Most understand that the tears keep our eyes wet and smooth and wash away irritants. Some might even further understand that the tears help the front of the eye focus the light that enters your eye into a clear image for the retina and brain to be able to see. Did you also know that the tear film is full of nutrients, hormones, and antibodies to protect the eye from infection and to facilitate the uptake of oxygen from the atmosphere! Yes, in order for the cornea to remain clear to allow for vision, there are no blood vessels in the normal central cornea. For this reason, the above listed metabolites, nutrients, antibodies, and even oxygen from the environment are transmitted to the cornea via the tears. So, what happens if the tear film is inadequate in amount or quality? You are at an increased risk of irritation, redness, blurred vision, even vision-threatening infection!

The Mayo Clinic describes “Dry eye disease is (as) a common condition that occurs when your tears aren't able to provide adequate lubrication for your eyes. Tears can be inadequate and unstable for many reasons. For example, dry eyes may occur if you don't produce enough tears or if you produce poor-quality tears. This tear instability leads to inflammation and damage of the eye's surface.”

Technically speaking, blepharitis means inflammation of the eyelids. There are multiple causes such as rosacea affecting the lids, microbes such as demodex mites, other bacterial and/or even fungal overgrowth on the lids, all leading to inflammation and irritation. Meibomian gland dysfunction, or plugging of the glands that make the oils which cover the tear film and prevent evaporation can also lead to inflammation and blepharitis. Both the resultant inflammation of blepharitis, as well as a poor quality of the lipid layer covering of the tear film, contribute to making the eye more dry and inflamed. Due to this inflammation, the eye’s ability to make a good quality tear film is further limited, and the eye becomes even drier. It is a vicious cycle of dryness and inflammation that builds on itself.

Blepharitis is present in anywhere between 37-47% of the population in the United States, per a 2009 survey of Ophthalmologists and Optometrists. Meibomian gland dysfunction (a form of blepharitis) is found in between 68-86% percent of all patients with dry eye disease.

Early on some people may not have any symptoms at all. Later, patients with dry eye disease often complain of irritated, red eyes. They may be extra sensitive to light. The eyes may feel heavy, strained, itchy. It may even feel as though one has a foreign body in the eye rubbing on the eye (gritty/sandy). Wind and light can make the symptoms worse. Depending on the cause of one’s dry eyes, they may be worse in the evening or in the morning. Lids may stick together in the morning. You may find it difficult to wear your contact lenses. Activities such as reading, working on a computer (or other screen), or driving may make the symptoms worse. One can even develop blurry vision as a direct result of the dryness alone.

According to the National Institutes of Health, dry eye disease affects up to 50% of individuals worldwide. In the United States, up to as many as 49 million individuals may struggle with dry eyes on a daily basis, and the incidence is increasing.

Some risk factors for dry eyes include age, female sex, hormonal changes, poor diet, lack of hydration, low environmental humidity, dirty/dusty environments, smoking, prior eye surgery (especially LASIK, blepharoplasty), prior gastrointestinal surgery, contact lens wear, computer/screen use, driving, certain diseases (eg. Diabetes, Thyroid disease, autoinflammatory diseases, gastrointestinal disease, glaucoma, lid malposition), and certain medications or treatments (acne medications, glaucoma drops, antihistamines, antidepressants, water pills, chemotherapy, radiation).

Activities where you are staring straight ahead decrease the blink rate from around 20-25 times per minute by at least half, and in some cases even down to as low as 5-6 times per minute. As a result, the tears evaporate faster leading the eyes to dry out.

I often suggest patients in dry climates or in winter run humidifiers, especially in the bedroom. Make sure you are eating a healthy diet and drinking enough water. Make sure that you are going regularly to your doctor for treatment of and prevention of disease. Warm compresses are soothing and can help clear out the glands in the lids that help form the oil layer of the tears. Lid hygiene with over-the-counter lid scrubbing pads/sprays can help limit the amount of inflammatory microbes living on the lid margins. Preservative-free, over-the-counter artificial tears can be placed multiple times per day to give moisture back temporarily to the ocular surface. One can also place thicker eye preparations such as gel or ointment into the eyes at night time.

There is some mixed evidence that omega 3 fatty acids found in supplements such as fish oil and flaxseed oil may improve the balance of the tear film.

The 20/20/20 rule is an activity used to lessen the drying effect of staring at a screen or a book. Every 20 minutes it is suggested that one looks approximately 20 feet away for about 20 seconds. I add to this that one should remember to blink, then put an artificial tear into the eyes.

At this point in time, beyond what we recommend the patient can do for their dry eyes at home, there are varied courses of treatment that can be offered in the office. For decades, we have had punctal plugs that can be placed in the tear drainage hole in each lid to prevent the tears that the eyes do make, from draining out of the surface of the eye and into the nose and back of the throat. These can be very helpful. Unfortunately, they often continue to fall out and need to be replaced, or they may remain but keep an otherwise unhealthy, inflammatory tear film in contact with the eye longer than if they were not in place.

As dry eye syndrome is significantly related to the level of inflammation on the ocular surface, steroid drops can be used temporarily to initially calm the eye. Unfortunately, when used for longer periods of time, steroid drops can cause both glaucoma and cataracts.

