Our approach to managing dry eye is stepwise and in accordance with current evidence, as most thoroughly outlined in DEWSII.
Management options for dry eye will include:
- Education regarding the condition, its management, treatment and prognosis, including dietary and environmental modification.
- Recommendation of correct lubricants suited for the various types of dry eye
- Lid hygiene and warm compresses of various types
- Management of blepharitis and Demodex mites
- In-ofﬁce, physical heating and expression of the meibomian glands (including device-assisted therapies, such as Moisture chamber goggles)
- Tear conservation through punctal occlusion if necessary
- Prescription medication;
- Topical antibiotics or antibiotic/steroid combination applied to the lid margins for anterior blepharitis (if present)
- Topical corticosteroids
- Topical non-glucocorticoid immunomodulatory drugs (such as cyclosporine)
- Therapeutic contact lens options
- Soft bandage lenses
- Rigid scleral lenses
- Amniotic membrane contact lenses
Dry Eye treatment aims to do three things:
- Firstly, to manage symptoms in the short term, to prevent discomfort.
- Secondly, to remove or treat the initial causes of Tear Film Instability. If you stop the fueling the fire, it’s easier to put it out.
- Thirdly, balancing the tear ingredients, heal any damage to the ocular surface and reduce any inflammation.
Eyelids often collect a buildup of bacteria, excess makeup or tear debris, which can reduce the quality of tears produced. A poor quality tear layer will dry up quickly or cause symptoms of discomfort.
As mentioned previously, we know eyelids are vital for replenishing our tears, and are responsible for housing many important tear producing glands. Additionally, just like a windscreen wiper, they swipe away the dirty tears and replace it with a fresh layer of clean tears with each blink. The lacrimal gland, the walnut sized gland up in under our eyebrow bone which produces the aqueous layer of the tears, requires the mechanical force from a blink to pump the tears onto the eyes surface.
Our eyelids also contain the meibomian glands which are responsible for secreting the oily top layer of our tear film. The openings of these oil producing glands need to be clear of debris to enable a small amount of oil to flow out of the gland with each blink. Dead skin cells, dust and debris can accumulate along our eyelid margins and risk clogging the openings of our oil glands. Debris around our eyelash follicles can help provide shelter for our natural bacteria enabling them to breed and increase in numbers. Swollen, red and irritated eyelids can house mites and create friction against the eye when we blink 18,000 times a day. It’s important to keep our eyelids clean if you have any dry eye symptoms.
Lid debridement is an in house treatment for dry eyes done within our practice, as it’s not safe to do at home.
After careful inspection of your eyelid margins we can determine if your glands are blocked or there is excess debris in and around the base of your eyelashes. If so we can either mechanically or manually remove the excess material and clean up your eyelids. Just like a pedicure for your feet, this is the pedicure for your eyelids!
After lid debridement, continuing to maintain a clean healthy eyelid surface is important. Cleaning this debris with antibacterial eyelid hygiene products at home can make a big improvement to tear production and assist in the management of your dry eye.
The goal with warm compresses in the treatment of dry eye is to heal the buttery oil in our eyelid glands enough to get it back to a more flowing liquid oil. Using a hot/microwave heat mask on the eyelids, followed by a gentle massage can help improve tear oil production.
Improving tear oil production and quality has shown to improve dry eye symptoms and reduce reliance on artificial tear drops.
Traditionally people talked about using a warm face washer to warm our eyelids, but the research shows that a warm washer doesn’t heat the oil enough, and doesn’t stay warm for long enough for effective treatment. The oil needs to be heated, like butter, to the right temperature, for the right period of time to melt properly.
The Eye Doctor is a mask designed for effective at home warm compression. This hot eye compress, featuring an antibacterial shield, helps relieve symptoms of dry eye. The compress is filled with beads that can be reheated over 365 times and heated in both the microwave and oven. After use, its best to then massage your eyelids carefully, being sure not to put pressure on the eye itself. This is designed to exfoliate and massage out the gland blockages after heating.
It is normal to have bacteria on our skin and eyelids as germs like warm, moist environments. Often when we have recurrent styes, dry eyes or inflamed eyelids it’s due to an overpopulation of these common eyelid bacteria, typically Staph Aureus. They can disrupt our eyelid oil glands, and make our eyelids feel itchy and our eyes gritty.
Blepharitis is a term we use for inflamed eyelids. Patients with blepharitis complain of tired, dry eyes and can often have red, itchy, inflamed eyelid margins. They can have crusts in their eyelashes that can look a little like dandruff.
Chronic blepharitis can lead to eyelid damage, can affect eyelid gland production and lead to loss of eyelashes.
Historically you may have heard about eyecare practitioners suggesting diluted baby shampoo to clean the lashes, but this is no longer recommended as a treatment for blepharitis. Baby shampoo changes the pH or acidity of the tears and whilst it will clean your lashes, it will make your dry eyes worse by exacerbating the dry eye cycle.
Ocusoft Platinum Plus is an antibacterial foaming eye wash used for blepharitis. It is a special shampoo designed exactly for cleaning eyelashes and eyelids. This product differs from other eye wash products that are washed off after use, as it achieves best results when applied just before bed and left on overnight.
