Eyedolatry: Dry Eye

Yes America, Playing Video Games Does Cause Dry Eye

Burning, red, and watery eyes: that's what I've always experienced just a short time into video game play. And with 27% of Americans playing video games at least a few hours each week, it's no surprise that dry eye syndrome is increasingly prevalent across all ages. Newly published research has confirmed what many eye doctors hypothesized to be true: video game play does result in dry eye, even among young and healthy individuals.

The study evaluated 41 college students who played video games over a 4 hour time window, with a 5 minute break every hour and fluid intake of "no more than" 2 cups during that time frame. All study participants played the game within a dedicated lab room which was monitored for consistent temperature and humidity to make sure that was not a confounding factor. Dry eye tests were performed before video game play and after; these tests included SPEED and OSDI questionnaires, Snellen Visual Acuity at distance and near, Tear Film Osmolarity (Tear Lab), Schirmer test without anesthesia, and Matrix-Metalloproteinase-9 (MMP-9) levels (Quidel).

At the end of the 4 hours of video game play, there was a statistically significant worsening in SPEED score index and MMP-9 levels for participants. The average SPEED score for participants nearly doubled at the end of the gaming window, with average soreness and irritation increasing 3x compared to baseline, and the frequency and severity of eye fatigue complaints doubling compared to baseline. Of the participants who had normal MMP-9 levels before gaming, 36% of participants had elevated levels after gaming. MMP-9 is an inflammatory biomarker found in the tear film that is elevated in patients with dry eye syndrome.

This is the first known study to prove that video game play specifically causes dry eye symptoms. Based on the 36% of participants who had changes in their MMP-9 levels after game play, in some individuals video game play can even trigger inflammatory changes to the eye. Because dry eye syndrome is so multi-factorial, it's important to understand the environmental situations that create more risk for your eyes so that if you suffer from chronic or severe dry eye syndrome you can appropriately modify your exposure to these high risk environments. The Tear Film and Ocular Surface Society Lifestyle Report identified environment and lifestyle as major contributors to dry eye/ocular surface disease - with windy environments, higher levels of air pollution, and digital screen use all being identified as exacerbating factors. Check out the full TFOS Lifestyle Report to learn more.

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Which Screen is Best for Your Eyes?

best screen for eyes 15:12

Whether you are working, reading, or mindlessly scrolling social media, screens are our constant companion these days. If you've noticed your eyes are feeling more tired, dry, and irritated than ever, that's because of our new best friend the screen as well. In order to keep our eyes hydrated, our body is internally wired to blink roughly every 13 seconds, releasing the oil that makes up our tear film with every blink. But when we are looking at screens, our blink rates plummet by as much as 66%, meaning less tear film released onto the surface of the eyes, and thus drier eyes. As expected, studies show that people working and reading on screens report significant discomfort. In a 2018 study of 100 medical school students, screen time caused 58.8% of participants to experience eye strain and fatigue, 23.3% reported headaches, and 13% reported blurry vision. In this same study, 75% of the medical students involved stated they would reduce their screen time as a measure to prevent dry eye.

Which screen is the best for your eyes? Studies show that smaller screens with lower brightness settings, like e-readers or smartphones are the best for visual comfort and ocular surface health!

But reducing screen time may not be that easy. Since the onset of the COVID19 pandemic, average screen time use in the United States has skyrocketed, with reports indicating that the average American adult (age 18+) is spending over 13 hours per day looking at screens. That's up from roughly 10 hours per day reported in 2019 and 8.4 hours per day in 2018. Knowing that cutting screen time when we're being asked to work from home, attend school from home, and entertain ourselves from home is extremely difficult, can we potentially reduce our symptoms of dry eye by at least choosing the least irritating device to look at?

A new study published in Optometry and Vision Science explored just this and found that the screen that you use does in fact matter! The study looked at the ocular surface health and comfort of 31 healthy adults between age 20 to 26 after reading on a variety of different devices. Baseline measurements of each participant's ocular surface was taken before using any screen time, including the Ocular Surface Disease Index (OSDI) questionnaire, the Computer Vision Syndrome Questionnaire, tear meniscus height, Schirmer test, noninvasive tear break-up time, tear film osmolarity, bulbar injection (redness), and pupil size. Participants were then asked to read for 15 minutes on a laptop computer screen, tablet, e-reader, or smartphone and the ocular surface measurements and questionnaires were repeated.

