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.

What can a good first step in lid hygiene look like?

Time and technology moves us ahead!
While i’ve previously posted on my preferred lid hygiene protocol, (See my post “More on Germs” from Feb 28) I now have a video of my ZEST-modified BlephEx treatment for removing the “plaque” (or biofilm) that let’s germs “camp out” and “eat your tears.” As I often state to my patients, this “germy plaque” means “more tears for them and less for you,” but then there is the added insult of how the “byproducts of the germ’s digestion” now pollutes your tears and convinces your eyes they are infected - even if they are not. This leads to irritation and higher levels of inflammation, as your immune system sends in all your “napalm, hand-grenades and bazookas” that are in your immune artillery - damaging your tiny tear glands and causing ever increasing degrees of dryness. To watch this video - click the link at the end of this post.

The beauty of adding the ZEST part, is that the Okra-based botanical cleaner is similar to the Zocuwipe I recommend in lid hygiene “homework.” This product has great cleaning properties, while also being non-toxic to your eyes and adding an extra degree of numbing (as a natural anesthetic). The shield protects your eye from the tip of the BlephEx device as well protecting from the “slurry” of soapy cleaning debris - even as it adds control over the natural instinct to close your lids tightly (which would make it hard to access your lid margins) so the cleaner/lid hygienist can do a great job by simply tipping the shield and exposing your lid where it needs to be clean. It also helps shield you from seeing the tip as it does the work. The Zocugel-part of the ZEST cleaning leaves a natural botanical oil in place of the “tasty” human oils that germs would prefer to feast on. The high speed “Dremel-like” tip of the BlephEx tool can then effectively burnish the plaque and germs off the lids and lashes. I see this as the optimal dental cleaning “preamble” to your doing effective “homework” to keep your lids and tears clean and your eyes healthy. Zest and thermaLid-modified BlephEx treatment

“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.

The “2-Ps” - Pingecula and Pterygium - and Dry Eye Disease…

Do you have a pinguecula? If you are beyond your teenage years and have spent any time outdoors in the sun and the wind without a good pair of sunglasses, then there is an excellent chance that you do (this condition is frequently called “Surfer’s eye” since surfers obviously spend a lot of time in the wind and sun, but anyone can get this without having to surf). If you have dry eyes, then this is certain to make this problem worse. I’ll paste a link to pictures and information from the American Academy of Ophthalmology regarding this common problem at the end of this posting, but will give you my “street version” generated from over 30 years of clinical experience, first. 

The sun’s UltraViolet Light (UV) will damage skin that can lead to premature aging - causing  fine lines, wrinkles and even deeper furrows - along with an increased risk of skin cancers - on your face (or anywhere else the sun can shine). The same UV will also lead to damage of the smooth, clear, moist membrane over the white part of your eye, called the conjunctiva. A scar-like repair follows, that deposits proteins, fats (the yellow) and sometimes calcium (like in bones and teeth). As this yellowish “bump” or lump appears, it behaves like a small island, sticking up out of the pool of tears which otherwise moisten and support this membrane. This yellowish lump or bump on the white of an eye is called a pingegula - and by itself, is of little consequence unless it becomes dry, irritated, inflamed (red) or grows very big (see below). Think of it as more of a “red flag” to call attention to sun damage and dry eye disease - since both are common causes that can do more harm than “just a little yellow spot,” visible on the white of the eye.

Poor tear volume, poor tear quality (especially poor oil - so less lubrication and greater evaporation) - or - common to many dry eye patients- both problems - will contribute to further damage and promote increasingly active, scar-like repair. As the “scar” increases, it tends to grow into the cornea (the clear, front part of the eye). At this point, it is called a pterygium and with continuing growth, it can cause increasing irritation and even eventually jeopardize vision.  While surgery is an option at any stage, it becomes increasingly necessary as the pterygium threatens to cover the pupil (where light enters the eye), potentially blocking light from coming in - but even when not directly in the path of light - it can disturb the light by bending the light rays like a prism and creating a “circus mirror-like effect,” called astigmatism..

Unfortunately, healing with bad tears and dry eyes will usually promote more scarring, leading to a potential recurrence of the pterygium. Further surgery begets more white scarring and can lead to permanent damage to the otherwise clear cornea. Prevention is key to avoiding the larger lumps that can be very obvious to the naked eye observer, even if they don’t impair the vision of the affected eye. This means wearing quality sunglasses outdoors - but also means taking care of dry eye disease. Artificial tears, topical steroids and other anti-inflammatories (like Restates and Xiidra) may be prescribed by an eye doctor to treat an irritated pinguecula or growing pterygium, but unless coupled with sunglass protection while targeting whatever is wrong with the cells and glands making tears, this can be another case of “kicking the can down the road” - where the basic problem(s) causing the pingecula or pterygium are not being addressed.

Before cataract surgery, it is necessary to get a “good read” on the curvature of the cornea. This is because the cornea provides 2/3 of the focusing power of the eye - so the lens implant replacing a cataract has to be the “fine tuning;” providing the final 1/3 power required for optimal focusing and for the best vision independent of glasses after cataract surgery. If any irregularity of the cornea’s surface - such as a pterygium - can change its size and shape over time (like a pterygium), then dealing with that before cataract surgery can have a big impact on determining the best implant power for the future vision correction. Dry eyes can cause an irregular surface, too (from dry, irregular, dead and dying cells on the corneal surface). THIS VISION CAN LITERALLY CHANGE WITH EVERY BLINK - so dry eyes commonly can cause intermittent, blurry vision - but also make it hard to get a good read on the corneal surface (or even to get a good refraction for glasses). Combining a dry eye with a pterygium is a type of “double whammy” where dryness can aggravate the pterygium - but also cause its own unique issues with vision and cataract surgery. All the more reason to consult a dry eye specialist when you are found to have either of the two P’s - or dry eye disease!

https://www.aao.org/eye-health/diseases/pinguecula-pterygium

Special cases for healing the eye’s surface - Part 2: Map-Dot-Fingerprint Corneal Dystrophy (MDF).

Map-Dot-Fingerprint Corneal Dystrophy (MDF) is a specialized version of Recurrent Corneal Erosion (see my last post on RCE). Unlike RCE, no deep scratch is required to set up the cornea for these open sores, because MDF is a genetic disorder that causes patches of “poor topsoil,” so the “turf” of cells growing on the corneal surface have poor “root systems” to otherwise help them stick on. Like RCE, patients suffer from these open sores worst if they have poor tears and similarly are often aware of the sores when they first open their eyes in the morning. This is because the “rocky” topsoil tends to elevate the epithelial (turf-like) cells above the normally smooth surface and the eyelids tend to “stick” to these elevated “islands” of cells – so the friction of opening lids can tear these cells loose and cause sudden open sores (like RCE).

When there are elevations of small islands, they look like “Dots” when discrete, but when they form whorl-like patterns, they can mimic a “Fingerprint” or even the continent of a country “Map.” It commonly requires special dyes and special lighting at a slit lamp (the clinical microscope used in a detailed eye exam) to see them, as they will displace the dye - like an island “sticking up out of the ocean” (of tears). Many MDF dry eye patients have patchy affected areas and if they are small and not in the center of the cornea, they may cause little-to-no trouble. Bigger trouble comes from larger patches – especially if they are centrally located. These areas can act like a “wet rug,” where whole areas can slip and slide with blinking, until they “break open” and cause sudden pain. Affected eyes can cause blurry vision from the shifting irregularities of this surface and can cause light sensitivity from glare and tearing from tortured corneal nerves reacting to these open sores.

For eyes who have this genetic problem causing recurrent erosions or are centrally (visually) affected - especially if anticipating cataract surgery with centrally affected corneas, it is common to require scraping the “turf” and “poor topsoil” away to allow better, smoother resurfacing from healing. We covered the various ways to help smooth the “topsoil” out and promote a good “root system” in the last (RCE) post. The reason to apply this to centrally affected corneas – especially before cataract surgery – is because good readings of the corneal surface are critical to determining the type and power of the implants used to focus the eye after cataract surgery (and permanently placed at the time of that cataract surgery). A wrong reading can translate to a wrong implant and a need for thicker glasses after the surgery (to make up for the poor focus from a wrong implant). We will cover this issue in greater detail when we cover Salzman’s Nodular Corneal Dystrophy and pterygium as they relate to cataract surgery.

With great tears and smaller affected areas of MDF, most patients will never know they even have this problem. This is because they have the lubrication and support to help even weak roots “hang on” and create a smoother, more rugged surface. “Bad tears” – especially combined with larger patches of weaker-rooted surface cells, tend to have the worst problems. Better support (as in the best tears) always seems to heal these problems better and faster, so it pays to have a dry eye specialist assist when you have a problem like MDF Corneal Dystrophy.

