“I’ve tried everything - now what?”

For most, this simply means finding a better dry eye doctor. This is because many of the patients who find me (or any other dry eye specialist with more than a few arrows in their quiver) arrive stating they have “tried everything” and are still suffering, where “everything” amounts to trying many brands of over the counter artificial tears, a few prescriptive drops (often including steroids that cause a brief reprieve in symptoms, but generally recur within days of stopping), some form of partial-but-high quality oil supplements (like high-priced fish oils), a warm compressing device (or two) and sometimes punctual plugs or amnion membranes. Some have tried a heated expression or two and some have tried IPL more than a few times - usually with variable or partial results. Rarely, they present on what many dry eye specialists would consider their best “homework” and fewer have truly tried “everything” that a more specialized dry eye provider might recommend. And yes, even a few of my patients - who have had the best I can offer - can still struggle.

Fortunately, I can usually get patients to a comfortable place with some combination of simple-to-advanced treatments and good “homework.” I’ve covered much of this in my previous postings. This most often requires a level of “maintenance” that has these patients getting a package of lid hygiene and advanced care treatments. This only delivers optimal results when used together with the homework I’ve spelled out in a number of posts, but is tailored to a patient’s unique issues. But since every case is different and the problems spawning dry eyes and related ocular surface disease can be diverse, there is no one program that will fix everyone - and there remain a few patients where - try as we may, we can’t easily (or even not-so-easily) get to that “happy place.”

So where do we go from there? First, it is important to realize that this is a “special group” who most often have deeper degrees of inflammation - frequently created from more severe forms of toxic, metabolic, diet/digestive, infectious or auto-immune diseases. To most ably address these patients, it is necessary to identify whatever deeper “root causes” exist. Covering all of these diseases would go far beyond what I can cover in posts like these. A good dry eye specialist will have the special training and/or extensive experience to figure this out and it may sometimes require consulting immune specialists (rheumatologists), endocrinologists, gastroenterologists, dietitians, dermatologists, and/or infectious disease specialists, along the way - depending on where the sleuthing leads. Once the deeper levels of disease are discovered and dealt with, it often helps deal with the related dry eye and surface disease/eye problems - to the point where we get to that safe, comfortable level.

In cases where we are still left with significant dry eye and surface issues, this is where we fall back on things like autologous serum tears (ASTs), amnion membranes and amnion fluid treatments, scleral lenses (remember the “fishbowl” analogy) and surgeries as simple as permanently closing tear duct openings (a better punctal plug for these advanced cases), or partially closing eyelids (lateral tarsorrhaphy) so less eye is exposed and less tears are needed. Newer surgeries can allow reseeding stem cells for the cornea (and perhaps eventually for the tear-producing cells and glands). Some eyes respond best to older procedure - covering severely damaged portions of the cornea with flaps from the conjunctiva. A few may require more innovative surgery, bypassing severely damaged lids and corneas with a plastic prosthesis that provides a level of vision in some of the most surface-damaged eyes, or, more experimental procedures used to “rewire” damaged nerves and/or transplant spit/salivary glands to supply moisture to the cornea.

Research continues to find newer, better ways to serve the unfortunate few who require the most advanced levels of dry eye and surface disease-related care. The old (Ben Franklin) adage about “an ounce of prevention is worth a pound of cure,” (or a stitch in time saves 9) is never more true than when it comes to dry eye care. Getting an early, appropriate diagnosis, adequate treatment and any needed, ongoing care can often prevent the need for these exceptional levels of care. Sadly, the most advanced, end-game procedures rarely result in anything close to what we would otherwise consider as a “normal” eye. In such cases, the goal is frequently “some level of vision” with “some level of comfort” and a reasonable level of safety.. Drinking enough water, eating enough healthy oil, doing regular, strong, adequate blinking and some cleaning of the lids seems a smaller price to pay to avoid all this - and yet, sometimes it seems just that may save some from much misery if delivered early enough to avoid that unhappy end game.