The Results

The very best ocular surface health and reported comfort were found when participants read on e-readers or smartphones. Reading on the laptop computer produced the worst disturbances of both ocular surface findings and questionnaire indices. Statistically significant differences were seen between computer use and e-reader/smartphone use in both the OSDI and the CVS-Q questionnaire, tear meniscus height, Schirmer test results, and tear break up time. Tear film osmolarity (a measurement of inflammation) and conjunctival injection (redness) was highest after computer use, followed by e-reader use, and then smartphone use.

Interestingly, the study also compared these results with and without the use of artificial tears. Using artificial tears had no statistically significant effect on any of the ocular surface findings.

Why does using an e-reader or a smartphone help reduce dry eye signs and symptoms over reading on a computer?

Study author Cristian Talens-Estarelles, MSc writes that the improved dry eye results with e-readers and smartphones are most likely "attributed to a lower gaze angle and the enhanced optical properties of the e-reader," noting that "the e-reader reflects rather than emits light from behind the screen, similar to how a printed paper behaves."

The advantages of reading from a smartphone or e-reader on the comfort and ocular surface health of our eyes include:

Smaller screen size. While it may be tempting if your eyes are bothering you to request a larger or even second monitor for work, thinking that a bigger viewing area will make things easier, the science actually shows making monitors larger or using multiple screen monitors is much more uncomfortable for the eyes. In a survey of more than 10,000 adults, only 53% of Americans working on a single screen experienced digital eye strain symptoms, compared to 75% of Americans who used multiple screens. Larger or multiple screen monitors require our eyes to be open wider and slow blink rate down as our brain focuses on peripheral vision to scan between multiple displays.
Lower angle of gaze. Research shows that viewing screens with a downward gaze is the most comfortable for the eyes because it encourages a more natural blink rate. Ergonomic research suggests and optimal screen height of 15-20 degrees below eye level. A disadvantage of larger and multiple screen monitors is that they are typically positioned directly at eye level instead of in this downward position of gaze which increases discomfort significantly.
Lower brightness levels. Reflections from our screens can cause significant visual discomfort, and studies show the screen we are looking at should never be brighter than the ambient room lighting. E-readers and smartphones, especially when Night-Shift mode is enabled, are superior options at reducing reflections and screen brightness to create a more natural viewing environment.

And with any screen use, don't forget taking breaks is the most important thing you can do. For every 20 minutes that you are working, reading, or playing on a screen, you should take a 20 second break to blink and look down a hallway or out a window (20 feet away). This is called the 20/20/20 Rule and research shows it's our best protection to keep eyes comfortable and blinking more naturally!

It's all about the blinking when it comes to keeping eyes happy. Study link here

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Omegas and Dry Eye: The Science Behind the Supplements

Dry Eye 11:44

We are what we eat, as the old saying goes, and as researchers delve deeper into chronic inflammatory conditions, the impact of our diet is hard to ignore. Dry Eye Syndrome is the most common chronic inflammatory condition of the eye, affecting an estimated 20-30 million Americans. The name “dry eye” is a bit of medical misnomer – we know now that the underlying mechanism is an inflammatory disruption of the ocular surface and tear film, causing symptoms ranging from dryness, watering, redness, fluctuating vision, burning, foreign body sensation, and chronic pain and discomfort. There are over 80 inflammatory molecules that have been identified in the human tear film, including cytokines, growth factors, interleukin, and macrophages. These inflammatory mediators are there naturally to protect and heal the eye from infection and injury, but external factors that increase or promote those normal inflammatory molecules can tip the scale for the body to begin chronically attacking itself. For many, simply using over the counter artificial tear drops provides no more than temporary relief of their symptoms; treating the underlying inflammation that’s causing discomfort is the true path to relief.

Dry eyes are often watery - the corneal nerves feel dryness, and create a watering response to try to help heal the corneal tissue. via

And that’s where we circle back to diet. Research has shown Americans have an exceedingly pro-inflammatory diet, increasing our risk for chronic conditions like dry eye as well as cardiovascular disease, diabetes, and chronic inflammatory conditions. If you’re a dry eye sufferer, what dietary choices can help you find relief?