Special cases for healing the eye’s surface - Part 1: Recurrent Corneal Erosions (RCE).

Sometimes there are special situations that require special techniques or technologies to heal them. I’ll focus on a few, relatively common ones, starting with RCE, this week.

-       Recurrent Corneal Erosions (or RCE).

When a cornea becomes relatively deeply injured (sometimes from something as otherwise innocuous as a baby’s fingernail), there can be times where the scratch – once healed, tends to “re-scratch” without an apparent cause. We call this “Recurrent Corneal Erosion” (or RCE). There tends to be a couple of common threads to this problem.

o   First, the “Turf.” The very surface of your cornea (the clear “window” for your sight) is covered in thin, clear cells. These cells have a kind of “glue” as well as a kind of “root system,” that can be thought of like “turf” (or grass in soil). When you have good grass anchored in good soil, with lots of rain and nutrients, it can be very vigorous, lush and green (think putting green). When it is trying to stick to dry, rocky soil, it tends to be weak, brown and easily disturbed (like my lawn in August). Deep scratches tend to scrape off the “topsoil” and expose the “rocky subsoil.”

o   Second, the “water and fertilizer.” If the support for this surface is the better “Salad Dressing” of the “Sprinkler System Tears,” then even with a deep scratch, the cells may have enough support to get back to their healthy, vigorous state and develop the kind of glue and roots that help them “stick.” But if the tears are too little, or overly diluted with salty “Fire Hose Tears,” (Not enough water and fertilizer), then these cells will tend to be weak, rough and prone to easily rubbing loose and “re-scratching.”

o   Third, proper protection. If the patient with this problem sleeps with their eyes a bit open (the not-uncommon problem we call nocturnal lagophthalmos – see my earlier posting on what I called “Mom’s Eyes” or NL), then there is a tendency to wake up in misery, since the exposure from NL will cause even a healthy surface to get damaged from dryness – and a weaker, loosely stuck surface, to more easily “re-scratch” when the dry lids suddenly open over that weak, delicate surface.

So how to fix RCE? There are lots of techniques, but a common approach is as follows:

-       Once identified by a dry eye or corneal specialist, it is not uncommon to protect by fitting a bandage contact lens – with-or-without an amnionic membrane (amnion may be used to “jumpstart” healing, as detailed in my last posting). This starts the ball rolling by letting the healing cells fill in the scratch without the rubbing of the dry lids, back and forth over the tenuous cells, as they lay down their “glue” to “stick.” If this has happened more than once, it may be necessary to smooth the surface (using a dry sponge that can even out the “subsoil” and remove any loose “glue” from prior attempts at healing). Alternatively, if the defect is not very central, a small, bent needle can lightly “prick” the surface to create little patches of looser “soil” for the cells to get a foothold (the roots go deeper and act a bit like a “thumbtack” to hold onto these tiny divots). In central problems - or those that are very problematic, a laser can be used to “sculpt” the surface in a way that removes the rockiest and roughest subsoil and paves the way for a smoother, better repair.

-       Equally important to giving the cells the right, smooth and proper soil, is to also give them the best tear-support you possibly can. This adds the right “water and fertilizer”to help these cells grow vigorously - and gets us back to my earlier posts on how to make a better tear (and all the options if that tear is still deficient in quantity or quality). It may be necessary to keep a bandage contact over the surface for weeks – or even months (with cleaning or exchanges as needed) – until the deeper “roots” can be established. Sleep masks (or sleep goggles) can be a huge help for those with NL – though something a simple (and cheap) as Press ‘N Seal – or – a lubricating nighttime ointment (for some) can also be useful. While a good repair can take days in children, it can take weeks-to-months in older adults and in severe cases – even with fair support, it may take a year-to-years. Better support (as in the best tears) always seems to heal these problems better and faster, so it pays to have a dry eye specialist assist when you have a problem like RCE.

What to do when the surface of your eye gets “broken” (scratched, operated on, infected or otherwise damaged).

When an eye gets scratched, or operated on, or has a dryness-related - or infection-related problem - that surface has to heal and healing comes from healthy tears and what is otherwise (hopefully) a healthy surface, populated with vigorous cells ready to spread rapidly across the injured area and “mend” it. 

When I was taking care of children’s eyes earlier in my career I noticed how quickly these eyes would heal, commonly overnight - even when the surface had been badly scratched or otherwise injured. This appeared to be in part due to their young age and very vigorous, healthy, reparative cells - as well as their very healthy tears. When I see older adults who have injured eyes - either intentionally from surgery, or accidentally from scratches, other trauma or chemicals, or infections, or even just dryness, then it can take a lot longer to heal and lead to bigger problems like scarring and loss of vision. 

The best option to heal many eye surface injuries is to protect that surface during the healing phases, commonly with what is called a bandage contact lens. These plastic lenses are soft and breathable and applied in the office with the ability to stay in place for weeks at a time - and allow the surface to heal underneath that bandage. Every time you blink or experience normal, dry puffs of air against the eye, this can blow-dry the surface trying to heal, even as tidal waves of tears (good or bad) and blinking-related friction of eyelids going back-and-forth over this rough, tentative surface can constantly erode that surface and prevent the healing. A contact lens can often provide that more stable, smooth surface for best healing. An alternative can be to patch the eye closed, sometimes with an ointment to help in the healing process, at the expense of blocking vision from the patch-closed eye, while the contact lens is clear and can allow vision depending on the extent of the injury. It is also easier to apply medications, if required (often an antibiotic and sometimes a steroid) to speed healing.

When tears have been a problem - as in Dry Eye patients - it is sometimes particularly helpful to apply a biologic membrane called amnion, (either dried membranes or frozen membranes, each of which have been specially treated to prevent a transfer of infectious material between the donor and the patient). The amnion is the membrane around a baby, while in a mothers womb, that holds the amniotic fluid or “water“ that contains many of the nutrients and healing factors that help the baby grow quickly and healthfully in the mothers womb. Once the baby is born, the membranes are no longer needed and would be commonly disposed of - but scientist have figured out how to preserve these membranes in a way where they can either be fixed to a ring and then deep-frozen - or dried out and packaged like a thin wafer. When applied to the eye as a kind of contact lens (Prokera-type amnion membranes are the frozen type, or small portions can be cut out and dried in a way that helps to preserve many of these factors. From my understanding of the science and from my clinical experience, when eyes are badly damaged or have terrible tears, the Prokera type membranes offer more of the healthful, supportive materials to help heal faster and better - but the patient has to put up with the plastic ring supporting this as a contact lens over the eye. The ring supports the membrane against the eye  and retains the membrane until it dissolves. This limits vision (a bit like looking through waxed paper) and can sometimes be a bit uncomfortable. Depending on the kind of injury or infection, regular visits will be scheduled, but always requires a visit within 7 to 10 days to the doctor's office in order to evaluate and usually to remove the ring (as the membrane commonly dissolves over this time). The alternative to a Prokera, is a dissolvable, dried amnion membrane, which is applied under one of the bandage contact lenses. As it dissolves, the vision gradually clears as the bandage-contact-lens takes over and eyes can sometimes go as long as weeks before being reevaluated or having the plastic ones removed - sometimes by the patient - but more frequently by the doctor. 

The universal truth is that tears are the "lifeblood" of the eye's surface - and are necessary for effective healing and support. If the tears are barely supportive, then it is sometimes an injury, infection or surgery that finally uncovers the borderline nature of the tears. The best healing happens with the best tears - so it is often necessary to fix the ability to make good tears, even as we help nurse eye injuries back to health. A contact lens (amnion or otherwise) may help jumpstart healing (amnion being a bit like putting the damaged surface back in the mother's womb), but unless you can make good tears, the surface remains at risk for further damage and poor healing. Since every case is different, it is best to work with a good dry eye specialist to help you.

Avoiding a “Heart Attack” on the surface of your eye…

To avoid giving your eyes a “heart attack,” we need to build up our blinks – not just more frequently, but also more forcefully (remember my January 2nd post on “blinking strong?”).

Because most dry eye disease is linked to clogging of the oil glands making the oil that normally protects against rapid evaporation (allowing as much as 20 seconds or more of staring to not be a problem), and because heat can help relieve this clogging (see earlier posts on this), I like to recommend heated “eyelid crunches.” For most, this is the use of a heat mask designed to deliver around 108-110 degrees Fahrenheit or 42-43 degrees Centigrade of moist heat for 3-5 minutes. During the first 3 minutes, relaxing the lids and letting the heat penetrate, and then for the next 1-2 minutes, forceful (as in conscious but not grimacing) 3-second squeezes of this lids together, followed by relaxing the lids for 3-seconds helps to do several things.

