Chronic inflammation of the meibomian glands (located on the eyelid margins) causes the glands to be obstructed by thick waxy secretions which leads to red and swollen eyelids, frothy tears on the lid margins,excessive tearing, itching, dry eyes or crusting of the eyelashes.
The term"diabetes mellitus" refers to a group of diseases that affect how your body uses blood glucose, commonly called blood sugar. Glucose is vital to your health because it's an important source of energy for the cells that make up your muscles and tissues. It' your brain's main source of fuel. If you have diabetes, no matter what type, it means you have too much glucose in your blood, although the reasons may differ. Too much glucose can lead to serious health problems.
Rheumatoid arthritis is a chronic inflammatory disorder that typically affects the small joints in your hands and feet. Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing a painful swelling that can eventually result in bone erosion and joint deformity. An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly attacks your own body's tissues. In addition to causing joint problems, rheumatoid arthritis can also affect your whole body with fevers and fatigue.
Lupus is a chronic inflammatory disease that occurs when your body's immune system attacks your own tissues and organs. Inflammation caused by lupus can affect many different body systems — including your joints, skin, kidneys, blood cells, brain, heart and lungs.
Scleroderma is a group of rare, progressive diseases that involve the hardening and tightening of the skin and connective tissues — the fibers that provide the framework and support for your body. Localized scleroderma affects only the skin. Systemic scleroderma also harms internal organs, such as the heart, lungs, kidneys and digestive tract.
Sjogren's syndrome is a disorder of your immune system identified by its two most common symptoms — dry eyes and a dry mouth. Sjogren's syndrome often accompanies other immune-system disorders, such as rheumatoid arthritis and lupus. In Sjogren's syndrome, the mucous membranes and moisture-secreting glands of your eyes and mouth are usually affected first — resulting in decreased production of tears and saliva.
A compound formed from an alcohol and an acid by removal of water that yields ethyl alcohol on hydrolysis
The meibomian glands are oil producing glands that are located in the upper and lower eye lids behind the eye lashes.
What Is Dry Eye?
Dry eye is a chronic condition in which there is an insufficient quantity or unhealthy quality of tears to lubricate and nourish the eye. Dry eye often goes undiagnosed and untreated, despite being a very common and treatable disease. As the population ages, its prevalence is going to increase. Currently between 20 and 25 million Americans suffer from dry eyes. This includes 3.2 million women over the age of 50 and 15% of all Americans over age 65.
With each blink of the eyelids, tears are spread across the front surface of the eye. Tears provide lubrication, reduce the risk of eye infection, wash away foreign matter on the eye, and keep the surface of the eyes smooth and clear. Tears are necessary to maintain the health of the ocular surface and to provide clear vision. People with dry eyes either do not produce enough tears or have a poor quality of tears. Treatments are directed at improving the tear film balance to maintain good quality vision and minimize symptoms.
What Is the Tear Film?
When you blink, a film of tears spreads over the eye, making the surface of the eye smooth and clear. Without this tear film, good vision is not possible.
The tear film consists of three layers:
- An oily layer
- A watery layer
- A mucus layer
Each layer has its own purpose.
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The oily layer, produced by the meibomian glands forms the outermost surface of the tear film. Its main purpose is to smooth the tear surface and reduce evaporation of tears. The middle watery layer makes up most of what we ordinarily think of as tears. This layer, produced by the lacrimal glands in the eyelids cleanses the eye and washes away foreign particles or irritants. The inner layer consists of mucus produced by the conjunctiva. Mucus allows the watery layer to spread evenly over the surface of the eye and helps the eye remain moist. Without mucus, tears would not stick to the eye.
What are the Symptoms of Dry Eyes?
- Stinging or burning eyes
- Grittiness or scratchiness
- Stringy mucus in or around the eyes
- Discomfort when wearing contact lenses
- Blurred or Fluctuating Vision
- Light Sensitivity
- A feeling of a foreign body or sand in the eye
- Excess tearing
- Redness of the eye
- Heavy eyelids
- Increased eye irritation from smoke or wind
- Decreased tolerance of reading, working on the computer, or any activity that requires sustained visual attention
Excess tearing from"dry eye" may sound illogical, but it can be understood as the eye's response to discomfort. If the tears responsible for maintaining lubrication do not keep the eye wet enough, the eye becomes irritated. Eye irritation prompts the gland that makes tears (called the lacrimal gland) to release a large volume of tears, overwhelming the tear drainage system. These excess tears then overflow from your eye.
