Why can’t I just use some tear drops or ointments instead of all this work?

Segment 11

As a dry eye specialist, I am often asked why drops and ointments don't work. Most of the time, it is because "artificial tears" are "artificial" - and your eyes are looking for the real deal - a mixture of water, salt, special proteins and special (human) oils. This is the function of the entire tear "works" - and is a 24/7/365 process involving the "sprinkler system" - that group of glands making the daily "salad dressing" of a healthy human tear. (We also have a "fire hose" which makes the emergency backup tear we use to wash out a loose lash, to emote or to back up the sprinkler system). It turns out that most of the time, drinking more water and reducing inflammation (sometimes with prescriptive drops) will help the water producing glands produce more water - but has no effect on the oil. Oil is made by tiny glands that line your eyelids and make their oil when you eat good oils and do "good blinks" - the process of bringing the lids together with enough force to "squeeze" the oil glands into dispensing their oil. How does my doctor determine the health of these oil glands? Symptoms of dry eye cause the dry eye specialist to look harder than most and will have equipment to image these glands to see how constipated and/or withered they look. Testing how long a tear holds together before dry spots from evaporation occur and testing salt levels in the tear are both good ways to see how dysfunctional these oil glands are. Pressing on the lids while looking with magnification, allows us to see how much and what kind of oil comes out of a gland. Their best performance is thin clear “salad dressing“ oil pouring out with very little pressure. More common is scant, thick, milky or toothpaste-like oils or even as wax. Worst is nothing coming out even with heavy pressure squeezing the lid. Advanced technologies can help us image how patients blink, so we can see how well - or, more commonly, how poorly the lids come together and then to image the amount of oil being produced by those blinks. Since we know there are other causes for Dry Eye disease, other than dysfunctional oil glands, a good exam will also include looking at the volume of tears produced by the “sprinkler system” and if suspected, the function of the “firehose.” This can involve small test tapes or threads, designed to soak up the new tears made over a five minute time frame, as well as to measure the volume resting on the lower eyelid. Tests for inflammation can involve dipstick test strips or red scale measurements and a special, in-office test can measure salt levels. A good dry eye specialist will also look at the surface and under-surfaces of the eyelids, the lashes and eye’s surfaces, as well as testing with dyes as part of a complete dry exam in order to determine what other issues may be involved. Many times it will take advanced treatments to get the oil glands back "online" though simple things you can do at home can also help (eating the good oils Omega 3-6-9, doing good blinks - sometimes with hot compresses to facilitate moving the stickier oils out of the glands, and even special lid hygiene treatments to deal with the common germs that often take advantage of these sticky oils and make them their food instead of your eye's).

Ointments are largely mineral oils (which are not organic/human based oils) so they are not nutritive, contain no antibodies and generally don’t “behave” like normal tear oils - so while I know some patients with severe MGD and secondary evaporative dry eye disease need this kind of ointment help, one of the goals of getting your oil glands working (as can be facilitated with IPL & and heated expression of oil gland clogging using a variety of techniques including my off-label RF treatments) is to get away from the ointments. Ointments will “seal” your surface from some of the good oils you begin to make (potentially limiting treatment effectiveness). As your own oils improve, you might be advised to wean off the over the counter and prescriptive ointments. As usual, every case is different and as usual, your best option is to heed the advice of your dry eye specialist.