Eyelids and tear film · H
Dry-eye types and a care ladder
Evaporative · aqueous-deficient · mixed
Last reviewed: 2026-10-06 · 潘家健醫生
Key points
- Dry eye includes evaporative, aqueous-deficient and mixed types; stepped care follows examination.
- This page is classification and care concepts — not a personal prescription or brand ranking.
- Sudden vision drop, severe pain and photophobia, asymmetric red swelling with heavy discharge, or dry mouth / joints / rash — not “ordinary dry eye.”
- Lubricant classes are on the lubricants page; this cannot replace a registered doctor visit.
Per TFOS DEWS II, evaporative dry eye is the majority and is driven mainly by meibomian gland dysfunction; aqueous-deficient disease is less common (including Sjögren syndrome); mixed disease is what clinics see most often. Vicious cycle: hyperosmolarity → inflammatory mediators and matrix metalloproteinases → goblet-cell and epithelial injury → a less stable tear film. This ladder is an international consensus framework, not a shopping list.
| Test | Common reference ranges (doctor interprets) |
|---|---|
| Tear break-up time TBUT / NITBUT | ≥10 s often acceptable; ≤5 s suggests marked instability |
| Schirmer I (no anaesthetic) | ≥10 mm / 5 min; <5 mm suggests marked aqueous deficiency |
| Osmolarity | About ≤308 mOsm/L is often treated as acceptable; a clear rise supports a dry-eye diagnosis |
| MMP-9 rapid test | Positive suggests ocular-surface inflammation; whether to medicate is still the doctor’s decision |
Why drops again and again still feel inadequate (education, not self-diagnosis)
Artificial tears / lubricants mainly ease dryness and intermittent blur; they usually cannot cure meibomian gland dysfunction or Sjögren syndrome (see lubricants and ocular-surface lubricants). If frequent watery lubrication alone helps little, a doctor may rethink:
- Whether evaporative disease / meibomian gland dysfunction dominates — warm compresses and lid hygiene matter; “two more drops” alone is often not enough
- Whether ocular-surface inflammation is also present — prescription anti-inflammatories (e.g. cyclosporine class) need a doctor’s prescription and take time; short-course steroids only under intraocular-pressure monitoring
- Whether the form is a poor match (preservative-free, more viscous, night ointment) — see the lubricant topic; no product names here
- Whether it is not plain dry eye at all (infection, an allergic flare, contact-lens–related keratitis, uveitis / scleritis, acute angle closure, and so on)
“Drops never help” is not a diagnosis; tear film, lid margin and ocular surface need examination before the next step. This ladder is an international consensus framework, not a shopping list.
Categories a doctor may discuss by severity
- Lubrication: preservative-free artificial tears (hyaluronic acid, carboxymethylcellulose, HP-Guar and similar classes); warm compresses; less screen time; humidify. Forms, preservatives, expectations and limits: lubricants and ocular-surface lubricants; warm-compress steps: warm compress and lid massage
- Night gel or ointment; dietary omega-3: the DREAM randomised trial (Asbell et al. / DREAM Study, NEJM 2018) in people with moderate-to-worse symptoms did not show superiority of n-3 fatty-acid supplements over placebo for the primary symptom outcome — individual; not a medicine advertisement for treating eye disease, and not a brand comparison
- Prescription anti-inflammatory drops (e.g. cyclosporine class) need a doctor’s prescription and take time to work; short-course steroids only under intraocular-pressure monitoring
- Punctal plugs are usually considered after inflammation is controlled; IPL, thermal pulsation and similar devices are clinic procedures — benefit and need vary
- Severe Sjögren, graft-versus-host disease, or persistent epithelial defect: a doctor may discuss autologous serum and similar options, subject to infection-control and prescribing rules
- Scleral and other specialty contact lenses that keep a tear reservoir need a fitting
Selected public references (not a full bibliography)
These are the public studies this page draws on. PMID links go to PubMed (US National Library of Medicine) so you can check them. Figures are from those studies — not your prognosis and not a clinic success rate. Links are not a shop.
- Craig JP, Nichols KK, Akpek EK, et al. TFOS DEWS II definition and classification report. Ocul Surf. 2017;15(3):276-283. PMID 28736335國際乾眼定義與分類（蒸發／水液／混合）。教育架構；不是個人診斷標籤。
- Jones L, Downie LE, Korb D, et al. TFOS DEWS II Management and Therapy Report. Ocul Surf. 2017;15(3):575-628. PMID 28736343分階處理共識。潤滑減輕症狀，不是根治；階梯不是購物清單。
- Dry Eye Assessment and Management Study Research Group; Asbell PA, Maguire MG, et al. n-3 Fatty Acid Supplementation for the Treatment of Dry Eye Disease. N Engl J Med. 2018;378(18):1681-1690. DOI 10.1056/NEJMoa1709691. PMID 29652551DREAM：n-3 補充相對安慰劑未達主要徵狀優效。不是個人預後／不是品牌比較。
This is general medical information, not a diagnosis, and cannot replace an in-person consultation with a registered ophthalmologist, refraction, or a dilated fundus exam. It is not advice to use any medicine or undergo any procedure. Medicines (including off-label use), laser or surgery must be decided by a registered doctor after examination, according to indications and Hong Kong registration. Figures from the literature are published averages, not any clinic’s results. This site does not book, prescribe or refer. Do not change treatment on your own.