Dry Eye

What Is Dry Eye?

Your tears keep your eyes lubricated and healthy. They provide nutrients and protect your eyes from infections. Dry eye is the result of a decrease in the quality and/or quantity of tears produced, or an increase in the evaporation of the tears from the surface of your eyes. People with dry eyes may experience irritated, gritty, scratchy, or burning eyes. Not treating dry eye can lead to long-term consequences such as chronic infection, inflammation, abrasion of the corneal surface, desiccation of the skin in front of your eyes, and scarring, affecting the quality of your life.

Types Of Dry Eye Disease

Evaporative Dry Eye

The meibomian glands can be blocked for many reasons; for instance, not blinking enough can accumulate debris and therefore block the glands. These glands don't secrete enough tears, and the tears they secrete have very poor quality as tears evaporate and the surface of the eye is exposed to the environment.

Aqueous Deficiency: Dry Eye

It happens when the lacrimal gland does not secrete enough of the middle aqueous layer. Tear volume decreases; hence, there is less water and more salt in the tears (hyperosmolarity). Consequently, salty tears cause inflammation of the tissues on the surface of the eye. Age and some health problems can cause aqueous deficiency in dry eyes.

Mixed Dry Eye

It is possible to have a combination of both aqueous-deficient and evaporative dry eyes, and this is often referred to as "mixed dry eye." In mixed dry eye, there is an imbalance in both the quantity and quality of tears.

Aqueous deficient dry eye occurs when there is insufficient production of the watery component of tears, while evaporative dry eye is associated with problems in the lipid (oil) layer, often linked to conditions like Meibomian Gland Dysfunction (MGD).

This combination can make managing dry eye symptoms more complex. If you suspect you have mixed dry eyes or are experiencing persistent dry eye symptoms, it's important to make an appointment for a thorough examination and appropriate management strategies tailored to your specific condition.

Causes Of Dry Eye

Dry eye can be caused by many different reasons. The most common causes of dry eye are:

Age

Dry eye is part of the natural aging process. Tear production slows with age, and this can lead to dry eyes.

Autoimmune Diseases

Autoimmune diseases, such as Psoriatic Arthritis, Rheumatoid Arthritis, Sjogren’s, Thyroid diseases, Multiple sclerosis, exert their impact by triggering inflammation throughout the body. This inflammation extends to the lacrimal gland, diminishing tear production and releasing inflammatory mediators into the tear film, exacerbating dry eye symptoms in the process.

Excessive Screen Time

Extended screen time—be it on a computer, tablet, or cell phone—significantly reduces your blinking rate, nearly by 50%. Each blink plays a crucial role in tear drainage, the excretion of lipids from meibomian glands, and the even distribution of these lipids across your eyes. With a reduced blinking rate, dry eye symptoms worsen, emphasizing the importance of mindful breaks and eye care during prolonged screen use.

Gender

Women are more prone to experiencing dry eye, attributed to hormonal changes during menopause, pregnancy, and contraceptive use. Menopausal shifts, specifically the decline in androgen hormone levels, adversely affect the production of oil from the meibomian glands and fluid from the lacrimal glands. This imbalance results in dry eyes, leading to irritation and discomfort.

Meibomian Gland Dysfunction (MGD) (Drop Out MGD)

MGD, or Meibomian Gland Dysfunction, involves inflammation and thickening of the oil glands in the eyelids. Frequently coexisting with conditions like blepharitis and rosacea, MGD exacerbates dry eye syndrome by impeding the normal secretion of oils, contributing to discomfort and irritation.

Medical /Ocular Conditions

Ectropion, characterized by the outward turning of eyelids, can lead to incomplete closure during blinking. This inability to fully close the eyes may result in irritation and contribute to dry eye symptoms.

Blepharitis

Blepharitis triggers inflammation in the oil glands of the eyelids, leading to irritation, itchiness, and the formation of dandruff-like scales on the lashes. These symptoms can impact eye comfort and overall ocular health.

What Is Blepharitis?

