CEC Dry Eye Clinic

There are a number of simple, common sense measures that can benefit those who suffer from any type of dry eye. Be sure to check with your medical doctors regarding the safety and advisability of your following the recommendations listed below.

• Hydration: Many of us fail to keep pace with our fluid needs and can become chronically dehydrated.  Except for those who might be adversely affected by robust fluid intake (cardiac and renal problems, etc.), it is usually advisable for an adult to drink approximately eight 8 oz. glasses of water or other appropriate fluid substitute per day.  This is approximately 2 liters.  Fluid requirements obviously vary depending on climate exercise level and other factors but the above is a good general guideline.
• Omega-3 supplementation…this is ideally achieved by ingestion of the natural foods that have the highest concentration of Omega 3…also good for joint and heart health:
  • seafood (in order of concentration of Omega-3):
    • wild salmon
    • arctic char
    • Atlantic mackerel
    • sardines
    • black cod (sablefish)
    • anchovies
    • oysters
  • seeds and nuts:
    • flaxseed
    • chia seeds
    • butternuts
    • walnuts
  • via supplement capsules:
    • “ester” form of Omega-3…this is the least desirable form of Omega-3 supplementation…it is quicker and easier to purify this form of Omega-3 fatty acids but it is not easily absorbable
    • “triglyceride” form of Omega-3…this is the naturally occurring form of Omega-3 found in seafood…it is more difficult and expensive to manufacture but provides a superior form of easily absorbable Omega-3.

  Triglyceride form Omega-3 supplements are clearly labeled as such to avoid confusion.  The Center for Eye Care provides this type of Omega-3 in a product manufactured by Physician Recommended Nutriceuticals (PRN), available in our Provisions Store located in the Optical Department.  A liquid form is available for ease of administration.

  • Free Essential Fatty Acids (EFAs)…products such as Omega XL® consist of easily digestible and absorbable nutrients in small capsules
  • Environmental and Work Conditions: Management of humidity levels especially in the workplace can significantly improve symptoms. Consider the use of a small personal humidifier as needed. In addition, your proximity to HVAC registers / vents can expose the eyes to drying air currents; therefore it is important to optimize these conditions for ocular comfort.  Observance of the 20/20/20 rule of thumb can also help…every 20 minutes, look 20 feet away for 20 seconds. This is a simple mnemonic which can be varied as needed for relief of excessive close range eye strain and the resulting aggravation of ocular surface drying. Outdoor exposure to wind, dust and excessive UV can have a dramatic drying effect.  The use of appropriate protective eyewear is recommended, such as sunglasses with side wrap or side shields.
  • Management of Systemic Medications: check with your doctor regarding the possibility of reducing or eliminating certain medications that may be adversely affecting your Dry Eye (see medications listed above under CAUSES of Dry Eye)
  • Tear Substitutes / Artificial Tears:
    Many artificial tears are available over the counter.  Let our experts tell you which drop is best for your condition.  There are also special preparations that are only available in the eye doctor’s office or online which can provide prolonged relief due to longer retention time on the ocular surface. Oasis ®Tears are among this class of tear substitute.
  • Contact Lens re-wetting drops: Soft contact lens wearers often require specifically formulated “re-wetting” drops that can temporarily saturate the lens and supplement the natural tear film. These work to both counteract any associated relative dry eye and to “cushion” the lens and allow for smoother movement on the cornea.  Excessive need for these drops may signal the need for refitting / replacing lenses or a reduction in wear time. Persistent discomfort and redness could signal a corneal infection or ulcer and should prompt an examination.
  • Ophthalmic Gels: are very effective for overnight lubrication of the eyes and can be critical for use in cases of exposure keratitis from lid abnormalities and thyroid eye disease. These gels should be applied to the eye just before sleep since they will cause significantly blurred vision for long periods, preventing reading or watching TV.  Systane® Ultra Gel is available in the CEC Provisions Store for your convenience.
  • Anti-inflammatory Eye Drop Medications:
    • Corticosteroids such as Lotemax ® (loteprednol etabonate ophthalmic suspension), a prescription eye drop medication, can be used under physician supervision for short periods and can provide relief from the symptoms of Dry Eye when used judicially.
    • Restasis® (cyclosporine ophthalmic emulsion) is a long term prescription anti-inflammatory agent that can have a variably beneficial effect, most specifically in cases of aqueous deficient Dry Eye due to Primary or Secondary Sjogrens Syndrome.

