…for dry eyes. So it’s a significant problem. These baby boomers are happening. There’s gonna be more dry eyes. But it turns out actually that I am now seeing teenagers and people in their 20s and 30s with dry eyes because everyone is playing, all these kids are playing these games all day long, and they’re staring and not blinking. Their eyes are drying out and they start to show cascade of problems that leads to dry eyes which I’m gonna show you about.
So, we’ll start.
So there’s a whole mixture of dry eyes. Dry eyes is just not one problem, it’s one disease but encompasses many etiologies. So it’s not just straightforward that I don’t have water in my eye. That’s not it.
So there’s two basic forms of dry eyes. That is the tear film. So we’re gonna go over that. There’s three layers to your tear film. There’s the mucus layer, a water or liquid layer, and an oily layer. So, the aqueous tear efficiency, and these numbers are probably a little bit high, at 40%, but this type of dry eye is due to you not producing enough of the liquid part of your tear. But that’s probably maybe, in my experience, maybe 25%. That ready tear deficiency is probably 75% of dry eye. The problem is there’s a little mixture between the two to get a little bit of both.
So dry eyes is just an aqueous decreased production of the aging among… It could be different things, you lost nerves supply in your eye or something happened but the major cause that we’re gonna discuss of dry eyes is Meibomian gland dysfunction or disease. That is by far the most common cause of dry eyes.
Also, the common patterns along with it is a lot of people have blepharitis along with the dry eyes, so why is that related? So blepharitis means inflammation of lids. So the latin word for lid is bleph. So blepharitis is an inflammation or infection to your eyelids, especially right where the lashes are. And the old term for this is called granulated eyelids, that is an old common term that people used.
So you can have just the anterior portion of the lid infected where the lashes are and this can be related to a staph bacteria very commonly that hangs around, and/or a skin condition or it could be rosacea. So those things can cause us anterior. More posterior are Meibomian gland disease. These little spots where the glands are like little postules and right is here is where the openings are to your Meibomian glands.
So this is a deeper level of inflammation or infection. And this is what your tear film looks like. I told you that it’s more than just one. There’s a whole bunch of stuff in your tear film. Just your normal electrolytes, so when you get a blood test, your potassium level, your salt level, your chloride level, all that is measured in your body. Your body has to maintain a certain amount of electrolytes so that you and I wouldn’t be talking if it wasn’t in the normal range. And if you take a lot of salt in, then your salt is gonna be high because your body is gonna retain water to balance that out. Your body always maintain a certain level.
Years ago, there’s a little protein called lactoferrum and I have a machine years ago that would measure that. But that was a lab test with a liquid reagent and the company who made it just had trouble keeping them consistent so our test results weren’t adequate, but eventually that probably would come back someday. So if you’re lactoferum levels were low then you knew that your tear film was low.
Also, you have a lot of mucin layer and then you have the water layer and then sitting on top is the oily layer. All these different electrolytes, chemicals, IGE, different kinds, all these things are located in your tear. So it’s very complex.
So how do we diagnose dry eyes? One way is we put a little yellow dye that you get to get your pressure checked. We put that in your eye and then we count. When it starts breaking apart the sun is smooth tear film of that dye, and so that’s starts the break up time. We tell people don’t blink at the count of seconds; how many seconds does it count before this starts falling apart. Any normal person has about eight or nine seconds before things start to separate.
Your eyes can be readily injected and may have different stains that may be put on the eye and these things are actually dead cells. So your eye dries up so much to the point that the cells on your eye actually degenerate. Your eyes have mucus membranes just like your stomach and your mouth. If you do not have enough moisture there those cells will die. So for stainings, this is staining for fluorescein .. for once.
And then also how often should you blink? Blinking is extremely important. An average person blinks about 15 times a minute. That’s a lot of blinking. Someone who has Parkinson’s disease which you can tell; actually someone who has Parkinson’s, I can tell right away because they don’t blink. And they have horrible dry eyebrows.
Another test that we use for this, probably been around for 40 or 50 years, is the Sharper’s test. So this little strip of paper is put in the eye and is left there for 5 minutes and then we measure how many millimeters of that paper did your tears wet? I don’t use it very much because compared to what we have today, it’s just not as usual ‘cause you need to get more specific than that.
And then there’s now a tear eye osmolarity. This is a different machine. There’s now a lot, but we now have a tear osmolarity machine. That’s part of my work. So when you come in for dry eyes, we take a sample of your tear and then it measures how salty your tear film is. So I’ve already told you that your body has to have a normal salt level or you’re not walking around. But, your eye is exposed to the environment. And so we have the tears affect the background of your eye, the salt can’t or minerals and all those things in your tear, it’s left behind.
So therefore, what’s left behind is more hypertonic or more salty, more concentrated. So we can measure exactly how salty your tears are, which tells me how much liquid do you have in your eye. That’s not a guess; we get specific numbers.
We also have a little gadget that we use that we come and generally press an amount of pressure and we then press on these glands to see what kind of liquid is coming out of the glands. Is anything coming out? If it’s coming out, is it clear?” Is it cloudy? Is it coming out like cheese?
