Dry Eye

 Dry Eye

Dry eye disease was recently redefined as a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, ocular surface inflammation and damage and neurosensory abnormalities play etiological roles. Meibomian gland dysfunction (MGD) represents the leading cause of evaporative dry eye, the most common subtype of dry eye. MGD is characterized by hyper keratinization of the meibomian gland ductal epithelium, leading to obstruction and plugging of the gland orifice. Moreover, quantitative and qualitative changes in the meibum lipid composition lead to increased viscosity and reduced gland outflow onto the tear film. The stasis of meibum inside the gland promotes proliferation of bacteria, producing lipases and esterases that increase the viscosity and melting temperature of the meibum, thus setting up a vicious spiral. Hyposecretion of meibomian lipids causes thinning of the tear film`s lipid layer, with consequent tear film instability. This results increased evaporation rate of tear and onset of dry eye.

 
Dry Eye Syndrome

Dry Eye Syndrome (DES) affects approximately 10% of people between the ages of 30 and 60 and 15% of adults over age 65.  It is caused by an unhealthy tear film and can create many symptoms.  While the condition can be mild, it can also be a significant problem that affects day-to-day living.  There are many treatment options.  Your doctor will help you determine which treatment is best for you.

What are tears?  

Tears are a mixture of saltwater, mucous (mucin), and oil (lipid).  These components form a smooth gel-like “coat”, called the tear film, on the surface of the eye.  The tear film has many important functions:  

    Moisturizes and protects the surface of the eye
    Washes away debris and germs
    Carries nutrients to the surface of the eye
    Contains proteins that prevent infection, control inflammation, and digest harmful proteins secreted by bacteria
    Acts as an important focusing surface for the eye  

An imbalance in the saltwater, mucous, or oil components can disrupt the tear film and cause Dry Eye Syndrome.
What is dry eye?

Dry eye is a chronic eye condition. Normally, a layer of tears covers the surface of the eye to keep it moist, and meibomian glands in the eyelids secrete oils to slow evaporation of these tears. Dry eye results if there is an insufficient supply of tears or if the tears evaporate too quickly. Meibomian gland dysfunction (MGD), where the glands don’t function properly either due to blockage or oil deficiency, is a leading cause of dry eye. People with dry eye may experience discomfort and have difficulty in reading, using a computer, watching TV and driving. In its most severe form, dry eye can be accompanied by inflammation of the eye surface, sleep disturbances and depression. The detrimental effects (physical, emotional, financial) can be quite significant. Dry eye is commonly confused with other conditions, in particular allergies. It can be tricky to diagnose because symptoms vary, are subjective and can be described in many different ways (e.g. ‘feels gritty’ vs ‘feels like something in my eye’). The condition can’t be cured, but available treatments aim to relieve symptoms and improve quality of life. The earlier dry eye is detected and treatment started the better.

Types of Dry eye

Meibomian Gland Dysfunction and Evaporative Dry Eye disease are real and common conditions that affect vision and quality of life. Unfortunately, since we haven’t been able to easily observe the underlying physiology of dry eye disease, it’s been difficult to identify and treat effectively – leaving sufferers frustrated and unable to find long-term relief for dry eye symptoms.

With breakthrough technology, it’s now possible to treat the root cause of Evaporative Dry Eye that caused by a blockage of eyelid glands called Meibomian Gland Dysfunction. These blocked eyelid glands result in a deficiency in the tear film oil, which is responsible for preventing the tears from evaporating too quickly.

What causes Evaporative Dry Eye? (Also known as Meibomian Gland Dysfunction)
Tears are made up of three layers:         

    Lipid (oil) layer lubricates and prevents evaporation
    Aqueous (water) layer nourishes and protects the cornea
    Mucin layer adheres tears to the eye

 

Glands in the eyelids called Meibomian glands create the lipid (oil) layer of tear film. 70% of dry eye disease is caused by evaporative or lipid deficient dry eye. Evaporative Dry Eye disease is most often caused by a blockage or obstruction in the eyelid glands, which can lead to a lipid (oil) deficiency in the tears. Blockage of eyelid glands is called Meibomian Gland Dysfunction.  The cause of obstruction is believed to be poor quality oil production and Omega 3 deficiency. Re-esterified Omega 3 supplements such as Omega Eye are very useful and important in correcting the underlying cause.