• Warm / Hot Compresses
  This is a mainstay of blepharitis / MGD treatment. Moist heat can help promote improved oil gland function when used consistently.  This can be accomplished by using a simple face cloth soaked in hot tap water, wrung out and re-warmed /reapplied several times over a 5-10 minute period.  Alternatively, there are many new products such as the Bruder Mask, which contains tiny moisture beads and can be heated in the microwave for seconds and then worn for a few minutes to provide effective relief.
• “Fire and Ice”
  This is a regimen of moist heat application followed by cold compresses. The heat softens secretions and dilates the pores encouraging oil delivery to the tear film. Then the cold compress constricts the capillaries that can become dilated and engorged by the heat thus reducing the concentration of inflammatory chemicals common to all forms of blepharitis
• Lid Hygiene / Cleaning Regimens
  Blepharitis is accompanied by an accumulation of dead skin cells, dried mucus, bacterial overgrowth and, in many women, impregnation of the delicate lid margin skin with mascara, eyeliner and other make-up residue.  The inflamed eyelids must be continuously cleansed of these contaminants which will otherwise exacerbate the problem and lead to its chronicity.  There are many products available for this purpose including Oasis® Lid and Lash Cleaner and various lid wipes.  All are stocked at the CEC Provisions Store for your convenience.
• Blephex®
  This is a quick and painless in-office procedure used to combat dry eye and blepharitis. This hand held device uses a spinning, medical grade, micro-sponge that gently exfoliates the lashes and eyelids to remove debris. The sponge is then disposed of and a new sponge is used for the next eye. After exfoliating, the eyes are thoroughly rinsed for immediate results.

  Most patients feel instant relief of their symptoms after a single treatment. With the debris cleared out, the ducts can begin to restore natural tear production. To keep the eyelids healthy and maintain these results, it is recommended to get a BlephEx® treatment about every six months. Keeping your eyelids healthy and clean can save you time and money by reducing the need of drops.

• Intense Pulsed Light (IPL)
  IPL is an option for patients who suffer from evaporative dry eye and haven’t seen adequate results from more conventional treatments. This painless treatment uses bursts of light directed at the lower eyelids and upper cheek areas to heat the blocked eyelid glands. Our physician then manually expresses and clears the residue from the eyelids allowing for instant results. IPL works best when combined with Blephex treatments and the general measures covered above.   The number of treatments (Blephex® and / or IPL) needed depends on the severity of your condition. Contact our office for a consultation to see if IPL is right for you.
• Combination Treatment
  The above two treatments (Blephex® and IPL) are synergistic and can be used together to enhance oil gland function in the eyelids leading to a more stable tear film.
• Omega-3 supplementation
  (see above)
• Topical Antibiotic / Steroid Medication
  Cortiscosteroid containing eye drops can effectively treat inflammation caused by and associated with blepharitis / dry eye and are safe for short periods.  Prolonged use can cause cataracts and glaucoma and should always be used under physician supervision.  Combination Antibiotic / corticosteroid drops are also used especially in evaporative dry eye due to blepharitis / MGD.
• Oral Antibiotics
  Tetracycline-class oral antibiotics (particularly Doxycycline) can be very helpful in managing chronic severe blepharitis / meibomian gland dysfunction and rosacea. This may require prolonged use, which can be problematic due side effects and sunlight and dairy restrictions. Recently, the use of short-term azithromycin (5 day course) has been proposed as a similarly effective program with much less chance of adverse side effects and few restrictions.
• Lipiflow®
  The Lipiflow® device is intended to compress and heat the eyelids in order to help improve meibomian gland function. Results can vary and the treatments are considerably more expensive than Blephex® and IPL and is not endorsed by the CEC Dry Eye Clinic.
• All of the management options listed above can be used in different combinations and at different times at your physician’s discretion to reduce or eliminate the problems associated with chronic blepharitis / meibomian gland dysfunction.  In most cases this is a chronic condition and will require continued efforts to keep signs and symptoms to a minimum.

These are tiny silicone inserts that can be placed in the tear drainage ducts of the eyelids to reduce drainage of both natural and instilled artificial tears.  The plugs are very well tolerated and are not visible to others. They can be placed in both lower and upper lids and typically remain in place for many months at a time.  This is a tear conservation measure that can provide a great deal of relief to many patients.  They are inserted in the office by the eye doctor in just a few seconds and are usually covered by insurance.

These are thin, non-prescription breathable long term wear lenses that can serve as a protection of the ocular surface and as a reservoir of fluid from the natural tears or additionally applied drops.

Contact lens wear may be inadvisable in individuals with Dry Eye. If soft lenses are desired they may need to be worn for shorter periods than usual.  Rigid gas permeable lenses (RGPs), unlike soft lenses, do not require hydration and may be a better option for mild to moderate Dry Eye.  These lenses are also easier to maintain and can provide better visual acuity than soft lenses.

