April is the month we are focused on women’s health. Since dry eye is more prevalent in women, I want to talk about dry eye.
Dry eye is a frequent problem challenging eye care physicians on a daily basis. What does “dry eye” mean? The function of the blinking lid is to lubricate the surface of the cornea, the clear outer covering of our eyes. The first layer of the tear film closest to the cornea is a protein layer. In the middle is an aqueous, or water layer, and the outermost layer is composed of a lipid, or oil layer. So when we blink we cover our corneas with a protein layer, water layer and oil layer. Disturbing any of these layers will cause dry eye symptoms, including burning, scratchy, gritty, frequent watering, pain, blur and tiredness.
In the protein layer we find goblet cells, which make the protein. These cells are hormone dependent. Specifically, the hormone is testosterone. Both men and women make testosterone but men make more. As we go through life we make less testosterone. Since women start out with less testosterone they wind up with less testosterone compared to men when we age. Less testosterone causes the goblet cells to make less protein and this leads to a protein deficiency and dry eye. Women tend to develop dry eyes more than men because of this testosterone link. The outer oil layer of our tears is important because it prevents evaporation of the middle water layer. In the tears less oil means more evaporation of the middle water layer. This leads to an aqueous deficiency and dry eye. As you age, your skin gets dryer, producing less oil, so too do the oil glands in your eyelid also make less oil for the tear film. Two other big factors that reduce the water layer of the tears are the medicines we take and our medical diseases. Antihistamines for allergies dry out our sinuses but they also reduce the water component of our tears. Statins for high cholesterol, beta blockers for high blood pressure or heart problems, antianxiety, antidepressant, diet medications, and sleeping medications are some of the more common medications that lead to an aqueous deficiency and dry eye. Thyroid disease, diabetes, rheumatoid arthritis, lupus, Sjogrens syndrome are some of the diseases that lead to an aqueous deficiency and dry eye.
Most patients do not understand how their eyes are dry when they complain that their eyes water all the time. When we do not make enough protein, water or oil the eyes start to dry. When we get dry enough, the brain senses that the eyes need more moisture so our lacrimal gland is turned on. A flood of tears are produced. The gland is then turned off. When the eye gets dry enough the brain turns on the lacrimal gland and again a flood of tears is produced. This cycle continues but the cause of the watery eyes is the drying of the eyes. Reflex tears are watery and don’t contain any protein or so they don’t lubricate as well as the slow constant tear flow.
So, what can be done? There are different levels of management of dry eyes. Let’s start out with the least cost to the patient. As the levels increase, so does the cost.
The first level of management is learning to control your environment. Make sure you are not sitting directly underneath a fan or the air conditioner vent is not blowing directly on your face. In your car, do not have the vents pointed at your face. Keep them pointed down.
The second level of management is the use of over the counter lubricating drops and the start of oral omega 3. I recommend Systane Balance, Refresh Optive Advanced or Soothe XP. You should use one drop four times a day. This product has an oil component. If we can replace the outer oil layer of the tears this will help to prevent evaporation of the middle water layer. There is an inflammatory component to dry eyes. Taking Omega 3 or fish oil gives us an anti-inflammatory response. If a person is allergic to fish oil, flaxseed oil can be used. To get this response the omega 3 has to be taken in a certain quantity. Start at 2000 mg of fish oil every day. It can take up to six months to realize an effect. If there is no improvement in three months, increase fish oil to 4000 mg every day. A good product, Nordic Natural Liquid, can be found in health food stores and vitamin shops and on Amazon.com. We’re finding for postop sensitivity, the Retaine MGD preservative free drop seems to be a very good drop and has the most oil of any of the preservative frees.
The third level of management includes Hydro Eye and prescription eye drops. Hydro Eye uses a little bit of omega 3 and a lot of omega 6 as well as some vitamins and minerals. The company gives a guarantee that if you use two bottles of Hydro Eye and it does not help, they will give you your money back. I have seen good results with the use of Hydro Eye but I offer it as a second choice because it costs more than the fish oil or flaxseed oil. If you take Hydro Eye you do not need to take fish oil or flaxseed oil. If you take blood thinner medication, let your doctor know that you are going to start taking fish oil, flaxseed oil, or Hydro eye. These can increase the potency of the blood thinner and your doctor may have to decrease the dosage.
If this does not help we move to dry eye prescription eye drops. Restasis was the first prescription approved for dry eye. It is expensive, does not work for everyone, and many patients complain that it burns and makes their eyes red and they usually stop taking it. Xiidra is a new drop for dry eye. It is also expensive and sometimes leaves a bad taste that can last for about 30 minutes. There is a drop called Lotemax gel that is very effective. Lotemax gel is a steroid which is an anti-inflammatory medication. The problem with this medication is the side effects. It can cause cataracts, an increase in eye pressure, which is glaucoma, and increase your risk for eye infections. I choose Lotemax gel because this particular steroid has been shown to cause the above side effects less than a generic steroid. If we use this, we use it sparingly.
The fourth management level involves a procedure called punctal occlusion. I usually use collagen plugs and plug the drains. Since the tears do not drain away you have more tears available to help lubricate the cornea. The plug melts away after two weeks.
New studies are showing a relation between the Meibomian glands and dry eyes. Our Meibomian glands make the oil component of our tears. This oil should be clear and flow easily out of the gland but in some individuals the oil becomes cloudy and thickens, making it difficult to flow out of the glands. There are special devices that are designed to heat and massage the glands to help restore normal flow. These devices are expensive and time consuming for the patient and more studies are needed to see how effective they are. Knowing this, I encourage patients with dry eye symptoms to use hot compresses on the lids as hot as you can stand for 20 minutes so that the clogged oil in the gland will melt. Afterwards, with your finger, apply mild pressure on the top lid and roll your finger down. On the bottom lid apply pressure on the bottom of the lid and roll your finger up. This helps to express the oil form the Meibomian glands and to start the free flow of oil again. We encourage you to incorporate this procedure into your daily cleaning hygiene. We are also starting to dry eye in younger patients that use mobile devices. The theory is we blink less frequently when using these devices. This leads to an increase in the evaporation of the aqueous part of our tears. Eventually this causes an increase in inflammation which contributes to the destruction of our Meibomian and Lacrimal glands and leads to dry eye symptoms.
Dry eye is complicated and there is no instant cure. With the above management levels and your direct participation, your dry eye symptoms hopefully will be relieved.
The eye doctors at Eye Specialists of Mid-Florida, P.A. would be happy to evaluate your dry eye symptoms and give you our best management options and assist in your ongoing care.