This is the second part of my last blog post about dry eye. The first post covered symptoms and risk factors/causes of dry eye. Now we’ll talk about what’s going on on the surface of your eye as well as some of the treatment options and managements for dry eye!
Types of Dry Eye:
There are two main types of dry eye that we’ll discuss today. I characterize them based on what kind of tears are missing from your tear layer. There are normally 3 types of tears you should have: Oil, water, and mucous tears.
The oil layer sits on top of the other tears to make sure they don’t evaporate too quickly. These are produced by the eyelids. The water layer is from the lacrimal gland located just above the eyebrow, near the temple. The mucous layer holds your tears onto the eye and is produced by a thin layer above the white part (scleral) of your eye called the conjunctiva.
The first type of dry eye we see the most is oil deficiency dry eye. The eyelid glands, called meibomian glands, create the oil layer and releases it into your tear film every time you blink. In normal cases, the oil looks kind of like olive oil. When there’s inflammation, it can range from being milky and cloudy to thick and chunky. In severe cases, oil production will stop and the glands can unfortunately die.
In water based dry eye, the lacrimal gland (as well as a few other glands) are typically not producing enough tears. This is often due to inflammation as well.
When you aren’t producing the right types of tears, often the eye will try to compensate with other types. We’re supposed to have a balanced tear film, but once something is out of whack, everything else can follow!
Treatment Options:
So what can we do to treat dry eye? It’s just artificial tear drops, right? Or ointments?
Well that couldn’t be further from the truth! As dry eye is often caused by inflammation, the goal is to break the inflammatory cycle. Inflammation leads to dryness, which causes more inflammation, leading to more dryness… You see where the problem lies?
While artificial tears are often a first line of therapy, they’re not the only thing we can do. In most cases, we will start patients on them, as they will help to improve the symptoms of dry eye, but not the underlying cause.
Often times we’ll recommend patients start to take Omega-3’s in their diets, warm compresses, and eyelid scrubs in our basic early on therapy to begin improving the oil gland problems.
From there, we can often look to try out some medications, such as Restasis or Xiidra, two eye drops that are FDA approved to treat dry eye by reducing inflammation and helping your body to produce more of its own tears, rather than just replacing them like artificial tears.
Punctal plugs are another common method that we recommend for treating dry eye. These are small collagen plugs that are placed into the drain pipe of the eyelid so that the tears remain on your eye longer. This is a great method of treatment because it’s passive! Many times patients who are using artificial tears 2-4 times per day (or more) often feel like they can reduce the amount of artificial tears they need by 50-75%! While this method isn’t fixing the underlying problem, it is providing more comfort more quickly, as the medication treatments often can take a while to work.
Neuro-stimulation is a new method to treat dry eye that is showing to be successful, but still in the early stages. In some cases, we can recommend a special device called TrueTear. Now bear with me here, as this method will sound a little… odd to most folks.
The device is a TENS unit (that stands for transcutaneous electrical nerve stimulation) that stimulates one of the nerves connected to the eye to help it produce more normal tears. The device is actually inserted shallowly into the nasal cavity (yes, up your nose!), which is held in place and stimulates tear production. This can provide instant relief of symptoms in some cases. Over the time, the device can often be used less and less as your body learns to create more tears. It’s very promising technology and can in some cases be less expensive than certain medications over time. This device isn’t for everyone though, so if you’d like a demo of it, just let us know and we can discuss it!
Amniotic membranes are a more advanced therapy option, but can be necessary in some cases where the dry eye is so advanced that it’s resistant to other treatments.
Amniotic membranes are small, thin tissue grafts that are made up of amniotic stem cells (essentially blank cells that haven’t yet been assigned a function). What happens is that the membrane is placed across the eye and over the course of 5-10 days will dissolve. As it does so, it will provide new cells to be assigned to the eye, as well as other healing and growth factors to help speed up the healing process. These can work exceptionally well to provide us with a jump start in severe disease when it’s resistant to all other therapies.
I can go on with more and more therapies, but like I said last time… I could go on and on with dry eye discussion for probably 3-4 more blog posts of this length and still barely scratch the surface. Dry eye is a complex condition that often has multiple factors needing to be accounted for during the treatment process.
So what’s the problem if we don’t treat the dry eye early? Patients who are treated too late or are non-compliant with their therapies can progress to the point where the dry eye becomes unbearably painful. It can also lead to corneal changes that can cause scarring and eventually vision loss that has to be corrected either with surgery or with a special type of contact lens. The disease can be hard to manage, but with early intervention, we can prevent the worst cases from occurring in the first place.
If you have symptoms of dry eye or would like to have a dry eye examination, please tell us at your annual examinations! While in some cases, we can spot this pretty early on, in some cases it can be far more subtle and require additional tests to tell us what’s really going on.
I hope this was informative!
Dr. Nick