Montes Eye


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DRY EYES



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Dry Eyes





Jorge A . Montes, MD, FACS



Dry eye symptoms and dry eye disease affect many people and are the most common conditions that present to the eye clinic - even if the reason for the visit was unrelated to dry eyes. Before we start discussing dry eyes, we need to understand the layers that coat and protect our eye - The Tear Film.


THE TEAR FILM AND ITS PLAYERS

The tear film has three essential layers:

1) The Outer Lipid Layer (oil layer) - Produced by the meibomian glands found on this inside layer of the eyelid.

2) The Middle Aqueous Layer (largest layer) - Produced by the lacrimal gland

3) The Inner Mucous Layer - Produced by specialized goblet cells on the eye's skin, the conjunctiva.




TEAR FILM IN ACTION

All layers in the tear film are essential, yet the oil layer is the most commonly affected. This study shows the tear film's oil layer producing an iridescence effect just as an oil drop in water would make. Preservation of this layer is vital to maintain a healthy ocular surface.



Tear Film Evaluation



obtained with lipiview



This video shows the normal oil layer being replaced with every blink



Tear Film Evaluation



OBTAINED WITH LIPIVIEW



This video shows incomplete blinks and poor replacement of the oil layer



SIGNS AND SYMPTOMS

A dry eye has many symptoms, and they vary from patient to patient; however, most people will present with a combination of the symptoms below.

  • • Tearing (a reflex secretion of tears due to dryness)
  • • Blurry vision
  • • Redness
  • • Pain - Pinprick sensation
  • • Itchiness
  • •Foreign body sensation (most commonly described as a having a piece of dirt or hair under the eyelid)
  • • Vague ocular discomfort - radiating to the back of the eye
  • • Pressure like sensation to the eye
  • • Subconjunctival hemorrhages

The picture below depicts a photo of a dry eye. The dry spots become more pronounced and facile to see with the assistance of fluorescein staining and the cobalt blue light.



​CAUSES

Two categories encompass most causes of dry eyes:


1) Aqueous Tear Deficiency (ATD)

The lacrimal gland is at fault in ATD as it does not produce enough of the tear film's water component. Some medications can decrease your tears' production, so a thorough review of your medications is essential at all visits by your ophthalmologist.


2) Evaporative Dry Eye

The meibomian glands will atrophy or decrease in size and function over time. These glands are responsible for producing the oil layer of the tear film. Without this layer, the water layer evaporates quickly and leads to symptoms of dry eyes.


Common Causes of dry eye include:
• Autoimmune Conditions

• Aging

• Medication Effects

• Activities that decrease blink rate (computer work, reading, driving, near activities, prolonged viewing of television)

• Use of Fans - In the car or at home

• Lasik or Eye Surgery

• Contact Lens Use

• Bell's Palsy




commmon causes of dry eye



Autoimmune conditions can affect the lacrimal glands, and rosacea may affect meibomian gland production. Although conflicting evidence exists, LASIK can cause dry eyes in many patients. Age alone can also cause dry eyes through both mechanisms.


As is evident, the medical history assessment and exam determine which category of dry eyes you may have. Sometimes, tests are done in the clinic to determine which type of dryness is present.


In the end, you may hear dry eyes be called many things, such as:

• Keratoconjunctivitis sicca, Sjogren's

• Keratoconjunctivitis sicca, non-Sjogren's

• Superficial Punctate Keratitis

• Dry Eye Disease

• Dry Eye Syndrome



REGIMENS AND TREATMENTS

Lubricants

Lubricants are the mainstay treatment in any form of dry eyes and are the foundation for treating dryness successfully. It is with lubricants that the tear film becomes stabilized. The middle-aqueous layer is protected from evaporation when the outer oil layer is intact and present.


Most patients improve symptoms by adding a scheduled lubricating regimen alone. The drops should be non-preserved to eliminate any extra exposure to preservatives. We divide the treatments into daytime and nighttime regimens:


Daytime - Scheduled non-preserved lubricant drops starting at 4 times a day

Nightime - A single nighttime application of an ointment before going to bed.



non-preserved Lubricating drops



sterile Lubricating ointments



Omega-3 Fatty Acids

Omega-3 fatty acids are added to increase the quality of the oil secreted by the meibomian glands.


Eyelid Hygiene and Warm Compresses

The process of cleaning the opening to a gland that mainly produces oil is essential. The oily substance that the glands produce changes consistently over time and leads to meibomian gland dysfunction or chalazion formation if there is no steady flow of oil.


Eyelid hygiene is done by diluting baby shampoo in water and scrubbing the eyelids' margin, or by using commercial eyelid wipes to perform the scrubs. These wipes contain mild soaps to dissolve and remove any coagulated oil on the eyelids' margin.


Eyelid cleansing can also decrease bacterial load in the area, which will alleviate inflammation in the area. Also, many formulations of dilute hypochlorous acid are available that gently clean the eyelid margins.



eyelid hygeine shampoo and wipes



eyelid cleansers



Once the eyelid margins are clean, the focus has to turn to the meibomian gland contents. Preserving the health of the meibomian glands can be achieved by ensuring constant flow. We accomplish this by performing warm compresses regularly. Alternatively, a yearly treatment with Lipiflow is useful in patients with meibomian gland disease and prevents further loss of meibomian gland function.


There are masks available that will make the process of applying the warm compresses easier. The masks are heated quickly in the microwave, making the process cleaner and quicker than performing a warm compress with warm water and a clean washcloth, and because of that, compliance increases.



warm compress masks



PHARMACOLOGIC AGENTS

Prescribed pharmacologic agents can relieve symptoms when lubricants fail to do so. Some pharmacological agents include anti-inflammatory agents - either steroids or immunomodulatory agents (Restasis, Xiidra, Cequa).


PUNCTAL OCCLUSION

Punctal occlusion is a minor procedure performed at the slit lamp whereby a minuscule silicone or collagenous plug is placed in the opening of the eye's drainage system of the lower eyelid. This procedure prevents the tears from going into the nose via the eyes "drainage system." A discussion of risk vs. benefit first has to take place with your physician before deciding to place a punctal plug.


SERUM TEARS

We allow the body's natural immune system to decrease inflammation on the eye's ocular surface. Blood draw through a third-party company is required to obtain, clean, and place the serum into preservative-free individual-use bottles before shipping to your home. Serum tears are an additional option that can be added to any regimen if clinically necessary.


MOISTURE CHAMBERS

The severe forms of dryness require moisture chambers to prevent significant evaporative losses, i.e., CPAP users, Bell's palsy patients, etc. Placing the moisture chambers includes adding a lubricating ointment on the eye's surface and placing a Tegaderm film over the eyelids. This process prevents evaporation and increases humidity that allows the eye to maintain its lubrication.



Nighttime moisture chambers



PROGNOSIS

Dry eye is a very complex and multifactorial disease process. Attention to the ocular exam, medical history, and exacerbating causes is crucial to developing a treatment plan that will increase comfort and diminish symptoms. There is no cure, but with great effort from the ophthalmologist, dry eyes and can be controlled.



Animation videos



Dry Eye Animation:



By: Tear science lipiflow



This video shows the most common cause of dry eye and provides an option for treatment



Tear Film Animation:



Tear Layer Animation - Shows the Three Layers of the Tear Film





DHR Health Eye Institute



4500 North 10th Street, Suite 100, McAllen, TX 78504
Phone: 956-362-2070
Fax: 956-362-2074