First, the action of a strong blink encourages the oil-producing (Meibomian) glands to deliver their oil – and if that waxy oil is hot, it is more likely to be more liquid and less like wax – so it can move along. This helps to unclog the glands and make room for better, newer oil to follow the old, stale, rancid oils that were “bottled up” behind those clogs.

Second, those eyelid “crunches” help to strengthen the muscles that help you to blink – so future, unconscious blinks are more likely to be stronger blinks. Strong muscles = strong blinks.

Third, this repetitive use of the blinking muscles can encourage “muscle memory” – that unconscious movement that helps tennis players return balls easily, pianists and other musicians play smoothly, and bicyclists keep up a rhythmic pedal stroke. The hope is to get you blinking better throughout your day.

One constant advice for those using digital devices is the 20/20/20 rule. For every 20 minutes of close work, take 20 seconds to look 20 feet or further away. This relaxes the internal, focusing muscles of the eyes that have been straining in a constant state of near focus (unless you’re lucky enough to have a natural near focus that matches the distance of your device, in which case you’re not likely to be straining for your focus because you are “nearsighted” or Myopic). But in those 20 seconds, you should also concentrate on several “good, strong blinks.” Adding regular strong blinks throughout your day (back to my January 2nd post) is another great help in avoiding an “ocular surface Heart Attack.”

Not every patient will benefit from heated eyelid crunches. Some have good oil volume, but may benefit from “better oil,” Others with more inflammation and less obstructive MGD may increase their inflammation (dilating blood vessels that deliver inflammation, which can increase inflammation getting to the eyes) with heat. Ocular Rosacea patients will commonly have both issues (“bad oil” and inflammation). As usual, ask your dry eye specialist if you would benefit from heated “eyelid crunches.”

By the way, Happy “National Sjogren’s Syndrome Day!” Sjogren’s is an autoimmune disease affecting water-producing glands for your tears, for your saliva, for your gut, and for women, for their female wetting. While oil glands have little to do with this problem, they still are a significant part of the dry eye problem. Anything that helps oil, helps dry eyes - and while other attention to the water-piece of a tear can help the Sjogren’s-piece (especially anti-inflammatory medications that fight the autoimmune features of Sjogren’s), it is still important to deal with any oil issues, too. More on Sjogren’s in future postings.

The Ocular “Heart Attack” of a Stare. (And why digital devices can cause these “heart attacks.”)

Why is staring at a screen like giving your eyes a “Heart Attack?”

Staring is the act of not blinking – so any activity that involves intense concentration is likely to induce staring. But sustained staring can be as bad a problem as a heart attack for your eyes!

To understand this, the first thing I point out to my patients is that the surface of your eye is a living surface – covered in living cells. Every living thing needs support and almost every living cell in your body gets that support from blood. Since we can’t see through blood, we have this wonderful thing called tears – basically like clear blood for those living cells that help us see. Fortunately, when our eyes are open, they are exposed to the oxygen in the air they come in contact with, so we don’t need red cells in our bloodstream – but much of the rest of our blood products are in our tears and the best tear is made of water, salt, protein and oil – the “salad dressing” we use for that clear blood-like product we call a tear.

Since tears are literally the “lifeblood” of that surface, then a blink is literally the “heartbeat” that circulates the tears over that surface. The old, used up tear that has nourished, lubricated, protected, and hydrated the surface is blinked away, down little tear ducts that “pump” the tears down the back of our throat (hence the salty taste we get when we activate that salty “firehose” called “reflex tearing” or most call actively crying). The fresh, healthy tear that has yet to do any “work” sits in the little “gutter” between our eyeball and the lower lids. Blinking compresses the tear drainage system (activating the “pump” that sucks the tears down our throat) but also brings the fresh, healthy tear up from that gutter to put a new dose of tears where they are needed. I’ve addressed how that tear reservoir becomes compromised by conjunctival chalasis (the loose membrane I’ve addressed in my earlier postings), but poor (weak) or partial blinking is like having a weak heartbeat and staring is like not having a heartbeat – hence a “heart attack!

Those who spend a lot of their time on digital devices almost always suffer from some of this problem (staring too much) – and while staring, the old, used up tear becomes increasingly compromised from evaporation (I’ve also posted on evaporative dry eye and the related oil problems). Evaporation leads to concentration of the tears (increasing salt levels) and dryness, which leads to irritation and then inflammation (the body’s defense response to irritation - also addressed in earlier posts). Irritation hurts the tiny tear glands making the tears, which progressively leads to increasing degrees of dry eye disease (the vicious cycle).

Next week I’ll relate my typical prescription to avoid this “heart attack.”

Do you have “Mom’s” (or Dad’s) eyes?

Do you have “Mom’s” (or Dad’s) eyes?

If you wake up feeling more dry, gritty or scratchy in the morning than when you went to bed at night, then you very well may!

OK, most of us will see an image of our parent’s face staring back from our mirrors at some stage of our life - but that isn’t exactly what I’m referring to.. Whether or not you are a mom (or dad) – you had a mom (and dad) – and chances are, it seemed like they were never really sleeping when you crept in at night. It was like you could never get away with anything because it seemed like they were always “awake.” For that reason, when patients complain that they feel drier on waking, I perform a “Korb-Blackie Nocturnal-Lagophthalmous light (NL) test” to see if they may be sleeping with eyes open (and why, if they do, I call this “mom’s eyes.”).

NL or “Nocturnal Lagophthalmous” describes the not-uncommon tendency to sleep with eyelids slightly “open.” In the light test described by Drs. Korb and Blackie, the room is dim and the light on the slit-lamp (eye exam microscope) is turned off as your eyes are examined. To illuminate, a small flashlight that focuses its light from the tip of a small, finger-like extension allows the examiner to shine a light at - and through - (transilluminating) the eyelids. When the lower lid is rolled over the light, the examiner can see the Meibomian Glands (the eyelid oil glands) in good detail – but when the examiner asks you to gently close your eyes “as if you are sleeping,” then the light is aimed through the upper lid, downwards. This creates a chance to see any gap between the lids as a pink line. The thicker the line, the more open the lids and the more exposure of the eyeball.

 Naturally the patient is not truly “asleep,” so a certain amount of this diagnosis is conjecture. However, the likelihood runs high in my clinical estimation. So how does this happen and why should we care?

 If you sneak up on a sleeping child, it is not uncommon to see a slight gap between their eyelids (perhaps they are preparing to be parents much later in life;). They generally can get away with it, as their young eyes are usually so healthy and their tears “swimming” in such great oil, that the oil floating on top of their tears “coats” the tear and blocks evaporation. Early in life, they also probably have yet to “learn” incomplete blinking (though with digital device exposure at ever earlier ages, kids seem to be learning this problem all to soon). Once the lids cover the pupil, light is blocked and the brain can sense the eyes as “closed,” even when less than fully touching upper and lower lids together – causing NL.

 As we age, it is all too common to train the Meibomian Glands to “not work” by doing “poor” (weak) or “partial” (incomplete) blinks. Add to that the modern American diet that is said to be 95 times less rich in the healthy Omega’s 3-6-9 oils (the building blocks of all the “good oils” in a human – and especially those of our tear oils) than just 100 years ago. For that we can thank processed foods (all the tasty stuff like corn-fed animal meats, white breads, pastas, etc). Remember that the best sources of these oils come from Fish, Tree Nuts and Seeds. Once we allow the MGs to clog up with poor oils and poor blinking (only strong blinks pump oils from the glands), then we lack good oils in our tears – and evaporation is inevitable.

 When sleeping with poor oils and slightly open lids, then evaporation can leave eyes drier on waking. Evaporation leaves higher levels of salts and crusty proteins that are irritating, and irritation can lead to inflammation – which leads to more dryness. Waking up dry is like waking up on the wrong side of the bed. You’re off to a “bad start.” Some “work arounds” include drinking more water at bedtime (though this may lead to bathroom interruptions when you’re trying to sleep), using a humidifier close to your bed (so there is less dryness in the air that would otherwise aide evaporation) – or going to bed with ointments or gels in your eyes. Some patients wake up several times at night to reinstall artificial tears. While this can reduce evaporation and aide in lubrication – the artificial tears, oils and gels available today are not even close to the complex, healthy oils that would ordinarily be a part of good tears. It also covers up (think Band-Aide) the relentless progression of the Meibomian Gland Dysfunction (MGD) that is like “kicking the can down the road” rather than properly addressing and hopefully fixing the MGD problem.

