Dry eye is a very common eye condition, but it rarely needs surgery. Some people with underlying conditions or severe, chronic dry eye benefit from surgical options.

Overall, dry eye can be irritating but harmless. If you have poor quality tears or structural problems with your tear ducts, you may struggle to keep your eyes moist enough, which can lead to damage to your sclera, cornea, and other tissues.

Most surgical treatments for dry eye are outpatient operations that partially or completely seal up your tear ducts, keeping tears on the surface of your eye longer. Some chronic health problems like autoimmune diseases may require salivary gland transplantation to keep your eyes moist.

Being diagnosed with dry eye does not mean you will automatically need surgery. But if eye drops do not help, surgery may be a valid option.

Causes of Dry Eyes

One of three developments lead to dry eyes. Either your lacrimal glands don't produce enough tears to sufficiently wet your eyes; you have low-quality tears that don't function optimally to wet your eyes; or your tears dry up too quickly.

Several underlying conditions, certain habits and specific environmental exposures lead to any or all of the conditions that cause dry eyes. The underlying conditions include:

  • Certain medications
  • Sjogren’s syndrome
  • Allergies
  • Aging
  • Excessive screen time
  • Vitamin A deficiency
  • Wind and low humidity
  • Long-term contact lens wear
  • Smoke exposure

Diagnosing Dry Eyes

An eye exam that includes a series of diagnostic tests is necessary to determine if you have dry eye syndrome. Your eye doctor first assesses your symptoms and their severity. Below are several diagnostic tests that your doctor will conduct to help diagnose dry eyes and rule out other eye conditions:

  • Schirmer’s Test. This is the most common diagnostic test. It helps your doctor determine whether your eyes produce sufficient tears to maintain eye moisture.
  • TearLab. Your doctor uses this test to assess the saltiness of your tears(osmolarity). If your osmolarity is too high, it can lead to eye surface damage resulting in dry eyes.
  • Phenol Red Thread Test. Physicians use this to assess whether the aqueous layer of your tears is diminished, thus inhibiting the spears of tears across your eye surface.
  • Tear Break Up Time. This is used to measure the time it takes your tears to evaporate. Tears that evaporate too fast cannot sufficiently lubricate your eyes.
  • InflammaDry. Eye doctors use this diagnostic tool to identify increased MMP-9 levels. Elevated levels of this protein that’s found in your lower eyelid lining may indicate eye inflammation.
  • LipiScan. This is a diagnostic imaging device used to assess the health of meibomian glands. Infection of these glands may lead to poor tear quality and consequently dry eyes.

Surgery for Dry Eyes: A Rare but Important Option

patient receiving cataract surgeryMaybe you blink a lot to clear your vision, maybe your eyes feel itchy a lot, or maybe your eyes often look red or irritated. These can be signs of chronic dry eye, a condition caused by tear glands that cannot make enough tears or tear glands that make low-quality tears that do not coat your eyes.

Dry eye is a common vision condition that affects millions of Americans every year.

If you find yourself using eye drops frequently to relieve itchy, stinging, or uncomfortable eyes, this could indicate that you have dry eye. Although it is a very treatable and common eye disease, it is important to have it diagnosed and start a treatment plan with your optometrist or ophthalmologist. There could be more serious vision problems later if you do not get the right treatment now.

In rare cases, you may need surgery to treat dry eye. Your doctor will typically prescribe lifestyle changes, prescription eye drops, and other options first. But you may ultimately find that the best way to treat dry eye is with eyelid surgery to adjust how tears flow around your eye.

What Are Standard Treatments for Dry Eye?

Treatment for Dry Eye Syndrome utilizes a step ladder approach corresponding to the severity of the condition. A fundamental first step of treatment involves avoiding the aggravating factors and exposure such as air conditioning, dry heating air and cigarette smoke. The other standard treatments include:

  • Artificial tears or eye drops
  • Anti-inflammatory treatment
  • Cholinergic drugs
  • Specialty contact lenses
  • Surgery for dry eyes

Artificial Tears/Eye Drops

Artificial tears are effective treatment options for all levels of dry eye severity. Artificial tears help increase the stability of tear film, reduce ocular surface stress and improve the optical quality of the eye surface.

