Dry Eye is a Disease eyethera can Help

Dry Eye is a Disease eyethera can Help Dry Eye is a chronic, progressive disease that is currently affecting millions of people at all ages, it can be a complicated disease to diagnose and treat, but we are working to make it less complicated. Please enjoy the complimentary educational material contained herein. Dr. Edward Jaccoma MD 1

How important is your sight? All vision begins with the first interaction of light with your eyes - and that can only be optimal when the surface of your eyes are at their best - moist, well nourished, lubricated, smooth and clear. When the tears used to provide these healthy functions fail us, we call that dry eye disease. What are the symptoms of dry eye disease? Everyone is affected differently and their experiences will be as individual as they are. Common symptoms may include a sense of burning or dryness (though not always). In fact, the first symptoms of an overly dry eye can be a reflexive tearing (described below). Other symptoms may be a more general sense of discomfort, irritation, sensitivity to light, grittiness or feeling like there is something scratching the eye. Stinging, itching, tiredness of the eyes, blurring vision (especially when engaged in prolonged visual activity like reading or working on a computer) and redness of the whites of the eyes are all associated with dry eye disease. Left untreated, dry eye disease tends to be both chronic and progressive We at New England Dry Eye and eyethera take eyesight seriously. Thanks to the recent work of many giants in the dry eye field, we have made truly significant strides in understanding and treating this problem. How do we diagnose Dry Eye Disease (DED)? Dry Eye Disease is able to be divided into 3 major types: 1. Aqueous deficiency (too little moisture is produced) 2. Evaporative dry eye disease (poor tear quality - generally caused by Meibomian Gland Dysfunction - MGD) 3. A combination of the two We determine which of these issues is causing an individual patient's problem using a thorough history, a series of laboratory and computerized tests and a comprehensive, dry eyefocused eye exam. It is important to distinguish this type of exam - parts of which may not be covered by insurance companies - from the routine medical eye exam, in which a full range of medical eye diseases are screened for - an exam commonly covered by most insurance companies, but is not specific enough for this very focused evaluation utilizing more advanced technology. 2

Your tears are very important When discussing the two ways our eyes make their tears, we like to use the analogy of a "sprinkler system" producing minute-by-minute moisture for the surface of the eye and a "fire hose." The components of healthy, sprinkler system tears, are a mixture of water, salt, protein and oil - think of this as akin to clear salad dressing. As in salad dressing, oil and water don't mix - so the oil, floating on the surface of the tear film, helps to seal that moisture in and acts to lubricate and nourish the cells living on the surface of the eye. Oil makes the tears more "stable" - preventing evaporation (think of it acting as a liquid Saran Wrap over the tears). The "fire hose" produces primarily saltwater and tends to send in a flood. More on tears In cases where the eye is deficient in oil, the water of the "salad dressing" evaporates too easily and can trigger the "fire hose." This "fire hose" is pouring from a large (lacrimal) gland and is responsible as an emergency back-up to the sprinkler system. It is the gland we cry with if we get emotional, have something get in our eye, or if the "sprinkler system" let's us down. When the sprinkler system fails us in any way, the fire hose will frequently be triggered - resulting in the overflow of salty tears that cause our eyes to "water" and frequently to sting or burn (the effect of putting this salt into a dry, sore eye). This is referred to as "reflex tearing" - when irritation triggers the eye to cry. Things that can exacerbate dry eye symptoms: Allergies (the pollen and dust that gets into dry eyes is not easily "washed" off the surface due to the deficiency of the tears. This allows the irritants longer contact time with the eye and causes more itching). Contact lenses (may act as little sponges on the surface of the eye, They generally require more lubrication to work better and they may allow irritants more time to interact with the eye). Eyelid irregularities such as lids and lashes that turn in (entropion with or without trichiasis) or turn out (ectropion) may stress a dry eye more than a well lubricated eye. Conditions like Grave's thyroid disease (may result in protruding, prominent eyes that result in more exposure). Nerve problems (like Bell's palsy which can make it harder for an eye to close and protect itself from dryness, or like diabetic neuropathy - a deficient nerve supply to the cornea weakens it and poor circulation - common in more advanced diabetes-related 3