Blepharitis is a chronic inflammation of the eyelid margins. It can be associated with factors like bacteria or skin conditions such as dandruff, seborrheic dermatitis, and rosacea. Symptoms may include redness, itching, and the formation of scales or crusts along the eyelid margins. While not contagious, blepharitis often requires ongoing eyelid hygiene and, in some cases, medical intervention for management.

Types Of Blepharitis

Blepharitis can be categorized into two main types:

Anterior Blepharitis

This involves inflammation at the front edge of the eyelids, near the eyelashes. It is often associated with bacteria (staphylococcus) or skin conditions like seborrheic dermatitis.

Posterior Blepharitis

This type affects the inner edge of the eyelids, where the Meibomian glands are located. Dysfunction of these oil-producing glands, known as Meibomian Gland Dysfunction (MGD), is a common cause of posterior blepharitis.

Both types can occur simultaneously, and an eye care professional can determine the specific type and appropriate treatment based on the underlying factors contributing to the condition. Link

Common Symptoms Of Blepharitis

Crusty eyelids, eyes may look red and irritated, itchy, or scratchy eyes, mattering and goopy eyes, flakes of skin collecting around the eyes or eyelids. You may feel a gritty sensation and dryness.

Blepharitis Treatment

Blepharitis treatment presents challenges due to its recurring nature. Tailored to the specific type, interventions may involve warm compresses, regular cleaning of the eyelids with specialized products to exfoliate oil, and the use of topical and oral medications. A sustained, long-term commitment to meticulous eyelid hygiene is essential for effective blepharitis management.

Office treatments

Much like the plaque that accumulates on teeth, your eyelids can develop a biofilm, creating a stubborn layer that includes demodex and other debris. Over time, this buildup can lead to irritation. Just as regular dental cleanings are essential for oral health, professional eyelid cleaning is a key practice to ensure the well-being of your eyelids, promoting lasting comfort for your eyes.

How BlephEx® Works

BlephEx® is a painless in-office procedure performed by Dr. Dussan. A revolutionary new patented BlephEx® handpiece is used to very precisely spin a soft medical-grade micro-sponge along the edge of your eyelids and lashes. This procedure effectively removes years of accumulated bacterial biofilm, much like a dental cleaning removes accumulated plaque, also a biofilm. Once the biofilm is removed, your eyelids are cleaner and healthier.

A BlephEx treatment takes about 6 to 8 minutes to remove any scurf (flakes on the skin’s surface), discard debris, and exfoliate the eyelids.

After the procedure, Dr Dussan will provide maintenance instructions and options for nightly lid hygiene to ensure the eyelids stay clean and healthy.

How Often Should I Have BlephEx Treatments

BlephEx treatments should be administered every 6 to 12 months, depending on the severity of the condition. Routine care is essential for keeping bacteria to a minimum, and the prevention of biofilm development. Irregular treatments can cause biofilm redevelopment, resulting in a recurrence of inflammation and damaged tear glands.

Blepharitis and Dry Eye Disease

Because blepharitis and dry eye are closely linked, BlephEx is sometimes used as a treatment for dry eye as well as blepharitis. This treatment can help remove blockages from the meibomian glands, which alter your tear quality and result in dry eye symptoms. All of this to say: BlephEx may have been designed to treat blepharitis, but it can also treat dry eye disease.

What Are The Treatment Steps?

1. Photograph eyelid pretreatment

2. Moisten lids to loosen debris.

3. Apply 1 drop of anesthetic in each eye

4. Treatment with a Blephex motorised probe

5. Photograph eyelids post-treatment

Dry Eye Symptoms

• Gritty and sandy sensation

• Redness, irritation of the eyes, or eyelid

• Contact lens intolerance or wearing time is reduced

• Vision gets blurry and after blinking, it clears up

• Whitish and mucous discharge

• Burning or pain in the eyes or on the lids

• Frequent vision changes.

• Blurry vision comes and goes.

Diagnosing Dry Eye

Before beginning your dry eye evaluation, Dr. Dussan “will specifically" want to know about the following "because “they can be the cause or aggravate your dry eyes.

Medical Conditions (for instance, Diabetes, thyroid disease, rheumatoid arthritis)

• Medications you are on (for instance antihistamines, painkillers, acne control medications, birth control pills, etc.)

