For many people diagnosed with dry eye disease, over-the-counter (OTC) artificial tears are enough to ease occasional burning, redness, and irritation. But if symptoms persist despite regular use, it may be a sign that your dry eye needs more targeted treatment.
Dry eye develops when the eyes don’t make enough tears or something affects one or more layers of the tear film. It can happen as you get older due to hormonal changes, but it’s also caused by diseases like rheumatoid arthritis, thyroid disease, and lupus, or by the use of medications such as antihistamines, beta-blockers, and antidepressants.
Dry eye is common in people who look at computer screens for long periods of time, wear contact lenses, and smoke.
But lingering symptoms shouldn’t be ignored or endlessly self-treated with eye drops. If you’re encountering the following signs and symptoms even with regular use of OTC drops, it may be time to talk to your eye doctor about prescription medications or other treatments to manage daily discomfort and provide lasting relief.
1. Frequent Use of Eye Drops
Artificial tears are the mainstay therapy for dry eye, but using them constantly may signal that your symptoms are no longer adequately controlled and it’s time to find the underlying condition and escalate treatment.
“If you feel the need to use OTC lubricating eye drops more than occasionally, it’s very much worth your time to get a comprehensive eye examination and mention the fact to your optometrist,” says Viola Kanevsky, an optometrist based in New York City and a subject matter expert for the American Optometric Association. “Having to use them several times a day every day indicates there is a deeper issue that needs to be addressed.”
Not all OTC eye drops are created equal either. Some options, especially ones designed to relieve red eyes, may be exacerbating your condition, according to Nicole Bajic, MD, an ophthalmologist at the Cole Eye Institute at Cleveland Clinic in Ohio.
“All too often I will hear from a patient that they’re using OTC drops that help for a little bit only to find out they’re using red-eye relief drops. These are vasoconstrictors,” Dr. Bajic says. These drops temporarily shrink blood vessels in the eye, reducing redness but potentially worsening dryness over time.
“Right after the drops, the eye looks whiter. But when they wear off, the redness comes back with a vengeance because it's really dry. It's this vicious cycle that perpetuates,” she says.
Preservatives designed to keep bacteria from growing inside the bottle can also become problematic with frequent use.
Some people encounter eye irritation, more dryness, or even inflammation on the surface of the eye.
If you’re using OTC eye drops with preservatives, you should limit yourself to four applications per day.
Preservative-free drops can be used as often as needed, but if they aren’t resolving your symptoms, speak to your doctor, Bajic says.
2. Fluctuating or Blurry Vision
Beyond irritation and discomfort, dry eye can affect visual clarity.
The eyes are coated by a tear film made up of three components: an oily layer, a watery layer, and mucus. When any of these layers become unstable, vision can temporarily blur.
“The tear film is more complicated than just being water,” Bajic says. “We need a perfect combination of all three to have a good tear film.”
People with dry eye often notice that their vision clears briefly after blinking, then becomes blurry again while reading, driving, or staring at screens, she says.
Digital eye strain can worsen symptoms significantly.
Bajic says that when people focus intensely on screens, the brain’s natural reflex to blink at regular intervals is overridden, because you're trying to focus on something. “You open your eyes wide, and you're not blinking as often as you should, so your eyes are drying out,” she says.
Persistent fluctuating vision may be a warning sign that OTC lubrication alone may no longer be enough, Bajic says.
3. Watery Eyes
One of the more confusing symptoms of dry eye is excessive tearing, says
Ashley Brissette, MD, a spokesperson for the American Academy of Ophthalmology and an ophthalmologist at Kelly Vision in New York City.
“Having a lot of tears in your eyes being a symptom of dry eye might sound odd, but your eyes make more tears when they are irritated by dry eye,” says Brissette.
Kanevsky says that many patients are surprised to learn this connection. “Epiphora, or excessive tearing, is often an early sign of insufficient oil in the tear film or poor lid apposition,” she says. (Poor lid apposition is when the eyelids don’t rest tightly and correctly against the eye’s surface.)
