Dry Eye Syndrome
Many patients in Northern Nevada mistakenly blame the climate for their dry eye, but in reality our arid environment is only one of many factors contributing to the development of this all to common disease. Dry eye is something of a misnomer, as tearing can often be a sign that you have what is better described as tear film dysfunction or ocular surface disease. The tear that protects our eyes is complex in nature and the treatment of tear film dysfunctions can be just as complex. Common symptoms associated with tear film dysfunction include dryness, stinging, burning, redness, tearing, grittiness, blurred vision, double vision, foreign body sensations, sensitivity to light, easily fatigued or tired eyes. Tear film dysfunctions are also a common cause of contact lens discomfort and may increase your risk for corneal scarring and infection.
As many as 3.2 million women and 1.68 million men over 50 in America are affected by dry eye syndrome. We know that factors like age, being female, prior refractive surgery like LASIK, certain medications like Accutane, conditions like Sjogren’s disease, excessive multivitamin use, radiation treatments and diets low in vitamin A and omega-3 fatty acids increase the risk that you will experience dry eye syndrome. Testing for dry eye syndrome includes:
Diagnostic dyes to assess tear film quality and surface damage. Sodium Fluorescein (yellow) allows the doctors at the Visionary Eye Center to evaluate how quickly your tear film breaks apart and stains damaged areas of the eye, especially on the corneal surface. Lissamine Green stains dead cells due to dessication and highlights conjunctival damage.
Phenol red threads and Schirmer’s strips are used to determine tear quantity. By placing one of these threads or strips in the eye it is possible to assess certain aspects of your dry eye. There does exist some controversy regarding both tests as to what they actually measure, be it tear volume, basal tear secretion, reflex tearing or a combination of the three. Regardless, their correlation between low amounts of wetting and dry eye remains high.
The Ocular Surface Disease Index is a scientifically validated 20 question test that allows us document symptoms of dry eye and monitor your status. One of the most frustrating things about managing dry eye can be the poor correlation between our clinical test results and the patient’s symptoms. By using this questionairre we can provide a measure of your dry eye despite seemingly normal test results and examination. Click here to take the test.
Tear osmolarity is the newest test we have for determining how severe your dry eye is. If you remember from high school, osmotic forces push and pull water in an attempt to equalize the concentration gradient. This process occurs on the ocular surface as poor quality tear film can actually draw water out of the surface of the eye and place these cells under great duress. Using a device called the Tear Lab Osmolarity Test we can now test for osmolarity as it relates to your current dry eye condition and monitor for improvement as we try different treatment methods. Unfortunately, Nevada is one of 3 states that do no allow optometrists to obtain a CLIA waiver to provide this vital diagnostic tool to our patients. We urge you to contact your state representatives to let them know that this law is antiquated and impedes the proper treatment of dry eye.
Today we have a multitude of dry eye treatment options, from artificial tears to surgery to specialty protective shells. Read on to discover some of what we have available.
Artificial tears and lubricants have been the mainstay in dry eye treatment since the beginning. Artificial tear technology has progressed dramatically in the last decade, seeing the introduction of several new types of tear replacements that aim to target specific tear components. Your tears are made of three main components, the inner mucous layer, the middle aqueous layer and the outer oil layer. The inner mucousal layer helps the tear stick to the eye. The middle aqueous layer provides moisture and antimicrobial enzymes. Finally, the outer oil layer is comprised of lipids that slows evaporation. Dysfunction in any of these layers can begin the inflammatory cycle that is dry eye. To combat these tear film dysfunctions, researchers have developed multiple artificial tear types aimed at the varying components of the tear. Our favorite lubricants at this time include Oasis Tears and Oasis Tears Plus, Retaine MGD, Retaine PM ointment and Tears Again Liposome Spray.
Lipid based emulsions are used to combat dysfunctions of the oil layer, often caused by meibomian gland dysfunction and blepharitis. These tears tend to be milky and may cause smoky vision after instillation. These are one of the main categories used in our office as evaporative dry eye disease is highly exacerbated by our dry climate in Nevada. Examples include Retaine MGD (PF), Systane Balance (P), Optive Advanced (P and PF).
The majority of artificial tears focus on enhancing the aqueous layer of the tears and increasing lubricity. Most of these tears use molecules like carboxyl methylcellulose, propylene glycol, glycerin, hydroxypropyl methylcellulose, polyethylene glycol and dextran as the active ingredient. There are too many options in this category to list, so we will focus on the few that have special features.
One of our favorite inactive ingredients is sodium hyalruonate, which has been shown to have protective effects on the corneal epithelium aiding healing and some versions actually release water molecules when you blink. Oasis Tears (PF), the thicker Oasis Tears Plus (PF) and Blink (TP and PF) all contain sodium hyalruoante.
Another great inactive ingredient is hydroxypropyl guar. This gel forming molecule increases retention time of the tear and forms an anchoring bandage over damaged corneal epithelial cells. HP-Guar is found in Systane (P and PF), Systane Ultra (P and PF) and Systane Gel Drops (P).
