Dry Eye – Ask Eye Doc

Written by: Dr. Stephanie Mulick, O.D. When educating my patients on dry eye syndrome, I like to describe our corneas like the windshield of our car and the eyelids like the windshield wipers. There are small glands that line the upper and lower eyelids called the meibomian glands (illustrated below) that are like the misters of our windshield wipers. There are about 50 meibomian glands in our upper eyelid and about 30 in our lower eyelid, which are stimulated to produce tears with each blink. photo credits: Dryeyeandmgd.com As you can see in the illustration above our tear film is made up of three layers: The mucin layer is the deepest layer of the tear film. It is a sticky layer that helps keep the tears on the eye. The mucin layer is created by the goblet cells of the conjunctiva (the clear covering of the sclera or the white of the eye) and lacrimal glands. The aqueous layer is the middle layer produced by the lacrimal gland, which provides our eyes moisture and oxygen. The middle aqueous layer also has antibacterial functions. The lipid layer is the outermost layer which helps to prevent evaporation to keep the tear film on the eye longer. The lipid layer is produced by the meibomian glands. Each of these three layers of tear film has a role in keeping our eyes moist. 3 Types of tears: Basal tears: Our day-to-day tears keep the eye moist. Reflex tears: The lacrimal gland produces reflex tears that occur when something gets into the eye when it's windy or we laugh, cough, or sneeze. Emotional tears: We are all familiar with emotional tears. The lacrimal gland is triggered in response to strong emotions such as sadness, humor, and happiness. Symptoms of Dry Eye Syndrome: Irritation Foreign body sensation Burning Intermittent fluctuations in vision Photophobia/light sensitivity Tired/Heavy eyes Red eyes Tearing Occasionally eyes crusted shut in the morning Occasionally severe pain upon waking (Recurrent corneal erosion) Sandy/gritty sensation 21 Causes of Dry Eye Syndrome: Meibomian Gland Dysfunction Meibomian Gland Dysfunction Blepharitis Rosacea Acne Omega-3 deficiencies Dehydration Advanced age Hormone changes/Menopause Dry windy environment Medications Air conditioning and heater Computer use Eye surgery Vitamin A deficiency Sjogren’s Syndrome Autoimmune diseases Allergies Smoke Contact Lenses Lagophthalmos Diabetes Meibomian Gland Dysfunction (MGD): One of the main causes of dry eye syndrome is Meibomian gland dysfunction. Meibomian gland dysfunction means that the small glands lining the upper and lower eyelids become blocked with thick oil causing Meibomian gland obstruction and inflammation (Imagine the misters of your windshield wipers getting clogged). Sometimes you can see your own clogged meibomian glands in the mirror, the lid margin may have a notch or divot or you may see oil caps along the margin of your eyelid. This is much easier to see with a high-powered microscope, called a slit lamp that the Eye Doctor will use to examine your eyes. This photo shows the thick oil being pushed out of the meibomian glands. photo credits: premium vision When the Meibomian glands are clogged, tear production decreases and symptoms of dry eye syndrome can present. Even though the meibomian glands are blocked the lacrimal gland will still work to produce the aqueous layer of the tear; this can lead to symptoms of watery eyes. In some cases, a clogged meibomian gland can lead to inflammation and cause or stye or chalazion. To find out more read my post on Styes and Chalazion. Meibomian Gland Dysfunction Treatment: The best treatment for MGD is heat to melt the oil that is clogging the meibomian glands. (click here to view the 5 best dry eye masks on Amazon). You can do this by using a hot compress mask, a hot bowl of water with a lid, and two washcloths that you would alternate in succession to maintain heat. I have even heard of patients using hot potatoes or hot tea bags; you can also purchase a dry eye mask that heats up in a microwave. As long as you can keep the heat on the eyelids for 10-20 minutes. Less than 10 minutes does not allow the oil enough time to melt. Make sure to clean your face and eyelids before using a hot compress. After about 10-20 minutes of heat, make sure to clean the eyelids well to wipe clean the melted oils. You want to make sure to use a product that will cut the oil, just wiping the eyelids with a wet cloth will not remove the oil. Products such as Ocusoft lid scrubs (I prefer the OcuSoft Plus that does not need to be rinsed off and has antibacterial properties), Systane Eyelid Wipes, or even