Watch an informative video - Introduction to Dry Eye
What Causes Dry Eye?
Dry eye can be a temporary or a chronic condition that can have multiple causes. Patients typically fall in two categories: those who have excessive tear evaporation and those who do not produce enough tears.
There are a number of factors that can cause excessive tear evaporation including environmental conditions, some oral medications, certain sustained visual tasks and inflammatory conditions of the eyelids.
The environmental factors include:
- being exposed to forced hot air heat at home, in the car, or at work, dry climates, air travel
- reduced blinking from contact lens wear
- air pollution
- even just blowing your hair dry
- cigarette smoke
Visual tasks that can lead to excessive tear evaporation from reduced blinking include:
- extended periods of reading
- prolonged computer use
Your tears may also evaporate too quickly if you suffer from a particular eyelid inflammation known as meibomian gland dysfunction or posterior blepharitis. The meibomian glands are the oil producing glands of the eyelids. Rosacea, a skin disorder, can be seen quite commonly in association with this posterior blepharitis.
Inadequate tear production is another cause of dry eye, especially after the age of 40. As we age, tear production decreases which affects the watery or largest component of our tear film. Although this can occur in men and women, it affects women more often, especially after menopause because of hormonal changes. Other causes include damage to the lacrimal glands from inflammation and radiation, systemic diseases such as diabetes, rheumatoid arthritis, lupus, scleroderma and Sjogren's syndrome, long-term contact lens wear, refractive eye procedures such as LASIK and certain medications.
The development of dry eyes can have many causes. They include:
- Age – dry eye is a part of the natural aging process. The majority of people over age 40 experience some symptoms of dry eyes.
- Gender – women are more likely to develop dry eyes due to hormonal changes caused by menopause, the use of oral contraceptives, and pregnancy.
- Medications – certain medicines, including antihistamines, decongestants, pain relievers, blood pressure medications and antidepressants, can reduce the amount of tears produced in the eyes and produce dry eye symptoms.
- Medical conditions – persons with Sjogren's syndrome, rheumatoid arthritis, lupus, ocular rosacea, diabetes and thyroid problems are more likely to have symptoms of dry eyes. Also, problems with inflammation of the eyelids (blepharitis), inflammation of the surfaces of the eye, or the inward or outward turning of eyelids can cause dry eyes to develop.
- Environmental conditions – exposure to smoke, wind and dry climates can increase tear evaporation resulting in dry eye symptoms. Failure to blink regularly, such as when staring at a computer screen for long periods of time, can also contribute to drying of the eyes.
- Other factors – long term use of contact lenses can be a factor in the development of dry eyes. Refractive eye surgeries, such as LASIK, can cause decreased tear production and dry eyes. Alcohol consumption, smoking and genetic predisposition also contribute to dry eyes.
- Low omega 3 fatty acid – intake can alter the tear film composition leading to a decreased top lipid layer with faster tear evaporation and secondary dry eye issues.
How are Dry Eyes Diagnosed?
Dry eyes can be diagnosed through a comprehensive eye examination and specialized testing. This testing, with special emphasis on the evaluation of the quantity and quality of tears produced by the eyes, may include:
- Patient history to determine any symptoms the patient is experiencing and the presence of any general health problems, medications taken, or environmental factors that may be contributing to the dry eye problem.
- Dry Eye Questionnaire
- External examination of the eye including lid structure and blink dynamics.
- Evaluation of the eyelids and cornea using bright light and magnification.
- Measurement of the quantity and quality of tears for any abnormalities. Special dyes may be instilled in the eyes to better observe tear flow and to highlight any changes to the outer surface of the eye caused by insufficient tears.
Tear Osmolarity Testing for Dry Eye Disease is the only available objective test to determine the severity of Dry Eye Disease. This test measures the concentration of your tears. Matossian Eye Associates is pleased to announce that we have been certified as one of only a few practices in the tri-state area as an accredited dry eye center of excellence by Tear Lab Corporation. We are licensed to perform tear osmolarity testing.
We take a tiny sample of tears from each eye & measure the Osmolarity or concentration of the tears. The collection is painless & the analysis takes a few seconds. Once your Doctor has a measurement, s/he can design a personalized treatment plan specifically for you.
