“Why do my oil supplements not work?

In my dry eye specialty practice, I see discouraged patients frequently, coming with the complaint they’ve tried all kinds of supplements, diets and treatments without relief. Most have tried all this at home or on the advice of a general eye doctor or a friend, without seeing dry eye specialists, but some have seen many. When it comes to failed drops (like prescribed Restasis, Xiidra, steroids, etc, or over the counter/non-prescriptive artificial tears) and oral supplements, there are many reasons for this complaint and I’ll list 5 of the most common here:

>> 1) Most cases of dry eye (but certainly not all) are caused by or contributed to by obstruction of the oil producing glands called Meibomian Glands (loosely dubbed MGD for Meibomian Gland Dysfunction). These obstructions vary in type, but commonly involve waxy products caused by stagnation of the oils caused by poor blinks (like as occurs from staring at digital screens like we’re all doing now) and inadequate consumption of the right balance of the “essential” Omega Oils, 3,6&9. If the glands are clogged, then taking good oils (or any other products that don’t unclog), then this is analogous to putting great oil in a bottle with a big, tight cork in it and the supplement “fails.” Unclogging has to be coupled with these supplements to get effective care.

>> 2) Not all oils are well absorbed. If you have lost your gallbladder through surgery or diseases like stone blockages, then you’ve lost the ability to easily digest greasy, oily foods. Gallbladder supplements can help and without them, you may have to take small, frequent doses, so your liver can trickle the enzymes you need into the part of your gut that digests and absorbs the oils.

>> 3) Not all oils are equally “good.” Using olive oil as an example (which is largely Omega 7 and while a good polyunsaturated oil, it isn’t the right oil for your tear glands), we’ve all seen the range of quality and expense we face at the supermarket. Most recognize “Extra Virgin Olive Oil” or EVOO, as the best. The first “pressing” is considered the best - and organic, carefully tended olives take it a step further. They will market this as “organic, extra virgin, cold pressed olive oil.” (also called EVOO & it tends to be the most pricey). This oil is the most like the olive which is well recognized by our gut and is well-absorbed, as well as well-utilized by our body. Once the company pressing those olives has extracted what they can by pressing in a cold vice, they can add more heat and pressure to extract more “olive oil,” but this merits a lower grade and when they add even more heat, pressure and chemicals (like hexane), they can get out the “dregs” which they can sell as “cooking oil” - but isn’t what you’d want on your salad for dressing. The dry eye supplements - and I’ll use flax seed as the next example, are similar but not marked the same way. The “organic, extra virgin, cold pressed flaxseed oil” is sometimes called “organic, cold pressed extra high ligand oil” but flaxseed oil is processed the same way as olives. By the time you get to the dregs, they sell that as linseed oil (better for sealing decks than for dry eye supplements, but some companies can still market grades close to it as flaxseed oil). Needless to say those supplements don’t help the way the EVOO-like flaxseed oil can. In one way or another, the other oils like fish, borage, black current seed, etc, follow the same analogy and unfortunately, you will usually get what you pay for. Cheaper supplements are less likely to be helpful.

>> 4) Not all dry eye disease is caused by MGD. A common cause or contributor behind MGD is Aqueous Tear Deficiency (ATD), or too little water. All the oil supplements in the world won’t fix the ATD part of a dry eye problem. Fortunately, this is we’re anti-inflammatory medications (like Restasis, Xiidra, steroids, etc) can help. OTC artificial tears are only a “BandAid” that temporarily offers some relief but doesn’t deal with the root causes of the dry eye process. Some artificial tears (especially if they come in big, multi-use bottles) contain harsh chemicals called preservatives, which neutralize germs at the expense of neutralizing the tear glands. This can make you increasingly dependent on these products. Other common “co-contributors” like conjunctival chalasis, allergies, blepharitis etc, all require specific treatments and until they are addressed, your symptoms may persist and the supplements “don’t work.”

>> 5) Dry eye disease doesn’t tend to happen overnight. In fact it usually takes decades before it is obvious (that’s another long discussion), so the corollary is that improvement tends to take “a long time.” Depending on how aggressive the treatments are and how bad the disease has progressed, improvement can be slower than watching paint dry. It seems to take forever even when daily (tiny) gains are being made. We all want to get noticeable improvement when we’re shelling out big bucks for our care, but that rarely happens when you’re digging out from bigger problems. Supplements, coupled with appropriate care guided by a dry eye specialist who’s properly diagnosed and addressing your specific problems remains the best way to get better.

Dry eye: Cataract and Glaucoma Segment

Dry Eye and Glaucoma Segment:
As a dry eye specialist who also sees glaucoma patients, my general recommended protocol is:

- Evaluate each glaucoma patient for candidacy for SLT (Selective Laser Trabeculoplasty) treatment. SLT “rejuvenates” the drainage area inside the eye, which allows the pressure to regulate naturally. It can be used as first-line treatment in appropriate patients - especially with dry eye, as it generally reduces pressure as well as any single eye drop can.

- Follow the rule “less is more”. This applies to the number of medications and to the frequency of application. This means to aim for “lowering the pressure enough” without overkill. It also applies to the total amount of preservatives applied to eyes. Glaucoma drops usually have the same preserving chemicals as Artificial Tears (to inhibit germs from living in the reusable bottle) and can be just as toxic. These chemicals can be hard on the tear glands and on the surface of the eyes. Unfortunately, just as the preservative free (PF) tears cost more, so too are most PF glaucoma meds.

