The Patient's Guide to Dry Eye Syndrome: Lacrimal Gland Insufficiency

We have covered the Meibomian glands of the eyelid quite in depth now, and how clogged glands are often the culprit for dry eyes.  Remember, those Meibomian glands secrete the oily surface layer of the tear film, that locks the tears onto the eye and prevents evaporation.  There is another gland located higher up in your eye lid area, tucked just under the brow bone, that is responsible for the actual "watery" component of tear production.  The lacrimal gland is responsible for the "aqueous" middle layer of the tears.  This gland is responsible for emotional and reflex tearing, as well as producing the aqueous layer of regular tear film.  So just because you cry easily, doesn't mean you don't have dry eyes.

The lacrimal gland is usually not the problem when someone has Dry Eye Syndrome; Meibomian gland issues are much more common.  But when the lacrimal gland is not functioning properly the type of dryness that results is usually very severe.  These people are using artificial tear drops every hour or two, lubricating gels at night, and sometimes even need specialized "moisture goggles" to help protect their eyes from drying out.  The lacrimal gland can be damaged in conditions like sarcoidosis and Sjogren's Syndrome.  The latter condition involves extreme dryness of both the eyes and mouth.  Sjogren's has an auto-immune component, so patients with conditions like lupus, rheumatoid arthritis, and other auto-immune disorders are much more likely to experience dryness from reduced lacrimal gland function.  The culprits are inflammatory mediators released by the body's own cells that disrupt normal functioning of the lacrimal gland.  

The Tranquileyes moisture goggles.  These sometimes come with a gel bead packet that can be heated and used to treat Meibomian Gland clogging at the same time! 

Restasis is also another great option for these patients.  Restasis is still a relatively new pharmaceutical in the grand scheme of things, so there is much debate on what types of dry eye the drop is and isn't effective for.  The theory behind Restasis is that it is a potent anti-inflammatory agent (cyclosporine to be precise) that helps block the chemical mediators causing inflammation of the lacrimal gland, and increase your own tear production.  Restasis is dosed twice daily, every single day, and can take as long as 3 to 6 months to become fully effective.  Most patients begin seeing some relief within 1 month. This drop is quite a big time commitment, and involves an expensive copay on most medical insurances, but in some cases it is the best option for relief.  

Restasis comes in individual vials.  To save on copays, I always recommend recapping the vials, storing in a nice clean environment with the vial upright if possible, and then using the same vial again for your nighttime dose.  

Other experimental treatments for severe Dry Eye resulting from lacrimal gland insufficiency include using testosterone cream (to help balance androgen levels; I will discuss this more when we discuss hormonal causes of dry eye) and autologous serum tear drops.  These drops are comprised of your own blood that is centrifuged and prepared into a dosable tear drop that retains your own chemical mediators and growth factors that are always found in natural tears but not found in pharmaceutically manufactured tears.  Needless to say, I have never prescribed this yet for patients but there is some interesting literature out there!