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. 

Redness, pain, blurry vision, gritty sensation, watering - all of these are the common signs of ocular surface disease, better known as dry eye syndrome. Until this year, the only FDA-approved eye drops to treat dry eye were focused on the anti-inflammatory pathway (Restasis 0.05% cyclosporine, Xiidra 5% lifitegrast, and Cequa 0.09% cyclosporine). If you're reading this article, chances are you have tried one or more of these treatment options. Each of these drops have had varying levels of success in helping patients control their signs and symptoms of dry eye, and have common side effects that include redness and burning with drop use. What's more, these drops have to be used long term to achieve symptom reduction and studies show that up to 60% of patients with dry eye syndrome using cyclosporine or lifitegrast discontinue drop use within a year of starting treatment.  Whether due to side effects, inconvenience, or ineffectiveness, this research suggests that many dry eye patients aren't finding lasting relief with the available prescription options for treatment. 

Need a rewetting drop?  Try browsing the eye drop aisle at your local pharmacy and you will immediately find yourself overwhelmed with the number of products available.  Dry Eye Syndrome is one of the most common ocular problems of our generation.  Between endless marathons of computer use and the dryness associated with so many common systemic medications for allergies, high blood pressure, and anxiety or depression, dryness is a way of life for many Americans.  Only your doctor can tell you what kind of Dry Eye you suffer from (yes, there are different types!).  Here's a break down of the best over the counter tears for the underlying causes of your dryness.

Clogged meibomian oil glands are a very common cause of dryness!  Photo via Review of Optometry

Ectropion is very common as the eyelids naturally begin to loose elasticity and sag.

A new study out of Tokyo published in this month's American Journal of Ophthalmology (link here) reports that caffeine may improve tear film secretion.  The true implication for dry eye treatment gleaned from this study's results are obviously in their infancy, but here is a breakdown of what researchers have found:

Pictured in blue is the layer of tear film that coats the surface of the eye,  The tear film meniscus is the  thickness of tears measured at the lower lid margin.  In a patient without dry eye, the tear film meniscus would be greater than 2 mm.  Picture courtesy University of Oxford

Dry Eye Syndrome is a nagging, disruptive condition that a large percentage of patients suffer from.  I know I have been dedicating a lot of posts to this topic, but there is still so much to cover!  For example, most of my patients are very aware of how their work environment or their contact lens routine contributes to their dry eye complaints, but medications that you are taking on a regular basis can have an equal, if not more pronounced, affect on dryness!  That's one of the many reasons that when you go to an eye doctor they inundate you with questions about your overall medical history.  I can look at a patient's medication list and quickly pick out offending meds that are making their dryness more unbearable.  Here are the most commonly used culprits:

This patient's meibomian glands are not even visible due to scarring from chronic dry eye.  Photo courtesy Optometric Mangagment

If you have dry eye, at some point your doctor has probably mentioned Restasis.  I was recently told that Restasis is the most commonly prescribed pharmaceutical eye drop, and that statement doesn't surprise me in the least.  For patients suffering from dry eye, over the counter artificial tears are not always enough to relieve the signs and symptoms of dryness.  If you are having to use over the counter artificial tears routinely more than four to six times a day, then you are in need of more advanced intervention to treat your dry eye.  Restasis is the next step for many doctors, but there is a lot to understand about this drop.

1) When to use Restasis
Depending on who you ask, you are going to get different answers to this question.  Personally, I always treat meibomian gland issues (see this post) first with a combination of warm compresses, lid hygeine, and artificial tears as needed. If the glands start responding to treatment and the patient still is having complaints (dryness, watering, grittiness, sharp pain, etc), I offer punctal plugs or Restasis as the next therapy line.  You will have some doctors tell you that Restasis is best used on post-menapausal women, but I have seen it be effective in men as well, and there is no scientific evidence as of yet to limit the use to a certain population base.  In short, if tears and MGD treatment isn't resolving things, it is time to consider Restasis.



2) How Restasis Works

Vials come in trays, with 1 tray equal to 2 weeks technically, but really this amount will last 1 month if you recap.

I asked this question to my Allergan rep just last week, and he just gave me the simplest answer: "we don't know yet."   What we do know is that Restasis is cylcosporine (a potent anti-inflammatory that has been used in organ transplants in a different concentration).  The goal of this anti-inflammatory is to stop the production of T cells which are inflammatory mediators that are naturally in your tear film.  Chronically dry eyes have these T cells in higher concentration than normal eyes.  Point of interest: the T cell has a lifespan of 180 days, so Restasis should take 3 months to begin to effectively work.  Restasis also helps increase the production of tears, but how this happens is not effectively understood.

3) How to Write the Rx
Allergan provides an Advantage Pack with a card that can be activated for savings on the patient's copay.  This card doesn't work with Medicaid plans unfortunately.  In order to use this savings card, you have to write the Rx for 6 trays/90 day supply.  This is the most cost effective way to write this Rx for your patient!