 My usual “fix” is to start by reducing evaporation by creating a “terrarium” over the sleeper’s eyes. This can be as simple as using a plastic wrap under some type of sleep mask to hold it in place – or using a “Press N Seal” type of plastic which has a sticky surface on one side to help hold it in place. This allows many patients to try a simple, low-cost option (playing Sherlock Holmes) to see if this allows them a chance to wake up on the “right side” of the bed. If this appears to help, then the diagnosis is more secure. In most cases, patients will prefer to invest in a $50-60 pair of “sleep goggles” that are simpler to apply and easier to remove for those trips to the bathroom (many options exist, but the eyeeco brand https://www.eyeeco.com has several good ones to choose from).

 Following the terrarium approach, I think it is vital to properly diagnose and treat the degree of MGD causing the increasing symptoms of the problem (NL). Good tears can mean better sleep, better comfort, better vision, and a better appearance (less tired, red, dry or reflex-teary eyes). As usual, it is always better to check with your dry eye specialist to see what is best for you.

Why do expensive dry eye treatments fail? (And what is Maskin Probing?)

First - I am posting this on the first Monday of July - the official “Dry Eye Month!” Second, it happens to be the birthday of our nation - so Happy Birthday to the USA!

While I’ve blogged and posted extensively about common causes for such failures, one factor that I find to be a major, common theme, relates to the anatomic damage we find in the Meibomian Glands – those glands responsible for making the oils critical to good tears. Clinically we can image these glands with special photography, we can estimate the quantity and quality of the oils by assessing the “Tear Break Up Time” (TBUT) – or time it takes to see evaporation of tears off the eyes and most importantly, we can compress the glands and watch with a microscope to see how much and what kind of oil we can “squeeze out.” In healthy glands a little pressure will yield a “lot” of thin clear oil. Unfortunately, many times we find little to no oil – or we find chunks of waxy oils with high pressure.

In an extended discussion with Dr. Steve Maskin (USA inventor of the famous “Maskin Probes,” he is a cornea/dry eye specialist who has studied and written about dry eyes and obstructive MGD extensively and is based in Tampa, Florida) last year, he relates many dry eye treatment failures to multi-level degrees of scarring and strictures - or “periductal fibrosis” throughout the ducts of the MGs - which he finds is extremely common in MGD. This is akin to tiny “nooses” around the glands that can occur at different levels and block the deeper portions of the glands from participating in providing oils with a normal blink. (Remember that a single, strong, compression of the two lids together is considered a “good” or “normal blink.”) He feels this may be made worse with excessive attempts to purge the glands (hot or cold expression) – as cold or hot squeezing of those deeper portions of blocked glands - without clearing the scarring first - can cause more inflammation and damage (kind of like squeezing an acne pimple that doesn’t “pop”).

His fix is to do serially deeper probing of the glands, using tiny “piano-wire-like” probes that are placed by hand, with the help of a specialized microscope, into the mouths of each of the 25-30 Meibomian Gland ducts per eyelid, before instituting heated expression and/or IPL (generally a few weeks after the probing). To prevent further recurrence, he pursues lid hygiene and maintenance probing sessions (often yearly). My sense is that - caught early, simple heated expression can unclog MG obstructions and I tend to follow this “Korb/Blackie principal” in my practice. Once inflammation becomes more dominant, then adding IPL along with other anti-inflammatory/immune modulating treatments becomes helpful.

Once this periductal fibrosis begins to “prune off” the ducts, then probing appears increasingly beneficial. I’ve taken this to heart in my treatment algorithms. Dr. Maskin will inject steroids like Dexamethasone into the glands using proprietary, specialized cannulas and we discussed some of the more experimental therapies using stem cell products or anti-VEGF treatments, but I feel we still have a long way to go in fully understanding and then reversing this disease. When I do Maskin-style probing, I generally prefer starting with gentle IPL followed immediately by post IPL probing and then with off-label-aided Radio Frequency-heated expression right after probing. My rationale is to use the anti-inflammatory and pro-gland stimulation benefits of IPL but that RF can also make sense by melting residual waxy obstructions and helping to move that old, rancid, nasty oil out of these deeper pockets of the glands. I’m still waiting on the commercial availability of the micro-cannula (a tiny tube Dr. Maskin currently uses to deliver Dexamethasone or other anti-inflammatory products) though I typically prescribe a combination steroid and antibiotic drop taper of Tobradex to hopefully keep scars from recurring and germs from infiltrating/infecting in the immediate post-probing window.

That said, I think the obvious answer for now, is addressing this with general education, early detection and early treatments. The “ounce of prevention” has probably never been more needed as more of us spend the most productive hours of our lives with our digital devices - and diet, lifestyle and hygiene diverge increasingly further from the million years of evolution that produced the best environment that our eyes and bodies need - but no longer get. The “homework” of eating necessary nutrients, doing good blinking, getting good exercise, adequate rest and daily good lid hygiene become a baseline from which everything else flows in my practice.

What is “Neurostimulation” for dry eye treatment and do I need it?

To a large degree, everything about our body is regulated by nerves, so stimulating the right nerves, in the right sequence and pattern is the key to “living well.” Since tears are a vital part of looking, seeing and feeling better (our eyeThera motto), it stands to reason that controlling how and what kind of tears we make is key to our eye’s health.

Many times, patients ask me, “does that mean I should cry more?” Unfortunately, the reflex tearing we do when we visibly “cry,” is the product of our “fire hose,” so this is primarily a salt-water tear – and better for washing a loose lash out of our eye, than it is at nourishing. lubricating and supporting the surface. The “sprinkler system” tears are the “good stuff” with water, salt, protein and oil to take best care of our eyes. Fortunately, we have a nerve inside of our nose that connects to the entire sprinkler system and when activated properly, it can stimulate these cells and glands into doing what we need of them to make more and better tears – assuming that the cells and glands are up to it!

 I use the analogy of a “buggy whip” when stimulating the sprinkler system, that - when active - will give a slight “snap of the whip” to those harnessed cells and glands (what eye doctors refer to as the “lacrimal functional unit” – or LFU to those in the know). If the “horses” (or LFU) are able, then they can “giddie up and gallop” for you – but if they are 3-legged lame, then they will only limp along (and if dead – then it can be like whipping a dead horse).

 The original idea of applying this theory to dry eye came from a biotech engineer. In speaking with him at an eye conference where my eyeThera partners and I had the opportunity to meet, he explained that he was literally “sitting on the dock of a bay” (in San Francisco), preparing to eat a fish taco, when he sniffed it and inadvertently sniffed some of the taco pepper into his nose. This led to a bout of sneezing and then tearing. As an engineer, he spent a lot of time staring at computer screens and was aware he had dry eye disease – so having a bout of healthy tears flood his eyes was a welcome relief that left a lasting impression. Time spent with some eye doctors and other engineers led to his development of a tool originally dubbed “Oculeve” but later (when bought by the eye industry giant - Allergan (maker of Restasis) - for what could have been up to $1 Billion dollars, it was renamed “True Tear.”

 True Tear used a gel-coated electrical activator to deliver a small electrical “shock” to the spot inside your nose where the nerve exists, which will buggy whip the LFU. It allowed for varying degrees of “shock” – from negligible to forceful. Some of you reading this may have used True Tear – and if you did, then you know what I’m talking about. Unfortunately, the cost was prohibitive, in part due to the acquisition cost of the base unit, in part due to the ongoing cost of the applicator tips - and the fact that insurance companies didn’t want to pay for it. Also unfortunate, is that the response to the stimulator was variable – some found it worked great (with good horses) and some found it didn’t work at all (with very lame or dead horses). A single trial was often not enough to judge how well it would work – so an in-office demo was not a reliable indicator and a bunch of units were sold to patients who didn’t get much out of the device. Side effects could be discomfort and sneezing (like that taco pepper) and it needed to be reapplied throughout the day to get the full day’s tear response. Lastly, not all doctors wanted to buy a stock of units that might sit on the shelf or soon be returned by disgruntled patients – and this led to a commercial “flop” of what was otherwise good technology. Allergan stopped production and this could have been a final chapter to neurostimulation for dry eyes.

