Dry Eye Treatments

1. Underproduction called Aqueous Deficiency, where there is poor production of fluid by the lacrimal glands.
2. Evaporative – tears evaporate too quickly, where there is poor oil production by the meibomian glands.
3. Combination – mixed Aqueous & evaporative type.

However ALL patients with dry eye can have an inflammatory component.

• Persistently gritty, sore, foreign body sensation
• Red, itchy
• Misty or blurred vision
• Sharp shooting eye pain
• Watery eyes (paradoxical)

Dry eye does not frequently cause blindness, but as it is such an uncomfortable condition, it is a common reason for seeking assistance. Furthermore, dry eye syndrome is associated with a decreased ability to perform activities that require visual attention, such as reading, computer work and driving a car.

Patients with the most severe disease are at increased risk of developing corneal infection, scarring or ulceration. These conditions can cause permanent vision loss, misdirected eyelashes or loss of eyelashes and entropion (chronic blepharitis), so it is important to seek urgent professional help if you have severe symptoms of dry eye.

Severe dry eye is sometimes caused by Sjögren’s syndrome, which is an uncommon autoimmune disorder that also results in dry mouth and often arthritis.

There are many tests that indicate you may be suffering with dry eye. Not all tests are always performed, but include:

Tear Meniscus: the height of the tear film along the lower lid border (reduced in dry eye).

Tear Break Up Time (TBUT) – The speed at which tears break up reflects evaporation (<5 seconds indicates dry eye)

Schirmer’s Test – A test to measure quantity of tear production where strips of sterile blotting paper are placed at the outer corner of the eye for 5 minutes and the length of wetting is measured. However it is not a very reliable test, as it does not comment on tear quality.

Tear Osmolarity – A test to measure the osmolarity of tears (high & variable in dry eye). This is an extremely reliable test, but does not help differentiate between the different types of dry eye.

Blink – An assessment of whether the blink is partial or reduced.

Ocular surface staining –with the help of topical drops, to evaluate the tear film and study ocular surface damage.

Assessment of Meibum expressibility (meibomian gland secretions), which indicates function of the oil glands.

Assessment of the Meibomian glands – with Meibography, to assess the drop out of meibomian glands

Avoid anything that can aggravate dryness, such as:

• Very warm rooms (a humidifier may help)
• Hair driers
• Smoke
• Wind
• Contact lenses

HRT can aggravate dry eye. There is some evidence that, in older women, hormone replacement therapy makes dry eye worse; if you are using HRT, talk to your doctor about this.

Lubricating eye drops

First line of treatment is the use of artificial teardrops or gels, which can be bought over the counter. You may need to try out different types to see what combination relieves your symptoms of dry eye. Preservatives in eye drops can aggravate your eye, and if you are using them more than 4 times/day, I recommend using non-preserved drops instead. Some newer lubricating drops try to replicate the tear film, thus have been shown to be of benefit and newer preparations are being researched.

Omega 3 supplements

Our modern diet is sadly lacking in sufficient quantities of Omega 3 and there is an overbalance of Omega 6, which contributes to inflammation.  Omega 3 supplementation has been shown to be very useful for improving the function of Meibomian glands in blepharitis.  It is mportant that the correct preparation be used, as not all Omega 3 preparations are biocompatible. While recent long-term studies indicate a somewhat better bioavailability for omega 3 fatty acids in triglyceride versus ethyl ester form, the cost of high-omega-3 concentrates is generally much greater for the triglyceride forms versus equal amounts of omega-3 in the concentrated ethyl ester form. 

Steroids

In more severe cases of dry eye, the eye might become inflamed and anti-inflammatory medications including steroid eye drops may be prescribed for short-term use.

Restasis

This is an ophthalmic preparation of Cyclosporine, which is useful in decreasing inflammation and in Sjogren’s syndrome.

Punctal Occlusion

Punctal Occlusion (temporary or permanent) may be an option offered by your ophthalmologist in severe cases. This involves blocking ducts within your eyelid. Used incorrectly punctal occlusion can sometimes cause more problems especially in inflammatory dry eye.

http://oasismedical.com/dry-eye-products/punctum-plugs.html

Lid Hygiene : Warm compresses and Scrubs

Mainstay to treat anterior & posterior blepharitis. The Meibomian glands in the eyelids get blocked and as a result lead to evaporative dry eye.