4) What to Tell Your Patients

• Restasis is to be used twice a day.  Every day. 
•  It burns when it goes in and this is normal for this drop.
• It may take 3 to 6 months for this drop to reach full effectivity.  Some patients may notice relief as early as 3 weeks.
• Because it takes so long for Restasis to become effective, some doctors will start treatment with a more potent anti-inflammatory such as Lotemax dosed once or twice daily for a month.
• Your pharmacist's directions will tell you to throw the vial away after 1 use.  Do not do this.  Recap your vial after your morning dose and store in a clean environment, then use it again for your night time dose.  This will make the 3 month supply your doctor wrote your Rx for really last 6 months.

Recap your vials to get a full day's use (two drops per eye)

Punctal plugs are a concept that sounds quite scary when presented to a patient for the first time, but could have a number of benefits for multiple ocular conditions.  A new article by Review of Optometry features all of the unsung potential uses for plugs.  For a treatment once thought out of date due to the advent of Restasis, more and more doctors are returning to plugs for helping their patients achieve relief from dry eye.  Now we are finding new applications for this quick and painless procedure!

Properly inserted permanent plug

DRY EYE 
We recently discussed punctal plugs and their benefits for patients with dry eye, and Dry Eye Syndrome is still the most popular use for these devices.  Punctal plugs prevent rapid drainage of your own tears through your nasolacrimal tear duct, keeping a healthy layer of tear film on the eye for a longer time.  I especially prefer plugs on patients where there is minimal to no meibomian gland dysfunction and:

• Contact Lens Wearers with poor comfort due to dryness
• filamentary keratitis from advanced dry eye
• pre or post-op LASIK --- a healthy tear film will improve comfort and post-LASIK visual outcome!

Let's face the facts; women report dry eye symptoms more frequently than males in the same age group.  In a study by the American Journal of Ophthalmology, 7.8% of women over 50 report dry eye, versus only 4% of polled men.  The theoretical culprit?
As women go through menopause, androgen levels appear to drop, causing a range of side effects.  In the ocular world, the result is a significant reduction in the production and secretion of tears. We need tears constantly to keep the eye lubricated; these baseline tears are necessary for clear vision and comfort.  Reflex and emotional tearing are a different etiology, and are not the type of tearing we are discussing. Menopause isn't the only time imbalanced hormones wreck havoc on the eye in women; we can also see significant dryness and vision changes during pregnancy!

Treatment Options
If artificial tears and gel drops aren't offering enough relief, there are some more aggressive options to try.  When I prescribe tears for this population, sometimes an artificial tear with supplemental natural tear components like growth factors can be more beneficial than the standard OTC brands.  Viva drops are my favorite tear drop when I am trying to supplement missing components of natural tears.

In this patient population I also really like Restasis.  It tends to perform well in post-menopausal women, and I know some doctors that prescribe it strictly for this population.  Restasis increases tear production by reducing inflammatory mediators that cause poor tear film performance.  Remember, Restasis is a twice a day; every day drop, and sometimes it can take as long as 3-6 months to get relief.  Sometimes when initiating Restasis it is a good idea to pulse with a stronger anti-inflammatory like Lotemax until Restasis has time to get into the system.  Patients are less likely to give up if they see some relief!

A less common treatment involves direct hormone supplementation.  In this 2003 study, Dr. Connor of SCO fame offers testosterone cream as an effective option.  He recommends applying 3% Testosterone Cream twice daily to the eyelids.  No insertion into the eye itself is necessary.  Interestingly, estrogen supplementation is not found to be effective. The extra testosterone helps to counteract the androgen deficit found post-menopause.  After just two weeks of treatment, he reported 50% of patients had improved signs and symptoms.  I haven't prescribed this myself, but in the future if a patient is willing to try, I might have some case studies to report of my own.

We've been talking a lot about Dry Eye Syndrome and its causes and treatments, so I thought it was about time to address punctal plugs!  When my patients can't get relief from their dryness symptoms with artificial tear drops, I always suggest we try either Restasis or punctal plugs as our next option.  Restasis is a prescription drop that improves production of the patient's own tears.  There are some drawbacks however.
Restasis is:

• expensive; most insurances have high copays 
• time consuming; it is dosed twice a day every single day, potentially forever
• takes time to work; in some cases it can be as long as 3 to 6 months before the drop reaches optimum performance

Collagen plugs insert fully into the puncta and are not visible to the patient.  I use Eaglevision Durasert plugs most frequently of this type.

Permanent plugs: I find that the Parasol plugs are very easy to insert and remove.    Oasis is also a very nice brand.

We have covered the Meibomian glands of the eyelid quite in depth now, and how clogged glands are often the culprit for dry eyes.  Remember, those Meibomian glands secrete the oily surface layer of the tear film, that locks the tears onto the eye and prevents evaporation.  There is another gland located higher up in your eye lid area, tucked just under the brow bone, that is responsible for the actual "watery" component of tear production.  The lacrimal gland is responsible for the "aqueous" middle layer of the tears.  This gland is responsible for emotional and reflex tearing, as well as producing the aqueous layer of regular tear film.  So just because you cry easily, doesn't mean you don't have dry eyes.