disease - creates the perfect storm of a weak surface and inadequate tears to protect and nourish it). Rosacea (an inflammatory condition that can aggravate, if not directly cause a dry eye). On the face, this may present as a rosy or ruddy complexion with fine capillaries on or near the skin's surface. Around the eyelids, these same fine blood vessels may be seen best with a microscope as they cross over the eyelid margin. These fine vessels are reacting to signals in the oil glands within the skin that appear to be created by the action of microorganisms subsisting on these oils, the blood in these small vessels engage the body's infection-fighting defenses to a battle that can't be won. This puts "gas on the fire", fueling the inflammation to make skin and eyes red, sensitive and sore. Blepharitis (irritation of the lids that can affect the tear-producing glands and the tears. This is common in rosacea as well as existing in many other forms). Nocturnal lagopthalmous (a condition where the eyelids are not fully closed at night while one sleeps. This can result in excess exposure at night, when tear production is usually at its least. Sufferers often complain that they wake up with eyes that feel excessively dry as they climb out of bed in the morning). Conjunctival Chalasis Then there is the special circumstance of the condition known as "conjunctival chalasis." This is when the conjunctival membrane (the thin, clear membrane normally "shrink wrapped" over the white of the eye) becomes "loosely fit." One theory of how this happens is that the dry eye promotes more friction between the lids and this membrane, pulling and stretching it out of tautness (kind of like a loosely fit bed sheet over a mattress). Additionally, the inflammation generated by this friction may weaken the fine, root-like fibers and "glue" that holds the tissue in place, allowing it to slip and resulting in redundant pleats and folds in this membrane. When an eye has a more limited volume of tears to bathe the eye's surface, if that surface area is increased and further compromised by extra folds that can catch and retain some of these scant tears, then what tears exist will have a harder time doing their job. Treating Dry Eye Disease (DED) After we evaluate these tests in light of the dry eye history and exam, we put together a customized treatment plan. In cases of excessive conjunctival chalasis, we may recommend a thermal "plication," where we use radio frequency energy to tighten the loose membrane firmly back into place, improving the ability of tears to properly spread over and wet the eye. When reflex tearing leads to tears running down the cheeks, this can often be attributed to this loose 4

membrane lapping over the edge of the lower eyelid, acting as a spout for the tears to leave the eye as a crying tear would do (rather than the way our tears were designed to leave - via a tiny "storm drain" called a punctual opening that leads to the tear ducts - and then to our nose). Many insurance plans cover this useful, in-office treatment. Evaporative Dry Eye Disease In the case of evaporative dry eye, we put special attention on the Meibomian Glands. These are the tiny, oil producing glands that line the upper and lower eye lids and whose numbers approach 100-125+ in total. These glands are prone to blockage and once the tears become deprived of their important natural oil products, the tear film on the surface of the eye becomes unstable and moisture evaporates quickly from the eye. This leaves the salt and protein residue from that part of the sprinkler gland's tear film that doesn't evaporate, to gradually accumulate on the eye. This soupy, irritable film can blur vision and may make an eye feel as though it is burning, scratchy, or just "tired" - depending on the composition and degree of residue that accumulates. These concentrated salts and proteins (along with the residue from any overgrowth of skin germs) can break down any of the oily or waxy materials produced from the Meibomian Glands, producing soapy products that can cause stinging. All of this irritation can lead to inflammation - the eye's natural response to things that bother it. This can cause redness, but at the cellular level, this begins to damage the delicate tissues on the surface of the eyes and eyelids. This in turn leads to "Ocular Surface Diseases" - conditions which can cause ongoing irritation and ultimately can seriously harm eyes. MGD Meibomian Gland Dysfunction (MGD) has been found to be wholly (as much as 50%of the time) or partially (as much as another 35% of the time) responsible for dry eye disease and frequently begins during our younger years. Typically this slowly progresses during our adult lifetime. MGD can result from many factors including genetic, diet, environmental, age and hormonal influences - but also from how we blink The action of blinking helps to dispense a tiny bit of oil from each active Meibomian Gland. When the upper lid leaves the lower lid after lid closure from a "good" blink, it "pulls" some of this oil up over the tears - protecting the water from rapid evaporation. During childhood, we have our best, most robust surface eye cells and tears. As a result, we hardly have to blink to see clearly and maintain a clear surface. It turns out that many of us learn a poor blink. Without the firm closure that results in the dispensing of some oil, the oil becomes stagnant. Stagnant oil at body temperature exposed to air and the salts and chemicals of our tears as well as some germ by-products, tends to 5