baby shampoo work well for cleaning the eyelids. The length of time using hot compresses is much more beneficial than the number of times you use the hot compress. It is common for my patients to tell me that they use hot compresses until the hot cloth gets cold about 3-4 minutes several times per day. Really, this is just wasting your time. Think about melting butter, if you don’t heat it long enough it will not melt, the same goes for the oil in the meibomian glands. Although tedious, it is important to have the heat on the eyelids for a minimum of 10 minutes. Longer is usually better; however, you don’t want to heat your eyelids longer than 20 minutes because heat can cause inflammation. Don’t be surprised if after the heat treatment your eyes seem redder and more inflamed, that is normal. Your Eye Doctor can prescribe a topical ointment that can help reduce the risk of inflammation and infection. Do not use vaseline on your eyes, it will only increase meibomian gland dysfunction. There are expensive treatments that can be used to express the Meibomian glands by heating and compressing the glands using a device called Lipiflow or iLux (for more information on ILUX click here). Blepharitis: Blepharitis and Meibomian Gland Dysfunction go hand in hand. Blepharitis is a medical term that means inflammation of the eyelids. It presents with a dandruff-like buildup on the base of the eyelashes, increasing the risk for infection and inflammation; therefore, leading to dry eye syndrome. It is important to have your Eye Doctor examine your eyelids for blepharitis and recommend the proper treatment. photo credits: medicinenet.com Treatment for Blepharitis: The Treatment for Blepharitis is the same as Meibomian gland dysfunction. Again, you want to heat the eyelids for 10-20 minutes and wipe them clean with either baby shampoo or special eyelid cleaning pads such as Ocusoft or Systane Lid Wipes. It is sometimes necessary to use a prescription eye ointment from your Eye Doctor. Rosacea: Rosacea is an idiopathic skin disease (meaning it does not have a specific known cause) that presents with flushing and visible blood vessels on the skin, most commonly on the glabella (between the eyebrows), cheeks, nose, and chin. Rosacea typically affects females ages 30-50 with a fair complexion, who smoke and have a history of severe acne. Rosacea Treatment: Your dermatologist may prescribe an oral antibiotic or acne medication. Depending on the severity you may also be prescribed a topical ointment or cream. If you suffer from itchy, red skin make sure to see your Dermatologist. Acne: If you suffer from acne, you may use medication that helps to lower the amount of oil production in your skin. These medications, when taken orally or topically, can increase the risk for Dry Eye Syndrome. Acne Treatment: There are so many acne treatments. I personally have suffered from cystic acne since adolescence and have used just about every over-the-counter and Dermatologist prescribed medication imaginable. Keep in mind, I am not a Dermatologist and each person will have a different experience when it comes to acne treatment. For me, I have found that removing Dairy from my diet significantly reduces my symptoms. I also use an over-the-counter supplement called EstroBlock, which has been amazing for my hormonal acne as well as other hormone-related symptoms. I also take zinc and copper supplements which have been shown to reduce acne. Obviously, it is important to keep the skin clean. I have used Proactiv, LaRoche-Posay, Cetaphil, Neutrogena, Arbonne, you name it, I have probably tried it. What I have found works best for my cystic acne is Elta MD foaming facial cleanser and Keeva organic acne treatment cream with tea tree oil. My recommendation is to always consult your Dermatologist when it comes to acne treatment. Several topical and oral medications can be prescribed for the treatment of acne. Omega-3: Omega 3 fatty acids have been found to reduce symptoms of dry eyes (for the scientific research click here) as well as reduce the risk for Age-related macular degeneration (click here to view the scientific research). Omega-3 is an essential fatty acid found in foods such as avocado, nuts, seeds, seaweed, and oily fish (preferably wild-caught). The reason that omega-3 is so beneficial is that it has been found to reduce inflammation within our bodies. It is important to take a good source of omega-3 fatty acids preferably from wild-caught fish. Omega-3 fatty acids from vegetable sources such as chia, flaxseed, and nuts, are higher in ALA (alpha-linolenic acid) which has been