- Patients who start with dry eye generally get worse adding glaucoma meds and will have a harder time tolerating the drops needed to prevent blindness. I recommend aggressively treating the dry eye first, or at least upon starting glaucoma care (so eyes can better tolerate these necessary chemicals). For those with advancedWhenever possible, attempt to work in concert with both glaucoma and dry eye specialists.

Dry eye and Cataract Segment:

Dry eye after Cataract: As a dry eye doctor – and one who did 30 years of cataract surgery before turning over to full time dry eye and lid surgeries, I have seen a lot of patients who appeared to suddenly get their dry eye disease immediately - or soon after - their cataract surgery. In my experience, this most often relates to multiple reasons (where some or all the following would be true):-

- Dry eye disease is a chronic, progressive problem that tends to change so slowly for most, that from day to day, there is so little change that it is almost imperceptible to the person with it. I use the analogy of the single straw placed daily on a camel’s back. From one day to the next, the camel doesn’t experience any difference – until one day, that “final straw” breaks the camel’s back. From the camel’s perspective, it was only the final straw that did it.-

- The surface of the eye is a sheet of living cells, each dependent on tears for their support and for healing. Every living cell in the human body requires support, but cells outside of the eye will get their support from blood. Eyes can’t have blood on them as we couldn’t see through blood, so we have tears instead. When an arm or leg is operated on, poor blood can mean poor healing and a complicated, less optimal outcome.-

- Cataract surgery is, by definition, surgery. Anytime we operate on an eye, that eye must heal. If the tears are not the best, then like the arm or leg, poor tears can also mean poor healing and a complicated, less optimal outcome.-

- To heal the inside of the eye, we commonly rely on use of multiple eye drops. Each drop is some chemical (or chemicals) that is/are designed to help that internal healing, but between the nature of those chemicals and the preservatives common to keeping those chemicals from germ contamination, the frequent exchange of the tears by those chemicals can leave the surface raw and irritated.-

- Irritation causes our immune system to react and bring on inflammation. Inflammation works against the tiny tear glands that are trying to make our tears – so during the healing from cataract surgery, we frequently promote more dryness in the effort to promote the internal healing required from that surgery.-

- While most eye’s tear glands will recover back to their baseline after cataract surgery (once the use of the post-operative eye drops are stopped and the eye is otherwise healed), for some, this can act as “the final straw” and break the camel’s back – causing a more substantial vicious cycle of inflammation and dryness that can be hard to recover from.-

- Also, returning to baseline may still be suboptimal and once an eye realizes it is unhappy from dryness, then (returning to my analogy) taking a little straw off the back can still leave a lot of straw on that back – and now the eye (or camel) realizes there was a problem that it didn’t perceive before.

Dry eye before Cataract Surgery - having a poor tear going into cataract surgery can cause poor readings of the corneal curvature that can translate into using the wrong power or style of implant and you have some eyes that end up with – at best - a greater need for post-operative glasses than would otherwise be required – or at worst – a style of implant that a dry eye can’t cope with and causes poor visual outcomes until the implant is exchanged or the dry eye is corrected adequately (if it can be).For all these reasons, I find it important to determine the level of dry eye and to correct it as best as possible prior to evaluating for cataract surgery.

Controlling Dry Eye Disease throughout the postoperative period (and beyond) is equally important.There are some patients whose poor vision is less the effect of the cataract and more related to the irregular corneal surface – who go through the cataract surgery only to discover that their vision is no better until the dry eye is corrected. This implies that the cataract operation may not have been wholly necessary and that simply correcting the dry eye would have taken care of their visual problems (until the cataract more fully progressed – sometimes years later).

Ideally, every cataract surgeon will also be a great dry eye doctor, but as some prefer to stay focused on the surgery, then it is incumbent on those surgeons to rely on other dry eye specialists to help get their patients to be best cared for. Team efforts often yield the best outcomes, which is why I (and many of my dry eye doctor colleagues) commonly work closely with other doctors and eye surgeons in taking care of our eye patients.

Hope this helps!

Segment 12. IPL for dry eye - common concerns and questions

Does IPL hurt? The key to IPL treatments is to adjust the frequency of the light to the target you want to treat. Because inflammation is carried by blood in blood vessels, the typical wavelength we chose for dry eye treatments is directed to that. The vessels can be thought of as a “tree of inflammation” where the roots are where all the vessels should be and the trunk, branches and twigs are reaching up to the surface and into the tear glands. The first treatment targets what the light can “see” - largely the twigs on the surface. Lots of red = lots of target (& relates to degrees of discomfort - more target = more discomfort). These vessels will “regress” or shrink, after a good treatment. This leaves a layer of skin that becomes clear over the next, “branch level” of vessels. Waiting an appropriate time allows the next treatment to reach through the less red skin, down to the next red level (of branches). Each treatment can clear more redness. Less redness means less target, less inflammation (& less discomfort). However, it can be useful in many cases, to increase the power, so as to reach the lower levels of red - so subsequent treatment may be as - or more - uncomfortable- than the first. While we can adjust settings to be less uncomfortable, we try to balance this with what is more likely to work best in clearing more redness and inflammation. Usually this is at least 4 consecutive treatments (typically 3-5 weeks apart, though that can vary with clinical findings and treatment objectives). Experienced specialists will be able to guide you. 