• Time your spend in front of devices (computer, ipads, cell phone )

• Contact lens wear (wearing time, disposing time, and habits).

• Environmental allergies (for instance pollen, animal dandruff, , dust)

• Hormonal changes

• History of cancer treatments (such as radiation and chemotherapy)

• History of medications use such accurate

During Your Eye Exam

Dr. Dussan will evaluate the overall health of the surface of your eyes. She would use special equipment to evaluate the quality and quantity of your tears. She will give you a special test to help her figure out what your type of dry eye is.

We have a quantitative test that helps determine whether the eye produces enough tears to keep it lubricated.

A special paper strip is placed inside and temporally the lower lid of each eye. The procedure takes 5 minutes and the patient will keep their eyes closed.

The test can be done with or without numbing drops. Normal results would indicate 10 mm of moisture on paper after 5 minutes.

Dr Dussan uses a test to look for inflammatory markers in the tears

Evaluating Your Meibomian Glands

Dr. Dussan uses state-of-the-art technology to image your meibomian glands to determine if you have meibomian gland dysfunction.”

If your eyes are uncomfortably dry, it is crucial to accurately diagnose the root of the problem. There can be other associated conditions (such as meibomian gland dysfunction, blepharitis, ocular rosacea, contact lens related problems,
demodex. etc) that need to be identified and treated also in order to have a successful dry eye treatment.

Meibomian glands are tiny oil glands that line at the edge of both your upper and lower lids, near your eyelashes. These glands produce oil that forms the outermost layer of your tear. It stabilizes the tear film by preventing the tears from evaporating.

The meibomian glands can be blocked for many reasons. For instance, not blinking enough can accumulate debris and therefore block the glands. These glands won’t secrete enough oil (lipids) into the tears, and the tears they secrete, have very poor quality as tears evaporate and leave the surface of the eye exposed to the environment and your eyes become much drier.

Healthy meibomian glands release oil similar to olive oil or baby oil in color and viscosity. When the glands are inflamed or clogged, as an early sign, the oil they produce is more turbid or cloudy in color. Aa a more advance MGD, the oil becomes more cheesy or toothpaste-like texture. Nonfunctioning glands or dead glands, they wouldn’t release any type of oil at all.

Untreated, meibomian glands dysfunction is chronic and progressive. Allow to progress, the damage to meibomian glands is irreparable and. A lead to significant discomfort with dry eye, irritated and inflamed eyes, recurrent infections, scarring of the surface of your eyes and decreased vision.

“Sadly to say but once Meibomian glands are gone they don’t ever come back”

Diagnosing MGD

A thorough medical history focused on your symptoms and examined your eye lids with a microscope (slit lamp). A careful examination of your eyelid’s margins, meibomian gland orifices and eyelashes with a gentle pressure of your meibomian glands to evaluate the quantity and quality of the meibum produce by your meibomian glands.

​​​​​​​Diagnosing MGD involves a comprehensive approach. We begin with a detailed medical history, focusing on your symptoms, and a meticulous examination of your eyelids using a slit lamp microscope. This includes assessing your eyelid margins, meibomian gland orifices, and eyelashes, with gentle pressure on your meibomian glands to evaluate the quantity and quality of meibum produced. Our practice employs advanced imaging technology for a direct, in vivo visualization of the meibomian gland morphology, allowing us to assess quantitative changes that indicate the functionality of your meibomian glands."

Our practice offers specialized imaging technology to directly visualize the morphology (shape) of the meibomian glands in vivo. This technology allows us to evaluate qualitative and quantitative changes to your meibomian glands.

Treating Dry Eye

Treating dry eye disease requires a personalized and dynamic approach tailored to each stage of the condition. Numerous treatment options are available, and the journey begins with education about your specific condition, dietary adjustments, and environmental changes to optimize your eye health.

Preservative free artificial tears & preservative free gel

• Preservative free artificial tears. These drops provide you with the lubrication that your eyes are not producing, Artificial tears would only provide lubrication but they need to be used with frequency since they only provide temporary relief of your symptoms.