found to have less of an anti-inflammatory effect when compared to EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid) found in oily fish, like wild-caught salmon, mackerel, sardines, and anchovies. Omega-3, 6, and 9 are types of dietary fats called polyunsaturated fats. Traditional diets are high in omega-6 and 9 and lower in omega-3. Getting the proper ratio of omega-6 to omega-3 plays an important role in the inflammatory process. It is recommended to have a ratio of 4:1 or less omega-6 to omega-3 for the best anti-inflammatory effects. Because the body cannot produce omega-3, it is important to eat foods that contain high amounts of omega-3 whenever possible. When comparing farm-raised salmon to wild-caught salmon there are several benefits to eating wild-caught; however, farm-raised salmon is still a good source of omega-3 fatty acids. Farm-raised salmon (which is more likely served at restaurants, unless specified that it is wild-caught) has 5 times more omega-6 than wild-caught salmon and 3 times more saturated fats. Wild-caught salmon also has a higher mineral profile, providing a good source of zinc and potassium. How to choose the best omega-3 fish oil supplement: Many companies produce omega-3 supplements. When purchasing omega-3 supplements look for cold-pressed, meaning limited heat exposure. Polyunsaturated fats (omega-3, omega-6, and omega-9) are easily oxidized with heat and light, making them rancid and ineffective. Ideally, take at least 2000mg of fish oil per day. Some companies claim that the triglyceride form has better absorption and safety, but so far the science-based studies do not show a significant difference between the triglyceride form and the Ethyl ester form; however, studies are still being conducted. I use Nordic Naturals pro-omega which are in the triglyceride form. Dehydration: This sounds easy, but just drinking more water can help with dry eye symptoms. In a society where we consume caffeine (a diuretic) and medications that dry us out, it is good to add more water to your diet. Sometimes we catch ourselves snacking when really we just need some water and our hunger can be satisfied. Our body requires good hydration to function optimally. The Institute of Medicine of the National Academies, Washington DC created a table for the recommended daily allowance of water, based on age. For a person, 19 years or older the daily recommended water intake is 2.7 liters per day, which amounts to 33.81 fluid ounces. WebMD suggests drinking at least half an ounce of water for each pound you weigh, every day. For instance, if you weigh 150 pounds then you should drink 75 ounces of water each day. Advanced Age: I always say if you are lucky enough to live a long life, you may be more prone to developing symptoms of Dry eye syndrome. The longer we live the more build-up of oils we will have in the Meibomian glands, but also the mechanism to produce the tear film is not as effective as it once was. “An autopsy study by Roen and colleagues found that 75% of lacrimal glands showed abnormalities such as inflammation and fibrosis.” Inflammation and fibrosis of the lacrimal glands lead to less tear production. “The Women’s Health Study and Physician’s Health noted that dry eye prevalence increases in women and men every five years after the age of 50, with greater prevalence in women compared to men. Age-related eyelid alterations include lid laxity, meibomian gland atrophy, and orifice metaplasia, decrease in tear volume with increased tear break-up time, and dry eye.” Another factor related to age-related dry eye syndrome is the fact that there is a high correlation between increased age and increased consumption of prescription medications due to “co-morbidities such as cardiovascular diseases, type 2 diabetes, depression, glaucoma, and other ocular diseases.” (Click here to view the scientific data). Treatment of Age-related Dry Eye Syndrome: Age-Related Dry Eye is treated the same. Review the Dry eye Treatment List below in this post. Prescription Eye drops: Restasis, Xiidra, and Cequa can provide benefits (for more information on these eye drops review below in the Prescription eye drop heading). The same treatment for Meibomian gland dysfunction and blepharitis can also help with Age-related Dry eye symptoms. Using hot compresses, lid scrubs, as well as over-the-counter Artificial tears at least 3-4 times daily can help reduce symptoms by providing more moisture for the ocular surface. Some devices can be used to heat and melt the oil that clogs the meibomian gland. (For more information on the review of specific devices