Other causes of Dry eye:

• Environmental factors Low humidity or air movement across the eye can increase evaporation of the tear film.  This includes:

• Dry climate
• Use of a fireplace, heater, or air conditioner
• Windy conditions
• Car vents, hair dryers, and room/ceiling fans
• “Leaky” masks for sleep apnea  

• Other environmental factors including dust, dirt, cigarette smoke, and pollution may worsen Dry Eye Syndrome.   
• Medications Some medications can cause the eyes to be dry, including the following:

• Oral antihistamines (like Benadryl, or diphenhydramine)
• Antidepressants (like Elavil, or amitriptyline)
• Decongestants (like Sudafed, or pseudoephedrine)
• Hormone replacement therapy

• Some eye drops contain preservatives that can cause or worsen dry eye syndrome.   You should speak with your doctor about any prescription medications you think may be contributing to Dry Eye Syndrome.
• Eyelids and blinking the eyelids spread the tear film evenly over the surface of the eye with every blink.  Medical conditions and activities that can prevent lid closure or decrease blinking include:

• Thyroid disease 
• Parkinson Disease
• Reading
• Computer work 
• Watching TV

• Aging-related changes of the eyelids and scars following injury can also impair proper eyelid function.
• Medical Conditions Dry Eye Syndrome can be present in people with autoimmune disease or other systemic conditions, including the following:

• Diabetes mellitus
• Rosacea
• Sjögren syndrome
• Rheumatoid arthritis
• Systemic lupus erythematous
• Sarcoidosis

• Ocular Conditions Contact lens wear, prior refractive surgery (like LASIK), and eye allergies can contribute to dry eyes.  
• Hormonal Causes Women who are postmenopausal tend to have reduced tear secretion, even if taking hormone replacement (like estrogen). Pregnant women tend to have increased tear secretion. The effect of estrogen replacement therapy on tear secretion is not completely understood.

Common Symptoms

• Dryness
• Feeling of foreign body sensation in eye
• Tearing
• Tiredness
• Discomfort & irritation
• Burning or stinging sensation
• Sensitivity to light
• Itching
• Grittiness
• Vision disturbance
• Discharge
• Redness

These symptoms may also be accompanied by:

• Difficulty preforming visual tasks, such as reading, watching TV and driving
• Inability to wear contact lenses
• Need to use eye drops constantly
• Trouble being out in the sun
• Symptoms that worsen late in the day

How do you diagnose dry eye?

Ophthalmologists use a combination of tests to diagnose dry eye, including:

• Schirmer tear test: Determines if the eye produces  enough tears to keep it moist „
• Tear-film osmolarity test: Measures the concentration  of various components of the tears „
• Tear breakup time: Measures how quickly the tear  film evaporates „
• Corneal fluorescein staining: Shows any abrasions  or scratches on the cornea „
•  Meibography: Analysis of meibomian gland function „
• Tear analysis: Looks for inflammatory markers in  the tear film „
• Symptom questionnaires: Helps the ophthalmologist determine the severity of your symptoms.

While more prevalent in older adults, evaporative dry eye disease can occur at any age.  At Ophthalmic Consultants of the Capital Region, we are diagnosing evaporative dry eye in young adults and children, possibly because of the common use of smart phones and computers.  At Ophthalmic Consultants, the Lipiview imaging interferometer has allowed the rapid assessment of blink function, and thickness and distribution of the meibomian lipids over the corneal surface with each blink.