 Fortunately, the same engineer spawned another company (Oyster Point) with another neurostimulator product named Tyrvaya. Using the knowledge that certain contact-chemicals (like pepper) could stimulate the necessary tear-producing nerve, he and some chemical engineers came up with another use of a common nicotine-blocking agent (marketed as Chantix) previously used to help people quit smoking. This binds to – and stimulates – the LFU nerve like the electrical “buggy whip,” but without the shock. A small dose, sprayed directly to the inside of the nose (in the area where eyeglass-frames would rest) does the trick. It also commonly causes sneezing, though most will adapt to the point where sneezing is minimal. Twice a day suffices for most – but again – only if the LFU can make a tear.

 Better news is that many insurance companies are now beginning to cover some – or most – of the cost – so it can be more affordable. It is easy to use once you get the knack of it (and your prescribing doctor can give more detailed instructions if you are considered a candidate). The company has made efforts to supply samples to a large number of dry eye clinics and dry eye specialists – so there is a good chance that your US-based doctor can get you a 2-week trial for free.

 For those with aversions to spraying chemicals up their nose, there is also a stimulator called the iTear, that stimulates the same nerve – but on the track it takes outside of the nose. This electrical device sends a vibrational stimulus through the skin around the same area of the nose as the spray (and also where the True Tear applicators would be aimed) – but from the outside (rather than inside) of the nose. It is supplied as a small, compact device that is prescribed (and often sold) by your dry eye doctor. You get an initial “fill” of the prescription when you register the device and then can get ongoing “refills” online through the doctor’s prescription.

It suffers the same fate as every other “buggy whip” if the LFU horses are “lame” – but with ongoing use and with supportive treatments (like the “homework” I promote, often in concert with the off-label RF heated “unplugging” of the oil glands and IPL treatments to reduce inflammation and to stimulate the glands), I find that many can benefit from these “Neurostimulation” treatments. As always, it is important to work in concert with your dry eye specialist and primary care doctors to make sure these treatments are right for you.

More on IPL:

I’ve had several good questions raised about the efficacy and safety of IPL in various patient skin types and skin problems lately. I’m posting my replies for you here.

How dark can skin be and still be safely treated with IPL?

It depends on how much pigment (largely based on Fitzpatrick skin type). Fitzpatrick describes his skin types (1-6) I-VI, based on the amount of pigment and the way skin reacts to the ultraviolet light in sunlight. Some borderline (5’s) V’s can be brought down to IV’s or even III’s with careful sun protection and sometimes bleaching agents like topical hydroquinone (strongest) or other weaker, more natural products. All skin types can benefit from heated expressions (I like off label RF, but there are many others), if there are signs of obstruction. Lid hygiene helps a lot, too. Check with your dry eye specialist for their recommendations and good luck. If you are interested in learning your Fitzpatrick skin type, you can find it through a variety of online quiz’s, but it often helps to have an experienced clinician help “steer” your answers, as I find many of us can over or under estimate some of the questions and can help us get a more refined starting point for IPL treatments. One useful online quiz is here: https://www.proprofs.com/quiz-school/story.php?title=fitzpatrick-scale-quiz

How do we determine when to do more IPL treatments?

In my dry eye and rejuvenation center, another round of testing for tear volume and quality is generally done a month or so after the 4th treatment. If results are sub-optimal but substantial, then “stay the course” with the ongoing “homework” (typically oral Omega supplements, lid hygiene and warm, moist eyelid compresses with blink exercises) and retest 3 months later. Anytime results stop short of adequate, more IPL (& heated expression if indicated) can be considered. If the MGs are significantly short (or other evidence of being “choked” by scarring or deeper clogging), then Maskin probing may be considered. Each case is different, so check with your dry eye specialist.

Is treatment over eyelids necessary and – if so - how close to the lash line do we need to treat?

While there continues to be some debate among IPL using doctors as to whether to treat over lids or not, like Dr. Periman, (and a great many more) I find best results by treating over lids. As to how close to get to the lash line, since the blood vessels (feeding the inflammation to the tears) course through the outer to inner margins, I find that treating 1-2mm away from the lash line to be very effective, while taking less risk of diminishing the lashes whose growth bulbs are in that 2mm fringe. The IPL filters we use also make damage to lashes less likely and treating close to the lash line has the added advantage of heating the area where the oil producing glands most often clog up - so you can soften that waxy clogging, too. That the light appears to also stimulate the cells making the tears and knocking off some of the germs that eat those tears - are yet other reasons to treat as much of the active oil gland area (so over more lid area) as is safely possible.

When do you only treat with heat and when with IPL? Is a combination of both always necessary?

If your only problem is obstructive MGD (clogged oil glands), then any good, heated expression can be helpful - from Lipiflow, TearCare or iLux - to my preference of off label use of RF (radio frequency). However, if there is some related inflammation or severe MGD, then adding IPL can be a huge extra benefit. Each case is different, but my general protocol is to do IPL followed immediately by the RF heated expression in cases of obstructive MGD and concurrent lid inflammation. My experience-led rationale:

- blockages are generally of a wax-like nature, with a high melting point. Though IPL may heat enough in some cases to melt those plugs, the lids cool so quickly that the waxy oils can congeal back to thicker “toothpaste-to-macaroni” consistency that is hard to effectively and efficiently express. The lids are still warm, but not hot enough, so the RF can reheat quickly and efficiently to allow effective expression.

- one of the values of IPL is to slightly (on purpose) “injure” the abnormal blood vessels that are close to the surface and are delivering inflammatory cells and proteins to the lids, tears and therefore the eyes. Adding more heat at a juncture where they are still warm appears the better timing, as once the session is over, the healing and vessel regression (shrinking) can begin. Adding heat (without IPL) later will dilate those vessels we want to shrink, but dilation can encourage them to carry more blood and to grow back. (This can be one of the paradoxes of applying hot compresses to eyelids with active Rosacea when the clogging plugs are absent. non-obstructive MGD may occur after effective expression or in cases where inflammation is the principal problem), or when those plugs are so waxy and “hard” that the heat applied with home tools can’t melt them (so you only foster more inflammation without helping the obstruction).

- IPL alone typically takes 3-4 treatment sessions before patients experience significant relief. Adding RF expression at the outset of IPL treatment can help “jumpstart” the relief.

- MGs are often so “dysfunctional” from clogging and withering, that they may require multiple sessions of expression and since IPL also requires multiple treatments, the ability to pair IPL with RF is more cost effective and more efficient (I can reduce costs in such “packages” since I can spend less time with better efficiency).

Why is IPL not working?

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 than but can be a bit tricky for upper lid treatments. I prefer off label use of radio frequency (RF). 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 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 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.  It is also important to be taking excellent Omega oil supplements to “nourish” these oil glands with the building blocks they need to make good oils. Omega 3 is good oil (and usually supplied from a refined fish oil) but diets may still be lacking in the Omega 6&9’s. I generally advocate some high-quality Flax Seed Oil to the Fish oil supplements (or – better – a combination 3-6-9 supplement with all the above), though you might check with your provider. Strong, regular blinking (often coupled with hot moist compresses) and good lid hygiene complete the “support system” that most oil glands need to do their best. IPL is a jumpstart (often coupled with a good, heated expression of clogging) but without good, ongoing support, the glands may not be able to work up to their potential. Major withering of these glands may need a prolonged course of IPL (and expression) treatments and sometimes may need added interventions like Maskin Probing (more on this in future postings).

Again, each case is different, so best to go with the recommendations of your dry eye specialist.

CCH part 3: When do we treat CCH – and what are the non-surgical options?

A brief recap and some general observations (noting I cannot diagnose, recommend, or treat specific patients or their specific problems in a general blog like this):

 -        CCH can prevent a “new” tear, resting in its “well” or “reservoir” under the lower eyelid from easily coming up and replacing the older, “used up” tear with every blink. This becomes especially important if the amount of this “sprinkler system” tear is too little to begin with (typical of “Aqueous Tear Deficiency”, or ATD). In ATD, the pleats and folds of the loose membrane typical of CCH can act as a “washboard” that restricts flow – and the loose membrane shortens the reservoir, which reduces the amount of tear it can hold. Another problem exists when the new tear is a “poor tear” (as in not the good “salad dressing tear” that we should have). This is most common when the tear doesn’t have enough good oil (typical of “evaporative dry eye” – also known as “mechanical dry eye” or “Meibomian Gland Dysfunction” – also known by my preferred abbreviation, as MGD). Now the pleats and folds can “rub” back and forth with every blink, resulting in friction that abrades the membranes, causing irritation and inflammation (a major cause of dry eye and related symptoms). Add to that the twisting and shearing of the membrane that can strain and break the tiny blood vessels in that membrane and cause puddles of blood to cause red spots, splotches and even a total red coloring of the whites of the eyes (also called subconjunctival hemorrhages – these are “bruises” that can look scary but are usually not going to cause significant problems for most patients).