solidify - turning by degree into soaps (saponification) and waxes (esterification). Soaps upset the tear film (as well as your eye) and waxes block the openings to the oil glands. Once blocked, these glands can either continue to produce oils that lead to a chalazion or "stye" or they gradually atrophy or "wither" - following the adage that you "use it or lose it." Once gone, they cannot regenerate and you may become permanently affected. It is important to understand that MGD is a chronic, progressive disease - that left untreated, it can result in the permanent loss of the Meibomian Glands themselves. MGD Assessment and Treatment The good news is that we can now more easily diagnose and treat MGD - thereby preventing the permanent loss of these important glands and re-establishing a healthy tear film. This is done with the use of Tear Science's Lipiview (a scanner that measures the oil in the tears and monitors the quality of blinking), specialized photography (the Oculus Meiboscan) and with direct (transillumination) and indirect (computerized non-invasive tear breakup time scanning) evaluation of the delicate Meibomian Glands themselves. Ancillary testing, like Tear Lab's Tear Osmolarity can help to further nail down the diagnosis and direct treatment. Once it is determined that a patient has MGD, then depending upon the severity, we may recommend a Lipiflow treatment to gently heat the waxy blockage in these glands and then to express this waxy oil so that the glands can head back to health. Omega Oil supplements are often recommended - to ensure they receive the necessary nutritious building blocks they need to make healthy oil. Blink exercises may be advised, when appropriate, to ensure the glands get sufficiently "milked." Hot moist compresses may help to keep the oil from congealing and to keep the pores open that allow the free flow of this oil. Lid hygiene helps to remove the "biofilm" of germs encased in the varnish-like veneer of waxy debris lining the eyelids and aggravating rosacea and belpharitis-related dry eye disease. The office-based BlephEx treatment is an exciting new technology that offers a great step forward in establishing a healthy lid margin and daily, home-based treatments can help to prolong the benefits. For those with more advanced rosacea-related inflammation, oral tetracycline-derived drugs or IPL (Intense Pulsed Light) therapy may be beneficial. Ronaldo Toyos, MD teamed up with Dermamed to create a "smart program" of this advanced light therapy, especially targeting the abnormal, inflammation-bearing blood vessels. This monthly 4-step treatment helps to safely close them without harming the necessary circulation deeper in the lids or damaging the eyeballs beneath them. The heat from the light also offers an opportunity to express the waxy plugs and jumpstart healthier oil production from the meibomian glands. 6

If MGD is caught early, it may be possible to turn it around with home-based treatments and even if a Lipiflow or IPL treatment is recommended, the benefits appear to be improved and extended through ongoing home care. For those with primary aqueous deficiency, other products and treatments may be required. For mixed cases, it may take combined therapy for best results. With more advanced MGD, it may require multiple or serial treatments to achieve an optimal outcome - and at the extreme of MGD, it may not be possible to adequately reverse the disease - hence the need for earlier diagnosis and treatment. At New England Dry Eye and through our corporate partner, eyethera, we offer state-of-the-art diagnostics and a full range of in-office treatments and home care for your dry eye condition - come see what we can do for you (or consult your local doctor) Sincerely, Dr. Edward H. Jaccoma, MD and the staff at New England Dry Eye and eyethera 7