read below under Dry Eye Devices). Going back to the image of our eyelids as the windshield wipers and our cornea as the windshield; when the cornea is dry the eyelids move up and down over it causing friction which can lead to the sensation of something in the eye as well as redness and irritation. Punctal plugs can also offer relief from dry eye symptoms. There are two small openings called puncta or punctum, one on the lower eyelid and one on the upper eyelid near the nose. The punctum is where the tears drain from the eye. Like a sink, the eye produces tears and drains the tears. By using a punctal plug your Eye Doctor can plug one of the drains usually the lower eyelid puncta is plugged, keeping the tear in the eye longer as it is unable to drain as quickly. Some devices can be used to heat and melt the oil that clogs the meibomian gland. (For more information on the review of the specific devices read below under Dry Eye Devices). As far as more holistic treatments to avoid the comorbidities associated with aging, the use of intermittent fasting (IF) or calorie restriction (CF) and supplementation with vitamins and antioxidants have been shown to have some benefits. “Calorie restriction (CR) without malnutrition has emerged in the 21st century as a potential strategy to prevent age-related diseases.” (click here to view the scientific research). Intermittent Fasting (IF) or Calorie Restriction (CR) is not a novel concept, in fact, it was first introduced in 1935 but has recently gained popularity after studies have shown increase life span, decreased risk of cardiovascular disease, and decreased occurrence of tumors in rodents and non-human primates. I personally have been practicing Intermittent fasting 1-2 days per week for a couple of years and have noticed improved digestion, mental capability, and energy. I am excited to see what research will reveal in the future of this technique. And of course, do not smoke cigarettes. Nicotine causes the narrowing of blood vessels and the release of toxins into our bodies. Unfortunately, the effects of cigarette smoke don’t just affect the smoker but also anyone around the smoker (ie: second-hand smoke). It is well known that smoking is bad for our health and decreases one's lifespan. It also contributes to early aging including wrinkling of the skin, Cataracts, and Age-related macular degeneration, which can lead to loss of vision progressively over time. The amount of humidity we are exposed to can affect our tear film. The drier the atmosphere the drier our eyes will be. Using a humidifier can help with dry eye symptoms. Hormones/Menopause: Hormones influence the production of all three layers of the tear film: mucin, aqueous, and lipid layer. Studies have shown that hormone replacement therapy can be an effective treatment. Dry windy environment: The amount of humidity we are exposed to can affect our tear film. The drier the atmosphere the drier our eyes will be. Using a humidifier can help with dry eye symptoms. 10 Medications that can increase dry eye symptoms: Antihistamines and Decongestants Antidepressants and Anti-anxiety drugs (such as Zoloft, Paxil, Elavil, Endep, etc.) Birth control pills Hypertensive drugs classified as beta-blockers Diuretics Hormone Replacement Therapy (HRT) Gastrointestinal drugs classified as proton pump inhibitors (such as Prilosec, Prevacid, Zantac, etc.) High dose Ibuprofen Chemotherapy Antipsychotic drugs Air conditioner/Heater: Air conditioning and heaters can dry out the air and our eyes. It is especially true in the car or airplane where we are close to the air vents. Try to direct the airflow from the vents away from your eyes. Computer use: The use of computers has increased significantly in the past 10 years. It is common to see people staring at their cell phones (I know I am guilty of this at times). When we are intently focused our blink rate decreases. It has been shown that with increased screen time we have more incomplete blinks. This means that the Meibomian glands are not being stimulated as often to produce lubrication to keep our eyes moist. Since our tear film is produced with each blink, our eyes will become dry if we do not blink completely. The angle from which we view the screen can also contribute to dry eyes. When we are lower than the monitor or directly in front of it, then our eyes are open much wider than if we are sitting higher than the monitor. This can lead to more evaporation of the tears since there is more exposure to the ocular surface. Sitting higher than the monitor can help reduce the evaporation of the tear film by