Ocular surface disease | Huntereyesurgeons

Part A — Understanding the ocular surface

1. What is ocular surface disease?

“Dry eye” is the everyday name, but for most people it is a slight misnomer. The eye is usually not short of tears so much as the tears are not doing their job — so a better name is tear dysfunction. In the majority of patients the tears evaporate too quickly because the oily part of the tear film has failed; in others the eye genuinely makes too few tears; in some the surface itself has lost the ability to stay wet and heal; and in some the lids simply fail to cover the eye properly, leaving it exposed. All of these end in the same place: an irritated ocular surface.

These conditions are extremely common, and they get steadily more common — and often more troublesome — with age. For most people they are more of a nuisance than a danger, they tend to come and go over many years, and they respond very well to regular, disciplined care.

The single most important idea in this guide

Ocular surface disease is controlled, not cured. There is no one-off fix. But with the right routine you can keep it quiet for long stretches and settle the flares when they come. The patients who do best are the ones who are regular and disciplined — a little, often, every day, like looking after your teeth.

2. The tear film — your eye’s first lens

Your tears are not just water. The tear film has three parts working together: a watery layer that does most of the wetting, a sticky mucous layer underneath that helps it spread evenly, and a very thin oily layer on top, made by the meibomian glands in the eyelids.

Tears are one of the eye’s natural defences — they coat, protect and nourish the surface. Just as importantly, the tear film is the eye’s first lens: light passes through it before anything else. So when the film is uneven, the vision blurs, then clears for a moment when you blink. The oily layer is the key to keeping it stable: think of it as the lid on a cup of coffee, stopping the watery tears underneath from evaporating between blinks.

3. The four ways the surface dries out

It helps to know which type (or mix of types) you have, because the treatment differs. Whatever the cause, the symptoms are much the same, which is why they are all grouped together as ocular surface disease.

Type 1 — The oil fails (evaporative)

By far the most common. The oily layer fails because the eyelid oil glands are inflamed — this is blepharitis, usually linked with the skin condition rosacea. The tears are there, but they evaporate too fast. Part B of this guide is devoted to it.

Type 2 — Not enough tears (aqueous-deficient)

The tear-producing (lacrimal) glands make too little. This becomes more common with age — by about 40 you make roughly half the tears you did as a child — and affects women especially after menopause. It can be driven by autoimmune inflammation, including Sjögren’s syndrome, and by certain medications. Part C covers how we replace and protect the tears.

Type 3 — The surface won’t wet or heal (neurotrophic)

The cornea loses some of its nerve supply, so it no longer senses dryness well or maintains itself properly. This can happen after laser refractive surgery such as LASIK, which divides some of the corneal nerves. Part D covers it.

Type 4 — The eye is left exposed (exposure keratopathy)

The lids fail to cover the eye, so part of the surface is left exposed to the air and dries out. This can happen when the blink is incomplete — as in a facial nerve palsy, or after botulinum toxin (Botox) near the eye — or when the blink rate falls, which is common in older people and in conditions such as Parkinson’s disease. It can also happen overnight if the eyes do not fully close. Section 18 covers it.

Most people are a mix

These types overlap. The same person can have inflamed oil glands and reduced tear production at once, which is why we often treat on more than one front.

4. What you might notice

Whatever the underlying type, the symptoms are much the same:

Irritability — a constant sense that something is not right with the eye
Stickiness, especially first thing in the morning
Scratchiness and grittiness, the feeling of something in the eye
The urge to rub
Stinging and burning
Redness — the small blood vessels on the surface of the eye become injected
Sensitivity to light
Vision that blurs and then clears when you blink (the tear film is the first lens)
Watering — paradoxically, a wet eye is often a dry eye

Why a watery eye is often a dry eye

It feels back-to-front, but the commonest cause of a watering eye is preceding dryness. There is a lag in the watering reflex: the surface dries and is irritated, and the eye then over-produces a reflex flood of tears in response.

A simple clue to which type you have

When something moves you, can you still cry actual tears? People whose tear glands are genuinely under-producing often find they can no longer well up with emotion, whereas in the common evaporative type emotional tears are normal. It is a rough clue, not a diagnosis — but a useful one.

5. Could it affect my sight?

For the great majority of people, no — it is irritating, not sight-threatening. But it is worth being clear about what severe, uncontrolled disease can do, because preventing exactly this is the point of treating it.