The problem is that these reflex tears are typically poor quality and evaporate quickly, meaning the eyes can still feel dry, gritty, or irritated despite watering excessively.
Some people also develop a persistent foreign body sensation — the feeling that something is stuck in their eyes.
“Some people have the tearing as a compensatory mechanism from the brain, because the brain is very smart, and it realizes, Hey I'm dry. I should send out more tears,” Bajic says.
4. Morning Grit
Waking up with red, scratchy, or gritty eyes can be a sign that dry eye symptoms are progressing.
During sleep, tear production naturally decreases. For people with dry eye disease, that can leave the eyes feeling irritated or sandy in the morning.
Researchers have suggested that symptom severity is typically worse upon waking than later in the morning.
5. Difficulty Wearing Contact Lenses
Contact lenses can sometimes make dry eye symptoms worse for a few reasons: Incorrect fitting, wearing the same contacts too long or overnight, eye allergies, and reduced airflow to your cornea are a few examples.
“Contact lenses can certainly dry the eyes faster,” Kanevsky says. “Soft lenses especially need fluid to maintain hydration.”
Brissette explains that contacts can disrupt the eye’s natural tear distribution and interfere with the oily layer that helps prevent evaporation. “Over time this can lead to tear film instability, increased evaporation, and inflammation — classic signs of dry eye disease,” she says.
Still, you don’t necessarily have to give up contact lenses permanently if you have dry eyes.
“Ask your doctor if a particular combination of contact lens material, eye drops, disinfectant, and environmental modification can help increase safety and duration of comfortable wear,” Kanevsky says.
Modifications — such as limiting how long you wear the same pair of contacts, keeping contacts away from water, and washing your hands before putting contacts in your eyes — can make a difference.
In more severe cases, temporary breaks from contact lenses may help reduce irritation while treatment is underway.
What to Expect at the Eye Doctor
If symptoms persist despite OTC treatment, an eye doctor may conduct tests to evaluate the severity and underlying cause of your dry eye.
Brissette says that ophthalmologists can assess tear quality, tear production, blinking patterns, eyelid health, and the surface of the eye itself.
Common tests include the following:
- Tear film breakup time is a test that measures how long your tears remain stable on the surface of your eye after blinking before dry spots begin to form.
- A Schirmer test measures how much tear production your eyes make by placing small strips of paper under the lower eyelids to see how quickly they become wet.
“There are several simple assessments available to patients to quantify the severity of their symptoms,” Kanevsky says, including questionnaires to track symptom progression and response to treatment.
Doctors may also look for underlying conditions that can contribute to severe dry eye. “It’s really important if someone has signs of a potential autoimmune condition like Sjögren’s syndrome, that you assess for that,” Bajic says.
There are many treatment options available beyond OTC tears:
- Prescription Anti-Inflammatory Eye Drops Medications such as cyclosporine (Restasis, Cequa, Vevye) and lifitegrast (Xiidra) can help reduce inflammation linked to dry eye and improve natural tear production over time. “For those with more persistent symptoms, prescription eye drops can be very effective,” says Brissette.
- Prescription Artificial Tears Newer prescription drops like perfluorohexyloctane (Miebo) are designed to provide a film layer on the eyes to prevent tears and moisture from evaporating, Bajic says.
- Varenicline Nasal Spray Rather than being placed in the eyes, this prescription nasal spray (Tyrvaya) stimulates the body’s natural tear reflex to increase tear production, Brissette says.
- Punctal Plugs Tiny plugs inserted into the tear ducts can help keep tears on the surface of the eyes longer by slowing drainage. Brissette says that they can help your natural tears stay in your eyes longer.
- Thermal Pulsation and Meibomian Gland Expression These in-office procedures help unclog the oil-producing glands in the eyelids, improving the quality and stability of the tear film.
- Bandage or Scleral Contact Lenses Specialty lenses can help protect the surface of the eye and retain moisture in people with severe or difficult-to-treat dry eye.