Omegas and Inflammation

The most compelling dry eye research on nutrition focuses on omega fatty acids. They are essential dietary nutrients, but as humans we have to get all of our omega fatty acids from our diet – we are unable to synthesize our own. Omega fatty acids have a primary function in lipid (fat) metabolism, but also have anti-inflammatory actions such as lowering the blood stream concentration of inflammatory mediators like C-Reactive protein, interleukin, and tumor necrosis factor. Predominantly it’s the omega 3 fatty acids that we associate with having this anti-inflammatory action; these nutrients are found in fish, eggs, and flaxseed oil. But there is also an important omega-6 fatty acids that also works to combat inflammation, This omega-6, GLA (gamma linolenic acid), is largely absent from our diet, and not found in oils from fish or flaxseed. GLA is obtainable only from a few sources such as borage seed oil, evening primrose oil,and black currant seed oil.

Unfortunately the American diet is loaded up with another omega-6 called arachidonic acid (AA) – a potent pro-inflammatory that’s abundant in meat and dairy. Arachidonic acid is so central to inflammation, that its metabolism is the target of nearly all NSAIDS, from aspirin and ibuprofen to Celebrex (celecoxib).

It’s commonly assumed that all omega-6s are unhealthy– and many have heard that a better ratio of omega-3 to -6, can help reduce inflammation. However, it’s important to remember that this only applies to the inflammatory dietary omega-6 that's so common in our diet in meat and dairy products. Anti-inflammatory omega-6 like GLA is mostly lacking in our diet.

Why not just take Omega 3 fatty acids alone?

Most supplements on the market for dry eye focus on fish-oil derived Omega 3 fatty acids like ‎Eicosapentaenoic acid (EHA) and ‎Docosahexaenoic acid (DHA). There’s abundant research supporting the anti-inflammatory effects of omega 3 fatty acids, so why is the addition of GLA beneficial for dry eye? Gamma-linoleic acid (GLA) specifically gives rise to prostaglandin E1 a potent anti-inflammatory which also stimulates tear production (Pholpramool, 1979, 1983). Prostaglandin E1 inhibits several types of tumor necrosis factor, interleukins, and leukotrienes in the tear film.

When GLA and EPA are combined in the proper balance, they work in conjunction to promote anti-inflammatory prostaglandins E1 and E3 and inhibit pro-inflammatory prostaglandin E2. The result is an increase in tear production, and a reduction in surface inflammation.

The Research and Results

Let’s be honest, when is the last time you topped off your lunch of Siberian pine nuts and salmon with a black currant seed oil dressing? So changing to a perfect diet is ideal yes, but perhaps not easy enough to be feasible for the average American. Reducing your dietary pro-inflammatory intake is an excellent starting place, but you’ll also likely need to supplement with anti-inflammatory sources of omega 3 and 6 fatty acids. The HydroEye Study was published in 2013 by Dr. John Sheppard and Dr. Stephen Pflugfelder. Thirty eight post-menopausal patients with moderate to severe keratoconjuncitivis sicca (dry eye) were started on a supplement of omega 6 gamma-linolenic acid and omega 3 polyunsaturated fatty acids or placebo for 6 months. They were evaluated for dry eye improvement with standard diagnostic tests including Ocular Surface Disease Index (OSDI), Schirmer test, tear breakup time, conjunctival fluorescein and lissamine green staining, as well as the expression of inflammatory cellular indicators dendritic cell CD11c integrin and HLA-DR (a key dry eye indicator) in conjunctival compression cytology. At 12-24 weeks, the supplement group had clinically significant improvement in symptoms (as measured by OSDI scores) versus placebo, significantly lower HLA-DR intensity and CD11c expression , and smoother corneas, as measured with topography (SAI Index).

There’s abundant research supporting the combination of omega 6 gamma-linoleic acid (GLA) and omega 3 fatty acids in the improvement of both the signs and symptoms of dry eye. A 2003 study followed patients for 45 days taking supplements versus placebo, and the supplement group had improved symptoms, corneal and conjunctival staining, and ocular surface inflammation mediator expression. A 2008 study of contact lens wearers with dry eye given evening primrose oil (an omega 6 fatty acid) for 6 months versus placebo (olive oil in this case) showed improved symptoms of dry eye, tear meniscus height, and improved contact lens comfort.