Anti-inflammatory Treatment

Ocular surface and lacrimal gland inflammation often cause moderate to severe dry eye syndrome. As such, anti-inflammatory treatment to tackle inflammation and ocular surface damage help with moderate to severe dry eye syndrome.

Cholinergic Drugs

Cholinergic drugs such as cevimeline and pilocarpine are medications that help stimulate tear production. They are available as eye drops, gels or pills.

Specialty Contact Lenses

Scleral lenses are contact lenses that help repair eye surfaces and are beneficial for patients with moderate to severe dry eye mainly caused by meibomian gland dysfunction.

Types of Surgery for Severe Dry Eye

man using eyedropTypes of dry eye surgery involve your tear ducts, specifically those that allow tears to drain out of your eyes quickly. Surgical options might involve:

  • Closing tear ducts.
  • Adjusting the lower eyelid so it is not loose.
  • Adjusting eyelids so they close all the way during blinking.

An oculoplastic surgeon can adjust your eyelid shape or size so your eyes close completely, which allows tears to move around your eye. Sometimes, improving the muscle or skin tone in your eyelids is enough to prevent your eyes from feeling dry or itchy.

Surgery for dry eyes becomes an option when standards treatments fail to alleviate the symptoms. Your doctor may recommend any one of the following surgical options:

  • Intense Pulsed Light Therapy: IPL therapy uses light pulses to destroy vascular structures in your eyelid selectively. This option is used when Meibomian gland syndrome (MGD) is the cause of your dry eyes.
  • Laser Surgery: LASIK surgery to correct vision may improve preexisting dry eye condition.
  • Amniotic Membrane Implant: This option is viable if your dry eye causes keratitis or damage to the eye surface. Doctors implant an amniotic membrane to your eye surface, which serves as a physical barrier.

Other surgical options may include:

Punctal Plugs

These may be temporary and are made from silicone, or they could be implanted permanently. Punctal plugs reportedly reduce the need for artificial eye drops, although you can still use these drops as needed with the plugs in place.

If you need this procedure, your eye doctor will give you a thorough exam to ensure there are no other conditions that require treatment. They will also discuss your history of managing dry eye to determine which treatments have not worked well before. Then, they will discuss which type of plugs might work best.

  • Temporary: These are collagen plugs designed to naturally dissolve into the body. Often, your ophthalmologist will try these first, partially to see if this temporary treatment can help and partially to see how your body reacts to plugs in your tear ducts.
  • Silicone or acrylic: This is a type of permanent plug made from material designed to be barely noticeable to the body. If needed, these can be removed. These punctal plugs sit just at the entrance of the tear ducts.
  • Intracanalicular: This type of plug is intended to be permanent, remaining in place for years. The plug is placed deep into the tear canal, keeping the eyes moist. If they need to be removed for any reason, this will require surgery.

Regardless of the type of plug, it will only take numbing eye drops and a few minutes with an eye surgeon to put punctal plugs in place. These are often put into the right position using small forceps. Punctal plugs do not require major surgery, so recovery is fast. You may feel a little discomfort for a day or two, but this will go away.

Side effects from punctal plugs are rare, but may include:

  • Inflammation of the eye.
  • Allergic reaction to the material.
  • Excessive eye watering.
  • Plugs sticking out.

Thermal Cautery

A surgeon will use a heated wire to shrink tissues in the area of your tear ducts, so tears do not flow out as rapidly. Punctal plugs are the most common solution, but if you have a poor reaction to the materials used in these devices, or your ophthalmologist deems you are better suited to a permanent solution, thermal cautery can be used to permanently close your tear ducts.

Like punctal plugs, thermal cautery requires a thorough eye exam to ensure you have no underlying health problems. The surgery itself is a simple outpatient procedure with a rapid healing time. It takes only a few minutes, and you will get a local anesthetic. You should have normal vision within a day or two after the operation.