Why is IPL alone, not sufficient for clearing obstructed tear-oil glands? IPL’s major shortcoming is that despite a variable degree of MG heating (depending on the device and protocols used as well as the skin type being treated), by the time the MGs are expressed (which can be significantly delayed after removing the ultrasound gel and positioning at a slitlamp) - and some IPL protocols don’t include any expression- the waxy clogs may be too solid to respond to expression pressures. Lots of technology has evolved to help address this issue. Lipiflow was the first in-office device, but has limitations on the amount of heat, pressure and surface area it covers. TearCare can provide more uniform heat, but can also suffer from a time delay to expression. iLux is more customizable but can be a bit tricky for upper lid treatments. I prefer off label use of radio frequency (RF) for full customization (with the  unique “side effect” of leaving skin looking a bit younger, with fewer fine lines and wrinkles). As a part owner of eyeThera, (my financial disclosure), I find the thermashields I helped devise for expression with RF can also be a benefit for other heated expression (TearCare and Mibo to name two). If you and your provider wish to try a shield for this purpose, I try to do most of my expression in the final minutes of Mibo or TearCare heating, by moderate digital pressure (or QTip pressure) over the lid and against the “backstop” of a thermashield. This can be quick, comfortable for the patient - and therefor, more effective - in my limited experience - as I still use RF for most. eyeThera can provide a single shield if your provider will order through their website.  I also find it critical to take excellent Omega 3 oils but not to neglect the Omega 6&9’s. I generally advocate some high-quality Fax Seed Oil in addition to the Fish Oil supplements, (or to take a good combination supplement like the MaxiTears Dry Eye Formula) though each case is different and best to check with your provider.

 Can IPL cause loss of lashes? Lash loss is a frustrating problem that can have a complex list of causes. One of the most common causes is also one of the most common indications for RF - which is blepharitis (inflammation and irritation of the lids and lid margins, including the lashes and lash follicles). Lashes grow in a cycle that can take about 6 weeks from falling out to fully return, under ideal circumstances. Inflammation can interrupt this cycle. When we use IPL to treat blepharitis and related dry eye issues, we typically use a wavelength best suited (590nm). While this wavelength can temporarily affect the lash cycle, it commonly takes a wavelength closer to 755nm to more permanently affect or damage the lash follicle - so “permanent hair removal” would target that 755 wavelength. Some IPL machines have a broad band of light that could include a higher wavelength that could damage lash follicles, but the majority of dry eye specialists (myself included) use Lumenis’ technology (M22 or Optilight units), which can selectively target the lower 560-590 range for dry eye treatments that was FDA approved for this purpose. We also don’t aim the light directly over the lashes, so permanent loss of lashes is rare. 

 How long does it take for IPL to work? (1), it is not for everyone (can't treat skin of darker color), (2), it rarely has lasting or significant benefit before the 3rd to 4th treatment - so generally needs to be prescribed as a series of 4 treatments, (3), it requires maintenance treatments which varies depending on the patient. Those with larger numbers of blood vessels near the surface of the skin (which bring inflammation to the lids and eyes), those with more sensitive skin, those with more advanced degrees of dryness, those who don't do their "homework" (generally not taking good oils, not keeping lids and lashes clean, don't do good blinks or hot compresses) and those with "bad" genes (innately programmed to progress towards inflammation and dry eyes) may all need more treatments up front and more frequent maintenance. Most need 1 treatment every 6-12 months (some more and rarely less). As also stated above, the type of machine used along with the protocols and skills of the treating physician will also play a role (not all machines are equal). I find IPL a very effective tool (among others) for treating dry eye, rosacea and a variety of cosmetic and medical skin problems. The best treatment can only come from having a good exam and doing the "homework" the doctor prescribes.

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.

(not so) Secret Weapon of Dry Eye Treatment: Intense Pulsed Light, or IPL

Segment 10 C

Secret Weapon of Dry Eye Treatment: Intense Pulsed Light, or IPL

One treatment that can help to both reduce inflammation and improve oil glands is Intense Pulsed Light, or IPL. Originally designed, and subsequently FDA-approved to even-out complexions, remove unwanted hair and stimulate repair of older or sun-damaged skin, it was often used for years “off label” to treat dry eye disease. “Off label” means a technology was never investigated, nor approved, as a treatment for a specific disease (but does not necessarily mean it is ineffective in such treatment – just not approved as it has not been investigated by that agency). IPL for dry eye usually requires four (or more) sequential treatments and is not commonly covered by insurance companies due to the off label nature of this use. Late in 2021, the FDA approved IPL as safe and effective treatment for dry eye disease - so the secret is out! (Even though many dry eye specialists have known this for many years).

IPL appears to benefit dry eyes through several pathways. First, it can close the red, angry blood vessels in the lids that are carrying inflammation to the eyes. This is kind of like stopping the army before it leaves the gate, so it never gets to the eye. This may mean less need for drops to deal with inflammation, since inflammation doesn’t make it to the eye in the first place.