When the surface stays inflamed and unmanaged, the constant irritation and bacterial toxins can damage the cornea — the clear front window of the eye — in a stepwise way:

An unhealthy surface (epitheliopathy), with tiny scattered breaks in the surface cells (punctate epithelial erosions) — gritty, sore and sensitive to light.
Marginal keratitis — small, sore, inflamed spots at the edge of the cornea, from the immune reaction to bacterial toxins.
Ulceration, including bacterial keratitis — a weakened surface is more prone to ulcers, and an infected ulcer is serious and needs urgent care.
Corneal scarring and, at worst, permanent loss of vision if all this is left unchecked over time.

When to seek prompt eye care

Contact us, your optometrist, or seek prompt eye care for a genuinely painful, very red eye, marked sensitivity to light, or any drop in vision that does not clear with a blink. These go beyond ordinary day-to-day irritation and deserve a look.

6. Why it matters before eye surgery

Because surface disease is so common and so often silent, we look for it routinely — especially before cataract surgery and other eye operations. A healthy, smooth surface matters for two practical reasons:

Accuracy. The measurements used to choose the lens implant for cataract surgery rely on a smooth, healthy surface. An inflamed, dry surface makes those measurements less reliable, which can affect how sharp your vision is afterwards.
Safety and healing. Inflamed lids carry more bacteria, which we want to settle before any operation, and an unhealthy surface heals more slowly and less comfortably.

If we ask you to settle your eyes before surgery, this is why

Undiagnosed or uncontrolled surface disease can mean a longer recovery, more after-care, and a less sharp result. Getting the surface into good shape beforehand is a genuine investment in your outcome — not a delay for its own sake.

Part B — The oil failure: blepharitis and rosacea

This is the most common form of ocular surface disease, and the most rewarding to treat, because so much of it is in your own hands.

7. What is happening

Set into each eyelid is a row of about 25 to 30 meibomian glands — tiny oil glands whose openings sit just behind the lashes. Every blink squeezes a little oil onto the eye to stop the tears evaporating. In blepharitis these glands become inflamed and partly blocked, and the oil turns thick and waxy, like butter gone hard in the fridge. Less gets out, and what does is the wrong consistency — so the tears evaporate too fast.

Blepharitis usually travels with rosacea, a skin condition of the central face (forehead, cheeks, nose and chin) with flushing, redness, visible small vessels and bumps. The link makes sense: rosacea is inflammation of the skin’s oil glands, and the meibomian glands are oil glands too. Treating the face and the lids together helps both. Common rosacea triggers — heat, sun, alcohol, spicy food and stress — are worth noticing.

What causes it?

Honestly, it is poorly understood — but two things are worth saying clearly: it is not an infection (you cannot catch it or pass it on), and it is not caused by being unclean. What we think happens is an immune over-reaction to the “biofilm” that builds up on the lids — a sticky film of bacteria, much like the plaque on teeth — and to Demodex, microscopic mites that live in the lash follicles and become more numerous with age. There is also growing interest in the gut microbiome, though that is early science.

8. Treatment, and who manages it

Treatments fall into two groups. Topical treatments go on the lids, face and eyes — cleaning, drops, creams and in-clinic procedures. Systemic treatments are tablets that work from the inside. We almost always start with topical care and add systemic only if needed: a stepwise approach.

The stepwise ladder

1. Lid hygiene and warm compresses — for everyone, always. The foundation.

2. Lubricating drops for day-to-day comfort.

3. Target the mites (tea tree, ivermectin) if Demodex is a big part of it.

4. In-clinic cleaning or light (BlephEx, IPL) for tougher cases.

5. Systemic tablets — a short burst, or longer-term, for stubborn inflammation.

6. Specialist input if the cornea becomes significantly involved.

Who looks after this?

For most people, day-to-day surface care is very well managed by your optometrist or GP, who can guide your routine and prescribe when needed. Our focus at Hunter Eye Surgeons is surgery, so we generally do not run the long-term management ourselves. What we do is diagnose it, help get it under control around any operation, and involve an eye specialist or corneal specialist if there are severe corneal changes.