- Normal values are 308 milliosmoles/liter or less
- Mild to Moderate values are 309 to 350 milliosmoles/liter
- Severe Dry Eye values are greater than 350 milliosmoles/liter
How are Dry Eyes Treated?
Dry eyes can be a chronic condition, but your eye doctor can prescribe a series of treatments to keep your eyes healthy, more comfortable, and prevent your vision from being affected. The primary approaches used to manage and treat dry eyes include adding tears, conserving tears, increasing tear production, and treating the inflammation of the eyelids or eye surface that contributes to the dry eyes.
Adding tear solution – Mild cases of dry eyes can often be managed using over-the-counter artificial tear solutions and liposomal spray. These can be used as often as needed to supplement natural tear production. Preservative-free artificial tear solutions are recommended because they contain fewer additives that could further irritate the eyes. However, some people may have persistent dry eyes that don't respond to artificial tears alone. Additional steps need to be taken to treat their dry eyes.
Adding tear ointment – Artificial tear ointments ar also available over the counter for severe dry eyes. These ointments are great to use at night before bed. In fact you will still feel the effects of the ointment when you wake up in the morning. Since ointments stay in the eyes longer than drops. They will make vision blurry. As a result, it is not advisable to sue the artificial tear ointments during the day or while driving.
Not sure you are instilling your drops properly?
Conserving tears – An additional approach to reducing the symptoms of dry eyes is to keep natural tears in the eyes longer. This can be done by blocking the tear ducts through which the tears normally drain. The tear ducts can be blocked with tiny silicone or gel-like punctal plugs that can be removed, if needed. A surgical procedure to permanently close tear ducts can also be used. In either case, the goal is to keep the available tears in the eye longer to reduce problems related to dry eyes.
Increasing tear production – Prescription eye drops, such as Restasis, help increase your own tear production can be recommended by your eye doctor.
TranquilEye Kits are available for purchase at Matossian Eye Associates.
Treatment of the contributing eyelid or ocular surface inflammation – Prescription eye drops or ointments, warm compresses and lid massage, or eyelid cleaners may be recommended to help decrease inflammation of the eyelid margins.
Dry Eye Omega Benefits®
Optimal Relief for Dry Eyes
Persistent Dryness, scratching, and burning in your eyes are signs of dry eye syndrome. Dry eye syndrome is a chronic lack of sufficient lubrication and moisture on the ocular surface of the eye. Its consequences range from subtle but constant irritation to ocular inflammation of the anterior (front) tissues of the eye. Omega-3 essential fatty acids are helpful in systemically reducing the inflammation of the accessory lacrimal glands of the eyes. In addition, it has been found that these same Omega-3 essential fatty acids are beneficial in controlling meibomitis and chronic lid disease. Dry Eye Omega Benefits® is formulated with a high concentration of the anti-inflammatory Omega-3, EPA (eicosapentanoic acid) in its natural TG form combined with Vitamin D3 and works from within to help address and alleviate the irritation and discomfort associated with dry eye syndrome.
Dry Eye Omega Benefit®
- Natural Triglyceride Form for Maximum Absorption
- Highly Purified and Concentrated
- Molecularly Distilled in a Licensed Facility
- Independent Laboratory Tested
- Free of Mercury, PCBs, and Dioxins
- Free of Pro-Inflammatory Omega-6s!
At MEA we are sincere believers in the benefits of Omega 3. However, not all Omega 3 supplements are created equal. It is important to take supplements that are found in their triglyceride form which is naturally occurring with an absorption rate of 69%. Most products on the market are in ethyl ester form whose absorption rate is much lower, at 20%!
Some of the less expensive over-the-counter brands of Omega 3 may contain high levels of PCBs and heavy metals such as mercury. MEA carries Physician Recommended Nutriceuticals (PRN) which stands behind all of its products with the confidence that each one is of the purest, highest quality marine source Omega 3 available. They were so confident of the purity of their Omega 3 products that they had it verified and confirmed by a third party to be free of harmful contaminants. These products are available through physician recommendation only and are available at Matossian Eye Associates.
Intense Light Pulse (IPL) Therapy
“In the U.S., about six million women and three million men have moderate or severe symptoms of dry eye syndrome, and it is estimated that an additional 20 to 30 million people have mild cases of dry eye syndrome. Dry eye syndrome is one of the most common reasons that people visit their eye health professional.” - Market Scope 7/2008
One key source of potential tear-film trouble is the Meibomian gland. If these glands malfunction, the lipid layer may be reduced, allowing rapid evaporation of the tear complex. Furthermore, if the secretions from the Meibomian glands become trapped inside the glands, inflammation and bacteria can follow, worsening the problem.