LipiView – diagnostic technology

• The LipiView, is an instrument used to observe the tear film using digital images. A LipiView can capture the image of the tear film. The LipiView Ocular Surface Interferometer is used for the diagnosis of dry eyes. It involves broad spectrum white light interferometry. This LipiView interferometer provides an interferometric color assessment of the tear film by specular reflection (the mirror like reflection of light). 
• LipiView is the only device available that can quantify the absolute thickness of the tear film lipid layer to assist an eye care specialist in establishing the lipid deficient form of dry eye disease. They state that it offers the improved ability to determine the pathophysiology of a patient’s dry eye and direct treatment more effectively, thereby reducing unnecessary disease progression and wasted resources on therapies directed to improper causes. In addition, it is non-invasive and has no known contraindications. 
• The patient’s eye is positioned in front of a light source that is directed toward the tear film on the corneal surface. Light passes through the tear film and is specularly reflected into a camera. The light reflecting back through the lens in the camera forms an interference pattern, called an interferogram. The advanced computer system then captures the tear film layer thickness and stores the digital specular images of the tear film, which can be visually documented and monitored.

 

How do you treat dry eye?

Dry eye syndrome, also known as keratoconjunctivitis sicca, occurs when the eyes do not produce enough tears or the tears evaporate too quickly. This leads to the eyes drying out and becoming inflamed and irritated. Common evaporative dry eye symptoms can also mimic the symptoms of other conditions. For instance, itching may be due to allergy or dry eye, whilst both ocular fatigue and contact lens intolerance can have many causes. Thus, instead of determining aetiology and initiating effective treatment, many patients have been treated empirically based on the level of symptom severity.

There are many different treatments for dry eyes. Regardless of the treatment method, a period of consistent use of 6-8 weeks may be necessary before any benefit is seen.  The treatment may need to be continued to maintain the benefit, unless environmental or other causative factors are addressed. 

• Treatment may include the following measures to relieve symptoms and prevent complications: „

• Regular artificial tear drops: Artificial Tears Artificial tears are available over-the-counter and do not require a prescription. Some tears are thicker than others. Although thicker tears last longer, they can blur vision for several minutes. Your physician will tell you how often to use the artificial tears, typically 4 times a day or more. Your physician can help you choose among the many different brands and formulations.  Experimentation with different types may be needed to find one that does the following:

• Feels soothing when placed on the eye
• Only momentarily blurs the vision
• Does not cause any burning or redness 

• Artificial Tears Ointment: People with severe dry eyes will sometimes need to use an ointment. Ointment at bedtime is especially helpful if your eyes do not stay closed completely when you are sleeping, or if you have severe dry eye symptoms upon awakening. Ointments make the vision very blurry, so should be applied sparingly (about the size of a grain of rice) immediately before sleeping.

• Eyelid soaks and Scrubs: Dry Eye Syndrome can be caused by the Meibomian glands that secrete oil into the tear film.  The gland`s secretions may become decreased, increased, or too thick.  Your physician may prescribe a regimen of warm soaks and eyelid scrubs multiple times a day to address these problems. 
• Blink more often: Especially when using a computer or other electronic devices. „
• Warm compresses: With either a face cloth or heat bag. „
• Eyelid hygiene: Keep eyelids clean, especially if they get crusty.„  
• Humidify the room: With bowls of water around the room or a good quality humidifier.„
• Wear wraparound sunglasses: To stop the tear film from drying out too quickly. „
• Minimise exposure to heaters/air-conditioners: To stop the tear film from drying out too quickly.„
• Sometimes an oral antibiotic such as doxycycline is helpful, especially in people with acne rosacea. Low doses of these medications are used not to treat an infection but to thin the meibomian gland secretions and help stabilize the tear film. 
• Anti-Inflammatories: Physicians will sometimes prescribe anti-inflammatory eye drops to treat severe dry eyes. The most commonly prescribed medication for this condition is cyclosporine. It helps the body to produce more tears and takes 2-3 months to begin to improve symptoms.
• Topical steroids: Usually reserved for severe or chronic cases, but do carry a small risk of increasing eye pressure. Inform the ophthalmologist if you have a family history of glaucoma. „
• Environmental Modification