• Preservative free gel is an extra strength gel that stays on the surface of the eye for a longer period than artificial tears. Gels are more viscous or thicker than artificial tears. It is recommended for moderate to severe dry eye in patients that need to apply artificial tears multiple times. The downside of the gels is that they can make your vision temporarily blurry for a short period of time.

Anti-inflammatory Diet
Dietary changes can help to reduce inflammation in your body and our eyes.
What we put into our bodies can directly affect how we feel and how our bodies function, and our eyes are no exception.

Food is fuel, and supplying our bodies with the correct nutrients, vitamins, minerals, and supplements can help us lead healthier lives and decrease the risks of chronic conditions including dry eye disease. DED is chronic, and lifestyle changes including dietary changes are crucial in managing symptoms and decreasing the severity of the disease.

Topical cyclosporine -A (Restasis and Cequa)
Reduces chronic inflammation on your ocular tissues and improves your ocular surface integrity. Prevent the inflammatory cycle from continuing. Therefore , it provides symptom relief allowing your lacrimal glands to produce more tears.

Xiidra (liifitagrast)
Xiidra is a prescription eye drop that may be used to reduce inflammation associated with dry eye disease. The main side effects are eye irritation or redness and an unusual taste in the mouth. Xiidra is available in single-use containers that contain enough solution for one drop in each eye and should be discarded after one use.

Tacrolimus drops
Works similar to cyclosporine. Tacrolimus works by not letting inflammatory cells that cause inflammation be released. It comes in two presentations (eye drops and ointment). It is an inexpensive option for patients with dry eyes.

Tetracycline and Doxycycline
Low doses of these medications can work as a anti- anti-inflammatory. Several eye conditions can be treated such as ocular acne rosacea, meibomian gland dysfunction (MGD), recurrent corneal erosion (RCE),chronic corneal wounds. Doxycycline and tetracycline can significantly reduce ocular discomfort caused by (DED) dry eye disease.

Azasite
Azithromycin eye drops decrease eyelid inflammation and improves the quality and quantity of the lipid layer of the tear film. These eye drops seem to be a safe and effective treatment for (DED) caused by (MGD) meibomian gland dysfunction.

MIEBO
Works by increasing the actual thinkness of your tear layer which helps to prevent your tears from evaporating.

Omega 3
Omega-3 fatty acids are a necessary component of our diets, and the amount that you need per day can vary based on gender and age. However, consuming enough omega-3 fatty acid through food may be difficult due to the volume of food needed to achieve the optimal concentration in our body. Omega-3 supplements can be beneficial in providing the necessary amount to relieve symptoms of dry eye and slow the progression of certain eye conditions.

Omega-3 fatty acids are an important part of any complete dry eye relief treatment; they also benefit the health of your joints and your heart. Hydroeye

Tyrvaya
N-acestyl-cystane is an acetylated derivative of the natural amino acid, 1- cystaine. It has mucolytic, anticholinergic, antioxidant-collagenolytic, antioxidant properties. These properties help to fight inflammation and alleviate symptoms of dry eyes. Topical 5% NAC therapy has shown to be effective and well tolerated in patients with (MGD)meibomian gland dysfunction.

Autologous Serous Eye Drops
Autologous serum eye drops are drops that are made from your own blood. These tears can mimic the biological properties of your own tears such as vitamins A and C, growth factors, immunoglobulins, antioxidants, electrolytes and other vital components that your blood has. To get autologous serum eye drops you first give whole blood.

Then, that blood is centrifuged where red blood cells are separated from the serum. The serum component is diluted with saline solution. Autologous serum has to be compounded on sterile conditions. Dr Dussan would write a prescription with correct concentration to a company which will compound your tears.

Promote healthy cell growth and healing of the ocular surface, including albumin and vitamin A, as well as anti-inflammatory mediators well beyond that of commercially manufactured artificial tears.

Amniotic Membranes
Amniotic membrane is a biological tissue that comes from the innermost layer of the placenta which surrounds and protects the fetus. It is used as a corneal bandage. Amniotic membrane provides not only a nourishing and protective barrier to help facilitate corneal health but can also provide rejuvenating stem cell contributions to the cornea and prevent future corneal damage due to dryness.

