What is Dry Eye?
Dry eye is a progressive multifactorial medical condition of the ocular surface with health and lifestyle consequences when left untreated. According to the 2017 TFOS DEWS II report, over 30 million Americans suffer from dry eye disease with an estimated 6 million of them going undiagnosed or reporting no symptoms.
In simpler terms, dry eye is the dysfunction of one or many of the components that keep your eyes comfortable and clear. To keep your eyes moist, your glands, tear ducts, eyelids and surrounding systems need to work in harmony. When one of them doesn’t work correctly, the tear film and surface of your eye are affected and you start getting dry eye symptoms.
Even though many things may cause dry eye, meibomian gland dysfunction (MGD) is considered to be the primary cause.
Common symptoms of chronic dry eye include:
- Unstable, fluctuating, or blurry vision
- Environmental sensitivity to wind, dust, glare (increased symptoms on airplanes or cars)
- Burning or stinging of the eyes
- Tired or fatigued eyes
- Sandy or gritty feeling
- Foreign body sensation
- Watery eyes or excessive tearing
- Sticky eyes
- Sore Eyes
- Irritation or pain
- Light sensitivity or photophobia
- Contact lens intolerance or reduced wear time
- Reduced near-work or reading time
Dry Eye is caused primarily by:
- Unstable or poor quality tear film, also called Evaporative Dry Eye (EDE)
- Insufficient tears, also called Aqueous Deficient Dry Eye (ADE)
Other factors may also contribute to dry eyes symptoms:
- Age – dry eyes are a part of the natural aging process. The majority of people over age 65 experience some symptoms of dry eyes.
- Gender – women are more likely to develop dry eyes due to hormonal changes caused by pregnancy, the use of oral contraceptives and menopause.
- Medications – certain medicines, including antihistamines, decongestants, blood pressure medications and antidepressants, can reduce tear production.
- Medical conditions – people with autoimmune diseases like Rheumatoid Arthritis, Sjögren’s Syndrome, Scleroderma, Lupus, thyroid problems and even sometimes diabetes are more likely to have symptoms of dry eyes. Also, problems with inflammation of the eyelids (blepharitis), inflammation of the surfaces of the eye, in-turning/out-turning of the eyelids (ectropion/entropion) or meibomian gland dysfunction (MGD) can cause dry eyes to develop.
- Environmental conditions – exposure to smoke, wind and dry climates can increase tear evaporation resulting in dry eye symptoms. Failure to blink regularly, such as when staring at a computer screen, iPad or smartphone for long periods of time, can also contribute to drying of the eyes.
- Contact lens use or previous history of eye surgery – long-term use of contact lenses can be a factor in the development of dry eyes. Refractive eye surgeries, such as LASIK, can decrease tear production and contribute to dry eyes.
- Screentime – reading, staring at a smartphone or computer, driving and other similar activities require concentration which tends to make people blink less often or make them do incomplete blinks, therefore leading to increased tear evaporation.
Tear film has 2 very important functions:
- Visual: ensure you have crisp and stable vision by keeping the surface of your eye moist, smooth and clear so that light can be easily focused onto the inside of your eye. If you ever felt letters are dancing around, you have experienced unstable tear film.
- Protective: maintain the integrity of the cornea so that you are not bothered by wind, dust, air conditioning and vents. Tear film help wash away foreign matter, rinse away dust particles and protect your eyes from bacteria that can cause infections.
Without a stable tear film, you will experience dry eye symptoms. The eyes will have more difficultly functioning normally and keeping your vision clear in all types of environmental conditions, regardless of how high/low the humidity is or how hot/cold the temperature gets.
Dry eye is ultimately the dysfunction of the tear film. The tear film is a complex system that is comprised of the:
- Mucin layer: this mucous layer provides a “sticky” foundation and acts as a barrier to the eye surface
- Aqueous layer: this “watery” layer is produced by the lacrimal glands and provides moisture to the eye
- Lipid layer: this “oily” layer is produced by the meibomian glands and prevents the tears from evaporating
Each component needs to work in balance and harmony to keep the tear film stable. When you have an imbalance in these layers, the vision and comfort of your eyes are affected. Our doctor will evaluate what is causing the disruption in your tear film that makes you suffer from dry eye.