• Ocular Allergies: Dry Eye and ocular allergies often co-exist or can be confused with each other.  The eye doctor will seek to differentiate these and provide treatment as necessary.
• Rosacea (see above) can be managed by avoidance of triggers (spicy foods, alcohol, sunlight exposure, excess emotional stress, etc.) and periodic treatment with tetracycline class antibiotics along with management of accompanying blepharitis / MGD. Intense Pulsed Light (IPL) can be very helpful for both the rosacea and  any coexisting blepharitis / evaporative Dry Eye.
• Ectropion (eversion of the lower eyelid) can result from laxity due to aging or to various injuries or inflammations. This can result in destabilization of the normal tear film, poor spreading of tears on the ocular surface and excessive evaporation of tears.  Tearing due to dysfunction of the normal tear drainage apparatus can also occur.  If significant, surgery may be indicated to restore normal tear function.
• Eye lid weakness / paralysis from stroke, Bells Palsy or injury may require frequent use of lubricants (drops and gels) as well as surgical management to avoid excessive drying of the eye due to exposure, evaporation and poor tear spreading.
• Conjunctivochalasis: if significantly interfering with proper tear physiology, this may require surgical repair which can be performed in the office.
• Ocular Cicatricial Pemphigoid: This is a rare and potentially serious systemic autoimmune condition. Though lubricant and steroid drops can help to ameliorate symptoms, this requires long term systemic treatment with “immunomodulator” drugs such as cyclophosphamide, methotrexate and mycophenolate by an experienced internist or rheumatologist.

• Rheumatoid conditions:
  • Primary Sjogrens Syndrome: This is a systemic autoimmune condition which causes a combination of Dry Eye and Dry Mouth due to inflammation of the lacrimal and salivary glands.  This can also affect other systems in the body and is diagnosed by clinical signs / symptoms and blood tests.  Most recently a simple and very accurate in-office test (Sjo®) can be performed and requires a simple fingerstick sample of blood.
  • Secondary Sjogrens Syndrome: this refers to Dry Eye and Dry Mouth in association with another rheumatoid condition such as Rheumatoid arthritis.
  • Consultation with and co-management by a rheumatologist is usually advisable for optimized treatment of these conditions. Use of the proper systemic anti-inflammatory medications is critical to proper management of these potentially serious disorders.  In addition, one of the more commonly used medications for these conditions is Plaquenil (hydroxychloroquine) which can, in turn cause damage to the eye (maculopathy) when used for a number of years making continuous monitoring by the eye care professional a standard of care.
• Thyroid Eye Disease: Ocular involvement can occur across the spectrum of thyroid conditions, particularly in Graves Disease.  The eyes can become protuberant (“proptosis” or “exophthalmos”) and, due to poor lid closure, can result in evaporative Dry Eye due to exposure of the eye, especially overnight.  Co-management by both ophthalmic experts and internists / endocrinologists is critical to successful treatment of this potentially vision threatening condition.

Dry Eye can cause a number of problems for patients undergoing cataract or laser vision correction surgery:

• Dry Eye can lead to inaccurate measurements of the eye’s curvature that are critical to proper Intraocular Lens calculations. It is necessary to thoroughly treat any co-existing Dry Eye prior to taking final measurements.
• Active Dry Eye and blepharitis can increase the risk of a serious intraocular infection after cataract surgery (endophthalmitis). It may be wise to perform thorough lid cleaning with Blephex® and possible IPL before performing surgery (cataract or vision correction surgery).
• The visual results from both cataract and laser vision correction surgery depend on the presence of a healthy tear film which should be optimized prior to the surgery by any / all means necessary.

Most cases of Dry Eye are manageable by some or all of the measures discussed above and, though Dry Eye can be professionally or personally debilitating, it can frequently be managed to allow for resumption of preferred activities.  There are, however, very serious vision threatening degrees of Dry Eye that require more advanced treatments including:

• Moist Chamber Goggles: These are tight fitting, specially constructed goggles that will allow for the build up of moisture on and around the eyes by preventing evaporation.
• Scleral Contact Lenses: These are large diameter, rigid, gas permeable lenses that vault the cornea and allow for accumulation of a reservoir of moisture bathing the cornea while still allowing for oxygen transmission through the lens and in to the cornea.  These require special fitting kits and expertise and are not yet widely available.
• Autologous Serum Eye Drops: This is a a solution made from a patient’s own blood sample. The blood is centrifuged to remove the cellular elements and formulated by a special compounding pharmacy into eye drops.  The natural healing substances within the serum help to restore the integrity of the dried and damage ocular surface.
• ProKera® Amniotic Membrane Device: This is contact lens-like device consisting of a thin sheet of human amniotic membrane derived from placentas that is stretched around a flexible support ring and inserted by the eye doctor on the eye for a period of time to promote healing of severely damaged tissues.  The healing elements of the natural placental tissue provide the needed support for restoration of the ocular surface.