Punctual plugs

Punctual plugs are a type of occlusion device inserted into the tear duct of an eye to prevent drainage of tears. Punctual plugs can be temporary or permanent. Temporary plugs dissolve a few days after insertion. If your dry eye symptoms disappear when the temporary plugs are inserted, Dr Dussan may consider permanent punctual occlusion.

Meibomian Gland Dysfunction (MGD) And Treatment

Home treatment

Home treatments for Meibomian Gland Dysfunction (MGD) include warm compresses, lid hygiene, omega-3 supplements, blinking exercises, and staying hydrated. Consult with an eye care professional for personalized advice.

In-office treatments

LipiFlow Thermal Pulsation System

Apply heat to both the upper and lower lids in addition to pressure as the same time to express the meibomian glands clearing the meibomian gland obstruction.

What is Lipi-flow®?

Lipiflow is a groundbreaking technology used to treat dry eye disease caused by Meibomian Gland Dysfunction. The LipiFlow Thermal Pulsation treats the route cause by providing warmth to melt blockages and applies gentle pressure to unblock the glands.

How Does LipiFlow® Work?

• Prior to the procedure, the staff at Dussan eyecare will place anesthetic drops in your eyes.

• When your eyes are fully numb, Dr Dussan will place the LipiFlow® sterile, single-use activators under and over your eyelids without actually touching the surface of the eye.

• Once the activators are in place, the procedure takes about 12 minutes. The process begins with the activators exerting a constant pressure for the first two minutes as they warm to a temperature that begins to dissolve the gland obstructions.

• Over the next 10 minutes, the activators cycle through differing levels of pressure, providing the massage that starts the natural flow of oil.

What Are the Benefits of LipiFlow®?

After a LipiFlow® treatment, the Meibomian glands begin normal production of oils that are necessary for maintaining high-quality tears. These oils keep the tears from evaporating too quickly, thus improving the overall health of the surface of the eye.

In addition, a reduction in dry eye may improve visual clarity. It usually takes about six to eight weeks to achieve optimal results, but relief can last up to 12 months.

Is LipiFlow® Covered by Insurance

Meibomian Gland Expression

The doctor will apply numbing drops before the procedure and under a magnified view she would gently express the lids with a Mastrota paddle so that the meibum flows out of the opening of the glands.

Successful meibomian gland expression helps to increase the quality of oil production of the glands. Hence providing symptom relief and improving meibomian gland function

​​​​​​​Dry Eye and Contact Lens Discomfort

Dry eye disease (DED) is a prevalent concern for contact lens wearers, often causing discomfort and reducing wearing time. Managing dryness and discomfort is crucial to prevent discontinuation of contact lens use. With proper care of the ocular surface, lids, meibomian glands, and thoughtful selection of lenses and solutions, it is possible to enjoy comfortable contact lens wear.

While dry, itchy eyes and uncomfortable lenses can be distressing, there's a solution. Scleral contact lenses, designed for optimal comfort and hydration, create a natural tear chamber that shields the eye from debris and allergens. This ensures a clean and hydrated eye surface, offering long-lasting comfort and making life with contact lenses more enjoyable.

Dry Eyes and Migraines: Is there a correlation?

There is evidence suggesting a correlation between dry eye and migraines. An increased prevalence of dry eye disease has been observed in individuals who experience migraines. Dry eye symptoms, including inflammation on the cornea, can lead to eye strain, fatigue, irritation, light sensitivity, and blurred vision. Prolonged hours of eye strain and challenges in maintaining clear vision may contribute to triggering migraine headaches in susceptible individuals. Managing dry eye symptoms may have a positive impact on reducing the frequency or severity of migraines in some cases.

Dry eyes and migraines. Bengu E Koktekir

https://pubmed.ncbi.nlm.nih.gov/22710496/

Association between dry eye disease and migraine headaches in large population- bases study

https://pubmed.ncbi.nlm.nih.gov/30844042/

Neuropathic Ocular Pain

Neuropathic ocular pain, also known as neuropathic corneal pain or neuropathic keratopathy, refers to discomfort or pain in the eyes that is associated with nerve damage or dysfunction. This condition involves abnormal signaling or processing of nerve impulses in the cornea, which is the clear front surface of the eye.

