Please first read the prior blog post about Aqueous Deficient Dry Eye Disease.
The goal of treatment for Aqueous Deficient Dry Eye is to decrease the inflammation of the lacrimal glands. At Peak, after we image and evaluate your eyes for dryness using the Oculus K5M, I will then use a microscope to view your cornea with the aid of sodium fluorescene dye. If there is damage to your cornea from dryness, it will look like Figure 1 above. First line treatment will be to use high quality over the counter artificial tears. The exact drop that I will recommend for you will depend on the results of the other dry eye tests and measurements that we perform, and will be specific for each patient. Many times I will recommend a preservative free artificial tear. That is because the preservative found in most bottled eye drops can cause damage to the ocular surface if used too frequently. A good rule of thumb is you should avoid using a preserved bottled drop more than 4 times per day, or you risk causing more harm that good.
If there is substantial damage, like what is seen in Figure 2 above, then I will likely prescribe a short course of a mild steroid eyedrop to quickly reduce the inflammation on your ocular surface, thus allowing your eye to heal properly. Steroids are very beneficial and safe for short term use, but do have potential complications if used long term, so we will transition to dry eye prescription eye drops that are safe for long term use, of which we have a few options. The first prescription drop to be FDA approved for the treatment of dry eye disease was Restasis in 2003. The benefit with this drop is it tends to be the cheapest and most widely covered under medical insurance plans, the negative being that we do not expect you to notice any improvement until 3 months after starting the drop. The next drug to be FDA approved for the treatment of Dry Eye Disease is Xiidra, with the benefit being it only takes 6 weeks to have an effect, but does come with a metallic taste in the back of your throat when you instill the drop for the first few days. Cequa is another option, which also has a shorter time to improvement (1-2 months), but is hard to get covered by insurance as it is so new.
In the next blog post, we will dig into how we can treat eyes with severe damage from aqueous deficient dry eye disease. I will place an amniotic membrane harvested for this specific purpose on the cornea for 1 week. In most cases your medical insurance will cover this treatment. The negatives for this is we can only treat one eye at a time, as it will substantially reduce your vision during the week that it is in place, and it is slightly uncomfortable at first.
If the damage seems to be lingering and is not improving with the above treatments, another option we will consider is autologous serum eye drops. These drops are made from the plasma of your own blood, and thus has a much more targeted affect on decreasing the inflammation on your ocular surface and promotes healing of your cornea. To make these drops, your blood is drawn, then centrifuged to separate the serum (plasma?) From the rest of the blood. This serum is harvested and put into eye drop bottles to be used daily. While very effective, this process is not cheap, so I only recommend it when necessary.
Historically, eye doctors would treat Aqueous Deficient Dry Eye with punctal plugs. You have 2 puncta on each eye that drain your tears, one in the upper eye lid and one on the lower eyelid. They are located on the nasal side of each lid, and they drain tears to the back of your Nose and throat. This is why when you cry, you nose starts to run. The thought behind blocking the puncta with a plug was that if a patient is not producing enough tears, we can block the drain, thus keeping the eyes more lubricated. However, as we just discussed, the major cause of Aqueous Deficient Dry Eye is inflammation, so if we block the drain of the eye, we are keeping the inflammatory factors on the ocular surface, thus making the inflammation worse. An analogy would be dirty water in a sink. We would not want to plug the drain of the sink if our goal is to remove the dirty water.
That being said, there are rare cases when I will recommend and install temporary punctal plugs, always in combination with some of the above treatments. Examples would be severe Sjogrens Syndrome, or a condition called Neurotrophic Corneal Ulcer, found most commonly in uncontrolled diabetic patients. For these patients, we must use everything at our disposal to keep the eye lubricated and protect the eye from permanent scarring that could lead to blindness.