What happens when you don’t have enough good oil and how do you fix it? (SLK, CCH and why blinking matters)…

While I’ve posted about blinks and the effect of blinking on making oil (links below), I recently was asked about SLK (and thereby CCH) – two structural eye problems which are the result of poor oil. BioTissue, among others, have dubbed this poor oil problem as “Mechanical Dry Eye” (or MDE), as friction is a driver (so a mechanical force). However, I think there is an equal contribution from the evaporation relating to lack of the “Saran Wrap-like” sealant effect of oil (so water evaporates from our tears, leaving a higher concentration of salt to cause more surface damage and leads to inflammation. Inflammation added to friction “unpeels” the glue and fibers that hold the conjunctival membrane to the underlying white of the eye (or sclera), allowing it to “come loose.” Further friction leads to more inflammation and the vicious cycle perpetuates dry eye and related surface eye diseases.

SLK (superior limbic keratoconjunctivitis) is essentially the same as CCH (conjunctivochalasis) - both are when the conjunctival membrane "comes loose" and develops pleats and folds that interfere with the proper eyelid “squeegee” of tear flow over the eye, as well as causing friction-related irritation. Instead of affecting the lower part of the eye like CCH, SLK affects the upper. Surprisingly it appears to be less common than CCH, possibly because the inflammatory tear products are in greater contact with the lower lid from gravity, possibly because our eyes more commonly track downwards rather than upwards – possibly due to the differences of the mechanical forces relating to the difference in the size and position of the upper vs lower lids -but the effect of friction and inflammation on the conjunctival membrane is the same. It also appears more common in Thyroid-related eye disease and Rheumatoid Arthritis, but then so is my perception of CCH, too.

 

An autograft (where a portion of conjunctiva harvested from another area and “transplanted” to cover the area exposed when the damaged conjunctiva is removed) - or the amnion surgery used by some in CCH repair (where a piece of amnion is glued or sutured over the exposed area) can work - but I found that radio frequency (RF) works great for both CCH and SLK - and offers the opportunity to do an (off label) RF-heated expression of the clogged MGs that appear common to causing both SLK and CCH. In the past, Silver Nitrate (on a wooden stick applicator) was also used to treat SLK - but it causes a chemical burn rather than an electrocautery or RF-plication "singe" - so I didn't find it better (as it seemed less predictable and doesn't fix the problem - obstructive MGD - causing the problem – SLK as we can with RF).

 

For more on CCH, see these earlier posts: https://www.eyethera.com/blog/what-is-conjunctival-chalasis-cch-and-why-should-i-care and for some embedded links to see how I actually do my treatments (and a study I published on the success of these treatments), see:

https://www.eyethera.com/blog/conjunctival-chalasis-cch-part-2-how-do-we-fix-it

Lastly:

https://www.eyethera.com/blog/cch-part-3-when-do-we-treat-cch-and-what-are-the-options

 

Early in my career, when I began to specialize more fully in all things related to dry eye disease, I had the good fortune to spend some time with a true giant in that specialty (Dr. Donald Korb – inventor of Lipiflow). Due to his influence, I became one of the first doctors to offer Lipiview and Lipiflow north of Boston (where Dr. Korb invented it). I gained a huge appreciation for the variety of blinks and blinkers (Lipiview was the first commercial technology to monitor blinks). My experience is that those with uniformly poor blinks tended to have worse MGD (dysfunction of the oil producing glands of the eyelids) and those fortunate few who had better blinks tended to have less MGD.

 

As a fellow partial blinker, I can relate to how confusing this is. I see it as a measure of higher IQ (since I have the same issue;) but I believe it boils down to the fact that nobody teaches us how to blink, so some (perhaps most) of us learn these “bad blinks.” As children we had perfect eyes and perfect tears - so we hardly had to blink. As we “grow up” we don’t do ourselves any favors by partial blinking. Digital devices add to partial blinking by staring and then stagnating oils. I’ve posted on some of this stuff here: 

https://www.eyethera.com/.../how-important-is-oil-to-our... and

https://www.eyethera.com/.../why-do-my-oil-supplements...

Here, I offer some tips on how to remedy our “bad blink habits:”

https://www.eyethera.com/blog/the-ocular-heart-attack-of-a-stare-and-why-digital-devices-can-cause-these-heart-attacks

and

https://www.eyethera.com/blog/avoiding-a-heart-attack-on-the-surface-of-your-eye

Probably the best way to deal with this issue is prevention through education. Helping our children develop good habits - working on better blinks, encouraging more time spent outside where natural stimulation from wind and sun can help promote good blink habits (and hopefully less time spent on digital devices - or at least following the 20/20/20 rule), good diet and exercise programs - and proper lid hygiene. Add to that regular eye checkups that can include monitoring the health of our tears and the surface of the eyes.

Some years ago, I had the good fortune to come across a European PhD candidate who was focused on these blink issues and he produced a useful website you can visit here:

https://www.blinkingmatters.com/

 

 

 

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What about Punctal Plugs (or - “Why not dam up those tears”)?

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Sjogren’s Disease: Autoimmune dry eye Part 5