Neuropathic corneal pain is a condition that makes your eyes oversensitive to any stimuli (air, light). It usually causes severe pain sensation and light sensitivity making your life difficult and it is associated with symptoms of anxiety and depression.

Symptoms of neuropathic pain may include foreign body sensation, light sensitivity and severe dryness. In fact, symptoms of neuropathic corneal pain can be confused with dry eye symptoms. Although, the signs of this disease are missing.

Why do you feel pain?

The human cornea is the most potent pain generator in the human body. The cornea is a densely innervated by tissue with approximately 7000 nerve terminals per square mm making the cornea extremely more sensitive than the skin.

Ocular neuropathic pain causes:

Neuropathic pain can results from damage to the corneal nerves causing perception such burning, stinging and eye pain. Corneal neuropathic pain can be associated with diseases such as Diabetes, previous eye surgery, Shingles, facial nerve problems, ongoing inflammation due to dry eye, herpetic keratitis, chemotherapy, toxicity from preservatives in drops. Etc.

Treatment management

• Artificial tears

• Typical and systemic antibiotics

• Dietary supplements

• Bandage contact lenses

• Scleral contact lenses

Anti-inflammatory

• Mild steroids

• Topical NSAID agents

• Cyclosporine

• Tacrolimus

• Amniotic membranes

• Scleral contact lenses

Neuroregeneration

• Autologous serum tears (20%)

Others

• Antidepressants

• Anticonvulsants

• Tramadol

• Gabapentin

• Opiods

Nutritional intervention strategies

• Increase Omega-3 supplementation, increase on fatty acids intake and some patient may benefit from gluten- free diet Vit B 12

Ocular Neuropathic pain

Management of ocular Neuropathic pain with Vit B12 supplements: a case report

Computer vision Syndrome (CVS)

Computer Vision Syndrome (CVS), also known as Digital Eye Strain, refers to a group of eye and vision-related problems resulting from prolonged use of digital devices such as computers, tablets, smartphones, and e-readers. The extended use of these devices can lead to eye discomfort and vision problems.

What are the symptoms of CVS

• Eyestrain: Discomfort or fatigue in the eyes.

• Headaches:Persistent headaches often originating from eye strain.

• Blurred Vision: Difficulty focusing on the screen or objects.

• Dry Eyes: Insufficient blinking while staring at a screen can lead to dry, irritated eyes.

• Neck and Shoulder Pain:Poor posture and screen positioning can contribute to discomfort.

Treatment for Computer Vision Syndrome (CVS)

Primarily involves managing symptoms and making lifestyle adjustments. Here are some general recommendations:

• Follow the 20-20-20 Rule: Take a 20-second break to look at something 20 feet away every 20 minutes to reduce eye strain.

• Adjust Screen Settings:Ensure proper screen brightness, contrast, and font size to make viewing more comfortable.

• Proper Lighting: Reduce glare and ambient lighting to minimize visual discomfort.

• Correct Ergonomics:Position your screen at eye level, maintain proper posture, and use an ergonomically designed chair.

• Blinking Exercises: Remember to blink regularly to prevent dry eyes. Consider using artificial tears if needed.

• Computer Glasses: Consult with an eye care professional about glasses specifically designed for computer use.

• Anti-Reflective Coating: Apply an anti-reflective coating to your glasses to reduce glare and reflections.

• Blue Light Filters: Consider using blue light filters or screen protectors to minimize exposure to potentially harmful blue light emitted by digital devices.

• Regular Eye Exams:Schedule regular eye examinations to address any underlying vision issues and receive guidance on managing CVS..

• Workspace Optimization: Create an ergonomic and comfortable workspace to minimize strain on your eyes and body.

Dry eye and refractive surgery

Dry eye is not necessarily a contraindication for refractive surgery. However, identifying and treating dry eyes are crucial for a successful refractive surgery outcome.

​​​​​​​If you are planning on having any refractive surgery (Lasik, Photorefractive surgery, Laser thermal keratoplasty, radial keratotomy etc) you will get screened for dry eye. In some cases, a patient with dry can be treated with eye drops or other medications before surgery.