But what about Meibomian Gland Dysfunction?

Meibomian gland dysfunction is the most common underlying component of dry eye, with an estimated 86% of dry eye sufferers having Meibomian gland dysfunction. Studies show omega supplementation improves this underlying cause of dry eye as well. A 2007 study showed improvement in meibomian gland function with oral omega-6 supplementation of linoleic acid and gamma-linoleic acid over 180 days. A group of 57 men and women with previously diagnosed Meibomian gland dysfunction were separated randomly into 3 groups: Group A received tablets containing linoleic acid (28.5 mg) and gamma-linolenic acid (15 mg) once daily, Group B performed eyelid hygiene once daily, and Group C received both treatments. All groups had improvement in signs and symptoms of Meibomian gland dysfunction, but Group C that combined lid hygiene and supplements had the biggest statistically significant improvement in lid inflammation, including lid margin edema, Meibomian gland turbidity, and corneal staining.

Take Home

Managing dry eye is complicated, and turning the lens on managing your diet is a logical source contributor, but doesn’t make change any easier. Nutritional supplements have shown to make significant impact on the signs and the symptoms of dry eye as early as within 60 days of routine use. At my practice, we recommend HydroEye supplements because its’ formula combines both GLA with Omega-3s from fish oil for a maximized anti-inflammatory effect. If you are suffering from dry eye, there’s really no risk in trying this supplement – ScienceBased Health offers a 60 day money back guarantee. The supplement also combines vitamins Cs and B6, plus magnesium to promote fatty acid metabolism (and help convert GLA to important prostaglandin E1), and vitamin A to for tear film mucin support. What you can’t do if you suffer from dry eye is ignore your symptoms in hopes that they will improve on their own. Dry eye, like all chronic inflammatory diseases, only worsens and becomes harder to treat as inflammation lingers unchecked for longer periods of time. Unlike over the counter eye drops that can’t change the inflammatory chemistry of the ocular surface and tear film at the root of your discomfort and visual symptoms, dietary supplements and changes to your daily food choices can help reduce your inflammation from the inside out. The eyes are a part of the body, and dry eye is just an expression on inflammation going on elsewhere. Approach it from the source for the best chance of relief!

If you are an optometrist interested in trying out HydroEye for yourself and your patients, head here to get your free 60 day sample!

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Take it All Off: We Love Eyes Delivers All-Natural Make-Up Removal

Dr. Tanya Gill 7:44

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Dry Eye Relief Without A Prescription: The Science Behind Retaine MGD

artificial tear 7:00

Overwhelmed by over the counter rewetting drop products? You aren't alone. My patients repeatedly come in confused by the selection on the shelf, and often using the completely wrong product for their personal ocular needs. If your eyes are dry, watery, scratchy, irritated, red, filmy or just overall uncomfortable, you likely have dry eye. A trip to your local eye doctor can confirm this diagnosis. But what eye drops should you be using to combat this dryness? Not all products are created equal, and Retaine MGD is definitely one of the best choices out there if you are suffering from chronic dry eye or meibomian gland dysfunction. Not only is it preservative free (meaning no irritation from the harsh preservatives bottled eye drops require to keep pathogens from growing inside), but its chemical design is made to provide the best lasting comfort of any over the counter drop on the market by simulating how our natural tear film attracts to the surface of the eye.

Note the slightly whitish hue of the drop inside? That's because this product isn't water or saline but an oil-based emulsion that's made to act like a restorative version of your own tear film.

Retaine MGD is an ophthalmic emulsion which separates it from the other liquid and gel based tear drops you've been using in the past. Emulsions are oil or lipid based, just like your normal tear film which is made up of oil and lipid secretions that are released from the meibomian glands in your top and bottom eyelid with every blink. This is why saline or water are terrible to use for dry eye -- your eye doesn't need water (and especially not salt water!!); it needs something as close to natural tear film as possible. Just like our natural tear film, Retaine MGD's lipid emulsion uses electrostatic attraction to bind to the corneal epithelium, spreading evenly and staying there to provide the relief your eyes are craving.

But it's not just scientific theory; it's proven to work!