Hypo-osmotic tears are designed to counteract the hyperosmolarity often found in dry eye patients. Examples include TheraTears (P and PF), and Hypotears (P and PF)
FreshKote (P) is a prescription artifical tear that features a high oncotic pressure that aids the cornea by reducing microcystic edema. It also contains components to supplement all three layers of the tear and restore proper osmolarity.
Ointments and gels can greatly increase the time the lubricants stays in the eye. Many of these products are just thicker versions of the counterparts listed above. These tend to cause blurred vision, so their use is often limited to before bedtime or for thos with nocturnal lagophthalmos (incomplete eyelid closure). Retaine PM (PF), Refresh PM (PF), Systane Nighttime (PF) and Systane Gel Drops (P).
Tears Again Liposome Spray (P) is a unique product that supplements the oil layer of the tear. This spray is great for those with trouble instilling eye drops and it is used often as a supplement with Oasis Tears in our office to provide a multipronged approach to treating our patients. As the tear layer is actually much smaller in volume than a typical eye drop, the amount of lipid that deposits along the lid margin and subsequently into the tear layer is more than adequate. Just make sure you spray this on with your eyes closed, as direct exposure may lead to burning.
Lacrisert (PF) is an one of kind prescription product for moderate to severe dry eye patients. It consists of a small hydroxypropyl cellulose rod that is inserted into the inferior cul-de-sac of the eye. The idea behind this product is to provide a constant supply of lubricant to the eye without regular drop instillation. Some patients note a foreign body sensation with this option when used during waking hours. A great use of Lacrisert is for patients that suffer from overnight dryness as the foreign body sensation is generally not noted during sleep.
A special note about preservatives. Listed above you will note that the product are listed with a P, PF or TP. These stand for preserved, preservative free and transient preservative. Some patients can be sensitive to preservatives in the products they use for treatment, so much so that some preservative reactions can exacerbate the dryness issues. For those patients using dry eye products on a consistent basis they should use the preservative free versions when available to avoid this complication.
- Warm compresses can aid those with lipid based tear film dysfunctions. In meibomian gland dysfunction the oil produced stagnates within the gland. By heating the lids it is possible to loosen the oil and when followed with a lid massage these glands can be expressed and restore oil flow onto the tear film.
- Meibomian gland expression is an in office procedure that can help clear blocked meibomian glands. Using a warm compress to first loosen the oils in the meibomian glands, an expressor paddle is used to massage the contents of the gland out, clearing any blockages. This concept has been taken to the extreme with the Lipiflow Thermal Pulsation System. Using a specialized eyepiece that fits over the eyelids, heat and pressure are applied to the lids in the same manner described above in an automated process.
- Fatty acids like Omega-3’s commonly found in fish oil have been shown to reduce inflammation and dry eye symptoms. Our biggest caution is beware of low concentrations and heavy metal toxicity. We specifically recommend 2000mg total of EPA and DHA daily. Our current trusted source of Omega-3’s is ProOmega from Nordic Naturals.
- Anti-inflammatory medications are a mainstay in dry eye therapy. Corticosteroids provide the biggest effect. We frequently use Lotemax and FML to rapidly reduce the inflammation associated with dry eye. Corticosteroids are very safe when used judiciously, but they do require frequent visits to monitor for spikes in intraocular pressure and cataract formation.
- Antibiotics with immunomodulating properties have become a great area of interest for use in dry eye therapy. Tetracyclines like doxycycline and minocycline, macrolides like azithromycin and most famously cyclosporin (Restasis) all show the ability to reduce inflammatory modulators on the ocular surface. These may be prescribed both topically and orally. For those taking tetracyclines we recommend caution when enjoying the sunny Nevada days as they can increase your risk of sunburn. Many of these drugs are safe for long-term treatment.
- Punctal plugs work to slow the natural drainage of tears from the eyes. Acting like little dams, punctal plugs are inserted into the puncta, the opening of the nasolacrimal duct. This painless in-office procedure only takes a minute and can provide much relief from patients with tear film volume issues.
- Moisture goggles can be worn to slow the effect wind has on the evaporation rate of the tear film. These can be soft goggles meant for overnight wear like the Tranquileyes, or for daytime use we find frames that come with a foam gasket like the ones from Wiley X work well.
- Treating concurrent conditions such as blepharitis and allergic conjunctivitis can help improve the quality of the tear film and reduce dry eye symptoms.
- Autologous serum is derived from the patient’s own blood. Blood serum has been shown to provide healing effects on corneal defects that have been resistant to previous treatments. This option is reserved for those with severe dry eye.
- Scleral shells can be used with patients with adequate tear volume. These large scleral contact lenses create a moisture chamber over the corneal surface, protecting it from the environment. This option is meant for those patient with severe dry eye. As the only office in Reno/Sparks with Visante OCT technology, our office is uniquely suited to fit these specialized lenses.
At the Visionary Eye Center we strive to stay on top of the latest in dry eye treatment options in order to ensure the best experience for our patients. Contact us today to start your journey towards dry eye relief.
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