It also heats the oil, so some glands can express their blockages with a squeeze after the treatment. Most often this requires the doctor to express the oils using a squeezing force under direct visualization using a microscope and certain tools. If the oil is truly like wax, then IPL may not heat enough to fully melt it and a stronger heat source may be required. For some, this may require some combination of deeper heat and expression, like on-label use of Lipiflow, ilux, SightScience’s TearCare or the off label use of other heating tools, like radio frequency (something I have researched extensively and have several published studies showing its usefulness in treating problems ranging from clogged glands to ironing loose membranes and loose skin). These treatments can be combined with a series of IPL treatments, but also are not commonly covered by insurance as they view this as more of a “spa treatment,” involving “only ”heat and massage.”

IPL treatments take out a layer of the unwanted blood vessels with every treatment. Staggered every 3 to 6 weeks, the surface vessels have time to clear - and expose the next, deeper layer for the next treatment. I see this like pruning a tree, where the top twigs give way to small branches, then we take out the bigger branches and finally get to the trunk. We stop at the “stump,” as the deeper, root-level is where the good vessels live and we don’t want to take those away.

Eventually some branches sprout from the stump, so IPL requires regular maintenance treatments, but IPL can have many benefits when used regularly, too.

What else can IPL do?  

As mentioned above, Intense Pulsed Light was originally designed to even-out complexions, reduce unwanted hair and stimulate skin into making better, younger looking skin - so it has earned its place in cosmetic skin care. IPL has been shown to help with acne, probably by mechanisms somewhat similar to what helps eyelid oil glands to make better tears.

Not only does it close angry blood vessels, but it also kills germs (as well as a common mite called Demodex) that commonly cause acne and otherwise aggravate oil glands.

IPL also appears to directly stimulate the cells making your tears.  It appears to give a “kick in the pants“ to the cells that make tear products, including water and oil. We call this “bio-stimulation” through “photo-bio-modulation.“ It seems the cellular furnaces making the energy for each cell are revved-up by the heat and light from IPL - so the cells can work better.

Unfortunately IPL is not for everybody, as those with the darkest skin have pigment (called melanin) that gets in the way of the light and prevents it from targeting the deeper blood vessels. As the pigment absorbs the heat from the strong light, too much can cause burning and damage to the surface of the skin. Those with medium pigment, who tan, should avoid tanning so as to help the light penetrate deeper and work better. Feel free to check with your eye care provider to see if you may be a candidate for IPL.

Segment 10 B - When we are at war with ourselves.

Segment 10 B

Dry Eye can mean - We are at war with ourselves.

I like to think of degrees of inflammation a bit like degrees of battle, ranging from the lowest level of an occasional sniper, up to the highest level of all out war between two strong armies – think of megaton bombs and flamethrowers going back and forth.

Dealing with inflammation means matching the level of retaliation with the degree of conflict. It doesn’t take much to stop a sniper, but it takes a lot to stop the attack of a strong army. The strongest eye-drop treatments come from the steroids, which vary from weaker, surface-active products like dilute Fluoromethalone (or FML) or Loteprednol (Inveltys, Eysuvis, Alrex or Lotemax) up to concentrated, prednisone-like products like Pred Forte (Prednisolone Acetate) or Durezol (difluprednate) and Dexamethasone.

These stronger drops can penetrate deeply and work quickly. Side effects are predictable and the strongest medicines can have strong negatives as well as positives. The longer and stronger we treat, the greater chance that our surface immune system can get so weak, it won’t help us when we need it and an infection can result.

Most strong (and some weaker) steroids can penetrate the eye and may eventually raise eye pressure, stirring up glaucoma or clouding the lens in our eye, causing cataracts. Though it usually takes weeks to months to see that, we need to remember that dry eye is a chronic disease, so we need medicines that are safe for long-term treatment. It is also true that if we don’t deal with the underlying causes of dry eye (like MGD), then when you stop the steroids, it is common to get what is referred to as “rebound” – where the inflammation can come roaring back.

This is where Cyclosporine and Lifitegrast, along with the biologics like Amnion-based and Autologous Serum-based tears, can shine. All are anti-inflammatory medications approved by the FDA (cyclosporine and ligifitigrast for twice daily use, with biologics more variably prescribed up to hourly), as safe and effective for long-term treatment. Cyclosporine can come in over-filled vials that can allow for convenient (and less expensive) off-label use of more than twice a day use - and though it is relatively weak, when it is used regularly for months to years, the longer it’s used, the better it seems to work. Few will find relief before two-to-three months, but we can often jumpstart that benefit with a few weeks of topical steroids. Lifitegrast comes in less filled vials, but rarely needs to be used more than twice daily and can offer relief a bit quicker than Cyclosporine. It is thicker, stickier and may leave more of a “chemical taste” in the back of the throat. These two different products work on different arms of immune system, so some patients may do best on a combination of the two. I find the greatest need for these topical anti-inflammatories in patients with red eyes and low “sprinkler system” output. The biologics are more of a “bandaid” offering more complete tear-like compositions that are also mildly anti-inflammatory and can be combined with any other anti-inflammatory treatments). Once started, many will be on these drops forever, so my general approach is to fix the oil glands and blepharitis, first. If better oil and less germ-related information is enough to reduce the redness and boost the sprinklers, then anti-inflammatory drops may not be needed (or can be used more sparingly).

In my next post, I will focus on other, non-eye-drop-related means for reducing inflammation.

Segment 10 A - What we know about inflammation…

Segment 10 A

What we know about inflammation - and what to do if you already have too much inflammation. 

