What is dry eye disease?

DED is a multifactorial ocular surface condition — characterised by symptoms (dryness, grittiness, burning, stinging, photophobia, blurred vision clearing with blinks) and signs (tear film instability, corneal staining). Affects approximately 300 million globally. Two mechanisms: aqueous-deficient (insufficient lacrimal production — Sjögren's) and evaporative (rapid evaporation, usually from MGD — the most common form). Most patients have a mixed picture.

What treatments are available?

Stepwise: Step 1: artificial tears (preservative-free); warm compresses + lid massage; screen hygiene; omega-3. Step 2: cyclosporine 0.05% (Restasis) or lifitegrast 5% (Xiidra) for anti-inflammatory effects; perfluorohexyloctane (Miebo 2023) for lipid layer. Step 3: autologous serum tears; punctal plugs; scleral lenses. Step 4: surgical (punctal cautery, tarsorrhaphy).

Could DED be Sjögren's syndrome?

Yes — test anti-Ro/SSA antibodies in all moderate-severe DED patients. Primary Sjögren's can present as isolated dry eye for years before other features (dry mouth, fatigue, arthralgia) appear. Sjögren's carries 40× elevated lymphoma risk — annual surveillance required. Early diagnosis enables systemic monitoring and treatment.

What is Miebo and why is it different?

Miebo (perfluorohexyloctane, PFHO) is the first eye drop specifically targeting the lipid layer of the tear film — reducing tear evaporation at its source. All previous drops added aqueous volume (water-based); Miebo addresses the evaporative (lipid layer) component. FDA-approved May 2023 for DED associated with MGD. A genuinely novel mechanism for evaporative dry eye.

How does GMJ News cover dry eye?

GMJ News covers TFOS DEWS II definition, 300M global burden, MGD as dominant cause (86%), warm compress evidence, PFHO Miebo 2023 (lipid layer mechanism), cyclosporine vs lifitegrast anti-inflammatory options, Sjögren's testing (anti-Ro/SSA, lymphoma risk), digital screen blink rate, preservative-free tear importance, and stepwise treatment.

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Dry Eye Disease

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Dry eye disease (DED) — a multifactorial condition of the ocular surface characterised by tear film instability, hyperosmolarity, inflammation and neurosensory abnormalities — affects an estimated 300 million people globally (TFOS DEWS II global prevalence study) and is among the most common conditions seen in ophthalmic practice, with meibomian gland dysfunction (MGD — lipid layer deficiency causing evaporative dry eye) accounting for the majority of cases and being substantially under-treated with simple warm compress and lid hygiene, despite being as effective as pharmacological interventions for mild disease (WHO). A therapeutic landmark arrived in 2023: perfluorohexyloctane (Miebo, Bausch + Lomb — FDA approved May 2023) became the first lubricating eye drop specifically targeting the lipid layer of the tear film — a completely novel mechanism addressing the evaporation component of evaporative dry eye.

Key messages

300 million people — most prevalent ocular surface disease

300 million people have dry eye disease globally (TFOS DEWS II 2017). Most common condition presenting to eye care practitioners. Prevalence increases with age (up to 30% of adults >65), female sex (especially post-menopause), digital screen use (reduced blink rate ~5/min vs normal ~15/min), and contact lens wear.

Meibomian gland dysfunction — dominant cause in approximately 86%

MGD: impaired secretion of meibum lipid layer → increased tear evaporation → evaporative dry eye (the most common form). Meibomian glands: approximately 25-30 sebaceous glands in each eyelid, visible at the lid margin. First-line treatment: warm compresses (45-55°C × 5-10 minutes) + lid massage + lid hygiene — as effective as pharmacological interventions for mild MGD.

Perfluorohexyloctane (Miebo) — FDA May 2023 — first lipid-layer-targeting drop

PFHO (Miebo, Bausch + Lomb): FDA approved May 2023 for DED associated with MGD. First lubricating eye drop specifically targeting the lipid layer of the tear film — reducing tear evaporation at source. GOBI and MOJAVE Phase 3 trials: significant OSDI, corneal staining and Schirmer improvements vs vehicle. A genuinely new mechanism after decades of aqueous supplementation.

Cyclosporine and lifitegrast — anti-inflammatory for moderate-severe DED

Cyclosporine 0.05% (Restasis, FDA 2003) and 0.09% (Cequa): topical calcineurin inhibitor reducing T-cell conjunctival inflammation. Effect takes 3-6 months. Lifitegrast 5% (Xiidra, FDA 2016): LFA-1/ICAM-1 inhibitor — faster onset (2-6 weeks). Both for moderate-severe DED with inflammatory component.