If you imagine the tear film like you would building a house:
- the mucin layer is the foundation
- the aqueous layer is the beams
- the lipid layer is the roof
When you have dry eye caused by meibomian gland dysfunction (MGD), your glands are clogged and are not producing enough lipid layer, meaning your roof has been compromised. With holes in your roof, you can’t maintain stable temperature in your house. Cool or hot air would escape out.
As such, when your lipid layer is compromised, your tears evaporate too quickly. You have to fix the roof (the lipid layer) for the house (the tear film) to be structurally sound and for you to live comfortably.
Blepharitis is an inflammation of the eyelids in which they become red, irritated and itchy and dandruff-like scales form on the eyelashes. It is a common eye disorder caused by either bacteria, a skin condition (such as dandruff of the scalp or rosacea) or demodex (eyelashes mites). It can affect people of all ages. Although uncomfortable, blepharitis is usually not contagious and generally does not cause any permanent damage to eyesight.
Blepharitis is classified into two types:
- Anterior blepharitis occurs at the outside front edge of the eyelid where the eyelashes attach.
- Posterior blepharitis affects the inner edge of the eyelid that touches the eyeball.
It is currently unclear whether blepharitis causes dry eye or dry eye causes blepharitis.
Blepharitis is often associated with either or both:
- Demodex mites: when bacteria multiply and overgrow at the margins of the eyelids and at the base of the eyelashes, a biofilm is formed. Biofilm is a toxic environment similar to plaque that forms on your teeth, from which parasitic eyelash mites called demodex can feed on. When untreated, demodex create a vicious cycle that worsens the eyelid inflammation and causes more dry eye symptoms.
- Meibomian gland dysfunction: bacteria in the eyelid biofilm produce substances called exotoxins that cause inflammation of the meibomian glands. Over time, inflamed meibomian glands become obstructed, which causes (and worsens) dry eye discomfort.
Demodex refers to 2 types of microscopic eyelash mites that live on humans:
- Demodex folliculorum, which live within hair follicles on eyelashes
- Demodex brevis, which live in sebaceous glands (oil glands) in the skin around the eyes
Most of the time, these mites are harmless and will go unnoticed. However, when they multiply and their population get out of control, Demodex can cause many ocular diseases like conjunctivitis, chalazia, blepharitis and contribute to dry eye symptoms, including eyelid itchiness and falling eyelashes.
These mites can also cause unwanted symptoms and skin problems like rosacea, androgenetic alopecia, non-specific facial dermatitis (acne-like blemishes). Demodex is transferred between hosts through contact with hair, eyebrows, and the oil glands of the face.
Meibomian gland dysfunction (MGD) is a common eye condition when the meibomian glands in your lids are clogged or have been compromised by chronic inflammation, demodex infestation, long-term use of contact lenses or failure to blink regularly when using digital device use without breaks.
When blocked, the meibomian glands secrete too little or no oil (meibum), which is needed to stabilize your tear film and help avoid your tears from evaporating too quickly.
Meibomian gland dysfunction is considered to be the primary cause of dry eye and is estimated to affect 86% of dry eye patients.
When available, an optometrist can check the structural quality of your meibomian glands by taking pictures of the inside of your lids with a meibographer as shown below.
- When the meibomian glands function properly, they will secrete clear oil naturally every time you blink to create a stable tear film.
- When blocked or clogged, the meibomian glands secrete little to no oil. Instead, they will secrete unhealthy crusty, pus or toothpaste-like oil when expressed with forceps.
- When left inflamed or clogged for too long, the meibomian glands may atrophy and die off. At that stage, you will suffer irreversible and permanent dry eye symptoms.
Treatment for Dry Eyes
Depending on the cause and severity of your dry eye, our optometrist will recommend one or a combination of both in-home and/or in-office treatments.
Most treatments will follow one or multiple treatment pathways:
- Adding tears – for mild cases, using over the counter artificial tears to supplement natural tear productions will provide immediate relief and can be used as often as needed. Preservative-free tears are preferred to minimize additives that may further irritate the eyes
- Conserving tears – for Aqueous Deficient Dry Eye (ADE), using punctal plugs to block the tear ducts or cauterization (sealing) of the tear ducts through which the tears normally drain will help keep available tears on the eye longer and will reduce dry eye problems
- Improving tears homeostatis with nutritional support – Omega-3 possess anti-inflammatory effects and may help positively impact meibomian gland secretion. Avoiding antihistamines or acne medication (unless necessary) and drinking more water will also improve overall hydration of the body and eyes. We recommend omega-3 in re-esterified (rTG) form such as PRN De3 in pills or liquid form or Nordic Naturals EPA Xtra for effective dry eye treatment.
