Treatment for Dry Eye Syndrome
The causes of dry eye syndrome are usually multifactorial. Although certain causes can exacerbate symptoms acutely, there is usually a summation effect that is gradual over time. The inflammation spills over into the lacrimal glands, oil glands, and epithelial surface of the cornea and conjunctiva and it can often be difficult to tell where the problem originally started. Treatment varies depending on which parts appear to be most severely affected.
The most basic treatment is use artificial tears to lubricate the surface of the eye. Not all tears are created equal. Artificial tears in a bottle are convenient but also contain preservatives, which may have an irritating effect on sensitive eyes. Preservative-free tears can be used without fear of injury, but tend to be less convenient and more expensive. Different brands (Systane, Refresh, Theratears etc.) have different concentrations of oil and water and general concentration (osmolarity). Gels tend to last longer on the surface of the eye but also cause blurriness. Non-gel medications do not blur the vision appreciably but the effects can be more short-term. We especially like Retaine because:
- It is hypotonic. This helps cancel out the harmful salt effect from the tears that are being produced.
- The positive particles of the tears stick onto the negatively-charged ocular surface, resulting in electrostatic attraction and long-lasting relief
- The lipid layer helps to protect and lubricate the cornea.
Inflammation is at the root of virtually all types of dry eye. Topical steroids can be an excellent way to calm down the inflammation quickly but they are poor long-term options due to harmful side effects (increased intraocular pressure, cataracts). Restasis is a great option for chronic use due to its safety profile. It is the only FDA approved medication to improve tear production and is available by prescription only. Long-term studies have shown improvement in symptoms and objective findings such as increased goblet cells. Decreasing inflammation in the lacrimal glands causes an improvement in the quality and quantity of tears.
Other than burning, Restasis is usually well tolerated. It takes 3-6 months to take effect for most people, so it must be used for some time before judging its efficacy. Patience is key with this medication! Stopping the medication slowly undoes any benefit that has been achieved, so it must be maintained much like you would take medication for high blood pressure. The medicine helps control the problem, but does not cure you.
Xiidra is a new medication that was recently FDA-approved for the improvement in signs and symptoms of dry eye disease. Unlike Restasis, which tries to control inflammation at different points in the inflammatory cycle, Xiidra concentrates solely on the ICAM-1/LFA-1 interaction. Similar to Restasis, breaking the cycle of inflammation is critical to preventing dry eye disease from getting worse.
Side effects of Xiidra include irritation, blurry vision and/or a bad taste in the mouth. The majority of patients find this to be more of a nuisance than a dealbreaker. According to the FDA-trials, patients noted an improvement as early as 2 weeks later. Also much like Restasis, the medication has to be continued indefinitely to help control the problem.
Omega-3 fatty acid supplements are popular because they are natural and are beneficial to the ocular surface. Unlike omega-6 fatty acids, which are implicated in problems like heart disease, omega-3s are protective and help decrease dry eye symptoms. The mechanism of action is not quite clear, but levels of lactoferrin in the tear film have been shown to be elevated. The problem with taking omega 3 supplements (e.g. fish oil, flaxseed oil) is that there is no standardization between the brands. Not all of them work the same. We have had great success with HydroEye supplements. They contain a specific type of omega 3 called GLA, which is derived from black currant seed oil and cannot be obtained easily through the diet. It requires continual use and takes approximately 60 days to experience any improvement in symptoms.
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Bacteria live on your lashes. They live on everybody’s lashes. However, sometimes they get out of control. Hypochlor spray is a new compound—hypochlorous acid, which is secreted by white blood cells in your blood to kill organisms. Spraying it on your eyelids has the same effect and can be considered all-natural since it is no different than your normal immune system. This helps to eliminate the vast majority of the pathologic organisms on your eyelids and restore order. It works within minutes and typically takes about 2 weeks to see results. Ocusoft pads offer another option in killing bacteria on the eyelid. They also help mechanically debride bacteria off the eyelids, which can be equally important for population control.
Heat can help melt the thick viscous oil that clogs the meibomian glands, similar to melting a stick of butter in the microwave. In order to accomplish this, the temperature of the eyelids must increase sufficiently. Because the oil glands are on the back surface of the eyelids and warm compresses are applied to the front of the eye, continuous heat needs to be applied for at least 10-12 minutes so the heat can penetrate through the eyelid and get to the meibomian glands. Warm washcloths typically do a poor job of sustaining heat for this amount of time. There are a few eye masks that we find effective for this. Therapearls contain multiple beads that are activated by placing in the microwave for approximately 10 seconds. Once activated, heat is given off for 10-12 minutes. Tranquileyes is an excellent option if more robust heat is necessary. The activators are snapped to start the process and can be reset by being placed in boiling water. After the heat is applied, fingers are used to compress the lids and express the oil from the meibomian glands, similar to squeezing the last bit of toothpaste out of the toothpaste container.
If the eye is not inflamed, then plugs can be used to block off the drainage system of the eye. Since tears are produced every time you blink, blocking one of the puncta will act like plugging a sink or tub—the water level rises. This can improve the quantity and coverage of the tear film until the eye is rescued by the next blink. This is generally very well tolerated. We find Odyssey punctal plugs to be especially safe and effective. Drs. Parbhu and Raja have punctal plugs themselves!