Eyes of the Sahara

 Dry Eyes

This week we will explore the opposite of tearing-dry eye.  Dry eye is a very common condition, present in over 30% of the adult population.  In a study I did in my Michigan practice nearly 60% of patients walking into the office had significant lissamine green staining of their eyes or inner eyelids.  Many common medications and diseases may exacerbate or cause dry eye symptoms.  Computer use or excessive staring at most anything also aggravates dry eye symptoms.

Dry Eyes Are Common

It is amazing how overlooked and undiagnosed dry eye is in average eye doctor’s practice.  Patients with dry eye complaints are often treated with a sample of artificial tears and told it is part of getting old.  In other patients the diagnosis is totally missed.  In this article I will describe how patients present with dry eye, how easy it is to diagnose and treat if the clinician uses a simple natural dye as a routine part of the eye exam.

Symptoms Of Dry Eyes

Patients with dry eye may present with a variety of symptoms.  These may range from variable and decreased vision to scratchy, burning eyes to abject pain and discomfort.  The tear film is one of  the most powerful refractive portion of the eye.  It is a thin layer of tears secreted by the eye that maintains the clarity of the cornea by keeping it moist.  If the tear film is dysfunctional, the cornea will not be able to bend the light rays properly and visual function may be mildly or moderately decreased.  If the tear film is not examined this diagnosis may be missed and the patient sent for a variety of tests that they do not necessarily need.  The doctor can easily access the integrity of the tear film by examining the patient’s cornea at the slit lamp.  After a drop of fluorescein stain is placed into the eye the patient blinks and the doctor determines how quickly the tear film breaks up.  Rapid break up time equals a dysfunctional tear film and dry eye.

 Lissamine Green: Dry eyes made simple

Using lissamine green stain is also helpful and an almost fool proof adjunct in diagnosing dry eye.  Lissamine green is a vital stain.  It stains devitalized tissue-sic -dry epithelial surfaces on the conjunctiva and cornea of the eye.   If the conjunctiva stains with lissamine green the eye is moderately dry.  If the cornea and conjunctiva stain with lissmine green it is severely dry eye.  This is a fool proof test and keeps us both honest.  If you are complaining of dry eye symptoms and your eyes do not stain with lissamine green and your tear film break-up is normal you do not have dry eye.  Your symptoms are caused by something else that I need to diagnose and this may have a very different treatment.

 Conjunctivochalasia: Redundant Conjunctiva

If the mucous membrane covering the white of the eye (conjunctiva) becomes less adherent to the underlying sclera it has a tendency to bunch up on itself.  This is called conjunctivochalasia.  These patients often have bleeding under the conjunctiva that looks terrible but is rarely dangerous.  After the blood resolves, an astute clinician can detect the loose folds of conjunctiva that may be very subtle or very obvious.  Many eye doctors do not appreciate their significance.

These patients may also have symptoms of dry eye and tearing but the treatment required is very different so it is important to recognize the differences.    If these folds block your tear drainage holes (puncta), your tears can’t get to the drain and they will overflow in spite of your eyelids and tear drainage system being normal.  If the folds of conjunctiva interfere with the flow of tears over your eye you may develop chronic inflammation and irritation of the eyes.

These tests are inexpensive, very accurate and very useful in evaluating dry eye symptoms.  If you do not leave your doctor’s office with green and orange stain around your eyes you have not had a complete dry eye examination.   Next time we will explore how to treat these problems.

If these symptoms sound familiar to you please call 941-921-5335 to see one of our dry eye specialist.