keeping the eyelid lower, covering more of the ocular surface. The 20/20/20 rule is to look away from the screen every 20 minutes at something 20 feet away for 20 seconds. This can also help us remember to blink more often as well as help reduce eye strain by relaxing accommodation or focus of the lens in the eye. To learn about blue light and its effect on our eyes click here. Eye Surgeries that can increase Dry Eye Symptoms: Dry Eye symptoms can be exacerbated by Eye surgery such as: Refractive Eye Surgery such as LASIK and PRK (click here to learn about refractive eye surgery options) Cataract Surgery (click here to learn about cataracts) Eyelid Surgery Vitamin-A Deficiency: Vitamin-A deficiency is extremely rare in the United States. It is more prevalent in non-developed countries. I added this because it seems to be searched frequently when looking at dry eye treatments. However, there is not enough research done on this topic. One small study of only 30 men showed improved quality of tears with short-term Vitamin-A supplementation but a decrease in tear quantity. There are several food sources of vitamin A including spinach, carrots, sweet potatoes, cantaloupe, mango, squash, pumpkin, and kale. A diet that includes whole foods rich in Vitamin A will supply your body with nutrients and antioxidants that it needs to strive. Sjogren’s: Sjogren’s is an autoimmune disease that usually presents in adults ages 40-60 years old with symptoms of dry eyes and mouth as well as joint pain and fatigue. Unfortunately, diagnosis is difficult since the symptoms and tests can often be confused with other inflammatory conditions such as rheumatoid arthritis, lupus, fibromyalgia, multiple sclerosis (MS), and chronic fatigue syndrome. There are specific inflammatory markers that can present and specific blood tests can be helpful in the diagnosis, but not always conclusive. Blood tests your physician may perform include: (click here to view Sjogrens.org) ANA (Anti-Nuclear Antibody): About 70% of Sjögren’s patients have a positive ANA test result. RF (Rheumatoid Factor): Antibody test for rheumatic diseases, including rheumatoid arthritis (RA), lupus, and Sjögren’s. 60-70% of Sjogren’s have a positive RF. SS-A (or Ro) and SS-B (or La): 70% of Sjögren’s patients are positive for SS-A, 40% are positive for SS-B ESR (Erythrocyte Sedimentation Rate): A measurement of inflammation IGs (Immunoglobulins): Are often elevated in Sjögren’s patients. Ocular Diagnostic Tests: Schirmer Test: a measurement of tear production. Rose Bengal, Fluorescein, and Lissamine Green: dyes that an Eye Doctor uses to examine the surface of the eye for dry spots. Tear lab: measures tear osmolarity to aid in the diagnosis of dry eye syndrome. The dental tests include: Salivary Flow: Measures the amount of saliva produced over a certain period of time. Salivary scintigraphy: A nuclear medicine test that measures salivary gland function. In some cases, a salivary gland biopsy (usually in the lower lip) is performed to confirm inflammatory cell (lymphocytic) infiltration. Auto-immune disease: Autoimmune diseases are inflammatory conditions that can cause inflammation anywhere in the body, including the eye. Inflammation of the eye can lead to dry eye syndrome. Allergies: Allergies, like autoimmune diseases, also cause inflammation, which can lead to dry eye syndrome. A common side effect of medications for the treatment of allergies is dryness of the eyes, mouth, and mucous membranes. To learn more about ocular allergies and treatments click here. Smoking: It is debatable as to whether smoking can cause dry eyes. Some study results have shown a correlation between smoking and dry eye symptoms, while other studies have found no correlation. This to me is inconclusive. However, smoking, in general, should be avoided due to health repercussions. It is well known that smoking increases aging in the body and the eyes. Cigarette smoking is a risk factor for cataract development, age-related macular degeneration, and Diabetic retinopathy. I’m sure we have all had the unpleasant experience of second-hand smoke and the resulting red, irritated eyes; so regardless of the inconclusive study results, I firsthand can tell you that my eyes become irritated with cigarette smoke exposure. Contact Lenses: I have personally worn contact lenses for 29 years (wow, time flies). Contact lenses have come a long way. Contact lenses today are much more comfortable as well as oxygen permeable when compared to 20 years ago. Contact lenses can exacerbate symptoms of dry eye. If you wear contact lenses and suffer from dry