We now have multiple topical nonsteroidal drops that attempt to restore more normal tear production by decreasing inflammation on the ocular surface. Stinging is a well known side effect of such drops, and different ones can take anywhere from 1-3 months to have their full effect. Some people are bothered by the taste of some of these drops. The drug manufacturers often maintain special programs to help patients be able to afford the drops as, even when approved by insurance companies, the monthly charges for many of the drops are very high. Despite some of these hurdles in getting the medications, if the patient is motivated to continue taking such drops long-term, they often (between 35-72% of the time) will achieve some level of improvement with topical medications.

Aside from drops, there is a nasal spray available that increases one’s liquid tear volume. It does so within ½ hour of instillation, but it both irritates the nasal passages for as long as ½ hour after use, and does not improve the quality of the tear film.

Aside from topical drops and ointments for dry eyes, for the blepharitis that very often accompanies dry eye syndrome, some patients can be put on oral tetracyclines or Azithromycin. In my personal clinical experience, while tetracyclines can be more effective than a lot of the topical medications, they have a great deal of side effects and interactions with other medications that limit their functionality as an ideal long-term solution for a large number of patients.

For very severe dry eyes, some patients may have serum tears prepared every 3 months from their blood plasma. These are very effective, but must be prepared specially from the patient’s own blood, for the rest of their lives.

There are constantly new drugs being developed.

Without getting into some of the more delicate, in depth surgeries that exist, I will just say that if the eyes are dry enough that they are in danger of a vision threatening infection, the lids can be either partially or fully sutured closed, either temporarily or permanently.

Large scleral contact lenses can be used for some patients with very dry eyes to keep the eyes bathed in fluid while the lenses are worn. These are only used in severe cases when other solutions are limited. They are cumbersome for patients to place and remove, can be very uncomfortable, and (as with all contact lenses, especially in dry eye patients) represent a potential source of vision-threatening infection. Despite the difficulties, for patients with severely dry eyes, without other options, these lenses represent a solution of significant benefit.

Noninvasive procedures with minimal, to no, downtime can be done at a patient’s visit to treat their dry eyes. The two main types of these procedures are aimed at decreasing the level of inflammation on the lid margins (a major contributor to ocular surface disease and dry eye) and decreasing the plugging of the meibomian glands in the eyelids that make the lipid portion of the tear film.

Intense Pulsed Light (IPL) has been used for decades in many fields of medicine to help eradicate inflammation and strengthen collagen. While companies have been using IPL for Rosacea and to tighten the skin, Inmode has for the first time optimized their IPL handpiece (Lumecca I) for use specifically on the lids to treat Demodex mites and Rosacea blepharitis, two of the main culprits in the cause of blepharitis and its associated dry eyes. The fact that it also strengthens the collagen and targets dilated blood vessels and pigmentation spots in the skin is a bonus!

No. Due to the light from the device being taken up specifically by the skin’s pigment, IPL cannot be performed on very darkly pigmented patients, and can only be used with great caution in patients of moderate pigmentation. If you are interested in IPL, please contact your ophthalmologist to determine if you are a candidate.

Yes! There are a few devices on the market that attempt to target the meibomian gland plugging. For both safety and efficacy reasons, I have chosen the Forma I by Inmode for my patients. It is the newest, state-of-the-art technology for the in office treatment of meibomian gland dysfunction. It is a one-of-a-kind device, in which Inmode has, once again, optimized well-respected technology used for many years now for its use on the eyelids. It employs bipolar radiofrequency that delivers electric current to the dermis at the exact level of the meibomian glands. This produces heat at a highly regulated temperature to melt the solidified lipids that are blocking the glands.

Lumecca I can be likened to the feeling of a rubber band snapping against the skin, but is not painful. Patients actually tend to enjoy the Forma I procedure and say it seems similar to a “hot stone massage”.

As opposed to the IPL, patients of all pigment types can undergo radiofrequency for the meibomian glands. Beyond pigmentation questions, if you are interested in Forma I, it is always important to check with your ophthalmologist to see if you would be a good candidate.

NO. Neither of these procedures involves any type of harmful radiation. That is not a concern.

After instilling topical ocular anesthetic, I apply gentle pressure to the lid margins with a special flat forceps to express the old, poor quality lipids from the glands so that the glands can begin to make new healthier oils for your tears.

Lumecca I/Lumecca takes about 2 - 5 minutes. Forma I takes about 20 minutes. Manual lid expression takes about 5 minutes.

I recommend you do warm compresses daily. If you are using any special creams for your skin, those may need to be stopped temporarily for a couple weeks prior to the procedure.

There is minimal to no downtime to these in office procedures. I do recommend patients do cold compresses 3x/day for the first two days and use medical grade sunscreen (~SPF40+). A week after the procedure, you can return to your regular skin care regimen.

When treated for the first time, for the treatment of blepharitis and dry eye syndrome, most patients benefit from an initial four treatments, approximately one month apart. You may begin to notice significant improvement in your ocular symptoms even after the first treatment. After that, different patients may need one “tune up” anywhere between every 3 months to every year, depending on their individual needs.