Salivary Gland Transplantation

If your tear glands themselves are a problem and not creating enough tears, a surgeon may remove salivary glands from your lower lip and graft them into your upper eyelid. This is a rare procedure but could be necessary to prevent damage to your cornea, sclera, and conjunctiva.

Salivary gland transplantation is most often applied to people with cicatricial disorders, in which mucous membranes are attacked by an autoimmune condition.

This is a major surgery, so you will need to work closely with your physician and your ophthalmologist to manage your health, including the use of general anesthesia. During the surgery, minor salivary glands and some mucous membrane tissue will be removed from a small part of your lip to create a complex graft. This will then be implanted where your tear glands should be. This is a rare procedure, but medical researchers report good outcomes in people who need it.

Saliva is similar to tears in some ways, containing important components like:

  • Electrolytes
  • Immunoglobulins
  • Proteins
  • Enzymes
  • Mucins

These keep mucous membranes healthy, so transporting one type of gland to another can be beneficial, even if it is not exactly the same. Studies examining surgical outcomes reported improvements in dry eye problems like light sensitivity, feeling like there is an object in the eye, and overall eye pain.

When to Consider Surgery

Doctors recommend surgery only when the standards treatments and preventative measures aren’t effective at treating your symptoms. Consult your doctor about surgical options if your symptoms fail to improve, your symptoms get worse, your current treatments stop working, or if your condition severely impedes your quality of life.

Lifestyle Changes and Home Remedies

You can manage dry eyes effectively by frequently washing your eyelids and using OTC eye drops and other products such as warm compresses that help lubricate your eyes and reduce inflammation.

You can also adopt some relatively easy, but significant, lifestyles changes that will improve your eyes. Among them:

  • Blinking more
  • Reducing screen time (TVs, computer monitors, tablets and cell phones)
  • Consuming more oily fish (contain omega-3 fatty acids)
  • Staying well-hydrated
  • Wearing protective eyewear when engaging in outdoor activities
  • Using a humidifier
  • Avoiding eye irritants such as smoke and dust

Costs

One reputable study on the economic burden of dry eye syndrome indicated that the annual medical care treatment costs for patients with dry eye symptoms were:

  • $678 a year for mild symptoms
  • $771 a year for moderate symptoms
  • $1,267 a year for severe symptoms

Treatment costs include the initial assessment cost and ongoing treatment costs. However, this study was published in 2011, and costs are likely higher today.

The cost of dry eye surgery will vary considerably depending on the type of procedure, your insurance coverage, and your location.

Surgery: The Last Resort

Overall, the best treatments for dry eye are pharmacological. Over-the-counter or prescription eye drops are most likely to be used to manage symptoms and prevent damage to the delicate tissues on the outside of your eye.

Your ophthalmologist may determine you need better treatment if eye drops are not useful. Severe cases of dry eye can benefit from these long-term solutions.

References

Dry Eye Diagnosis and Treatment. (August 2019). American Academy of Ophthalmology (AAO).

What to Know About Punctal Plugs for Dry Eye. (June 2018). Medical News Today.

A Stepwise Approach to Treating OSD. (July 2009). Review of Ophthalmology.

Minor Salivary Gland Transplantation for Severe Dry Eyes. (November 2017). Cornea.

Dry Eye . (December 2020). National Eye Institute.

Causes of Chronic Dry Eye. (July 2020) Healthline.

Dry Eye Syndrome Diagnosis. (December 2020). Optometrists Network.

Diagnosis and Treatment of Dry Eye Disease. (January 2015). Deutsches Arzteblatt International, Department of Ophthalmology.

Dry Eye Treatment. (September 2020). Mayo Clinic.

Dry Eye Symptoms after LASIK. (August 2021). Refractive Surgery Council.

Amniotic Membrane Transplantation for Dry Eye. (March 2020). Taiwan Journal of Ophthalmology.

Economic Burden of Dry Eye Disease. (August 2011). Healio News.

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