EyeBag

This is an effective and simple option to provide warmth to the eyelids without the fuss of hot water etc. The EyeBag is placed in a microwave oven for 30 seconds, and then placed on the closed eyelids for about 10 minutes following which massage/scrubs can be performed.

http://www.eyebagcompany.com

Blephasteam Goggles

An electrical pair of goggles that provides warmth and steam to treat MGD. Many patients prefer using this device although it is a slightly more expensive option, as it offers moist heat.

http://www.spectrum-thea.co.uk/apps/content/html/

Lipiflow

A highly sophisticated treatment option that warms the lids and squeezes them to evacuate meibum within the oil glands. Excellent for kick starting treatment in selected cases, the use of regular lid hygiene is recommended to maintain the health and function of the glands.

http://www.lipiflow.com/dryeye

Blepharitis cannot be cured, but symptoms can be controlled with good eye hygiene and lubricant eye drops.

Blepharitis is a chronic (long-term) condition. Most people experience repeated episodes followed by periods with no symptoms. 

Eye hygiene for Anterior Blepharitis

 It is important to clean your eyelids every day, whether or not you have any symptoms. Good eye hygiene helps ease your symptoms and prevents them from reoccurring. Follow the steps below to keep your eyes clean:

1. Apply a warm compress (a cloth or tissue dipped in with warm water) to your closed eyelids for five to ten minutes. Gently rub the compress over your closed eyelids for two to three minutes to help loosen any crusting.

2. Use a cotton bud moistened with boiled cooled water and gently rub the edge of your eyelids to clean them. If you have difficulty using a bud use proprietary cleaning pads e.g: Supranettes wipe by Alcon, Lid Care pads by CIBA, or Blephaclean/ Blephasol wipes by Spectrum Thea, or Ocusoft /Ocusoft plus eye pads by Scope Ophthalmics.

Carry out these steps twice a day at first, then once a day when your symptoms have improved. 

Eye hygiene for Posterior Blepharitis

 It is important you perform Hot compress and eyelid margin massage every day

Step 1: Hot Compress

Either heat the lids with a flannel soaked in hot water Or use a heat pad such as the “Eyebag” from www.eyebagcompany.com. Apply to closed eyes for 4-5 minutes. Reheat as necessary.

Step 2: Massage

Express the oily secretions from the meibomian glands by using a cotton bud or your finger. Firm pressure is required to milk the secretions towards the gland opening on the lid margin. Use a rotary motion down (or up) towards the lid margin. Work your way across the whole upper and lower lid. Do NOT stretch the lid

Step 3: Add Lid Scrubs or Wipes

Gently rub the edge of your eyelids with lid wipes to clean them, if you have mixed anterior & posterior blepharitis (Lid wipes advised are:  Supranettes wipe by Alcon OR Lid Care pads by CIBA OR Blephaclean/ Blephasol wipes by Spectrum Thea OR Ocusoft /Ocusoft plus eye pads by Scope Ophthalmics).

Topical Antibiotics

If you have blepharitis that does not respond to regular cleaning, you may be prescribed a course of antibiotic ointments or steroids. You will need to use these for four to six weeks.

You may be prescribed:

• fucithalmic or maxitrol steroid/antibiotic eye ointment (to be rubbed gently onto the edge of your eyelids as prescribed)
• 1 % azithromycin eye drops

Oral Antibiotics

In some circumstances, you may be prescribed oral antibiotics (e.g Doxycycline or Azithromycin) at the start of your treatment. For example, oral antibiotics may be prescribed when it is clear that a skin condition, such as rosacea, is aggravating your blepharitis. Oral antibiotics may also be recommended if your blepharitis does not respond to other treatment.

Most people respond well after treatment, hence it is important for you to finish the course of antibiotics, even if your symptoms get better.

Cautions

Doxycycline used to treat blepharitis has been known to make people more sensitive to the effects of the sun. Therefore, avoid prolonged exposure to sunlight and using sun lamps or sun beds while you are taking them.

Side effects of oral antibiotics are rare because the dose is relatively low. However, they may include vomiting, diarrhoea and yeast infections in women.

Treating Other Conditions

You may need to use an anti-dandruff shampoo on your scalp and eyebrows if you have:

• seborrhoeic dermatitis
• dandruff (dry, flaky skin on your scalp)

If you have dry eye syndrome, which frequently occurs alongside blepharitis, you may need separate treatment for this, such as lubricant eye drops.

• Dry eye syndrome
• Conjunctivitis
• Meibomian cyst
• Styes