The Eye Practice

Dry Eyes we know are very common.  Some people that suffer from dry eyes are nearly debilitated by the burning, gritty irritation. In fact it is such a problem that there seems to be a link between dry eyes and depression (Kim et al. 2011).

To date we have had a multitude of treatments, which most of the time have proved to be ineffective.  Possibly here lies the frustration that many patients face.

Dry Eyes are caused by two basic mechanisms:

1. Aqueous (water) deficiency
2. Lipid (oil) deficiency

At least 65% of dry eyes have a lipid (oil) deficiency, which most current treatments do not attend to.  In fact a recent study showed that up to 86% of dry eye patients have lipid deficiency (Lemp et al. 2012). 

Most treatments deal with aqueous (water) deficiency. In nearly 100% of cases eye practitioners have treated dry eyes with aqueous replenishing eye drops.  Most patients will say that even though they help the effect remains for a few minutes before the symptoms come raging back.

It seems logical that treating lipid (oil) deficiency, otherwise known as meibomian gland dysfunction, might produce better outcomes for our patients.

To date meibomian gland dysfunction has been treated with warm compresses and gentle massage of the eye lids.  This makes sense as meibomian gland dysfunction represents the failure of the meibomian glands in the eyelids to secrete oil into the eye and protect the aqueous (watery) layer of the tear film from evaporating.  This excess evaporation of the water component of the tear is thought to produce the symptoms of dry eyes.

    

The concept is that by applying heat adjacent to the meibomian glands we will melt the meibomian oil that has solidified and blocked up the glands.  The gentle massage will then promote the liberation of the liquified oil into the tear film and coat the eye with the protective layer that it so desperately needs.

The problem with this treatment is that in most cases to be effective requires to be done twice a day and the use of a microwaveable heat pack moulded into the eye sockets must be held against the eye for at least 5 minutes per session - compliance with this regimen is very difficult and can take weeks to get a perceived effect.  From then on it is ongoing forever - only the most desperate dry eye patients will continue with this very inconvenient treatment.

Over the last number of years a brilliant optometrist (Dr Donald Korb) with the help of a company called Tears Science has developed an in office procedure called LipiView® and Lipiflow® that promises to revolutionize dry eye treatment for meibomian gland dysfunction.

Over the course of the next few posts we will discuss the introduction of the amazing technology into The Eye Practice.  At this stage we will be the first eye care facility in the country to start using this FDA approved instrument to help our dry eye patients.  We have had inquiries from as far as New Zealand and Melbourne.  The need for this unique dry eye treatment is unquestioned.  Stay tuned for more tomorrow.

References:

Lemp et al.

Lemp MA, Crews LA, Bron AJ, Foulks GN, Sullivan BD. Distribution of aqueous-deficient and evaporative dry eye in a clinic-based patient cohort: a retrospective study. Cornea. 2012 May;31(5):472-8.

Kim et al.

Kim KW, Han SB, Han ER, Woo SJ, Lee JJ, Yoon JC, Hyon JY.  Association between depression and dry eye disease in an elderly population. Invest Ophthalmol Vis Sci. 2011 Oct 10;52(11):7954-8.

Eye Strain and Dry Eyes are now a significant issue with teenagers.  Anyone that has a teenager knows all too well that they live on their FaceBook whether they are on their computer (supposedly doing their homework) or on their phone.  They all have phones don't they!

See the following short video that describes this ever increasing problem.

 

Dry Eyes can soe serious consequences and need to be aggressively managed - sometimes by a number of different specialists.  One of these conditions, which we see a lot of at The Eye Practice is Sjogren's Syndrome.

Sjogren's Syndrome is a serious auto-immune disorder where the immune system attacks the mucus membranes. Considering you have mucus membranes throughout your whole body, this can become quite serious.  In particular Sjogren's syndrome attacks the salivary glands of the mouth and the tear glands of the eyes.  Dry mouth and dry eyes are the most common symptoms.

Many eye doctors wind up working in conjunction with Rheumatologists in order to make sure our patients with Sjogren's are getting the best treatments possible for their symptoms and complications. Sometimes, patients don't even know they have Sjogren's, until they see their eye doctor – and we ask about any other potential systemic problems. Once the assessment has been made, we can refer you to a Rheumatologist for a proper evaluation.

       

The major characteristic of Sjogren's Syndrome, and the reason we see patients with this disorder, is dry eye. In severe cases, or during a flare-up (when the eye is under attack from the immune system), corneal inflammation can occur, along with other issues, such as blepharitis.

Relief for dry eye from Sjogren's Syndrome is possible. There are several measures that can help, that can be done in our office, and when you get home from your treatments.

•    LipiFlow® Treatments – These treatments are done in office with a patented medical device that uses heat and vibrations to soften and loosen blockages from the meibomian glands to increase the lipid layer output into the tear film. We hope to have this device at The Eye Practice in the near future.

