Dry Eye

Dry Eye Disease is caused by a lack of adequate tear production, poor quality tears that evaporate too fast, or a combination of both of these factors. The main symptoms of Dry Eye Disease are irritation, redness, grittiness, foreign body sensation, dryness, and, paradoxically, excessive tearing and watery eyes.

Per the TFOS DEWS II report, there are 2 main types of Dry Eye Disease: Aqueous Deficient Dry Eye and Evaporative Dry Eye.

If you have Aqueous Deficient Dry Eye, it means that you are not producing enough tears from your lacrimal glands. These glands are located between your upper eyelid and your eyebrow. Certain diseases can lead to this, such as Sjogrens Syndrome, but arise without a specific cause.

Evaporative Dry Eye means that you are likely producing plenty of tears, but the tears that you are producing are of poor quality and evaporating too fast. However, in practice, most patients have a combination of both of these types of Dry Eye Disease and our goal in care is to determine which combination of treatment options are best for your unique combination of Dry Eye Disease.

In addition to the comprehensive eye exam, every patient that mentions dryness, irritation, itchiness, or discomfort of the eyes will undergo specific dry eye testing with the Oculus K5M. Dr. Cap will review these images in the exam room and explain what each test means for the short and long term health of your ocular surface. The most important of these tests is imaging of your Meibomian gland, a measurement of tear production, and how long it takes for your tears to evaporate. This information, along with factors relative to your unique lifestyle, habits, and the type of dry eye diesease you are experiencing, enables Dr. Cap to tailor any necessary treatment to your ocular system.

Dry Eye Disease is caused by a lack of adequate tear production, poor quality tears that evaporate too fast, or a combination of both of these factors.

The first line treatment for dry eye disease usually consists of specific over-the-counter artificial tears that target the type of dry eye disease that you are suffering from, and at home therapy to increase the liquidity of the oil in your meibomian glands. Diet, supplements, and screen time are also discussed. However, many times this only provides a temporary improvement of symptoms, and more effective treatment is required.

Intense Pulsed Light (IPL) treatment is a revolutionary dry eye treatment offered exclusively in Durango by Peak Eyecare. Although new to the field of eyecare, this technology has been used for years by dermatologists to treat a variety of skin conditions including rosacea and pigmented skin lesions. Aestheticians have also seen benefits using it for cosmetic purposes. For close to a decade, eye doctors have found that when IPL is applied around the eyelids, patients report a substantial, long lasting improvement in dry eye symptoms.

IPL treatment sessions last for approximately 10 minutes and are well-tolerated by most patients. Some patients may notice a slight discomfort, but never any pain. By the second or third treatment, many patients will see improvements in their dry eye symptoms. A vast majority will experience impressive improvements in their dry eye symptoms by the end of the fourth treatment.

As we begin treatment, you may feel slight discomfort with each pulse, similar to a mild rubber band snap at worst or a tingle of your skin at best. We perform 6-7 treatments per each side of the face. Once completed, we will remove the gel and the eye stickers, and apply high quality sunscreen to your face. It is important that you avoid any sun burn or sun tan for the 2 weeks following each treatment.

At Peak Eyecare, we perform 4 treatment sessions, each separated by 3-4 weeks. Our goal in IPL therapy is to reduced your symptoms of irritated, scratchy, red, or dry eyes, and to decrease your dependence on artificial tears. From my experience, I expect you to notice improvement around the 3rd treatment.

If you have any questions about IPL treatment, please don’t hesitate to contact our office for more information. Nothing gives our team more satisfaction than finding solutions for our patients struggling with Dry Eye Disease.

The most obvious symptom of evaporative dry eye is blurry vision that gets better after you blink. Most patients also have irritated, red, dry eyes while others may actually have the symptom of watery eyes.

By far the most common type of dry eye disease is evaporative dry eye. There are 2 types of dry eye disease, aqueous deficient and evaporative. However, 83% of all dry eye patients have an evaporate component to their dry eye. This means that you may be producing plenty of tears, but because the quality of the tears are low, they evaporate way too fast. This negatively affects your eyes in a few ways. First, your visual clarity will likely suffer. The first part of your eye that an image hits is your tear film, and if your tear film is disrupted, you will have intermittent blurry vision no matter how perfect your glasses or contact lens prescription is. If you find that your vision comes in and out of focus when driving, on the computer, or any other visually demanding time, there is a high likelihood that you are suffering from evaporative dry eye. Second, evaporative dry eye makes your eyes feel irritated, dry, and appear red. Your tear film is not adequately protecting the cornea, which has one of the highest concentrations of nerve endings in the body. Finally, evaporative dry eye can lead to the perplexing symptom of watery eyes when you actually have dry eyes. If the tear film evaporates too fast, your eyes feel dry, and they send a signal to the brain, saying “we are dry, we need more tears!!” The brain responds by dumping more tears on your eyes, causing your eyes to water. However, these tears are still of poor quality, evaporating too fast, and continuing the signal cascade to the brain. If you find that you are constantly wiping tears away from your eyes, except when watching a sad movie, you are likely suffering from evaporative dry eye. We can test this directly by focusing a microscopic video camera on your tear film, and record how long it takes for your tear film to evaporate between blinks

My first line of treatment for evaporative dry eye is performing warm compress for 10 min every day at home. This is best done with an eye specific mask that you put in the microwave for 20-30 seconds, then with your eyes softly closed, place the mask over your eyes. The heat from the mask warms the thick meibum above its melting point, allowing it to flow much more easily from your meibomian glands, thus keeping your tears more stable. An analogy would be butter on a pan. If we apply heat to the pan, we can melt the thick butter until it becomes more liquid. A few of my patients have asked what they can do if they do not have a microwave, and the workaround is using a hot washcloth. However, the washcloth loses its heat after only a few minutes, so if you chose to do this route, you need to keep a pot of warm water next to you in order to keep on reheating the cloth throughout the 10 min. A mask like a Bruder mask is much more effective.