9. The cornerstone: warmth and cleaning

The single most effective treatment is something you do yourself, it costs almost nothing, and it is entirely in your hands. It has two jobs: warmth to melt the thickened oil so the glands can empty, and cleaning to clear the crusts and break up the biofilm along the lid margin. Start twice a day while things settle, then ease back to once a day, or a few times a week, as maintenance. Warmth first, then cleaning.

The whole battle, in one sentence

Warmth melts the oil; cleaning clears the crust and the biofilm. Done regularly, that is most of the treatment for most people.

10. Warm compresses, done properly

The two things people get wrong are not enough time, and letting the compress go cold.

Warm a clean face cloth in warm — not scalding — water and wring it out, or use a microwavable eye mask, which holds heat far longer.
Close your eyes and hold it gently over the lids for five to ten minutes, re-warming as it cools.
Afterwards, with eyes closed, gently roll or press the lids towards the lashes to express the softened oil.

In an acute flare, do this two to four times a day. The trick to keeping it up is to attach it to something you already do — in the shower, while the kettle boils, or during the evening news.

11. Cleaning the lids and face

Once the warmth has done its work, gently clean along the base of the lashes — the lid margin, not the eyeball — and the surrounding skin. That is where the crust, bacteria and biofilm collect. There are many products, and the best one is simply the one you will actually use:

Ocusoft Lid Scrub and similar cleansers (wipes or foam), made for the job.
Tea tree based wipes if mites are involved — the active ingredient kills Demodex. Use a proper eyelid product, never neat tea tree oil.
Dilute baby shampoo is the old, cheap standby and still works.
Hypochlorous acid sprays are a newer, very gentle way to reduce the bacterial load.

The golden rule for anything you put near the eye

Whatever you use must NOT sting the surface of the eye. If a product stings, stop it and choose a gentler one. There are plenty of options — comfort is what keeps you doing it.

12. When more is needed

Flare-ups — steroids (short term only)

For an angry flare, a short course of a mild steroid cream or drop (for example hydrocortisone, Hycor) calms it quickly. Short courses only: used near the eye for long periods, steroids can raise the eye’s pressure (glaucoma) and cause cataract, and the ointment blurs vision. Always use exactly as prescribed and return for review.

Targeting Demodex mites

If mites are prominent — a tell-tale sign is “collarettes,” small cuffs of debris at the lash bases — we target them with tea tree (terpinen-4-ol) lid products, or ivermectin 1% cream (Soolantra) on the facial skin, which dermatologists use for rosacea. A newer mite-specific eye drop, lotilaner (Xdemvy), became the first approved Demodex treatment in the United States in 2023 but is not yet available in Australia.

In-clinic procedures and devices

BlephEx gently spins a soft micro-sponge along the lid margin to exfoliate away crusts, biofilm and bacteria — a thorough lid-margin clean done in the clinic.

Thermal pulsation (LipiFlow) warms and squeezes the glands in one session, though evidence that it beats a good home routine long-term is mixed.

Intense Pulsed Light (IPL) is very effective for some patients.

What the evidence says about IPL

Recent randomised trials, and a 2025 review pooling them, found IPL improves meibomian gland function and dry-eye symptoms, and some patients get marked relief. It usually takes several sessions, it is not a permanent cure, and the overall quality of the evidence is still maturing.

Systemic tablets

For inflammation that will not settle with topical care, a tetracycline antibiotic taken by mouth works well. At these doses it is not really treating an infection — it calms the gland inflammation and improves the oil chemistry. The doxycycline regimens we commonly use are 50 mg once daily for about three months (a low, anti-inflammatory dose), or 100 mg once daily for about two weeks (a shorter, stronger burst) — in practice, this really works. Some people need only a short burst while they get their hygiene under control; others, with stubborn disease, do best on longer-term low-dose treatment. Minocycline (Minomycin) and azithromycin are alternatives.

Cautions with the tablets

Doxycycline can make the skin sunburn far more easily — cover up and use sunscreen. Take tetracyclines with a full glass of water, sitting upright, not at bedtime; they are not used in pregnancy, breastfeeding or young children.

Azithromycin should be avoided if you have certain heart-rhythm conditions, as it can affect the heart’s rhythm. Always read the product information and tell whoever prescribes about your other conditions and medications.

