What if it’s not Dry Eye?

dry eye mimicker

There are many conditions that can mimic the signs and/or symptoms of dry eyes. Just to confuse the matter even further, dry eye disease may co-exist with any of these conditions. Often it is necessary to treat the dry eye disease as much as possible and deal with the other condition either concurrently, before or after, depending on the circumstances.

Some of the more common conditions that present to our practice as “dry eyes” include;

Anterior blepharitis

Anterior blepharitis is where there is debris and inflammation at the base of the lashes which may be due to a number of reasons but most commonly; poor lid hygiene, a Demodex infestation or seborrheic dermatitis. It often exists alongside dry eye disease and we generally treat it first using Blephex.

Ingrowing eyelashes

It is not uncommon to have ingrowing eyelashes that make your eyes irritated, watery and feel like there’s a foreign body sensation. They just need plucking out every few weeks. If that becomes burdensome then you can consider have laser removal of the offending lashes.


The symptoms of seasonal allergy are typically watery, itchy, irritated eyes. A good first step treatment for mild cases is just to use lubricating eye drops. This sometimes misleads people into thinking they have simply got dry eyes as their problem is solved by using artificial tears. In reality, the drops are rinsing away the allergen so the eye is not so irritated. Often oral antihistamines are used to alleviate the allergy symptoms but they are one of many medications that can cause the eyes to feel dry. Stopping the oral medication or switching to a different medication may help. However, if that’s not practical then managing the resultant dry eye is necessary.

Allergy or sensitivity to medications is also a problem in itself as well as sometimes being mistaken for dry eye. Many people are sensitive to preservatives in eye drops so their eyes become irritated. These drops could be simple lubricating drops but can also be glaucoma, steroid or even allergy medications! Most of these drops can be substituted with preservative-free alternatives.

Some clients have become sensitive to their contact lenses and/or contact lens solutions and they often complain of irritation and foreign body sensation. Changing to 1-day contact lenses can sometimes fix the problem but, if the case is more severe, contact lens wear needs to cease for sometimes months, and steroid and/or allergy drops may be required.

Chalazia and styes (hordeola)

Most people would be familiar with styes as they are quite common and often seen in children. The stye sits at the edge of the lid and is usually pus-filled and inflamed. A chalazion is simply a blockage and infection of one of the glands that is under the lid. It can feel like a small pea and can be quite tender to touch.

Both chalazia and styes tend to clear up on their own but warm compresses can help. If they’re not settling down then medications can be prescribed or they can be excised.

Recurrent corneal epithelial erosion (RCEE)

If you have had a trauma to the cornea at some point such as a foreign body or abrasion then you may develop RCEE. This is a condition where the area of cornea that was damaged is not attached as firmly as it was before and is prone to ripping off occasionally – usually about 3 o’clock in the morning! Sometimes there is no history of previous corneal trauma but there may be corneal dystrophy and sometimes there is no obvious cause.

It is a painful condition and can take minutes, hours or days to heal depending on the severity. It’s a condition that needs to be managed by your eye care practitioner who can give you advice on how to prevent recurrence and possibly look at more long-term solutions. Frequent lubrication, especially before retiring, makes a big difference. There are also other options such as a course of oral antibiotics, and procedures such as stromal needling or laser treatment may be an option.

Lids out of alignment

There are a number of conditions where the eyelids don’t sit “correctly”. The lids may curl inwards (ectropia) or droop outwards (entropia). There is also a condition called lagophthalmos where the eyes don’t fully close. This can be due to any number of conditions such as a stroke or Bell’s palsy.

If the lids are not closing correctly then the tears in the eye just run out or evaporate away making the eyes dry and uncomfortable. A referral to an oculoplastic surgeon for assessment and treatment is usually necessary.

Floppy eyelid syndrome

This is a condition that affects mainly obese clients especially if they also suffer from obstructive sleep apnea (OSA). They often have a history of having irritated eyes and may have had treatments for allergy or conjunctivitis that haven’t really resolved their symptoms.

OSA is a condition that needs careful management by the client’s primary health care practitioner  due to its association with more significant general health and serious eye conditions.

Corneal neuralgia

This is a very painful, unpleasant condition that we don’t see very often. For some reason, the corneal nerves become hypersensitive and the individual experiences severe, sometimes debilitating, eye pain. When we examine the eye there is often little if any sign of any irritation, infection or dry eye damage.

This is a rare condition that seems to be triggered by some event such as; an attack of shingles (herpes zoster) that’s affected the eye, following chemotherapy, nerve-damage associated with diabetes, and can also develop months or years after having procedures such as LASIK or cataract surgery.

Any sign of dry eye can be treated which can sometimes reduce the severity of the symptoms. There is some evidence that it responds well to the use of autologous serum tears and amniotic membrane.