-        The obvious goal is to restore an adequate, healthful, “salad dressing tear.” If patients have an adequate volume of healthy tears, then even a significant amount of CCH will “matter less.” Even if we need to “operate” – by removing, heating/burning or otherwise tightening the conjunctival membrane, then healing will be facilitated by having that healthy tear. So - my general advice is to work on making a great tear before doing any surgery.

-        While “waiting” to get tears up to snuff, CCH can be limited in its irritating contributions by lubrication. This can be achieved with artificial tears (ATs). As you know by now, I am less a fan of ATs as a long-term answer for dry eye patients (they are at best a “Band-Aid” on the problem. If you are not actively working on making better tears, then this allows you to “feel better” even as you “get worse” from this chronic, progressive disease we call dry eye). However, when we are actively working on making better tears, I am a strong advocate of using “Preservative Free Artificial Tears” of PFATs. The exact formula I recommend would be dependent on the issues of each case (and trial and error is a common approach to find what works “best” in each case).

-        Reducing inflammation is another challenge. Using steroids is the strongest approach – but as you also know by now, I don’t like using steroids for long-term control of inflammation – preferring to target “root causes,” as steroids can have many unpleasant side effects (such as increasing the risk of cataracts, glaucoma, and infections) – especially when used for the long-term. Weaker medications like Restasis (or other cyclosporine products like Cequa, some newer generics, or Ikervis and the rest) and Xiidra (lifitigrast) are both better long-term choices than steroids, but are still not primarily addressing root causes. I prefer IPL, Omegas 3-6-9 oral supplements, anti-inflammatory diets, in some cases, altered lifestyles - and generally getting the MGs back online (heated expressions, Maskin probing when indicated, lid hygiene, etc).

-        Decongestants or other vasoconstrictors (like phenylephrine, brimonidine/Lumify or Upneeq/oxymetazoline ) will shrink tissues congested by swollen blood vessels (by stimulating the muscles that squeeze and constrict the vessels, thereby limiting the fluid that would otherwise swell the membrane). Because friction will injure the vessels and cause them to swell and be leaky, shrinking the vessels will have the opposite effect. The problem common to asking (or flogging) the muscles to constantly “squeeze” is that sooner or later, these overworked muscles need to “relax.” This leads to subsequent swelling and leaking – so these medications (supplied in drops) will eventually lose their effectiveness and can make the issue worse over time. They also are commonly supplied in larger vials or bottles that have preservatives - the harsh chemicals that can damage tear glands and aggravate dry eyes. For this reason, I see them as more “cosmetic” than therapeutic – and better for a hot date on certain occasions that are not more frequent than a few times a week – and then as a short-term “fix,” rather than addressing root causes.

-        This brings me back to my favorite “fix” for CCH – the radiofrequency “plications” that lightly iron out the folds and then sear the base in a way that allows the membrane to “stick,” and no longer be loose or baggy. The added benefit is that the same heat can be used (off label) to heat and express the blockages in the MGs that allows the oils to flow - and to naturally fix the root cause of CCH. This fixes the problem causing the problem and is an elegant, efficient, two-step, in-office procedure that is a common part of my practice.

-        If doing our best to fix MGD, ATD, (allergies, lid hygiene or the many other co-contributors of dry eye) is still unable to adequately reduce the dry eye issues and it appears some significant amount of these issues relate to CCH – then fixing that problem makes lots of sense. How much we can address making better tears is often dependent on cost considerations and the fact that insurance may not cover all the costs. Fortunately, using my technique (of RF) to plicate CCH is commonly covered by most US-based insurance companies as of this writing.

-        The common “downtime” of the RF procedure to those with decent tears is typically 3-5 days of discomfort (from the small burns) – I use the example of burning your mouth with a hot pepperoni pizza bite. For a few days your mouth does not feel good, and you might avoid eating (or drinking) hot foods or beverages (so avoid hot eyelid compresses). After a few days, the discomfort diminishes to the degree that most have little to no discomfort (and are back to eating hot pizza in the case of a burned mouth – or to using hot compresses in the case of the plications). One eye is typically done before the other – so the patient and I can decide if treating the second eye makes sense. Eye drops (a bit like after cataract surgery) help with proper healing and comfort. Those with especially poor tear quality or very diminished volume will sometimes take longer to recover - but usually on the order of a few extra days, up to an extra week. It is the rare patient that doesn’t decide to have the second eye treated - and rare that we don’t see significant improvement in the signs and symptoms of dry eye disease (as I noted in my study publication in the last segment).

A recent industry journal publication on CCH relates to another common “side effect” of CCH - a “subconjunctival hemorrhage” or bruise on the white part of the eye: https://www.optometrytimes.com/view/schs-mild-trauma-or-something-more-sinister-

Conjunctival Chalasis (CCH) part 2 - How do we fix it?

CCH is a common co-contributor to dry eyes and related dry eye signs and symptoms. A recent study shows that 98% of patients over the age of 60 have CCH – or, Mechanical Dry Eye (MDE) - and in my experience, it can begin very early in the course of dry eye disease (and at a much earlier age). While not clear what exactly is the cause, I think it is widely understood that the friction from poor tear quality and poor tear volume can aid in loosening the membrane - and the inflammation associated with friction and with the dry eye disease process itself, can also promote it. T., Yamagami, S., Usui, T., Funatsu, H., Mimura, Y., Noma, H., … & Amano, S. (2009). Changes of conjunctivochalasis with age in a hospital-based study. American journal of ophthalmology, 147(1), 171-177.

Because of the association with friction (the result of the “mechanical rubbing of the eyelid” against the rough surface of a dry eye), CCH is commonly also called “Mechanical Dry Eye” and a short video was created by a company (BioTissue) marketing a biologic tissue (amnion) used to help heal from a surgical procedure used to correct it. See this link: https://youtu.be/Z6Us18F5QwY

When it comes to surgically dealing with CCH, there are a number of options available. 

1- cut it off and let it grow back. This approach leaves a relatively large defect that heals like an open sore with granulation tissue and a degree of scar tissue. The final result will gradually convert to conjunctival tissue, but I’m not aware how well the related “sprinkler system” tear-producing cells are restored. It also doesn’t deal with the problem commonly thought to cause the CCH (that being the obstructive MGD and resulting mechanical dry eye, inflammation and friction relating to a lack of oil).

2- same, but glue in a segment of amnion as a biological Band-Aid or attempt to sew portions of the membrane and/or amnion together. This hastens healing but leaves us in the same position. (This is the company with the great video I linked above).

3- burn the loose folds of CCH with a hot wire. This leaves a scaffold of unburned tissue to help in the repair and even the burned membrane leaves some cover (avoiding the open sore over the underlying sclera). The red-hot wire tends to char the tissue which tends to leave more scar tissue than what I experience with the lighter coagulation from RF. It also fails to deal with the friction issues noted above. 

4-use a laser to burn or singe the loose folds. This is similar in some respects to RF, but I’m wary of damaging the eye with light that might injure the light-sensitive structure of the eye. I also find CCH seems to recur more rapidly than with other technology and it also fails to fix the problem causing the problem. 

5- MY FAVORITE! - use Radio Frequency (RF) to “burn” (or more lightly singe) the membrane, causing it to shrink, tighten and then “stick” to the eyeball beneath the membrane (recreating the nice “shrink-wrap” effect that restores the smooth reservoir referenced in the video above) - and then use the same energy to do a heated expression of the waxy obstructions of the MGs. This fixes the problem causing the problem. I published a study using this technology here: https://jdryeyedisease.com/index.php/JDED/article/view/35

In difficult cases, after the RF procedure, one can apply the biologic tissue (amnion) - referenced in the first video, but applied as a kind of contact lens “Band-Aid” (Prokera) which can hasten the healing and help ensure a deep “reservoir” is maintained.

Perhaps one of the reasons any of these techniques work to any degree, is that it really helps to have a smooth surface for the tears to easily come up from the “gutter” (or reservoir) of the lower lid and replace the old, used up tear on the surface of the cornea.

An interesting and - probably relevant aside, is that RF (along with lasers and other thermal treatments) is now commonly used (by GYN doctors) to promote vaginal restoration and lubrication. The lining of the vagina is similar to the conjunctiva and since ocular lubrication is similar, there may be similar benefits to RF in both cases. 

What is Conjunctival Chalasis (CCH) and why should I care?

To understand conjunctival chalasis – which is a common disorder of the surface of the eye - it’s best to understand the surface of your eye and how it works.