Tom Spoor, MD
Oculoplastics and Neuro-ophthalmology
Sarasota, Florida

Tom Spoor,MD
Oculoplastics and Neuro-ophthalmology
Warren, Michigan


Jody Abrams, MD, FACS
Sarasota Retina Institute
Sarasota, Florida 34239


  1. Dr Abrama: I am a FL/PA resident…I had cataract surgery in my left eye 4 days ago in PA…The goal for that eye was to acheive 20/30 vision and I believe that I had a successful outcome so far for that eye….However, I am experiencing double vision when using both eyes…each eye is ok when focusing by itself. My surgeon tells me to wait for the eye to heal but I feel that this double imaging has nothing to do with the cataract surgery. My vision has always been bad( I think the left eye was about a 9.5 for nearsightedness and the right eye was about a 5) and that is why I have put off this necessary cataract surgery for years, afraid to lose any vision…..About 5 years ago, I was fitted with a new eyeglass prescription which improved the vision in my left eye tremendously but I could not wear those glasses since they produced double vision and I just went on with my life mainly using my right eye to see.

    My question to you is, If my surgeon insists on having the cataract surgery on my right eye next week as scheduled, should I do so? I feel that he will want to do the surgery (correcting again to 20/30, hopefully) but I am afraid that I will continue to see double as I did with the 5 yr old eyeglass prescription.

    I had hoped to have the second cataract done 3/27 and return to FL in April….I know I have a brief window of time before the implanted lens is impossible to remove and redo? I appreciate any imput you can give me and I would like to consult with you when I am back in FL

    Thank you

    • JAbramsMD says:

      There are multiple reasons for double vision after cataract surgery, some related to the surgery, the lens, and sometimes when the vision gets better from the surgery people first start to notice that there is double vision. I think you make an important comment by saying that the double is only with both eyes open. Binocular double vision is a neurological issues of misalignment. Now this could be from the presciption of the two eyes being so different that the brain can not line the eyes up, but measurements are needed to determine this. By finding out what the deviation of the eyes are will give a indication of the problem. Unless there is an obvious weakness in a muscle, the problem is more from the the difference in refraction in the eyes. A difference of 5 diopters (the power in the glasses needed to see clearly) between the eyes can lead to double vision. So if there is good vision in the recently operated eye and there is no obvious muscle weakeness, then you will probably get better with the next cataract surgery.
      I hope this helps. I would be happy to answer any more questions you have, and honored to see you in our clinic upon your return here.

      Jody Abrams,MD
      Oculoplastics and Neuro-ophthalmology
      Sarasota, Florida

  2. Margaret Del Castillo says:

    I had a detached retina Nov. 2009, then a macular pucker developed, I was told I needed surgery and would have to
    keep my head down for 2 weeks as a bubble of gas would be put in. I refused. I’m told I need to have a cataract removed and after that is done the macular pucker surgery. I have double vision in that eye. My eyes have become extremely sensitive to light, and very dry. The surgeon says I will have 20/20 vision if she puts in a Toric lens.
    My optometrist says the cataract is very mild and I only have slight astigmatism so she doesn’t think a Toric lens is necessary. She also said I will not get 20/20 until after after the macular pucker surgery. I’m scared stiff to have any of it done. The dry eye solution sounds like something that I would like to have done first above anything else.
    Would you please comment on my concerns. Thank you

    • JAbramsMD says:

      I would be hesitant to tell anyone with previous retinal detachment and a macular pucker that they would get 20/20 vision with cataract surgery. There are to many other factors outside the lens change (cataract) that would could cause the vision to be down. I tell people often you are not going to hurt your eye if you let the cataract stay a little longer. What has the retina surgeon said about the macular pucker as far as your chance of getting better vision? If there is a macular hole then that changes the entire game. As for the double vision this sounds like it is either from your dry eyes or the macular pucker. As for the dry eyes there are multiple medications and treatments for this. I really encourage patients to try collagen tear duct plugs. They help a lot and are very safe and easy to put in.
      Good luck with your treatments. If there is any more I can answer please let me know.

      Jody Abrams, MD
      Oculoplastics and Neuro-ophthalmology
      Sarasota Retina Institute
      Sarasota, Florida

  3. there is an error in your information
    “The tear film is the most powerful refractive portion of the eye”
    This is not true, the cornea is the most powerful portion.

    • Jody Abrams, M.D. says:

      Thank you. I have corrected the error. Thanks for taking the time to read the article and comment on it.


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