Apart from avoiding inflammation - by eating healthy, taking anti-inflammatory supplements like Omega Oils 3-6-9 and by keeping eyelids free of harmful levels of germs, there are also more prescriptive ways to help, too. The glands making our tears are very sensitive to inflammation and too much of it will first shut them down - and then it will damage them.

Water-producing glands appear to be especially sensitive, and when dry eye doctors measure your volume, most of a healthy tear is water - so low volume means we have Aqueous Tear Dysfunction or ATD (and inflammation can aggravate MGD or Meibomian Gland Dysfunction, too).

To make more water, we usually need to drink more water, as well as to reduce water loss from things like caffeine, alcohol and other so-called “diuretics.”  We also can help by reducing inflammation with prescriptive eye-drops and certain treatments.

Anti-inflammatory prescriptive drops include those in the USA, containing cyclosporine as is commonly found in Restasis, Cequa, and Klarity-C. Another, newer class is Lifitegrast, found in Novartis’ (formerly Shire’s) name brand product called Xiidra. So far, we don’t have good studies comparing one drop to another, but each product has unique properties that may give them an edge over the other for certain patients. What they share in common is the ability to reduce some of the inflammation related to - and commonly causing - dry eye disease (remember the “vicious cycle”).

Another class of anti-inflammatory, prescriptive drops, include the “biological” drops utilizing human or human-like products. These include Amnion fluid-derived products (Regener-Eyes and StimulEyes are two), where amnionic fluid (the fluid around a human baby while in the mother’s womb, taken safely at delivery and processed carefully to exclude any transmissible diseases) is then mixed with artificial tears in various concentrations and applied as a prescriptive eye drop. Because these products contain some of the natural, supportive products that keep a baby healthy as it grows in the womb, these can offer similar benefits that also fight inflammation. Another version of this inflammatory biology is called Autologous Serum Tears, (ASTs) which involves taking blood from the dry eye patient, spinning it down to collect the clear fluid (serum in most cases, or platelet-rich-plasma in others) and mixing it with artificial tears (Vital Tears among other companies can help produce these). My clinical experience is that while both are biologic "tear" preparations, the processing that makes amnionic fluids a non-infectious product also negates some of the biologic activity and then they dilute it (in the case of Regener-Eyes, a bit for the Pro and a lot for the Lite), so the end product is a bit better than a standard Over-The-Counter Artificial Tear product. Because ASTs (like Vital Tears) can be concentrated to a customizable level (20-100%) and because it contains what the blood would contain of the patient's own biologic products (Nerve Growth Factor, Epidermal Growth Factor, etc), it is - in my patient base - a stronger and more meaningful product for most. The bigger benefits of the amnion products is the obvious - no need for blood drawing and - depending on the concentration and frequency of application - sometimes lower cost. The obvious problem with the Autologous Serum Tears, apart from cost and blood drawing - is that if a patient has "bad blood" (ie advanced autoimmune, or medications/infections that contribute to poor health) - their blood may be less "helpful". Certain Amnionic Membrane products (either frozen or freeze-dried) can “melt” some of the anti-inflammatory proteins and related substances into the tears as they dissolve, so can be thought of as a biologic contact lens that can function as a higher level of amnionic fluid and these are often used as a “jump start” for severely weakened surfaces of the eye and eye membranes. My primary goal is to help my patients make more of their own "good" tears - so that they can be less dependent (or completely independent) on these other products - but they do have an important place in helping some dry eye-damaged surfaces recover.

Going back to my analogy of the immune system mounting warfare against irritation caused by dryness, we can understand some of the fallout from this artillery fire could cause inadvertent damage to the delicate tear glands. In my next post, I will cover some of my protocols for using these anti-inflammatory tools.

More on Germs

Segment 9

How much are our Meibomian Glands like our teeth?

Quite a bit it turns out! Remember that germs like food as much as we like food and since we put food in our mouths, they hang out there and on our teeth. To make a favorable footing to thrive there, they create plaque - a sticky biofilm. More plaque allows more germs and then more damage to our teeth and gums. Well, germs on our lids make plaque too, just like those on our teeth. They damage our lids, lashes and the glands making our tears. Just like we go to the dentist and get our teeth cleaned, we now can go to the dry specialist and get our lids and lash’s cleaned of plaque. Several systems now exist to do this. At eyeThera we favor BlephEx (I like a hybrid “Zest” treatment with ZocuShield gel.) This video will help explain more about the standard BlephEx treatment:

NOTE this is a short video I did using a thermaShield to do a BlephEx lid hygiene treatment on a patient who had a previous BlephEx treatment without the shield. As I do the treatment, I ask him for his feedback and allow you to see the treatment as it unfolds. The actual treatment time is around 5 minutes longer (fully treating all 4 eyelids), so I’ve shortened the video to show the highlights. Following these upper and lower lid treatments, there is an animated video by the BlephEx company that helps to explain why we recommend this treatment - and what it is meant to accomplish for our dry eye patients.
I should note that the shield shown in the first video is a shield that I helped design - specifically for this problem (and for a radio frequency treatment over lids that I will discuss in a future posting), where it helps to keep much of the soapy solution out of direct contact with the eyeball. At the same time, it provides a better platform for the hygienist to more actively clean the lid margin’s and to help the patient relax and not squeeze in a way that would prevent a good treatment .
The second video does a great job of explaining the blepharitis problem and the nature of the treatment - but would make you believe that this simple treatment fixes everything - and that is only partially and generally true. It is a great starting point for treating blepharitis, which is almost universal among dry suffers, but just like a dentist cleans and examines your teeth - sometimes more is required. For instance, if you have cavities or broken teeth, then that gets fixed too. The Dentist also sends you home after your cleaning with instructions to floss, brush and gently care for your teeth with what would be called good “dental hygiene.“ Well at eyeThera we promote “lid hygiene “ using products like Avenova, a dilute form of pure hypochlorous acid as well as Okra (as ZocuWipes) or Tea-tree-oil-based products like BioTissue’s Cliradex, as well as the more mild, foaming face wash made by eyeeco, with natural botanical cleansers and a small percent of tea tree oil. (More on these specific products and my protocols in the next segment!)