• Direct car air vents away from the face
• Avoid ceiling fans or air ducts
• Wear glasses in windy outdoor conditions
• Use an air purifying filter to reduce dust or other allergens that can worsen dry eye symptoms

• Dietary Supplementation Omega-3-fatty acids may improve symptoms from dry eye syndrome and associated eyelid inflammation.  Sources of Omega-3-fatty acids include fatty fish (salmon, sardines), walnuts, chia seeds and flaxseed. Fish oil or fatty oil supplements are also available.
• Punctal Plugs: People with dry eye problems will sometimes have one or both of the puncta closed to increase the amount of tears on the eye surface. The plugs must be inserted by a physician and can be temporary or permanent. Physicians may also use a cautery tool to permanently close the puncta if the condition persists.
• Surgery may be necessary for scarred eyelids, eyelids that do not close completely or eyelids that are not positioned correctly.

 

• Newer treatments for dry eye include: „

• Intense pulsed light (IPL): Used to reduce inflammation along the rim of the eyelids to boost meibomian gland function. „
• Thermal pulsation: Special equipment applies heat and controlled pressure to the meibomian gland to promote the flow of oil. „
• Treatment of evaporative eye disease would necessarily require treatment of the root cause of the disorder. Under secretion of meibomian gland lipids is currently best treated with Lipiflow, the only FDA approved device for the treatment of evaporative dry eye disease and MGD. The method accomplished of programmed thermo-pulsation of the meibomian glands that evacuates the gland ducts of any blockages and in turn restores glandular function.

LipiFlow – thermal pulsation system

LipiFlow is a treatment device specifically designed for effectively removing blockages from the meibomian glands, allowing them to properly function and produce the oils that make up the top protective lipid layer of the tear film. LipiFlow is becoming the standard of care for MGD with studies demonstrating its safe and effective results. LipiFlow was designed to minimize patient discomfort during a 12 minute in-office treatment that most patients describe as a gently massaging of the eye lids.

The LipiFlow Thermal Pulsation System effectively relieves blockage of the eyelid glands. Opening the blocked eyelid glands allows the body to resume the natural production of lipids (oils) needed for the tear film.

LipiFlow is a quick, in-office treatment. LipiFlow typically does not require any downtime, so most patients are able to return to work or other daily activities immediately after the procedure. Most patients who have the LipiFlow treatment feel relief of their symptoms within two weeks or sooner.

In a controlled clinical trial the LipiFlow System showed significant improvement, on average, in the oil secretions from the eyelid glands and in the time that the tears remain on the eye before evaporating. The study also showed significant improvement, on average, in patient self-reported dry eye symptoms. At 4 weeks after LipiFlow treatment, 79% of patients reported improvement in dry eye symptoms.

Lipiflow thermal pulsation system is intended to be used for the treatment of dry eyes. It is a console that connects to a single-use activator, which is a biocompatible polycarbonate and silicone eyepiece that is inserted around the patient’s eyelid. The activator has two main components:

• An insulated lid warmer, resembling a contact lens that vaults the cornea and provides precision controlled heat to the tissue of the internal eyelid.
• An eye cup that provides intermittent pressure to the outer eyelid surface. 

 

How Does LipiFlow Work?

LipiFlow activators are single-use sterile devices that safely and comfortably deliver automated therapeutic energies to the Meibomian glands, while protecting the delicate structures of the patient’s eye. The activators are specifically designed to be placed under and over the eye lids and are contoured above the cornea, so that the activators themselves avoid contact with the core eye surface.  The placement of the activators on the eyes and treatment is a simple process that is done with minimal discomfort, on average.

Once the activators are placed on the eyes, treatment begins. The LipiFlow activator delivers a combination of heat and gentle pressure to the inner lids using what is called Vectored Thermal Pulse (VTP), with a simultaneous therapeutic motion on the outer lid.  This unique combination of patented vectored heat and gentle adaptive pressure safely removes gland obstruction or old gland content. The entire treatment takes 12 minutes and, as normal gland function recovers, maximum results are usually experienced 6-8 weeks after treatment.