Sjögren's syndrome — the most important systemic cause to exclude

Primary Sjögren's: dry eyes + dry mouth + anti-Ro/SSA antibodies (positive approximately 80%). Check anti-Ro/SSA antibodies in all moderate-severe DED. Sjögren's carries 40× elevated lymphoma risk — requires surveillance. Dry eye may be the presenting symptom for years before other features appear.

TFOS DEWS II definition — multifactorial disease

TFOS DEWS II (2017): DED is "a multifactorial disease of the ocular surface characterised by loss of homeostasis of the tear film, accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles." Emphasises multiple interacting pathological mechanisms.

Key statistics

~300M

people globally with dry eye disease (TFOS DEWS II 2017)

TFOS DEWS II

FDA May 2023

perfluorohexyloctane (Miebo) — first lipid-layer-targeting dry eye treatment

FDA 2023

~86%

of DED cases have MGD as a dominant contributing factor

TFOS DEWS II

3-6 months

for full effect of cyclosporine topical — patient counselling essential

FDA/TFOS

40×

elevated lymphoma risk in primary Sjögren's syndrome

EULAR/Sjögren's

~5/min

blink rate during screen use (vs ~15/min at rest) — major DED driver

TFOS/Optometry

DED stepwise treatment approach (TFOS DEWS II / AAO)

Source: TFOS DEWS II / AAO. Warm compresses + lid hygiene first for MGD; anti-inflammatory for moderate-severe.

Glossary of key terms

Tear film layers
OphthalmologyOuter lipid layer (meibomian glands — prevents evaporation, ~100nm); Middle aqueous-mucin layer (lacrimal glands + goblet cells — ~3-7μm; nutrient/O2 delivery); Inner mucin layer (membrane-associated mucins — adheres tear film to epithelium). DEWS II classification: Aqueous-deficient DED (ADDE: lacrimal gland failure — Sjögren's; non-Sjögren's); Evaporative DED (EDE: rapid evaporation — MGD dominant). Most cases are mixed.

MGD treatment
TFOS/OphthalmologyWarm compresses (45-55°C × 5-10 min — softens inspissated meibum); lid massage (expresses softened meibum); lid scrubs (removes collarettes, debris). Omega-3 (1-3g/day — modestly improves meibum quality). Azithromycin (topical or oral — anti-inflammatory effects on glands; Demodex eradication). Advanced: intense pulsed light (IPL) therapy; meibomian gland probing.

PFHO (Miebo)
FDA 2023/PharmacologyPerfluorohexyloctane (C6F13-C8H17): semifluorinated alkane; liquid at room temperature; spreads over tear film lipid layer; does not mix with water. Mechanism: deposits on outer lipid surface → reduces surface tension → decreases tear evaporation rate. GOBI (European) and MOJAVE (US) Phase 3 trials: significant OSDI, corneal fluorescein staining, Schirmer improvements. No preservatives needed (inherently antimicrobial). First novel DED mechanism in decades.

Lifitegrast (Xiidra)
FDA 2016LFA-1 (lymphocyte function-associated antigen-1) antagonist — blocks T-cell and APC binding via ICAM-1 → reduces T-cell-mediated ocular surface inflammation. FDA 2016 for signs and symptoms of DED. Faster onset than cyclosporine (2-6 weeks). Side effects: instillation site irritation; dysgeusia (altered taste from nasolacrimal drainage). Twice-daily dosing.

Sjögren's testing in DED
Rheumatology/OphthalmologyPrimary Sjögren's: anti-Ro/SSA antibodies (80%) + anti-La/SSB (50%) + Schirmer's test <5mm/5min + minor salivary gland biopsy (focus score ≥1). All moderate-severe DED patients: check anti-Ro/SSA. Systemic features: fatigue; arthralgia; peripheral neuropathy; primary biliary cholangitis; ILD; cryoglobulinaemia. Lymphoma risk: 40× elevated (MALT lymphoma, DLBCL) — mandates surveillance. SS can present as isolated dry eye for years.

Digital eye strain and DED
Public healthScreen use reduces blink rate ~15→~5/min → incomplete blinks → reduced meibum expression → tear film instability. 20-20-20 rule: every 20 minutes, look 20 feet away for 20 seconds. High-definition LED screens in low-humidity environments (air-conditioned offices) worsen DED. Contact lens + screen use = high-risk combination.