Dealing With Germs

Segment 8

Dealing with germs

CoVid19 has made us all hyper-aware of germs, but even before this novel coronavirus came along humans have been dealing with all kinds of germs for as long as we’ve existed on this planet. Recalling that tears are food and that germs are always looking for a free meal, it isn’t too surprising to discover that germs live around our lids and lashes and subsist on our tear oils and other tear products. When our oil glands are working their best our natural antibodies come through in our oils and deter most terms from multiplying to levels that can hurt us. But as the glands slow down and become dysfunctional, the oil stagnates and becomes a “buffet table“ for these germs to graze on. This leads to more tears for them and less for us, but then the byproducts of their digestion pollute our tears and lead to inflammation - our body’s response to irritation and the sense that germs are attacking us. Inflammation is our body’s defense system and is indiscriminate in its war on germs - at the high cost of hurting the glands that make all of our tear components leading to Dry Eye. More inflammation leads to evermore dryness, irritation and then inflammation - the so-called vicious cycle of dry eye. A common approach to inflammation is to prescribe anti-inflammatory products like Cyclosporine, Lifitegrast or steroid drops - but unless you also target the underlying, “root cause” of the inflammation (in this case, germs and related dryness), then the end result is “kicking the can down the road,” where the medication “covers up” the problem without effectively dealing with it. In this situation, it becomes necessary to add more anti-inflammatory medications as the germs continue to proliferate and stimulate our body’s defenses into an ongoing vicious cycle. It also explains why, as you wean off these medications, the relief they gave becomes incomplete - and eventually, all too temporary.

In my next post, I’ll concentrate on effective at-home care that can help us control the germs and limit the inflammation they provoke. Future posts will continue to explain how I generally deal with this problem using targeted, in-office treatments and additional home care strategies. One of the biggest problems we all face, is that we are all, as a general rule, living longer lives - and that as long as we live, we generally use our eyes more, too. This makes it clear that we need to take care of our eyes every day. I find the dental analogy works here for most. We tend to our teeth so they can last as long as we do. Brushing, flossing and regular trips to the dentist helps us stay ahead of the dental damage and decay that could rob us of of our pearly smile. The problem with our eyes is similar, except that we don’t have good “dentures” to replace our eyes if we fail them in our care. Germs are a big part of the dental problem and can be just as bad for our lids, tears - and therefore, our eyes, too. Stay tuned!

“You Are What You Eat”

Segment 7A

General guidelines for oil - or - back to “you are what you eat”

Unplugging the oil glands is an obvious first step. Because most of us are not going back to the 1000’s-year-old diet of fish, nuts and seeds, I recommend daily omega-3, 6 & 9 oil supplements. MedOp made the MaxiTear Dry Eye supplement we’ve recommended for years, but this company was bought out and their standard formula has been hard to come by. I found an Amazon supplier at: https://www.amazon.com/MaxiTears%C2%AE-Dry-Eye-Formula-Bottle/dp/B09HLB84J4/ref=sr_1_5?gclid=Cj0KCQiAlMCOBhCZARIsANLid6YqUk-u5sQ7owunUjT94xuw17HHaUY1xE_v_Uymxwbxz6yCD_D97VgaAo9PEALw_wcB&hvadid=177778061232&hvdev=c&hvlocphy=9002432&hvnetw=g&hvqmt=e&hvrand=15494291267728129816&hvtargid=kwd-14757575736&hydadcr=21222_9690766&keywords=maxitears+dry+eye+formula&qid=1641090704&sr=8-5

I like it because it offers an ideal blend of these oils, mixed with the principal protein in a healthy tear, called mucin. They also have included curcumin, which is an active anti-inflammatory component found in Tumeric and the capsules are small enough to be easily swallowed. They’re also covered in a special enteric coating designed to dissolve once a capsule gets through your stomach. This allows optimal digestion without having fishy aftertaste burps as can be common with many gelatin covered capsules.

Segment 7B

Do you have any digestion issues?