•    Moisture goggles – like the Blephasteam goggles we've talked about in the past, these goggles use warm steam to add water to the tear film, and encourage proper meibomian gland function.

•    Antibiotic gels – With dry eye caused by Sjogren's Syndrome, eye infections become common, and conjunctivitis is often seen as a complication. Antibiotic gels and drops are used to control infections, and provide relief to the eyes. These need to be preservative free as preservatives of any type can cause severe irritation in Sjogren's syndrome.

•    Cyclosporine – These drops encourage aqueous tear production – it is an immunomodulator that decreases swelling in the eye.

•    Warm compresses – Once you've been treated for dry eye, you can use warm compresses to help alleviate any additional eye discomfort. Use at bedtime and upon awakening for five minutes in order to get continued relief.

•    Over-the-counter (OTC) eye drops – Drops recommended by your eye doctor can help keep your eyes comfortable when you have Sjogren's – prevention of discomfort is much better than trying to treat the discomfort once it returns! These also must not have preservatives.

•    Eye hygiene – Avoid getting eye creams and lotions too close to your eyelids, as they can irritate the eye. Remove eye makeup completely every night, and never sleep with eye makeup on – this will help reduce risk of infections. Additionally, make sure that you wash your eyelids with proper eyelid cleansers.

•    Special lenses – People with Sjogren's Syndrome related dry eye have a tendency to be photosensitive – meaning bright lights are a hazard. Lenses with an FL-41 filter can help diminish the intensity of sunlight.

If you have Sjogren's Syndrome, or want help with chronic dry eye, give us a call on 9290 1899 or click here to book an appointment.

Dry Eyes are involved in at least 50% of the consultations we see at The Eye Practice.

As we said in a previous article, dry eye can be from a lack of lacrimal gland production, resulting in a lack of water in the eye, or a lack of meibomian gland function, resulting in a lack of oil in tears, which leads to dry eye. Another previous article discussed aqueous deficiency dry eye – the lack of water. Now, we look at oil deficient dry eye – also known as Evaporative Dry Eye.

What is Evaporative Dry Eye?

Evaporative Dry Eye is a dysfunction seen in the meibomian gland in the eyelids – the glands that give tears their slick, oily consistency. When these glands malfunction, tears wind up being too watery, and therefore, they evaporate too quickly. This rapid evaporation results in dry eye.

The meibomian gland produces what is known as the lipid layer of tears – it is a fatty and oily discharge, or secretion, that is supposed to prevent the aqueous (water) layer from rapid evaporation. Now you know that when the meibomian glands are damaged, they will not produce the lipid layer efficiently. This creates an imbalance, and a perfect formula for Evaporative Dry Eye.

A common cause of Evaporative Dry Eye is blepharitis – a chronic type of eyelid inflammation which is based at the eyelash follicles, and often results in meibomian gland dysfunction. Blepharitis symptoms are red, crusty eyelids with swelling, itching, and burning.

Obstructed meibomian glands, either by inflammation or by sebum plugging up the glands, is the main reason Evaporative Dry Eye occurs. 

What you can do about Evaporative Dry Eye

It's important to find out what's causing your meibomian glands to malfunction in order to get the right treatments done to bring you relief. Drops won't solve everything. In fact the best they can do is just mask the underlying problem.  Often dry eye patients will say that the drops help but 10 minutes later their eyes are irritating again.

Sometimes, warm compresses and eyelid massages can alleviate the symptoms. If you come into the office, we can have a closer look at the meibomian glands and expel anything that's plugging them up, such as sebum.

Other treatments for Evaporative Dry Eye include macrolides – anti-inflammatory antibiotics – a course of steroids along with antibiotics, and special formulas of artificial tears that have certain types of oil have helped ease the discomfort of Evaporative Dry Eye. Currently, macrolides are seeing an increase in use for this condition, due to their highly effective anti-inflammatory properties.

A new technique to treat Evaporative Dry Eye while in the office is the use of a thermal pulsation system. By simultaneously delivering heat to the inside of the eyelid, and massage to the outside of the eyelid, any blockages can be removed from the meibomian glands, providing you with relief.

If you have dry eye, even if you don't know which form, we'd be happy to help you. Call us on 9290 1899 or click here to book an appointment.

Dry Eyes as mentioned before can have many causes, which essentially can be classified under two types of dry eye.

The first type of dry eye occurs when your eyes don't develop enough tears to keep the eye lubricated with water – that comes from the lacrimal glands of the eye.This is called aqueous deficiency.

The second type of dry eye occurs when your eyes don't have enough oily lubrication to keep the eyes properly lubricated – that comes from the meibomian glands in the eyelids. This is called meibomian gland dysfunction.