eye symptoms, talk to your eye care professional about newer technologies that may help your symptoms. There are occasions when a dry eye patient just cannot tolerate contact lenses due to dry eye symptoms or allergies. In some cases, we can prescribe daily contact lenses to be worn for special occasions or sports activities. Lagophthalmos: Lagophthalmos is a medical term for eyelids that don’t fully close. You may have watched someone sleeping and notice that their eye is not closed completely. This lack of eyelid closure can lead to severe dryness due to prolonged exposure to the ocular surface. Patients with lagophthalmos may require surgery but often do well with a nighttime ointment like Refresh PM, lacrilube, genteal eye gel, or Systane nighttime gel. Eye masks made for sleeping can help to reduce the exposure of the eye and evaporation of the tears. If you don’t have an eye mask I have had some patients just tape the eyelids shut with a cotton pad or cotton ball. The only problem is that when they wake up the eyelids are taped shut. Diabetes: Diabetes is one of “the leading systemic risk factors for Dry Eye Syndrome,” according to a 2016 study in the Journal of Ophthalmology. Studies have shown that hyperglycemia (high blood sugar levels) can lead to dysfunction of the lacrimal gland causing Diabetic patients to present with symptoms of dry eye. For more information about Diabetes and the eye please click on my post about Diabetic Retinopathy. To avoid serious complications associated with Diabetes including dry eyes, visual impairment, bacterial infections, and Diabetic Retinopathy, it is important to have early intervention and treatment as well as an exercise protocol and dietary modifications including limiting carbohydrates and sugars. I go into more detail on Diabetes in my Diabetic Retinopathy post. Dry Eye Diagnostic measurements: Tear break-up time (TBUT): a measurement of tear film stability or how long the tear film stays on the cornea. The Doctor will instill fluorescein dye into the eye and evaluate the tear film under blue light. Rose Bengal: another dye used to evaluate corneal dryness Schirmer test: uses a filter paper inserted in the lower eyelid for 5 minutes to evaluate tear production. Tear osmolarity: a quick measurement done with a device that takes a sample of tears from each eye and measures the osmolarity or salinity of your tears. The higher the osmolarity the more dry eye symptoms a patient will have. With treatment, your Eye Doctor would like to see your tear osmolarity improve. 18 Effective Dry Eye treatments include: Hot compresses 10-20 minutes Eyelid cleaners such as OcuSoft, Systane lid wipes, or baby shampoo Artificial tears lubricate the eyes. Make sure it does not say to get the red out. Xiidra Restasis Punctal plugs Stay hydrated Omega 3 supplementation Avoid smoke and wind Review medication side effects Adjust your seat to be higher than your computer monitor Use daily contact lenses instead of extended wear contact lenses Use a humidifier Sleep with an eye mask if you have lagophthalmos Treat rosacea Treat blepharitis Eat a balanced diet high in omega 3 fatty acids and antioxidants Dry Eye Device: ILUX, Lipiflow, IPL Hot compresses 10-20 minutes: Dry eye mask: heat lasts about 5 minutes after microwaving for 20 seconds, so make sure to microwave the mask after 5 minutes of heat on the eyes to maintain 10-20 minutes of heat. Hot washcloth: To maintain 10-20 minutes of heat, it is recommended to use a hot bowl of water with a lid and use two washcloths to alternate the heat on your closed eyelids. Clean sock of rice or beans: It is best to use moist heat, so if you are using a homemade heat sack then use a wet washcloth on top for moisture. Some of my patients have used hot potatoes, teabags (not black tea), or other heating devices that they have at home Be sure not to burn your skin, but maintain moist heat for a minimum of 10 minutes. (Click here for Dr. Mulick's recommended Dry Eye Masks) Eyelid Cleaners: Baby shampoo, tea tree shampoo, or over-the-counter eyelid wipes such as Systane lid wipes or Ocusoft eyelid wipes should be used to keep the eyelids free from oils that can clog the meibomian glands. Artificial tears: Not all artificial tears are created equally. Whenever possible choose preservative-free. Some people can develop allergies to preservatives which can make their symptoms worse. Avoid eye drops that say “to get the red out” or “redness relief.” These types of eye drops have a chemical that constricts the blood vessels in the eyes, making them look nice and white; however, over time with