: 10.1016/j.ophtha.2009.09.029

4. "For CPAP Users." CPAP Users-Dry Eyes. Exeter Hospital, 2015. Web. 13 June 2015.

5. Nichols, Kelly K. "The International Workshop on Meibomian Gland Dysfunction: Introduction." Invest. Ophthalmol. Vis. Sci. Investigative Opthalmology & Visual Science 52.4 (2011): 1917. Web.

6. Mojon, DS, CW Hess, D. Goldblum, M. Böhnke, J. Körner, and J. Mathis. "Primary Open-angle Glaucoma Is Associated with Sleep Apnea Syndrome." Ophthalmologica 214.2 (200): 115-18. PubMed. Web. 13 July 2015.

7. Mojon, DS, CW Hess, D. Goldblum, M. Boehnke, F. Koemer, M. Gugger, C. Bassetti, and J. Mathis. "Normal-tension Glaucoma Is Associated with Sleep Apnea Syndrome." Ophthalmologica 216.3 (2002): 180-84.PubMed. Web. 13 July 2015.

8. Hashim, SP, FA Al Mansouri, M. Farouk, AA Al Hashemi, and R. Singh. "Prevalence of Glaucoma in Patients with Moderate to Severe Obstructive Sleep Apnea: Ocular Morbidity and Outcomes in a 3 Year Follow-up Study." Eye (Lond) 28.11 (2014): 1304-309. PubMed. Web.

9. Ching-Chun L, Chao-Chien H, Jau-Der H, et al. Obstructive sleep apnea and increased risk of glaucoma: a population-based matched-cohort study. Ophthalmology. 2013;120:1559-1564.

This article is an advertorial for the company Eyeeco. We would like to let you know that NewGradOptometry, LLC has chosen to work only with companies who support new graduate eyecare professionals, the profession of optometry and who our team believes in. We will always remain true to that.

About Antonio Chirumbolo, OD

Antonio Chirumbolo, OD is the Director of Client Services at CovalentCreative. He completed his optometry degree at the SUNY College of Optometry in 2013. Antonio is passionate about digital media, marketing, and advertising and in his free time still practices …

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