Demodex mites naturally live on our skin, but an overpopulation of Demodex can trigger inflammation and cause red sore eyelid rims.
Oust Demodex is a heavy duty antimicrobial foaming eye wash containing tea tree oil. This wash helps remove all the critters and microbes that might be around the eyelid margin aggravating the oil glands and eyelash follicles. It is particularly effective against demodex mites.
To best utilise the product, please place the desired amount of foam onto a lint free cloth, pad or fingertip. Close your eyes and gently cleanse eyelashes, brow and face. Do not directly touch eyes and rinse thoroughly to remove after use.
Blephasteam in the treatment of dry eye
Blephasteam is a unique eyelid-warming steam goggle that delivers a standardised, latent moist heat therapy around the eyelids to unblock the Meibomian Glands. The meibomian glands produce the oily top surface of the tear film.
When the glands are blocked little to no oil is produced causing the eyes to dry out which can lead to irritation, stinging, watery eyes and redness in the eyes. Eyelid warming is important as it is used to melt the solid or blocked lipids into a more viscous oil again. This allows the natural oils in your tear film to flow freely again and to form the oily layer of the tears which improves tear quality and reduces evaporation.
Just imagine oil turning into butter. The heat delivered on your eyelids melts the “butter” to turn into oil so it can be secreted from the glands as we blink. Heating the oil secreting glands can be done at home with warm compresses. However, warm compress cannot deliver the precise temperature for a controlled duration as clinically demonstrated to be beneficial for unblocking clogged meibomian oils. Warm compresses require continued reheating which is unnecessary with Blephasteam. The Blephasteam heats to the melting point of meibum and maintains that temperature for 10 minutes to ensure all the meibum inside the glands is melted correctly.
Blephasteam’s dual action heats and melts the meibomian secretions and obstructions. This allows normal function of the upper lid, facilitating release of the oily secretions on lid closure and allows the tears to resurface. By unblocking the meibomian glands, tear quality is improved reducing the symptoms of dry eye, which in turn has positive benefits for eye health, vision and comfort.
Blephasteam® treatment is convenient, safe and allows clear vision during the treatment. Patients are able to carry out normal task activities such as reading or using digital devices whilst undergoing the treatment.
After Blephasteam treatment, manual expression of the glands is also needed to unblock the glands fully. This gentle squeezing provides enough pressure to unblock the glands. Between 1 and 3 sessions with the Blephasteam goggles are often enough to maintain comfort for many months.
Bandage Contact lenses
A bandage CL is a therapeutic contact lens designed to protect an injured or diseased cornea from the mechanical trauma of a blinking eyelid. It is used in the treatment of severe dry eye disease.
The main aims of therapeutic contact lenses are pain relief, to promote and allow corneal healing, to protect the cornea, to keep it moist and prevent dehydration and to aid visual recovery.
The concept of a protective eye bandage originated in the first century A.D when Roman scholar Aulus Cornelius Celsus reportedly applied a honey-soaked piece of linen to the eye where a pterygium had just been removed, to prevent the eye and eyelid from sticking to each other.
Nowadays, bandage contact lenses are used for severe or persistent dry eye, recurrent erosion syndrome, corneal dystrophies, abrasions, post trauma or post surgical wound healing and non-infective corneal ulcers.
For nearly a century, amniotic membranes have been a highly effective treatment option for non-healing, chronic wounds on our skin. Now, due to recent advances in technology, we can embrace the natural anti-inflammatory, anti-scarring properties of human amniotic membranes to help rehabilitate the ocular surface of the eye.
As the name suggests, human amniotic membranes come from the innermost layer of the amniotic membrane that surrounds the developing fetus and is collected from full-term placental tissue and treated with antibiotics during collection.
It’s transparent structure, used in conjunction with a bandage contact lens, creates a physical barrier for any further damage and a natural healing environment for the wound to repair.
Some examples of when we would consider using Amniotic Membranes as a treatment include recurrent corneal erosions; persistent or severe dry eye, non healing corneal ulcers such as those associated with diabetes or viruses like herpes simplex or herpes zoster; and even chemical or physical burns to the eye.
Dry Eye Supplements
Oral Omega-3 supplementation has been proven to help with dry eye. This means increasing the amount of oily fish, such as salmon, tuna, mackerel, trout, and sardines, in your diet. One study showed a 30% decrease in the risk of dry eyes for every extra 1g of Omega 3 consumed per day. Read the nutrition label of any fish oil capsules carefully, and talk to your GP before making large dietary changes, especially if you are on blood thinners like Aspirin, Warfarin or Ibuprofen, or have liver disease or atrial fibrillation.
Other Treatments for Dry Eye
Other treatment and management options for dry eye include: steroid eye drops, scleral contact lenses, Lipiflow thermal pulsation system, IPL (intense pulsed light) therapy, punctal plugs, and others. These more involved management options work very well in cases where the normal treatments for dry eye don’t work as well as we would like. We don’t offer all of these treatments to our patients, but they are listed here for completeness.
Dry Eye tends to be very unique to each patient. An individualised approach to choosing dry eye treatments will bring the best results. Please contact us or book online to arrange a dry eye assessment appointment along with your comprehensive eye & vision examination.