When LipiFlow treatment is properly applied, the glands can resume normal oil production or what is known as lipids. This oil is essential for a healthy tear film and for protecting the tear layer or watery layer of your eyes.  When the water layer is exposed due to lack of oils on the top of the tear film due to Meibomian Gland Dysfunction (MGD) or gland blockages, the result is the leading cause of Dry Eye Symptoms.

The company claims that LipiFlow, has the potential to reduce the number of treatments needed. They also state it offers a more targeted approach to the treatment of dry eyes, eliminates compliance issues associated with traditional therapies, and the insulated lid warmer shields the eye from heat and pressure, thereby preventing the risk of corneal reshaping from warm compress methods.

Frequently Asked Questions (FAQ)

Who is at risk of getting dry eye?

Anyone can develop dry eye, but you are more likely to develop the condition as you get older (e.g. 50+).  Dry eye is more common in females, and is particularly common in post-menopausal women. People, who wear contact lenses, use computers or other screens for long periods of time, and/or live in dry, windy climates are also at increased risk of developing dry eye.

How can I have dry eyes when my eyes water all the time?

Excess watering or tearing is a common symptom of dry eyes and occurs in response to the eye irritation caused by dryness. Treatment, including artificial tears, will calm the underlying irritation and eventually reduce the reflex tearing.

 I use artificial tears, but they don’t seem to be helping.  Am I doing something wrong?

 If artificial tears do not initially seem to help, they usually need to be used more often and for a longer period of time.  Artificial tears must be used on a regular basis, usually several times a day, and for several weeks to improve dry eye symptoms. If symptoms persist after several weeks of frequent artificial tears, other treatments may be needed.

How does Dry Eye Syndrome cause blurry vision or double vision? 

The tear film is an important focusing surface for the eye. Dry Eye Syndrome can make this surface uneven or irregular, and can lead to problems with focusing. Blurry vision or double vision can then develop. Often, these visual symptoms occur while reading:  The vision is clear at first but becomes blurry after reading for a few minutes. Rest, wiping the eyes, or blinking temporarily clears the vision.  A similar pattern of symptoms can occur while using the computer or watching television.

If I am constantly producing tears, where do they all go?

Just as tears are constantly being produced, they are constantly being drained off the surface of the eyes.  With each blink, tears are pushed through tiny holes called “puncta” on the inner surface of the eyelid and into a tear drainage system.  The structures that produce the layers of the tear film must keep up with this constant drainage. The aqueous component of the tear film is made by the lacrimal gland. It sits just above the eye, behind the eyelid, within the eye socket. Mucin and lipid are produced by glands on the surface of the eye and on the eyelid margin.  Blinking spreads aqueous tears onto the surface of the eye. With each blink, tears are also squeezed through a tiny hole, or “puncta”, on both the upper and lower eyelid. The puncta are connected by a tiny plumbing system to the lacrimal sac, situated between the eye and the side of the nose. From there, the tears drain into the nose. We do not notice this drainage normally, but with excessive tearing or crying, we experience a “runny nose”.

Is lipiflow right for me?

Your eye care professional will perform a series of diagnostic tests to evaluate gland performance and the health of your gland secretions. This will help to determine the root cause of Dry Eye Disease.  You can assess your Dry Eye symptoms online and your doctor may have you complete a short questionnaire.  A series of other simple test can be performed that may include compression of the lid under a slit lamp and using Dynamic Meibomian Imaging (DMI) that provides a high resolution picture of your gland structure.  If you are experiencing Dry Eye symptoms, it is essential that you ask your eye doctor to check for Meibomian Gland Dysfunction (MGD).  If you have MGD, LipiFlow may be an optimal treatment to ensure long-term eye health and to alleviate Dry Eye and MGD symptoms.