continued use, these chemicals can cause neovascularization or new blood vessel growth. When the vessels of the eyes constrict from these “redness relief” eye drops it triggers a signal to the brain that the eyes are not receiving enough oxygen. To get more oxygen to the eye, neovascularization occurs. When the redness-relieving eye drop wears off then there are more blood vessels in the eye creating more redness and the need for more redness relief. For this reason, I do not recommend using redness-relief eye drops; instead, I prefer preservative-free eye drops for lubrication. When the ocular surface is dry, friction between the eyeball and the eyelids occurs which causes inflammation. By supplying artificial tears and lubricating the ocular surface, the friction is reduced. Here is a link to my post on Doctor recommended eye drops. Prescription Dry Eye Drops: Restasis, Xiidra, and Cequa are the three preservative-free U.S. FDA-approved eye drops. Restasis (0.05% cyclosporine) An FDA approved (1983) prescription eye drop used twice per day Restasis has been shown to reduce dry eye symptoms and signs after 30 days of use. Occasional burning is reported by patients which is often relieved by keeping the eye drops cold in the refrigerator. For patients who don’t get relief with over-the-counter artificial tears, Restasis can be a good addition. Xiidra (5% Lifitegrast) An FDA approved (2016) prescription eye drop used twice per day The OPUS-1 study demonstrated that patients had a decrease in dry eye symptoms after using Xiidra eye drops twice per day for over 84 days. For patients who don’t get relief with over-the-counter artificial tears, xiidra can be very beneficial if used as directed. Cequa (0.09% cyclosporine) An FDA approved (2018) prescription eye drop used twice per day The first cyclosporine product to use nano-micellar technology to get better penetration This eye drop is so new that I personally do not have patient testimonials for its efficacy. Stay tuned. All three eye drops are prescribed for use 1 drop in each eye twice per day. It is not uncommon to experience burning after the installation of eye drops. Keeping the eye drops in the refrigerator sometimes helps with this burning side effect. Punctal Plugs: A punctal plug is used to keep tears on the eyes longer by plugging the tear duct where the tears drain. This can be especially beneficial in patients who have an evaporative dry eye where the tears evaporate quickly. It is a quick painless in-office procedure performed by an eye doctor. Dry Eye Devices: There are several Dry Eye devices in use (here is a link to the journal from Review of Opthalmology titled Devices for Treating the Meibomian Glands). We use ILUX in our office. You may find other offices with similar devices with a different name such as Lipiflo, Eyexpress, and some clinicians use IPL (intense pulsed light). These devices safely heat the meibomian glands and express the clogged oil so that the gland can function properly. It is still recommended to use hot compresses and Artificial tears after the treatment to maintain good tear production and symptom relief. ILUX: this is what we use at Tayani Institute. It is very effective in treating dry eye symptoms. Most patients can be less symptomatic after the first treatment. ILUX is a painless procedure that takes about 8 minutes per eye. We still recommend using hot compresses and Artificial tears to maintain good eyelid hygiene. Lipiflow: has been used for many years and is also effective at treating meibomian gland dysfunction. IPL: Intense Pulsed Light has been used by a dermatologist for skin treatment and is new to the dry eye market. Clinicians are finding this can be beneficial for dry eye treatment. Conclusion: Dry eye is a multifactorial disease, meaning there are many causes and treatments. One of the main causes of dry eye syndrome is Meibomian gland dysfunction. If you can spare at least 10 minutes per day, hot compresses and eyelid scrubs can be a very effective treatment. Artificial tears help to provide moisture to your eyes. I recommend using Preservative free Artificial tears 3-4 times per day. Taking high-quality omega 3 supplements has also been shown to help reduce dry eye syndrome. Avoiding dry environments and “redness-relief” eye drops, directing the air vents away from your eyes, using a humidifier, and staying well hydrated are good habits to get into to avoid exacerbation of dry eye symptoms. When all else fails adding prescription eye drops, punctal plugs or in-office Dry Eye treatments can be a great addition to your dry eye treatment.