- Treating eyelid or ocular surface infammation and blockage – Our eye doctor may prescribe:
- Eyelid cleansers like Avenova® to reduce microbial and bacterial overload on the lids and restore healthy flora around the eyes
- Tea tree oil cleansers like Eye Eco Gentle 1% Tea Tree Facial & Eyelid cleanser to address demodex overpopulation and general lid hygiene
- Medication like Xiidra™, RESTASIS® or Cequa™, topical steroids like Lotemax® and/or antibiotics like docicycline to decrease inflammation
- Warm compresses like the Eye Eco DERM® mask followed by lid massage for in-home meibomian gland blockage relief
- TearCare® for in-office treatment of meibomain glands obstruction
- ZEST® (Zocular Eyelid System Treatment) or BlephEx™ for in-office treatments of blepharitis and demodex
- Referral for Intense Pulsed Light (IPL) therapy to address chronic eyelid inflammatory disease usually associated with ocular rosacea and chronic demodex infestation
What is TearCare®?
TearCare® is a blink-assisted device that provides adjustable heat to the eyelids in order to liquify and remove blockage associated with meibomian gland dysfunction (MGD). The procedure stimulates lipids (oil) to naturally flow again after each blink, as to restore the normal function of the tear film. The treatment is done in-office and will last 25-45 minutes:
- Depending on your condition, our eye doctor may start you with lid debridement, which is the scraping and exfoliating of your lid margins to uncap your meibomian glands’ orifices
- Controlled heat with a consistent and therapeutic temperature of 41-45°C (105.8-113°F) will be applied to your eyelids for 15 minutes with TearCare®. You should keep blinking vigorously to stimulate natural clearing of your meibomian glands
- Our optometrist will then manually express and unblock any remaining clogged meibomian glands
There are currently only 4 treatment options available on the market that are based on the tried and true method of applying heat to the lids and expressing the meibomian glands:
- Lipiflow® from Johnson & Johnson Vision
- TearCare® from Sight Sciences
- iLux® from Alcon
- Thermoflo I and Thermoflow IIx dual from MiBo Medical Group
Our office has selected TearCare® as the best treatment for our patients due to its:
- Proven effectiveness
- Ability to work equally well with both large or small eyelids
- Open-eyes system which allows patients to keep the eyes open during the treatment
Other adjunct meibomian gland therapies exist but they use different pathways for dry eye relief. Most of them are based on lid debridement and/or reduction of inflammatory markers. You can find them named as: BlephEx, NuLids, IPL (Intense Pulsed Light)… etc.
Please consult your optometrist or ophthalmologist to discuss which would work best for you. Not all therapies will be available in your area or at your local eye doctor’s office.
Normal functioning meibomian glands secrete clear oil. Clogged meibomian glands produce crusty, toothpaste-like or pus-looking meibum.
Clogged meibomian glands will make your eye easily sensitive to environmental factors such as wind, dust, air conditioning etc… Your vision won’t be as crisp because the tear film is unstable, which does not allow the light to reflect correctly and consistently onto your retina.
Studies have shown TearCare® can provide dry eye relief from meibomian gland dysfunction (MGD) for 6 months to a year. Some patients who’ve tremendously enjoyed TearCare® have asked how often they can do it. Based on their individual needs, we can do another treatment every 3 months.
Meibomian gland dysfunction, when left untreated, can have long-term health and lifestyle consequences:
- Inability to maintain stable and sharp vision, regardless of your prescription power or the quality of the lenses you purchased
- Constant watery eyes
- Contact lens intolerance (you can no longer wear contacts)
- Decrease in quality of life due to your inability to enjoy activities that are affected by wind, air, dust, air conditioning… such as biking, running, traveling by airplane or car
- Increase frequency of blepharitis or other eye infections
- Higher risk of complications from LASIK surgery
- Increased monthly cost in temporary relief treatments such as eye drops, heat masks… etc
- Tired or fatigued eyes
- Burning or stinging of the eyes
At the beginning stages of meibomian gland dysfunction (MGD), you may not have any symptoms. As MGD progresses, your meibomian glands will have decreased function, which is when you feel discomfort and dry eye.