Researchers have been refining a new approach to treat this problem, using intense pulsed light, or IPL, originally developed for use in dermatology. Brief, powerful bursts of light at specific wavelengths (in this case, between 500 and 800 nm) cause changes in blood vessels near the surface of the skin, raise skin temperature and eliminate problematic flora on the skin and eyes. This is thought to have a beneficial effect on Meibomian gland dysfunction.
The IPL treatment is performed in the office; takes only a few minutes and is painless. IPL works by closing the blood vessels that secrete the proteins causing chronic inflammation that damage the Meibomian glands. For those who have been suffering with dry eye syndrome with inadequate relief with other methods, IPL may be the appropriate therapy. Interestingly, the Intense Pulse Light machine was originally designed for skin rejuvenation but the technology has been completely reformatted for use the treatment of dry eye syndrome. Matossian Eye Associates is offering the IPL treatment through their acredited Dry Eye Center of Excellence.
Performing the Procedure
“When the patient comes in, we determine the skin type and the severity of the Meibomian gland dysfunction,” explains Dr. Matossian. “This treatment should only be used for patients whose skin is Fitzgerald type four or below, to avoid causing lightening of the skin color. We, then, give the treatment from ear to ear. If we just treat the lids, the blood vessels grow back much sooner, requiring more maintenance treatments. After placing a protective eye shield over the eyes, we treat the lower lid areas.”
Dr. Matossian states that she doesn’t directly treat the upper glands. “First of all, when you treat the side of the lid you close off blood vessels that feed into the upper glands,” she explains. “Also, once you get the lower glands working better, the lids appose each other better; as a result, the pumping mechanism that accompanies blinking is more effective in the upper glands. Third, some of the heat is transferred from the side treatment of the lower lids, so you get the warm compress effect on the upper glands indirectly.”
Dr. Matossian notes that it usually takes four treatments over the course of four months to get the secretions thin and working correctly. After the gland is normalized we do maintenance treatments every six months to a year. Younger patients need fewer treatments.
Other simple steps in addition to the above mentioned treatments that can help minimize environmental factors that cause or exacerbate dry eye include:
- Avoid air blowing in your eyes. Don't direct hair dryers, car heaters, air conditioners or fans toward your eyes.
- Wear glasses on windy days and goggles while swimming. The wraparound style of glasses may help reduce the effects of the wind.
- Add moisture to the air. In winter, a humidifier can add moisture to dry indoor air. Some people use specially designed glasses that form a moisture chamber around the eye, creating additional humidity. These glasses can be worn at night, and may be especially helpful for people that sleep with their eyes partially open. They can also be worn during the day to relieve dry eye symptoms.
- Avoid rubbing your eyes. You can irritate your eyes further by rubbing them.
- Take preventive steps. Use eye drops before, rather than after the symptoms begin; your eyes become irritated as a result of visually demanding activities. Try to avoid activities that might worsen the problem.
- Remember to blink. Consciously blinking repeatedly helps spread your own tears more evenly. When performing tasks that require intense visual concentration, take occasional breaks — adding up to about five minutes each hour — and rest your eyes by closing your lids for several seconds. Follow this by consciously increasing your blink rate. Be especially careful to follow these suggestions if you have had LASIK or a similar procedure.
- Avoid smoke. Smoke, whether yours or someone else's, can contribute to dry eyes.
- Avoid anti-histamine or other allergy medications: Often these medications are designed to ‘dry up’ your nose; they tend to dry your eyes at the same time.
As you can see the diagnosis and treatment of Dry eyes Syndrome, Ocular surface disease, or Meibomian Gland dysfunction is complex and requires patience and persistence on the part of the eye doctor and the patient. Through careful evaluation and systematic therapeutic approach dry patients can experience significant improvement. If you have any questions about dry eye or feel you may be suffering from dry eye please call to schedule an appointment with one of our doctors. Click here to contact us.
Other helpful links and Articles:
Dry Eye Zone
All About Dry Eye
Tear Film and Ocular Surface Society
Lubricating Drops Reduced Ocular Scattering in Mild to Moderate Dry Eye Disease
You are What you Eat