A 2015 clinical study followed 42 patients previously diagnosed with dry eye over the course of just 2 weeks. Subjects were instructed to insert 1-2 drops of Retaine MGD twice daily, once in the morning and once before bed. They were instructed to keep a record of how their eyes were feeling before putting in the drop at each application. At the end of two weeks, patients had statistically significant reduction in their pre-treatment signs and symptoms of dry eye, including ocular surface fluorescein staining, conjunctival redness, and self-reported symptoms of "dryness," "grittiness," and "ocular discomfort". Patients also reported statistically significant improvement in their ability to work on a computer at night. Other quality-of-life indices also showed improvement at the end of the 2 week study, including the ability to read at night, drive at night, and watch TV at night, but these improvements were not statistically significant.

Ocular surface staining is a commonly used dry eye assessment. NaFl (fluorescein) dye will only stick to damaged cell walls, allowing your eye doctor to see just how dry and damage your ocular tissue truly is. The above example shows severe dry eye staining. image via

So we know using the drop just twice a day improves the clinical signs and the symptoms of dry eye, but what did people think about the drop itself? Many products for dry eye, both prescription and over the counter, come with significant comfort complaints -- meaning patients don't actually like to use them. That's a problem if we're trying to get a product to work; it won't do anything sitting in the back of a bathroom drawer. But this study showed that patients found Retaine MGD both comfortable and non-invasive to vision. Only 2% of study participants used only negative words (listed in red below) to describe their experience with the drop. As a side note, you can see many people listed burning as a side effect, despite the fact there are no preservatives in this drop. Just goes to show you that people with significant dry eye are super sensitive to anything coming in contact with the ocular surface (just look at that picture of corneal staining again if you are wondering why that is). I tell my patients that if this drop burns, it means their eyes are so badly damaged by dryness that even the gentlest product is going to feel sensitive to them, and if they stay diligent with using their prescribed dry eye treatment we would expect sensitivity to improve as the ocular surface begins to heal.

What's even better about Retaine MGD? It's doctor recommended but you don't need a prescription. You can pick it up from your local eye doctor's office if they have an account with OCuSOFT, at your local Walgreens (and soon to be available in CVS), and online direct from OCuSOFT's website. The vials are also now re-capable, which means you can use the generous amount of drop inside each vial for your all day dry eye needs. Just used twice a day, you can expect significant results in only 2 weeks. Take the challenge for yourself and feel the difference!

Disclaimer: OCuSOFT did provide me with samples of Retaine MGD for the purpose of this article and currently serves as a Platinum Sponsor for Eyedolatry. All opinions written in this article are my own.

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Dry Eye Syndrome: A Photographic Review

blepharitis photo 10:59

If you have been diagnosed with dry eye, which 48% of Americans experience according to this study, your doctor has probably tried to describe the underlying cause of your dryness. You knew your eyes were feeling badly: itching, watering, redness, burning, pain, dryness, or blurriness between blinks are all common symptoms of dry eye syndrome. Now it is your doctor's job to find a way to make your eyes feel better and perform more optimally. In order to do that, they have to know what is causing your dryness. Current literature often breaks down dry eye syndrome as one of 2 categories:

Aqueous Deficient Dry Eye: Basically this means you aren't making enough tear film. In many cases this is associated with conditions like Sjogrens Syndrome where inflammatory mediators are reducing both tear and saliva production
Evaporative Dry Eye: Basically the tears that you make just dry right up off the ocular surface. This type of dry eye means you are producing tear film, but the tear film is missing the proper components to stay long enough on the eye.

If you are an eye doctor, you know these generalized break downs are way too simplistic, and usually a person has multiple causative dry eye factors. Evaporative dry eye is typically associated with issues with the oil glands of the eye, called Meibomian Gland Dysfunction. Every time you blink, these meibomian glands that lie in the eyelid secrete the oily top coat of the tear film that keeps tears on the eye. Studies suggest that as much as 60% of dry eye sufferers have Meibomian Gland Dysfunction as a major cause of their symptoms. This means that when I am checking your eyes for dryness, I look even more closely at your eyelid, where these meibomian tear glands are. What exactly am I looking for? Well, luckily I have a few patient pictures to illustrate:

Inspissated Meibomian Gland

A clogged, or inspissated, meibomian gland is a very common finding. In many cases, I will find one or two on the eyelids, but the patient will only have mild complaints associated with dryness. They will describe some itching along their lid margin, maybe some end of day dryness or intermittent blurry vision between blinks. They may have a history of styes (clogged meibomian glands that get infected with bacteria). I have even had some patient tell me that they see these in the mirror (great eyesight) and try to pop them! The best way to fight clogged meibomian glands is to use a warm cloth massage or eyelid cleansing product like Ocusoft eyelid pads or foam nightly before bed. This will open up the gland and let all of that nice tear film flow freely onto the eye again!