At its worse, meibomian glands that are left inflamed or clogged for too long will eventually atrophy (die off) and our eye doctors may not be able to revive them or bring them back.
A moist warm compress or heated eye mask functions with the same underlying principle as TearCare®:
- Heating the lids to liquify any clogged oil
- Clearing out obstructions in the meibomian glands
Though they target the meibomian gland dysfunction (MGD) root cause of dry eye and provide relief, they are less effective on both counts due to:
- Inability to reach measurable therapeutic temperature of 41-45°C (105.8-113°F) to melt meibum since each microwave has non-uniform power levels and timer settings
- Inability to maintain consistent therapeutic temperature for at least 10 minutes. You constantly have to reheat the warm compress every few minutes as it cools off very quickly
- Less than optimal contact between the warm compress and eyelids
- Difficulty for you to effectively express the meibomian glands through lid massage with your fingers. Most people forget and don’t do the finger lid massage after using the warm compress.
In addition, squeezing meibomian glands with your fingers is like squeezing toothpaste out of tube on a pillow. The back of your eyelids is your eye, which is soft tissue (like the pillow). Anything you manage to squeeze out won’t come out easily.
During your TearCare® treatment, our eye doctor uses forceps (a flat tweezer-like surgical instrument) to provide equal pressure on both sides of your meibomian glands to unclog them. Think of it as squeezing toothpaste out of a tube while placing it on a hard tabletop or counter. It is much easier and faster!
Medications like Xiidra™, RESTATIS® or Cequa™ address the persistent inflammation component of the ocular surface and tear film but does not resolve your clogged meibomian glands or eyelid inflammation. For blepharitis (eyelid inflammation), a hypochlorous acid spray such as Avenova® is faster acting and more effective.
Our eye doctor will determine when Xiidra™, RESTATIS® or Cequa™ is adequate for your dry eye treatment. Depending on your symptoms and cause of dry eye, these medications can be complimentary to TearCare®. Please note that these medications are not always covered by medical insurance, usually require pre-authorization, tend to be expensive and typically take at least 1-3 months to show result.
Starting a regimen on one of these medication is a long-term treatment option and patients should not start it unless they can commit to it.
No, TearCare® does not hurt.
When heat is applied to your lids, patients have described it as a spa-like experience. You will feel an almost immediate heat wave similar to you entering a hot tub. The smart lids will start at 41°C (105.8°F) and will increase 1°C (1.8°F) every 30 seconds until it reaches its maximum therapeutic temperature of 45°C (113°F). If the heat feels uncomfortable to you, we can adjust it and dial it back down.
For the manual expression of your meibomian glands, our eye doctor will apply numbing eye drops and you will feel a gentle squeeze on your eyelids every time the doctor clears your glands with the forceps. Patients describe it as feeling pressure being applied to the lids. It is normal for patients to experience watery eyes and tearing during this portion of the procedure.
TearCare®, similarly to Lipiflow® and iLux®, is considered one of the most effective treatments for dry eye caused by meibomian gland dysfunction (MGD).
You can watch TearCare being performed on “The Doctors” Show. We use the same Mediworks S390L Firefly WDR slit lamp and TearCare technology in our office.
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For additional information, please visit one of the following resources and references:
- Tear Film & Ocular Surface Society, July 2017, TFOS DEWS II® Report
- All About Vision, Dry Eye Syndrome: Symptoms and Causes
- Optometric Management, The Effective and Practical Dry Eye Practice
- International Journal of Clinical and Experimental Ophthalmology, 2017, Faulkner WJ, The Role of Omega-3 Essential Fatty Acids in Dry Eye Disease
- Optometry and Vision Science: official publication of the American Academy of Optometry vol. 92,9 (2015): e350-4. Korb DR and Blackie CA, “Dry Eye” Is the Wrong Diagnosis for Millions
- Modern Optometry, Collarettes Equal Demodex Blepharitis
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