Some people may have a hard time digesting fats and oils. These are most commonly folks who have had gallbladder surgery or a history of gallstones, though others may have Gluten issues or other gut inflammation diseases. In order to get the most out of oil supplements and to resume enjoying the occasional fatty meals, there are supplements designed to deliver natural gallbladder products that can aid in the digestion of these oil‘s. eyeThera found an ideal such product in a simple to take capsule from the AST company, called Lipase HP Plus, to help optimize absorption of your oil supplements. They can be purchased directly from their company at:

https://astenzymes.com/product/lipase-hp-plus/

If you have a healthy gallbladder and no problems with digestion, then you can take four of the Maxi Tears capsules with breakfast every morning. If you don’t have your gallbladder, or if you’re experiencing difficulty tolerating fats or greasy foods, then you can try taking one capsule with Breakfast, another with lunch, a third with supper and a fourth with a snack at bedtime - or

- take your 4 eyeThera Capsules 15 minutes after taking one or two AST capsules with breakfast 

- or you can take two oil capsules with one AST capsule at breakfast and two capsules with another AST capsule at supper time. Some experimentation may be necessary if you find difficulty taking these capsules, but without a steady intake of these essential oils, it is less likely you can solve your dry eye issues. It is also recommended that you consult with your primary care provider or dietary specialist for optimizing your Omega Oil intake. It is possible to measure blood levels in those patients who continue to struggle, in order to confirm if they are achieving optimal blood levels with their supplement and diet programs.

You’re still encouraged to eat fish, nuts and seeds - and if you regularly eat all of this, then you may be okay taking fewer omega oil supplements (or even none if your diet is perfect) - but if you’re trying to dig out of an MGD-related dry eye problem, then you need an “oil change” and may need all the dietary (and supplement) help you can get.

How Do We Fix The Oil Problem?

Segment 6

How do we fix the oil problem?

Before eating good oil, or doing good blinks, or even adopting a lifestyle geared to supporting the oil glands can otherwise be counted on to help - it is important to determine how blocked and dysfunctional the glands have become and what other issues may be contributing to dry eyes. For instance, certain medications and over-the-counter products can inhibit the glands - especially the so-called retinoids often marketed to treat acne and reverse skin aging. This brings us back to a good exam by a dry specialist.

If the glands have become inactive through poor diet and poor blinks, the oils tend to thicken into products that - by degree - look like buttermilk and then butter, lard and finally like candle wax. Once the oil becomes waxy, then this acts like a ”cork in the bottle” blocking the glands from working at all. Just as heat thins oil, or even wax if it gets hot enough - most modern treatments for these obstructions (called obstructive MGD) involve heat. At home, special devices have been developed for this purpose. In-office treatments involve more deeply applied, higher levels of heating than can be safely done at home. Heating is followed by degrees of squeezing or expression, to chase these now liquid waxes out of the glands. The FDA has approved many devices for this purpose, including Lipiflow, iLlux, Sight Science’s TearCare, and most recently Intense Pulsed Light or IPL.

Off-label treatments include devices not yet studied or approved by the FDA for this particular purpose - but are approved by the FDA for other uses. This would include treatments like Radio Frequency or RF. - approved to help reduce fine lines and wrinkles in skin - but also great for melting these waxy oils and aiding in their expression. RF can be used for many surgical applications, including ironing out the loose folds and wrinkles in a membrane (called the conjunctiva) lining the white part of the eye and inner parts of the eyelids (commonly called conjunctivochalasis, conjunctival chalasis or CCH). I’ve helped pioneer RF for these application and have published several studies showing its value. There will be more on these applications in subsequent blog postings - including the use of the thermaShields that I helped develop, which eyeThera (a company I am a part owner of) produces and which I routinely use in my dry eye practice. Now that others have discovered the benefits of using RF for treating dry eye disease, there are increasing numbers of practices offering this novel technology for this off-label application. What’s recommended for you will depend on what your specialist finds, which forms of heated expression and/or smoothing out and reattaching the loose membrane (CCH) they offer and what they feel will be most effective for your case.

How Do We Know If We Have Dry Eye Disease?

Segment 5

The components and importance of a good DRY EYE EXAM.

How does my doctor determine the health of these tear/oil glands? Symptoms of dry eye cause the dry eye specialist to look harder than most and they 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 dry eye specialists 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 or careful magnified exams can help us see and/or image how patients blink, so we can see how well - or, more commonly, how poorly the lids come together and then to see and/or 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 Lab 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.

How Important is Oil to Our Tears?

Segment 4

The importance of oil.

It’s easy to understand one reason why oil is so important to our tears and why it’s been found that as much as 85% of all Dry Eye can relate to dysfunction of these oil glands. This goes back to the fact that water and oil don’t mix - as oil will always “float” on the surface of water. This creates the “liquid plastic wrap” or sealant effect that keeps the water (and its salts and proteins) locked onto the surface of your eye. The lack of oil causes the evaporation or “evaporative dry eye” we discussed in the earlier segment. As I also mentioned earlier, this is called Meibomian Gland Dysfunction or MGD.

But tear oil serves other important functions.

• It serves as good food for living cells.

• It contains our natural antibodies that inhibit germs from eating the oil.

• It’s a great lubricant, so eyelids freely and easily move over the surface of your eyes.

  To make good oil there are several key things you need to know.

• - First it takes good oil to make good oil -
  - the best building blocks in our diet are the Omega‘s 3, 6 and 9. These oils are found, in different degrees, in foods and supplements containing fish, nuts and seeds. The best fish are small, oily fish like sardines, anchovies, herring and wild caught salmon, as the bigger ones like tuna have eaten many smaller fish which causes them to concentrate the pollutants and toxins like lead, mercury cadmium and PCBs in their oil. Nuts would be tree nuts - not peanuts which are legumes like peas and not true nuts. This would include cashews, almonds, walnuts and pecans. Seeds include flax, chia and hemp, pumpkin and sunflower as well as sesame, caraway and black currant seeds. For most of us this is the diet of 1000’s of years ago, since most of us now eat corn and soy derived meats, as well as processed foods like pizza and pasta. These Carb-rich foods can facilitate the inflammatory pathways akin to putting gasoline on a fire and scientists point out that in the last 100 years we Americans now eat 95 times less of these good oils - even as we use our eyes so many times more than we did in our grandparents times.