-        When you consider that a tear is the lifeblood of the surface of your eye, then the heartbeat is the blink - which moves that tear around. For this to work best, the surface of your eye must be smooth and even.  There is a little gutter; think of a broad well - or a reservoir between our lower lid and the eyeball, housing the best tear that we have. This tear has yet to do any “work,” so that when you blink that tear can come up out of that little gutter with the force of your eyelids coming together and spreading that tear evenly around. This fresh tear needs to replace the old, dirty, used-up tear on the surface of your eye. That old tear gets washed away, ultimately going down into your nose by way of a tear duct. When you have good tears, with good oil, there is very little friction and very little drag over that surface - but if you lose oil, thereby losing tear lubrication, then every time you blink there’s increasing degrees of friction and drag. That friction and drag will, by degree, pull and then stretch the membrane over the surface of the white of your eye. This thin, clear membrane is called the conjunctiva and when it comes loose, we call that chalasis – hence the term conjunctival chalasis (also called conjunctivochalasis or CCH for short).

-        Conjunctiva is commonly “shrink-wrapped” over that surface and reflects down into the gutter and then up over the inner surface of your lid - so that there is that nice smooth lining over the gutter housing a fresh healthy tear. With increasing friction comes inflammation or irritation which also weakens some of the support of that membrane to the underlying tissue. As the membrane comes loose from the friction pulling and stretching that membrane, then by degrees, the membrane starts to develop pleats, folds, and wrinkles. These wrinkles then disrupt and distract the tear from moving easily over the surface of your eye. Add poor tear volume to that disruption (the hallmark of Aqueous Tear Deficiency-related dry eye disease) and you end up with a tiny tear now being asked to crawl up a washboard of pleats, folds and wrinkles.  This poor distribution means a smaller tear becomes an increasingly dysfunctional, deficient tear. When you blink, if you feel some degree of discomfort in the course of your blink - particularly during strong blinking - then it is possible that this feeling of “running in loose socks,” is an indication that you may have conjunctivochalasis, or CCH. As usual, I recommend seeing a dry eye specialist to sort out the full extent of your dry eye problems and to help you overcome them.

Next week, I’ll address what we can do about CCH

When eyelids are irritated (including “mucus fishing” - as well as allergies, such as to our best friend - pets!)

As a dry eye specialist, I can’t diagnose or treat over the Internet, but anytime a patient reports a significant reaction on the eyelids, my first question is what are you putting on them? That’s because some chemicals (lid cleanser and makeup products in particular, as well as preservatives and even antibiotics) can cause this reaction. My next advice is to stop it. As lid skin is the thinnest skin of your body, it is often the “canary in the mine” that will show sensitivity ahead of most other areas, so even soap, shampoo and perfume (as well as soap and softener you wash clothes and bedding with) can add aggravation. A good exam is also required, as irritation of the lids (commonly called blepharitis) can arise from many causes best left to the diagnosis and treatment of dry eye specialists (see my prior post on blepharitis and germs).

A common source of irritation relates to allergies. Allergies tend to be magnified when you have dry eyes, as tears normally wash and support the ocular surface - poor tears means less washing and less support. Inflammation is a driver of dry eyes and is a byproduct of allergies - so the two often go together. Dogs, cats and any furry animal has a tendency to carry pollens, dusts and dust mites a bit like a duster would - and like that duster, having it near you can infuse some of that into the air around you. Running air purifiers and regular pet grooming can help mitigate some of the allergy issues. Sadly, the antihistamine products used to treat allergies can also have a drying effect on your water producing glands (nose, mouth and eyes) - so just "covering up" the allergies with medication is often not the best answer. Working with an allergist will likely help. We all love our 4 legged friends and having to cope with dry eyes and allergies related to them can be heartbreaking if it results in our having to part with them. Hopefully you can find a way around this that works for you and your dog, cat, gerbil, hamster, rabbit or other furry friend.

A common treatment of lid irritation is to buy over-the-counter or prescriptive ointments to apply to the lids. Ointments can contain lanolin (related to sheep’s wool - a common allergen) as well as antibiotics (if prescriptive) and 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 or with certain kinds of germ-related blepharitis 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 dry air (which is an intended result) but also from some of the good oils you begin to make (an unintended result that can potentially limit 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.

A special case of eyelid (and eyeball) irritation is the condition known to eye specialists, as “mucus fishing.” Dry eyes are often plagued by excessive mucus production and accumulation. This relates to several issues:

- When there is poor oil, as is most often the case in dry eyes (& there have been long posts on MGD, including my interview by Dr. Ziegler), then there is rapid evaporation of the water that is normally held in place by the thinner oils that would otherwise float on top. As water leaves, it leaves behind the proteins (mucus) and salts that don’t evaporate. This commonly causes increasing irritation and inflammation. The mucus forms strands and “gunk” relating to the added proteins of inflammation. Allergies and blepharitis (eyelid irritation often associated with the overgrowth of eyelid germs) can add fuel to the fire

- Once strands and sticky “goo” accumulates, many patients feel compelled to extract the goo by using finger tips, QTips or other things (edge of a tissue, etc). This has the term “Mucus Fishing” attached to it, as long strings can be serially “caught” and pulled out. The irony is that the more you fish, the more irritation (partly from friction, partly from further triggering of reflex tears that are salty and can have lots more proteins but no oils and sometimes by introducing germs from these “fishing objects” -fingers, etc) that trigger germ and inflammation-related immune responses. Other causes of “Goop” can include chronic infections that can cause inflammation (such as some cases of “pink eye”), but also could relate to blocked tear ducts (in which case germs can live in the “plumbing” that otherwise allows tears to leave the eye’s surface and travel to the nose).

The answer is to stop mucus fishing (if that’s what is going on) and see a good dry eye specialist to properly diagnose and treat the root causes of your dry eye disease (often related to MGD). Unfortunately in my experience there are no over the counter artificial tears that will fix this.

Why did I get a stye (Chalazion)?

Chalazia as tip of iceberg in children to adults:

A chalazion (or “Stye”) is essentially an acne pimple in your eyelid. Once one of these oil glands blocks, it can keep making oil and eventually exceed the capacity of the gland at which time it can burst into the skin around it and start an immune reaction. If there are germs trapped inside when it bursts, then that can start an eyelid infection and it may either spread into the lid or be contained in a “whitehead” that looks like a bigger acne pimple. What makes it different is the tough tarsal tissue (the skeleton on the eyelid) in which it is located. Often more important is the condition of the other 99-119 or so similar glands spread throughout the 4 lids as they may be heading in the same direction- or worse - withering instead of producing more oil and becoming a chalazion (or style) once blocked.

As a chalazion, your immune system will attack the oil and attempt to wall it off with scar tissue. Early on (typically in the first 2-3 weeks), hot compresses may “melt” the waxy blockages commonly involved in this problem (also know as obstructive MGD) and may allow the gland to open and drain through it’s natural opening. After 2-4 weeks, it will commonly begin “walling off,” so more heat may bring it to a “head” and allow it to drain through the skin or on the inside of the lid. The further out it gets, the harder the scar tissue becomes and the harder to get it to drain short of surgery.

If caught in the first month, in office procedures like IPL (Intense Pulsed Light or Broad Band Light) and/or radio frequency heating can often help resolve this without surgery. Injections of steroids can help “melt” some residual scar tissue as well. Once it socks in with scarring, that “band of steel” may leave surgery as the only option, but remember that the operation only solves that one “Zit” and doesn’t deal with all the other oil producing glands that may be following suite or are withering. This oil is critical to your tears and thus to your eye health, so I recommend you find a dry eye specialist with IPL and/or RF who can image and treat your glands. If there is infection involved, you may need topical and/or oral antibiotics in addition to other care. Once you get your glands on track, adding Omega 3-6-9 oral oils to your diet, working on stronger blinking, lid hygiene and occasional hot compresses are commonly needed to prevent recurrences. We all need to take better care of these glands since they need to last a lifetime and we are all living longer and using our eyes more than ever.

As one who deals almost daily with surgical degrees of chalazia, I have some strong opinions based on 30+ years of observations. Chalazia are de facto evidence of obstructive MGD and in my opinion, are begging for office-based levels of heated expression. Off label IPL and RF both appear highly useful for chronic chalazia (though better if caught in earlier stages). Lipiflow misses in acute settings as the activators don't fit well over solid cysts and when they do, the paddles get hung up on the "marbles" in the lids and don't compress over the remaining MGs. Hot compresses, Doxycycline and steroids are helpful in acute settings but don't relieve significant obstructions (waxy plugging) very well and leave remaining glands at risk for more chalazia or atrophy (or both). Lipid containing ATs are bandaids. I would strongly advocate for off label heating and expressing treatment in these cases.