Treating the rosacea on your skin

Settling the facial rosacea often helps the eyes, usually shared with your GP or dermatologist: skin creams (metronidazole gel, ivermectin cream, azelaic acid), the same oral antibiotics, trigger avoidance and sun protection. One caution — isotretinoin (Roaccutane), the strong acne tablet, tends to dry the eyes and worsen the meibomian glands, so it is generally avoided when the eyes are the main problem.

Part C — Low tear production

When the eye genuinely makes too few tears — with age, after menopause, with autoimmune conditions such as Sjögren’s syndrome, or from certain medications — the mainstay is to replace the tears, keep the ones you have, and where needed calm the inflammation that is choking tear production. A few things make this type worse and are worth managing: concentrated screen or reading work cuts your blink rate (we blink far less when we stare), and air-conditioning and heating dry the surface; a humid environment is protective.

A stepwise approach

Start with lubricating drops; step up to gels and ointments as needed; and do not neglect the drying that happens overnight. Most people are managed comfortably on this ladder, adding the next step only when the one before is not quite enough.

13. Lubricating drops — the first line

The first line of relief is ocular lubricants — artificial tears that supplement your own and coat the surface. They vary in thickness, composition and whether they contain preservative, and there are many over the counter. They all differ, so try several to learn what suits you. Thicker drops last longer but can blur the vision. If you are using drops more than about four times a day, choose a preservative-free brand so the preservative itself does not irritate the eye. Among the most popular in Australia at the moment are Cationorm — a preservative-free emulsion designed to restore the tear film’s lipid layer and its normal salt (electrolyte) balance — and Hylo-Forte (Hyaloforte), a longer-lasting, higher-strength hyaluronic-acid drop; Celluvisc is another preservative-free option.

The principle: regular and disciplined

Use the drops regularly and in a disciplined way — at least four times a day, more if needed — with the aim of eliminating symptoms altogether.

Put a drop in even when the eye feels fine, to head off symptoms later in the day. A healthy eye spreads fresh tears with every blink, every 5 to 15 seconds. You obviously cannot match that, but it shows why severe cases may need drops very frequently — some patients hourly. Keeping a simple diary of your drop use helps you and us get the frequency right.

14. Gels and ointments, day and night

For some people the damage happens overnight, when the eyes can dry or stay slightly open during sleep. Day-time drops are then supplemented at bedtime with a thicker gel (for example Genteal gel) or a thicker ointment (Lacrilube). The thicker the preparation, the longer it lasts — but the more it blurs the vision, so heavier ointments are usually for night-time.

In severe cases a thicker gel or ointment is needed during the day too. This is common in “exposure keratopathy,” where the lids do not close fully with each blink and part of the surface is constantly exposed to the air.

15. Keeping your own tears: punctal plugs

Tears drain away through tiny openings in the inner corner of the lids. Punctal plugs are small inserts that partly block this drainage, so the tears you have stay on the eye longer. We rarely ever use them. The reason is simple: they work only by increasing the volume of what is often an already sick tear film — and there is little sense in retaining a build-up of excessively salty tears. It is almost always better to add fresh, healthy tears from drops. That said, very occasionally — in a genuine deficit of tear production — a patient does benefit, and in those cases plugs are worth trying.

16. Calming the inflammation: ciclosporin

Because reduced tear production is often driven by inflammation in the tear glands, an anti-inflammatory drop can treat the cause rather than just the symptom. Ciclosporin eye drops do this — they reduce the inflammation, which over about 6 to 12 weeks improves the eye’s own tear production. The inflammation tends to return if the drops are stopped, so they are usually used long-term.

Good news — this has improved in Australia

When this information was first written, ciclosporin drops were hard to get and expensive (around $1,600 a year, imported). That has changed.

Ciclosporin drops are now approved in Australia and, for severe dry eye that meets the criteria, subsidised on the PBS (brands include Cequa and Ikervis); otherwise they are available on a private prescription. Lifitegrast (Xiidra) is another anti-inflammatory option. Your optometrist or eye doctor can advise whether you qualify and which suits you.

Part D — Exposure, the neurotrophic surface, and severe disease

17. After LASIK, and neurotrophic keratopathy

The cornea is one of the most nerve-rich tissues in the body, and those nerves do two jobs: they tell you when the eye is drying, so you blink and make tears, and they help the surface maintain and repair itself. When the nerve supply is reduced, the surface can become dry and slow to heal even when tear quantity seems adequate — a state called neurotrophic keratopathy.