At Peak Eyecare, we offer an in-office treatment called Thermal Expression. In this procedure, a pair of specialty designed googles are placed over your closed eyes for 10 min to safely heat your meibomian glands more than you can with just the mask at home. Patients almost always comment on how relaxing it feels during these 10 minutes. After that is finished, I will physically express your glands with a special tool with the help of my microscope. My goal is to squeeze out the toothpaste-like meibum that is blocking the glands until the meibum runs clear like olive oil. We do this procedure twice, separated by 2-3 weeks. It is imperative that you continue to use the warm compress at home during this time to keep the newly cleared glands from clogging up again. Patients report that they notice a big improvement in their symptoms and are less reliant on artificial tears after.

However, no matter how much we do to improve the consistency of the meibum, if we do not also address the inflammation surrounding the openings of these glands, they will continue to clog. At Peak Eyecare, we take high-magnification images of your lid margin to look for telangiectasia, which are tiny blood vessels on the surface of your skin, also known as “spider vessels” (see figure 2). If we see telangiectasia, we have proof that you have excessive inflammation around your meibomian gland openings, and we will be constantly battling the reclogging of your meibomian glands. Our first line of treatment for this is HydroEye Supplements, which is a combination of Omega 3 (Fish Oil) and GLA (an Omega 6 from Black Currant Seed Oil). Working together, these supplements decrease inflammation around the meibomian glands and help your lids produce a healthier meibum. Most patients notice an improvement after 30 days of taking the supplements.

By far the best treatment for inflammation and meibomian gland dysfunction is Intense Pulsed Light therapy, or IPL. This 4 part treatment provides the biggest improvement in the health of your meibomian glands, and the longest lasting relief of dry eye symptoms compared to any other treatment develops thus far. Please read my next post, IPL for Dry Eye Disease, for an in-depth look at this game-changing technology.

The best treatment by far for patients suffering from Evaporative Dry Eye Disease is Intense Pulsed Light treatment, or IPL. IPL treats the root cause of the disease, not just the symptoms.

IPL treatment has been used by Dermatologists and Aestheticians for the past 30 years. The goal of this treatment has been to remove skin blemishes such as sunspots, small blood vessels commonly called “spider vessels”, and unwanted hair follicles. When the treatment zone neared the eyelids, their patients reported a substantial improvement in their dry eye symptoms. In 2015, the first study on IPL specifically for Dry Eye Disease was conducted, and the researchers found substantial improvement in both the signs and symptoms of Dry Eye Disease in the treatment group. Since then, many more studies have been done, and it is quickly proving to be the most effective treatment we have for combating Evaporative Dry Eye Disease.

The signs and symptoms of Evaporative Dry Eye Disease include inflammatory biomarkers are released from the spider vessels found around the eyelids. This inflammation limits the amount of free-flowing, healthy oil that can be released from the meibomian glands in the eyelids. Further, bacteria and mites on the eyelid margin create a biofilm that also clogs the meibomian glands. When the meibomian glands become clogged, no oil is produced on the tear film, so your tears evaporate way too fast, causing signs and symptoms of Evaporative Dry Eye Disease.

IPL attacks Evaporative Dry Eye Disease multiple ways. During each treatment session, a high energy light is used to flash the treatment area on each lower eyelid. This high energy burst of light ablates the small spider vessels, or telangiectasia, that is found on the eyelids. When the telangiectasia is reduced, the inflammatory markers cannot be released, thus restoring healthy function to the meibomian glands. Also, this flash of light kills the bacteria and mites that make up the biofilm, further allowing the meibum to flow more freely.

Finally, IPL has the helpful side effect of making your skin look healthier, younger, and tighter by getting rid of unwanted skin blemishes. After all, Aestheticians have been using IPL solely for this purpose for years! 

IPL treatment for Dry Eye Disease is very simple, taking about 10 minutes per session. Before your first treatment, we will send you our IPL Packet, which will include a Dry Eye questionnaire, a consent form, and pre and post-treatment instructions. Starting 2 weeks before, you must avoid prolonged, unprotected sun exposure. This means it is ok being outside, but make sure you are wearing a hat and good quality sun screen. The goal is to avoid any sun burn or suntan prior to treatment.

When you arrive for your first treatment, we will collect the IPL Packet, answer any of your questions, and prep you for the treatment. This entails removing any and all make-up or face lotion before applying protective stickers over your eyelids. We will then apply ultrasound gel to the treatment zone, which consists of the lateral side of your brow, your upper cheek area and your nose. We do not need to directly pulse the eyelids, as the skin is too thin here and the energy radiates upwards from the light pulse to treat your meibomian glands.

There are 2 types of tears that your eyes can produce, Reflex tears and Basal tears.

Reflex tears occur as a response, or reflex, to an outside factor, such as a foreign body. While reflex tears serve an important role, they are not tears that play a role in Dry Eye Disease.

Basal tears are the tears that your body produces on a consistent basis to keep the front surfaces of the eye (the cornea and conjunctiva) lubricated and healthy.

Inflammation of the lacrimal glands can cause of decrease in basal tear production. The most severe form of this occurs in Sjogren’s Syndrome patients, where there is a deficiency in the production…. Throughout the body, including the mouth and eyes. Most patients have general, less severe inflammation of their lacrimal glands, which decrease the amount of basal tears that they produce. This leads to irritated, red, gritty-feeling eyes.

The first line of treatment will be to use high quality over the counter artificial tears. If there is substantial damage 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. 

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