These two types of dry eye can come from a variety of sources, some of which we will cover in later posts:

• Sjogren's Syndrome and other conditions – Sjogren's Syndrome is a type of immunological disorder that is characterized by dry eye, dry mouth, and either Rheumatoid Arthritis (RA) or Lupus. Dry eye can also occur with Ocular Rosacea and stand-alone Lupus or RA.

• Contact lens wear.

• Menopause in women and aging in men can contribute to dry eye.

• Environmental factors such as forced hot air, or arid climates. Even staring too long at a computer screen without adequate blinking can cause dry eye.

• Side effects of antihistamines, blood pressure medications, and other medicines can cause dry eye.

Whether or not you can identify the source of your dry eye, it's a good idea to see your therapeutic credentialed optometrist to determine the best course of treatment.

 

There are several different treatments that are commonly used to help ease dry eye:

• Eye Drops or Eye Sprays will always be the first thing offered.  They are simple to use and relatively effective if the dry eye symptoms are mild.  It is worth noting that where possible it is best to use eye drops that do not have preservatives.

• Corticosteroid eye drops are commonly used to calm down inflammation of the eyes that nearly always is part of the irritation.  These are quite safe to use assuming the cause of the eye problem has been diagnosed properly and are not used long term.  Any more than 2 weeks of treatment needs very careful follow up in case of complications.

• Cyclosporine: These are anti-inflammatory drops that repair corneal damage and help increase natural tear production. The treatment is required twice per day, and results take some time to see – anywhere from three to six months.

Less common treatment options include the following:

• Medication switching: If the cause of your dry eye is due to the side-effects of a medication, we may recommend switching to another medication that doesn't have such a side-effect.

• Punctal Plugs: These plugs, also known as lacrimal plugs, are temporary, silicone (or collagen) plugs that we can insert into the drainage holes of the eye that allow tears to pass from the eye into the nose. By doing so, more moisture is left in your eye. Permanent plugs are also an option for those with severe cases of dry eye.

• Punctal cautery: This surgical procedure does the same thing as punctal plugs, but it is a permanent solution.

• Blephasteam: These goggles have been shown on our blog before. While not a fashion statement, they add water and encourage more oily product from your glands. Treatment required is two, ten-minute sessions every day. The equipment costs 200 Pounds UK. Currently these are not available in Australia.

• Testosterone cream: This novel treatment is probably best used for post menopausal women.  Studies have shown great results with 3% cream applied to the upper lid.

No matter what the source of your dry eye, or type of dry eye you have, there are plenty of treatments available that can fit your specific needs. If you're having a problem with dry eye, call us on 9290 1899, or CLICK HERE to book an appointment.

DRY EYES like Eye Strain is an epidemic - Why?

Before we try and answer this question lets describe why the eyes need to be wet.

Eyes are made up of living cells.  Cells are made up of primarily water so being in a wet environment helps them function.  The coloured part of eye called the iris has a clear window in front of it called the cornea.  It is imperative for the corneal cells to be wet so that they remain clear and transparent.  If this window (cornea) loses its transparency good quality vision is also lost.

The eye is also wet so that if debris or germs enter the eye, they are able to be washed out.  The eye is able to defend itself against irritation and infection by increasing its water supply via extra tears.  It is not surprising then that the smallest bit of dust in your eye will set off the water works!  It is also normal if the eye is infected that it appears "glassy" due to the extra tears that have been produced in the eye to try and ward off the infection.

 

For many reasons the eyes need to have enough moisture to function at their best.  Dry Eyes though seem to be an increasing problem that at least half the people seeking an eye examination complain about to our optometrists at The Eye Practice.

The most severe form of dry eye is called Xerophthalmia.  This is caused from vitamin A deficiency in under developed countries and in particular affects children. 

Luckily for us in Australia it is not an issue.  What is an issue though is that many people complain of the following symptoms:

• Gritty eyes
• Sore eyes
• Stinging eyes 
• Itchy eyes - although this is often allergy
• Sensitive to glare

There are basically two forms of dry eye:

1. Evaporative dry eye.
2. Aqueous deficiency dry eye.

The first is caused to to lack of oil in the tear film and the second is caused due to lack of water in the tear film.  These types and their respective treatments will be discussed in future posts.

 

At The Eye Practice we believe there seems to be a significant increase in the number of people complaining of dry eye because many more people are working in front of computer screens and in air-conditioned environments.

Studies have shown that when the average person is doing computer work, their concentration increases and with this a reduction of blinking occurs.  Blinking is required to create tears to lubricate the eye.  In fact it has been estimated that when someone is working on a computer screen their blinking rate reduces down to 30% of what is normal.

To make matters worse most people that are working in front of computer screens are doing so in dehumidified air-conditioning.  This also dehydrates the surface of the eyes, which in turn creates irritation.

Dietary factors could also play a role and once again smoking rears its ugly head.  Smokers seem to suffer more from dry eye.  Another huge group of dry eye sufferers are contact lens wearers.