Posterior Blepharitis

This is obviously a bit more advanced. Not only is there significant blockage of every meibomian gland on this person's eyelid, but there is a ton of inflammation! Blepharitis is a common word in eyecare that translates in layman's terms to eyelid inflammation. All that redness? That's inflammation. This person is going to complain about sore or even puffy and swollen eyelids, and typically has some significant complaints with dryness, burning, and redness. Warm massages and lid cleansers are still used in this patient, but typically an anti-inflammatory treatment like steroid drops or ointments, or oral doxycycline would also be used at this point.

Chronic Infammation -- classic for Ocular Rosacea

Compared to the preceding photo, this person also has redness, but there is a pretty big difference here. This is a patient with ocular rosacea, a condition associated with chronic dryness and inflammation. Typically there are other facial areas of rosacea as well. The big give away? Those squiggly blood vessels on the eyelid margin are called telangiectasia, a hallmark of rosacea. This patient will typically have chronic, persistent dry eye complaints but get little relief from lid massages and warm compreses in my experience. Anti-inflammatory treatments like steroids or Restasis are typically the preferred treatment route, and oral treatments like doxycylcine are especially popular because they also improve facial patches of rosacea.

Long-standing Dry Eye

This is a great example of how a patient with chronic inflammation and meibomian gland issues looks. This eye has hallmarks of old inflammation (notice the faint telangiectasia by the lash roots), but no acute inflammation at the moment. The inflammation has subsided, but the meibomian glands still fail to function ideally. How can I tell? The glands towards the middle of the picture have a hardened, white center. If the patient blinks, or I put pressure on the lid at that area, there will likely be NO tear film coming out. This patient will still have dryness, because the glands aren't functioning like they should! At this point in the patient's treatment plan, we are turning to more chronic therapies. The inflammatory cycle has been broken so steroids and doxycycline will give less results, but the glands still aren't normalized. Sometimes treatment like Restasis that helps the body make more tear film, or new treatments like Lipiflow that pumps the meibomian glands open may be effective, but there is no permanent cure. This person will have a lifetime of battling their dry eye due to their poorly active meibomian glands. Once the glands have been damaged, their function may never be restored. That's why treating dry eye early and aggressively is so important!

There is no cure for dry eye or meibomian gland dysfunction, but new treatments to combat these signs and symptoms are being developed every day. Talk to your doctor if you have any of the symptoms of dry eye. Ask if they have external photography that can show you what factors are causing your dryness (or if they can describe what they see if they don't have a camera)! Your doctor is an eye specialist, trained to treat these conditions and educate you on your personal cause factors. External photographs like the ones featured here are a great way of tracking progress with treatments, and to educate patients about their personal culprit causing their dry eye symptoms. Keep in mind that not all insurances cover these photographs, unfortunately-- only medical insurances and NOT vision insurances will cover medical treatment or diagnosis of dry eye. By working with your doctor and trying different treatment plans geared toward your dry eye root cause(s), there is a way to manage these symptoms and achieve relief.

Look closely at your eyelids; if they are red or you notice clogged glands, you need to see your doctor to combat these issues early. The earlier we treat the causes of dry eye syndrome, the less likely you are to have permanently damaged meibomian glands (and permanent dry eye symptoms!).

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Yes America, Playing Video Games Does Cause Dry Eye

Which Screen is Best for Your Eyes?

It's all about the blinking when it comes to keeping eyes happy. Study link here

Omegas and Dry Eye: The Science Behind the Supplements

Take it All Off: We Love Eyes Delivers All-Natural Make-Up Removal

Dry Eye Relief Without A Prescription: The Science Behind Retaine MGD

Dry Eye Syndrome: A Photographic Review

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