Red, itchy, watery, inflamed eyes with clogged meibomian glands.  Sound familiar?  Ocular rosacea is very similar to Meibomian Gland Dysfunction/Posterior Blepharitis from my most recent dry eye post, and in fact some would consider it a subset of the same disease.  To draw on a personal example, I recently had a patient that had been treated by several different OD's for dryness.  He told me that a doctor had been treating his eyelid gland disease without success, and then he went to a specialist who took one look at his eyes and said he had ocular rosacea.  He wondered why no one had told him that before?  I'm not sure how convincing it was when I told him his ocular rosacea and eyelid gland issues were one and the same thing, just different variations of the same ocular syndrome.  There isn't a set definition for when we call these symptoms ocular rosacea versus when we just call them MGD or bleph, but here are some guidelines:

One of the most common types of dry eye I see is a direct result of clogging of the tear glands that line the upper and lower eyelids.  This type of dry eye is more common in younger patients and men than other etiologies.  If you are having dryness and also experiencing:

• itching, redness, or irritation along your lash line
• small white/yellow bumps along your lid
• recurrent styes
• thick, hazy tear film intermittently between blinks
• suffer from rosacea

Clogged Meibomian Glands: also called impacted or inspissated glands, or posterior blepharitis

As promised, the forthcoming posts are my opus to the overwhelming topic of dry eye.  The spectrum of Dry Eye Syndrome ranges from patients suffering from mild contact lens discomfort at the end of the day, to those at risk of needing a corneal graft due to the extreme damage done to their eye from dryness.  Most patients fall somewhere in the middle, with dryness being severe enough to cause marked discomfort at some point during the course of their day.

Do you have dry eye?  Here are some of the hallmark symptoms:

• dryness, itching, burning, sharp pains, and watering --- Though it seems counterintuitive, watering is a response to your eye being too dry!  The eye tries to protect its surface by producing emergency tears, but these tears do not have the proper components and run down the side of your face.  
• decreased visual quality or intermittent haziness, especially between blinks  (especially with Meibomian Gland Dysfunction specifically)
• discomfort at the computer --- Studies show we blink about half as often at the computer than we do in conversation!
• crusting or eyelid irritation 
• redness, both of the white of the eye and along the eyelids

At some point very soon, I know I need to dedicate a significant number of posts to Dry Eye Syndrome.  (It is in all caps, because this is a condition that significantly affects the quality of life of as many as 7 to 17% of the population depending on which studies you are looking at!).  People with Dry Eye experience redness, irritation, discomfort, blurred vision, sharp pain, watering, crusting, or dryness.  It is typically worsened with computer use, contact lens wear, and the use of ceiling fans and air conditioners.  Treatment ranges from over the counter drops to expensive prescriptions and ointments to lubricate the ocular surface.

This patient's meibomian glands are obviously clogged, causing a blockage of tear film secretion!

One of the leading causes of dryness is called Meibomian Gland Dysfunction, where the tear glands located along the top and bottom eyelid fail to properly release their oily tear film layer onto the eye, causing the tears to quickly evaporate and leave the surface dry.  To treat MGD, we often prescribe warm compresses with massage to open the gland orifice and force the tear secretion through the gland onto the eye.  Fish oil supplements and oral doxycycline can also help with the functioning of these sebaceous glands.  I will go into more detail concerning these treatments in the future, but this post is dedicated to the new treatment for MGD:  the LipiFlow device!

The LipiFlow device

A local company in Morrisville, NC called TearScience recently received FDA approval for this device to treat moderate to severe MGD.  As you can see from the image above, the major component of the device is a mechanical "cup" that is applied to your eyelids.  This machine heats the lids from the inside, then uses timed pulsations to express the clogged secretions from the meibomian glands.  The entire procedure lasts about 12 minutes, and there is very minimal discomfort reported by patients at this time.  The cup that sits over the eye is quite large, but it does not touch against the cornea (the clear dome of the eye), and as such, must be large enough to only touch the outer portions of the eye.  Yes, you read that right.  The suction cup-esque part of the device pictured above touches the inside of your eye.  Sounds uncomfortable, but you will be given a numbing drop before the device is inserted.

As you can see from this diagram, one part of the device is under the lids providing heat to the glands, and the other is external to provide pulsation to "milk" the glands

Things to know:
1) This procedure is very new, but results are showing that some patients are getting relief from their dry eye symptoms lasting anywhere from 3 months to more than a year!  For many patients life without artificial tear drops, or with significantly less drops, is well worse 12 minutes of pressure being applied to the lids.
2) Because this procedure is so new, only a very few clinics are offering it.  There is also no CPT code available, so this means in practical terms that no insurances will cover the procedure at this time.  Expect cost to be significant.  In my area, Duke Ophthalmology has access to the device, and the cost is around $1500.
3) The science isn't available yet as to how effective this machine is long term, or what the magnitude of objective improvements are in the level of dryness, such as tear film break up time and tear film osmolarity. The theories behind this device are the same that optometrists recommend to patients every day when they prescribe warm compresses with lid massage to improve meibomian gland secretion.  If you are interested in more information, please feel free to post here.  In the North Carolina area, there is a doctor at Duke who is accepting patients for this procedure for those that are interested!