Treating dry eye at The Eye Practice is one of our specialities.  We can treat it from many perspectives.  If you think you have a problem with dry eyes call us and make an appointment as soon as practical.  Dry Eyes causes significant discomfort and reduces productivity.  Call us on 9290 1899 or BOOK AN ONLINE APPOINTMENT.

 

 

Conjunctivitis also known as Pink Eye or just simple Red Eyes is a common consultation for the local General Medical Practitioner (GP).  As we discussed in a previous post, most Conjunctivitis or Pink Eye will resolve by themselves over the course of a number of days.  Does that mean we need to be complacent?  NOT AT ALL!  There are umpteen reasons why eyes get red, inflamed and irritable.

Getting an accurate diagnosis and therefore accurate treatment is not that straight forward.  A Therapeutically Trained Optometrist has both the education, the experience and importantly the equipment to get to the bottom of the problem. 

Your local GP is certainly educated but does not have the appropriate equipment to magnify the eyes to the level required for accurate diagnosis.  Optometrists in general have magnifying equipment called a Slit Lamp Biomicroscope that allows detailed viewing of the delicate structures of the eyes.

The image on the left is of an optometrist examining a patient, whilst the image on the right is the type of detail that can be observed. 

It is not possible to get this with the naked eye plus a pen torch that the GP in most cases would use. 

What we need to make clear here is that the GP just does not have the volume of eye issues coming in on a daily basis that would need him or her to invest in equipment like a SLIT LAMP BIOMICROSCOPE.

So what does the GP normally do with a red eye?  Depending on perceived severity in most cases they will prescribe a broad spectrum antibiotic called Chlorsig.  This comes in both a drop form and an ointment form.

   

Similar statistics exist for Chlorsig as do Bleph-10 mentioned in a previous post.  Millions of prescriptions per year are written for Chlorsig, which until very recently was available by prescription only from a pharmacy.  It is not possible that in a population the size of Australia that one in 5 people every year have a red eye that is caused by a bacterial infection.  GP's will default to Chlorsig just in case it is a bacterial infection (which in most cases it is not). 

If you think you have some form of Conjunctivitis call The Eye Practice now on 9290 1899 and make an appointment for an evaluation and a treatment plan. 

So what is the most common cause of Conjunctivitis, Pink Eye or Red Eyes?

We will answer this question and a whole host of other things to know about Conjunctivitis in upcoming posts.

What a year we have endured! It's been a long miserable winter and spring is finally upon us. For most Australians, the start of spring makes us get excited about warm sunny days, bright colours, flowers, picnics and generally fun outdoor activities.

But for many of us, spring also reminds us of the sneezing, sniffling and red eye irritations from allergies like hay fever, conjunctivitis, also known as pink eye, and sinusitis. This is due to the increased amount of pollens in the air. 1 in 5 Australians suffer.

Hay fever symptoms include:

• Red eyes, swollen or itchy eyes
• Runny nose
• Itchy mouth, nose or throat
• Sneezing
• Headaches
• Eczema and Dermatitis

Red Eye allergies can affect many of us, however spring is particularly difficult on those who wear contact lenses and those who suffer from asthma.

To treat and relieve symptoms, contact lens wearers should speak to their optometrist about possibly changing cleaning methods,or using daily disposable contact lenses. In most cases, symptoms can be relieved with prescription or over the counter drops, such as antihistamines.

The question is which drops?

That's where a therapeutically qualified optometrist comes in. They have been fully trained in the proper treatment of allergies and other eye issues like glaucoma. Going to the chemist is a minefield. There is a whole wall of eye drops to choose from. You could ask the pharmacist but you are relying on them to try and diagnose your problem across the counter. Is that what you want for your eyes? Did you know that red itchy eyes could be caused by a whole host of things that is generalized as conjunctivitis? Before starting any eye treatment it is imperative to diagnose the type of conjunctivitis you have. In a future article we will go into other types of conjunctivitis and their possible treatments.

At The Eye Practice giving Peace of Mind about your most important sense – Your Vision, is what we are all about. Being therapeutically qualified and using the latest eye examination technology, gives you that Peace of Mind, that you are at the right place!

Asthma sufferers should try and avoid going outdoors on very windy days particularly in the mornings and late afternoons, when pollen count is highest.

Other important tips to avoid eye allergies such as conjunctivitis, pink eye, hay fever and eczema / dermatitis around the eye include:

• Avoid rubbing or touching your eyes
• Never share contact lenses
• Never share eye makeup
• Avoid wearing eye makeup where possible
• Wear protective wraparound sunglasses when outdoors
• Clean surfaces regularly to avoid dust build up
• Avoid mowing lawns

Just remember that relief is at hand. Call and make an appointment with your optometrist and discuss what options are available to suit your needs.