What makes “enough,” ENOUGH and is there such a thing as “too much?”

Dry eye patients often get frustrated by the amount of time, effort and often, money, required to make dry eyes better. Some of them will ask when they can stop their treatments, or cut back on the “homework” I typically prescribe. The short answer is that sometimes we can’t figure this out until they cut back - but generally speaking, a certain amount of combined office treatments and “homework” is required to take care of our eyes - much like we take care of teeth if we want them to last like we do. Taking the common steps for many dry eye sufferers, one at a time, I’ll do my best to cover the main issues. Today we will cover the top 3 of my “homework items.”

Omega oils. As I’ve posted before, the majority of humans cannot process oils that are not essential, into essential oils (a bit like turning dirt into gold). The essentials are Omegas 3,6&9 - and foods rich in these are largely the “Paleo” foods of fish, nuts and seeds (remember, peanuts don’t count - as they are legumes like peas and so are not true nuts). Oil is used to support our cell’s membranes, provide insulation in our nerves and brains and support the oil-producing glands in our skin and eyelids that serve our tears, among other things. Oils we eat that are not used as oil are treated as food are either broken down to become sources of sugars or become stored as fat. Since we need a certain number of daily calories to survive, a diet rich in these oils can provide many of those calories without making us “fat.” Our great ancestors apparently existed by largely eating these foods - or by eating animals that ate those foods (we were the “hunter-gatherers”) - so our bodies are still programmed to need those oils. Adding 4-to-6 grams of these oils to our typical “modern” diet can help us get enough “essential oil.” The average American diet is 95 times less rich in the essential oils in just the last 100 years, which makes it hard to “overdo” these oils with supplements. When patients ask which is better, fish or flax seed oil, I generally respond with “both!” and then mention that adding a little borage or black currant seed oil is also helpful. If you have trouble digesting oils, then you may want to take this up with your doctor, as it could be a sign of digestive issues like gall bladder or liver disease. There are also digestive enzyme supplements that can often help (see my earlier posts on this topic).

Doing good blinks. Recalling that just as tears are the “lifeblood” of the surface of our eyes, then blinking is the heartbeat that constantly refreshes that surface by moving fresh tears up to replace the dried up, used up tears. Good blinks are more than frequent blinks (more frequent but weak blinks is like having a weak, fluttering heartbeat). The best blinks are those that completely close the eyelids together with a slight compression or “forcefully.” This does not require (and should not be) a full-on “grimace,” where your face twists into a “mad at the world” look, but rather a slight crinkling of the skin and muscles beneath the skin. Feeling the corners of your eye’s socket while you bring lids together, you should feel the muscle bunch up and push you fingers away from the edge of the boney margin. Out in the wind and sun (as our great ancestors would do, to hunt and gather), will generally encourage that kind of blinking. Sitting at home and staring at digital screens will promote the opposite effect (and potentially give your eye’s surface a “heart attack” - see my earlier post on that!). Too much grimacing can lead to crow’s feet wrinkles and can - for some - promote lids to turn in or out - as the forces push too hard and then encourage poor lid support (sometimes requiring surgery to fix) - so yes, too many extremely strong “blinks” can be bad. So finding that balance of a conscious, firm - but not excessive blink, is critical, since this also is the force that activates your oil producing glands into doing their job. See my post on hot moist compresses with “eyelid crunches” to see my best advice on how to properly encourage lids to produce good oil. As a side bar, I don’t recommend patients “pinching lids” or deeply massaging them, in order to express oil. These maneuvers risk damage to lids - or to eyes - or both (pinching can weaken lids that can then fail to support a good tear and excess massaging may promote the same problem, but can also risk direct damage to the eyeball).

Hot moist compresses. The majority of dry eyes have an element of clogged oil glands as a significant if not entire cause of their dry eye disease. The key to moving the waxy plugs that clog eyelid oil glands and getting the thick, sticky oils to clear out and make room for good oil production, is to provide “enough heat.” This requires leaving the heat on long enough to deeply penetrate the lid (for many, this is at least 3-5 minutes) to melt the wax - and then strongly blinking to clear that wax from the glands. Moist heat generally penetrates better than dry heat and there are a number of heating appliances designed to deliver this heat effectively to eyelids. Too much heat will obviously risk burning skin - so heating to around 108-110 degrees F and leaving it on for upwards of 3-to-5 minutes before the “eyelid crunches” (which turn over that now liquid oil) is good for most patients. But what if the problem with the oil glands is not waxy obstruction, but rather a more inflammatory, “bad oil?” This is akin to making kerosene when you need “salad dressing oil.” Adding heat doesn’t help and can make it worse by dilating the blood vessels that deliver that inflammation to the glands. So yes, sometimes any heat is “too much heat” and the best way to tell is by asking your dry eye specialist.