• Second, oil glands are little accordion-like structures in our eyelids and only work when squeezed– so it takes good blinks to make good oils. This may sound a bit crazy, but watch a child as they interact with digital devices and you can quickly understand why the average age of onset of Dry Eye suffers appears to be steadily shifting from older to younger people. The problem with this digital era is that it encourages us to stare, which is the act of not blinking. The more staring the less blinking and when you finally blink, instead of big strong blinks, we are prone to fast, weaker blinks - so we don’t miss anything! Cell phones, computers, notepads, TV, games - even driving and reading can all teach us poor blink habits. Thinking of the cow’s udder - if we milk a cow regularly it keeps giving good milk but stop milking it and that udder dries up. That is what’s happening to our glands too!!
  

Overly Salty Tears

Segment 3

Too much salt in the salad dressing.

While the recipe of the salad dressing is critically important - just like the recipe of our blood is to our body - the more common problems relating to dry eye come from

#1: too little oil - or to less healthy oil - also called Meibomian Gland Dysfunction or MGD and

#2: too little water, also known as Aqueous Tear Deficiency or ATD.

Less common is a lack of protein but very common is the excess of salt which is rarely related to your dietary salt intake - but most commonly affected by too little water to dilute it. The lack of water can occur for many reasons, not the least of which may come from not drinking or retaining enough water in your diet. However most happens from evaporation - when the warm water of our tears evaporates into the dry air around us because of insufficient oil floating on top. This leads to what is called evaporative dry eye due to MGD - the leading cause of all dry eye.

As the water leaves, the salts and proteins remain, gradually concentrating the dry spots left when the water evaporates. These dry patches are like little open sores on the surface of the eye - and the concentrated salts get rubbed into the sores with blinking. This leads to the burning, scratching and then reflex tearing - as the fire hose turns on - to wash the excess salts away.

This is also why many people with Dry Eye will complain of the opposite symptom - as in tearing, but remember that saltwater is not a great substitute for salad dressing and this tearing tends to create more burning and stinging, which leads to more irritation and more tearing.

This cycle of recurring open sores on the surface of the eye and the concentrated salts getting rubbed into the sores - with further evaporation and blinking - leading to yet more burning, scratching and then reflex tearing - results in increasing inflammation (your body’s response to irritation) and the vicious cycle of evaporative dry eye disease. When the salts and proteins concentrate and combine, we can get stringy strands or white mattering on the lids and lashes (from excess proteins and salts left when the water leaves from evaporation). And all because you need an oil change!

Why Tears Are Important

Segment 2

Why are tears important? Perhaps we should ask - why should we even worry about our tears?

Well, first we need to remember that the surface of our eyes is covered in a sheet of living cells and like every living part of our body these cells need support - things like water, food, oxygen and protection. Every living cell in our body can generally get this from blood, but if we had blood over our eyes we would have a hard time to see - so instead of blood we have tears - which means that tears need to be as complex as blood, but without the red cells that would get in the way of our vision.

Moisture is job number one and tears are so important that we have two ways to make tears - what I like to call a sprinkler system and a firehose. The firehose makes a saltwater tear that is good for flushing a loose eyelash out of our eye or helping us with our emotions - but being mostly salt and water it isn’t much like blood, so we should think of it more like an emergency back up system. The best tear comes from our sprinkler system made of many cells and glands that together make the best tears from water, salt, protein and oil - think salad dressing - and like salad dressing the water and oil don’t mix - with oil floating on the surface. Either system can wet our eyes, but only the salad dressing of the sprinkler system has all the good stuff to keep our eyes happy and healthy.

Introduction To Dry Eye Disease

Hi, I’m Dr. Edward Jaccoma - a “Dry Eye Guy”. I’m also a board-certified Ophthalmologist or “Eye MD,” with over 30 years of experience in dry eye and related eye care. In the following segments I’m going to address issues common to diagnosing and fixing most dry and related eye surface diseases. These segments include videos and diagrams simplifying what are often complex medical problems and are not designed to replace the care from your eye doctor.

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It’s estimated over 40 million Americans have this common disease and if you have any doubt if you may have dry eye, then this could be a simple test to see if you might have it.

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Blink Test

For the next 20 seconds, starting on my cue, you should try to stare - without blinking - to see how you will feel, but first I want you to set a 20 second timer and then blink two times. So it will be 2 blinks and then start your timer and no blinking for the 20 seconds the clock will measure for you.

Ready, 2 blinks and Go! (20 seconds).

Ok, blink all you want but remember how your eyes feel now or at anytime over the last 20 seconds.

• Any sense of stinging, burning or scratchiness?

• Sensitivity to light?

• Watering?

• Blurry vision?

  —- Are you now or commonly finding:

• Strings of eye mucous?

• A sense of eye fatigue?

• Redness of the eye whites?

If you’re not sure - then even if you don’t have it now, there’s a good chance that somewhere in your lifetime you will - because this is a common, chronic and progressive disease. If you think - or know - that you or someone you’re close to has dry disease, then I’ve got more information to share in the following segments.