The commonest version many people meet is dry eye after laser refractive surgery such as LASIK, which divides some of the corneal nerves as part of the procedure. This is common in the first few months and usually settles as the nerves regrow, over roughly 6 to 12 months, helped along by intensive lubrication. More persistent neurotrophic problems are uncommon — they can follow some infections, surgery or certain medical conditions — and are managed by a corneal specialist with more specialised treatments.

18. Exposure keratopathy — when the eye is left uncovered

Normally a full blink wipes a fresh layer of tears across the whole cornea. If part of the surface is not covered, it is left exposed to the air and dries out — exposure keratopathy. There are a few common reasons:

An incomplete blink. The lids do not fully close over the cornea — for example in a facial nerve palsy, where the muscle that shuts the eye is weak, or after botulinum toxin (Botox) near the eye.
A reduced blink rate. We blink less as we get older, and markedly less in some conditions such as Parkinson’s disease, so the surface dries between blinks.
Overnight exposure. If the eyes do not close fully during sleep, the surface dries overnight. An uncommon but important cause is floppy eyelid syndrome, in which a lax upper lid is dragged open against the pillow during sleep, leaving the eye exposed.

The mainstays are generous lubrication, a thicker gel or ointment at night, and protecting the eye overnight — sometimes with taping or a moisture chamber. Where the lids cannot close properly at all, the eye may need to be partially closed by a procedure (see the next section).

19. Severe disease: protecting the eye

A small number of people have severe disease where the priority becomes protecting the cornea from permanent damage. Measures here can include the heavier daytime ointments mentioned above and, in acute severe cases, partially closing the eye — temporarily with botulinum toxin (Botox) or a stitch, or with a small surgical procedure — to shield the surface and prevent scarring or, at worst, blindness. Some people with severe disease find real relief from moving to a more humid climate. This end of the spectrum is managed closely by an eye specialist or corneal specialist.

Part E — Diet, and living well

20. Diet and supplements

Diet matters. Surface disease is, at heart, inflammation, and an anti-inflammatory, Mediterranean-style way of eating — plenty of vegetables, olive oil and oily fish, less processed food, sugar and alcohol — is good for your eyes, your skin and your general health. Staying well hydrated and limiting your personal rosacea triggers all help.

Omega-3 supplements: worth knowing the evidence

Fish-oil and flaxseed capsules are popular, low-risk and cheap, and some smaller studies showed benefit. However, the largest independent trial (the DREAM study) found omega-3 supplements no better than a placebo for dry eye overall — though both groups improved, which keeps the debate alive.

The fair conclusion: getting omega-3 from your diet is sensible, and capsules are a reasonable low-cost add-on, but not a proven cure.

21. Living with ocular surface disease

Think of this as a marathon, not a sprint. Expect good spells and the occasional flare — that is the normal pattern, not a sign you are doing something wrong. The treatments work best as quiet daily habits rather than projects you keep starting and stopping. Tie your routine to something you already do each day, keep a lighter version going even when your eyes feel fine, and be disciplined with your drops. You will not “finish” treatment, but you can absolutely keep the condition comfortable and quiet.

22. Key points to remember

Ocular surface disease (“dry eye”) is very common and gets more troublesome with age. It is controlled, not cured — regular, disciplined care is what works.
There are four overlapping types: the oil fails (blepharitis — the commonest), too few tears are made, the surface won’t wet and heal (e.g. after LASIK), or the lids leave the eye exposed (incomplete blink, reduced blink rate, or overnight).
Symptoms are much the same whatever the type — irritation, grittiness, stinging, burning, redness, light sensitivity, and often watering, because a watery eye is usually a dry one.
Blepharitis is not an infection and not from being unclean. Warmth then cleaning is its cornerstone; mites, devices (BlephEx, IPL) and doxycycline tablets help tougher cases.
For low tear production: disciplined lubricating drops, gels or ointments at night, and — now available and PBS-subsidised for severe cases — ciclosporin drops to calm the inflammation.
Day-to-day care is well managed by your optometrist or GP; our focus is surgery, and settling the surface before cataract or other surgery gives a safer operation and a sharper result.
Seek prompt eye care for a painful, very red eye, light sensitivity, or vision that does not clear with a blink.