So you can see here that if you press on it, there’s a little, slight little liquid bump that’s coming out of these glands. So that’s a normal Meibomian gland. And this is what the glands look like inside your lid. So they come out and secrete to that into the open.
We’re working on getting another instrument, who knows what’s that gonna cost, that actually we would be able to examine how healthy those glands look with this instrument of some sort. But we’re working on that now.
So when we look at your lids now, we’re looking to see how this lid is normal looking, this gland’s totally clogged; there’s nothing coming out of that. You can see increased blood vessels. So all these is inflamed. All these are inflamed. And the stuff that are coming out of this is thick. So that’s not normal. If that’s what’s your Meibomian gland is producing, you’re gonna have blepharitis.
More subtle things, we can actually express what comes out. (We’ll skip over that.)
This is a more magnified view and you can see all this dryness. Your tear film is all foamy looking and all these little dry spots are dead cells. So people who get severe dry eyes usually have blurrier vision. So people commonly who have dry eyes complain of intermittabler vision ‘cause your eyes are semi-dry. How about if you’re blinking, what you’re doing, reading, not reading, knock doors. So people who complain with dry eyes, “Intermittably my eyes blur. Or after I read 10 or 15 minutes longer then they blur.” Because when you read you don’t blink as much then your eye dries up faster.
So there’s two break-up… and there’s different ways they can just fall apart or they can just sort of break up into little streaks where the film breaks apart. And like I said, this is normal, 7, 8 or 9 seconds. This is more staining, so all these are dead cells on the surface of some… Same thing here. This is a break-up time which shows you that the tear film is not very good.
So what happens? In a normal tear, you have an oily layer at the top. All those things that we showed you and your tear film and this mucus layer above. What happens is this lipid layer becomes worse then you don’t have enough protection here so then your tear starts to evaporate out and they get severe enough then it goes all the way down and this is where you start getting dead cells because there’s nothing covering over those cells to protect them.
So what happens, like we’re talking about hypo-osmolarity. So now all these stuff is more concentrated and this is what happens. So if your salt level goes up, the salt causes an inflammatory reaction on the cells on the surface of your eye. That inflammation then damages those cells, so now they don’t work as well and then it gets worse, so it’s a gradual increase on how bad dry eye gets. Over a year stop quickly, several years of time.
So now there’s a big panel that put together, having categorized from mild to moderate and the different treatments this organization has come up with. We follow some of these but I’ve sort of come up with my own system similar to that.
So in most cases, 75% of the time, we’re gonna have to get this lipid layer to be better so that your whole tear film is stable because if the lipid layer falls apart then everything underneath it falls apart.
So one way to try to get this tear a little better and we’ll go over that a little bit and we’ll go over three things, hot compresses in the night. So if you have have chronic blepharitis or chronic Meibomianitis, then we put people on hot compresses. We have a set of goggles here that we can use for people or you can take a wash cloth, put it in hot water. Hottest you can stand it without burning yourself. You hold it up when it cools down back in the water, back up for ten to 15 minutes. So you got to really work on it pretty good. Some people do it twice a day, at least first thing in the morning. The driest moment that they measured, so the driest time for your eyes is one second before you wake up in the morning. That’s your driest moment. Now there are other times when it’s dry, but they measured it and that’s typically the driest time.
So this is what your day looks like. The thing about hot compresses is that some outside is gonna go to the skin, the muscles, all these tissue to get to the gland of the back of the lid. So hot compresses help but it’s a little bit limited because you have to go to all these tissue to get the heat deeper in that’s why you need to use the tape, 10 to 15 minutes to work.
We also offer nutritional supplements which we’re gonna go over as well. There’s a lot of studies, older studies that say that omega 3 or fish oil, high doses of it improve your tear function. That’s probably true but there are things that are better than that now which we’ll go over.
This is an antibiotic for so if you have this staph bacteria around your lashes and this inflammation on your lid, then you put people on this and in another type of antibiotic. But this works really well. It kills the staph bacteria and actually helps in making the oily layer a little better and it’s only once at bedtime so it’s easy to use.
And also, which the drug company can’t put it in their label because they haven’t proved it, they haven’t gone back and done a study for the FDA, but it actually has significant anti-inflammatory properties. So it all actually comes down on the inflammation, which is great. So we use this especially after which we go over the treatment, when we do the lipid foam treatment we use this.
There’s a hot pair of glasses, they have this foam around, it seals your eyes, so people who have severe dry eyes. I have people come to my office who put tears in their eyes every ten minutes, seven days a week. They protect your eyes from the environment and they have this foam so it seals around their eyes so there’s no air getting in and drying their eye.
Because if you live in Arizona you would be a lot worse than by living here because it’s the environment has a significant factor on how dry your eyes are. If you go out to Walmart to go look for something, they run the airconditioner there at that place high, full-board, 24 hours a day and the air in there is extremely dry and then you’re staring to look at something and not blinking…
See Dry Eyes Part 2 for continuation of video…