I’ve seen what seems an epidemic of this problem in the younger age group. Duke University published on a study on nearly 100 kids between the ages of 4-16 (avg age 10.5yrs) and over 1/2 had some dry eye related issues with their oil-producing glands (MGD). We think it’s related to screen time and diet. Many kids are “picky eaters” - meaning they won’t consume significant amounts of the essential omega oils 3,6&9 (such as found in fish, tree nuts and seeds -) like “we” all ate 100 years ago, but researchers find we Americans eat 95% less of today (- largely thanks to plentiful processed foods). Make sure your kids get enough of these good foods (or sufficient supplements) to nourish these oil glands. Better, stronger blinks (as already suggested) along with hot (but not burning hot) moist compresses can often help, too.

The link to the Duke University study (suggesting upwards of half of kids between the ages of 4-16 years old have some degree of MGD) is here: https://www.ncbi.nlm.nih.gov/m/pubmed/29286952/ I published a couple of cases of kids presenting with chalazia (styes) who had advanced MGD and pretty bad dry eye (the 7 year old was already on artificial tears after multiple chalazia), here: http://www.jdryeyedisease.com/index.php/JDED/article/view/8.

Scary stuff. I'd advocate that if your child develops a stye, that you take your child to a dry eye doctor who has good tools to document the stage of dry eye so you can track progress and adjust treatments based on how it goes. (My experience is that most pediatric eye docs don't have the right equipment for this.) I routinely scan MGs on all my chalazia patients and rarely go a week without finding significant MGD in kids with them (& in adults). I see chalazia as the "tip of the iceberg" of MGD. Lots of glands going bad but only a few turn into "zits" in the lid with most withering quietly away. Most kids (and many adults) respond to the "homework" taking Omega Oils, daily hot moist compresses, good lid hygiene and good blink habits. Catch it early.

Contact lenses and dry eye - Part 2

When is cleaning bad?

Using the “all purpose“ cleaner and conditioner solutions to take care of your contacts can be a major problem. These products are designed to kill germs and clean deposits, while also lubricating and buffering the contact lens to make it more wettable and wearable. This sounds like a good idea but it turns out to be impossible! 

Anything harsh enough to kill most common germs while cleaning the lens, is also going to be too rough and toxic for your dry and sensitive eyes. These toxins can weaken the cells on the surface while damaging the "sprinkler system tear glands." They also can’t kill every germ, because that would also kill your eyes. Think what would happen if you were to put pure Clorox into your eyes - it would destroy them (while also killing every germ). 

Another problem has to do with the containers used to store the lenses while cleaning or not using these lenses. Because these "eye-kinder" solutions can’t kill every germ, the germs that survive - like a nasty little amoeba called Acanthamoeba - then hang out and multiply in the container. Once they get to a certain concentration or once the eye's surfaces become damaged enough by the chemicals in the spongy lens, then these germs can get the foothold they need to start an infection. In the worst case, this goes on to ulcerate the cornea and can lead to blindness if not a properly care for.

Yet another problem comes from the allergies that can be aggravated by a more sensitized surface and less healthy tears. Allergies can be caused by pollen, pollutants, fragrances, products in makeup, soaps on the fingers used to insert and remove the lenses - and yes, the dander from pet hair in the air that can surround us. Such materials soaked into and onto the contact lenses can lead to rejection - so much that you may have to give up wearing contact lenses all together. Allergies cause further inflammation that contributes even more to the dryness and irritation. Giant Papillary Conjunctivitis (or GPC) is a special, more aggressive form of reaction of the membranes of the outer eye and eyelids to either the material embedded in the spongier plastics, or to the actual plastic material the lens is made from - or the irritation from the edge of the contact lens “rubbing” against the membranes when you blink, GPC can sometimes be solved by changing the type of contact lens material, finding a lens with a smother edge, determining the type of allergens (pollen, dust, dander, mites, etc) and avoiding them - but ocular allergies can be helped by having a healthy tear film, too.

So called “dailies” are contact lenses designed to be worn for a specific period of time (usually just one day, as the name implies) and then thrown away. This can get around the cleaning issues, but doesn’t necessarily help with the allergy issues. They also tend to be more fragile, since they are designed for only a one-time use - so improper handling on initial insertion or attempts at re-use can be fraught with micro-tears and surface irregularities that can affect comfort and wear time as well as risk eye injuries.

How do we properly clean our contacts?

From the above discussion, it is easy to understand why it is important to properly clean and to properly care for the contact lenses - as well as to make your best tears (and control your environment). The best way to care for contact lenses is generally to use a hydrogen peroxide solution designed specifically for cleaning your type of contact lenses. Such kits contain peroxide solutions that will completely kill the germs, but then are turned to a harmless gas and water by a catalyst provided in the container used to clean and store your lenses. This powerful disinfecting and cleaning solution becomes harmless over the time specified by your cleaning system (generally overnight). This means that you can effectively clean your lenses without hurting your eyes - and have a better way of cleaning the container for those lenses at the same time. You may need to rinse your contacts with pure saline solution before putting them into your eyes as the pure water left from the peroxide cleaning can be irritating. Make sure you use an appropriate saline solution (preferably unpreserved and often best supplied in single use vials as the preservatives in the large saline bottles can sometimes be just as bad as the preservatives in artificial tears).

From inside the industry, a timely article:

 https://www.optometrytimes.com/view/contact-lens-disinfection-methods-still-matter

Contact lenses and dry eye - Part 1

EyeThera dry eye special segments

How can contact lenses contribute to dry eye misery? 

Remember that good blinks are important because they work tear oil (Meibomian) glands, while simultaneously washing old tears away and bringing fresh, new tears up from the lower lid "gutter" (or fresh "tear well") to cover the surface of the eye. 

Dryness triggers the blink reflex - but wearing a contact lens can shield the surface from recognizing it is becoming dry. Average "normal" blinking rates vary from 10 to 20 times a minute but becomes far less wearing contact lenses (as little as 5 or less times a minute). Those contact lens-shielded blinks also have a greater tendency to be what we can call "poor" or "partial“ blinks, which teach the oil glands not to work. Also importantly, these partial blinks expose the contact lens to greater evaporation. This can lead to more salt and protein deposits on the surface of the contact lens, making the contact lens less tolerable to wear and leading to inflammation of the eye.  This can cause the eye to "reject" them, while leading to more dry eye problems at the same time. 

Because soft contact lenses are little sponges, allowing oxygen and tears to work into and around them, they also catch and soak up pollutants, allergens like pollen, as well as finger-and airborne germs that get into and onto them. This can add to the irritation, inflammation and “rejection" of the contact lenses, as well as damaging the tear producing glands. This is why cleaning and proper fitting of contact lenses is required. Ironically, many of the cleaning products and protocols used to care for contacts can also lead to dry eye problems! (More on this below).

Some contact lenses are prescribed specifically to help dry eye patients. These are generally hard contacts called scleral lenses. They "vault" over the sensitive surface of the eye and hold some salty tear water over that cornea, so it doesn't dry out. Now the surface of the eye becomes the plastic of the contact lens instead of the sensitive cornea - so this can help in extreme cases of dry eye, while also correcting the need for glasses. 

So why don't we put all of our dry eye patients into these little "fish bowls?" Remembering that the cornea needs more than salty water to best survive, some who make very poor tears may need to add more "human" products to the tear water kept under these lenses. This is often accomplished by using Autologous Serum Tears (ASTs) - an artificial tear made more human-like by processing vials of your blood (the autologous part) and adding the health factors to the artificial tear. This generally means you need to give your blood by way of needle sticks, into a number of vials every few months. A lab processes out the red blood cells and mixes up the ASTs, freezes them and provides them in little dropper bottles that should remain frozen until they are used by you over those months. The cost is not covered by most insurance plans and can run three to four hundred dollars a month, in addition to the cost of the contact lenses (which may be covered under some insurance plans - check with your doctor on this if you're interested).

These specialty contact lenses need frequent removal, cleaning and replenishment of the salty water and/or ASTs throughout the day - so they can be a major nuisance to use - but can also be a lifesaver (or sightsaver) when used in the more advanced - or end-stages of dry eye disease. ASTs can also be used without these lenses and can help to add necessary components to improve the quality of poor tears. Ask your dry eye specialist if you qualify - but also remember that if you take good care of your tear glands, then it becomes less likely you will ever need this degree of special (expensive and inconvenient) dry eye care.