Dr Seipser with Dr Alison Tendler at the recent Academy of Cataract and Refractive Surgeons meeting. Dr. Tendler is an expert in dry eye treatment and is also the spokeswoman for Restasis. Restasis is one of the many treatments used for dry eye patients at Siepser Laser Eye Care.
Dry eye is one of the most common complaints patients present in eye doctors’ offices. It is a widespread problem and is more prevalent as you age. Dry eye can cause much discomfort but is only dangerous in its severest forms. It is a common ailment in arthritis sufferers as well as women over 40 because of shifts in hormonal balance due to due to decreased estrogen levels. Dry eye can be manifested multiple ways but understanding it begins with tear function
The eye lubrication system is made up of three components that act in harmony. The largest component is water. It is not pure H20 but a complex salt solution having a commonality with many of the aqueous solutions in the body. Mucus, another component, allows the tear film’s water to adhere smoothly to the surface of the eye. This is important because the front surface of the eye, the epithelium, is actually quite hydrophobic or non-water loving, somewhat akin to the hood of a well polished car. A droplet or two of water on the waxed hood of a car will bead and not spread over the surface.
If tears were the only made up of these two components, water and mucus, there would be a great deal of evaporation off the surface leading to dry spots. It would be difficult for the tears to stay on the surface of the eye without drying quickly. This problem is overcome with the presence of the third component, the oil film on the front surface of the cornea. It is a little bit like olive oil over water which would keep water from evaporating. Since this olive oil-like substance is denser and does not readily evaporate itself, it keeps the tear film smooth, persistent and sealed in position.
The components of tears are produced in different parts of the eye. The water part of tears comes from the lacrimal gland. Contrary to general thought, the lacrimal gland is not the hole on the inner side of your eye but actually, a gland on the superolateral or outside quarter half of the upper lid. This gland produces the aqueous portion of tears.
The mucus layer is made mostly by the conjunctiva, the diaphanous surface on the white part of the eye. Its multiple mucus producing goblet cells pour this gooey, tacky substance onto the surface of the eye. It is spread and smoothed by movement of the lids allowing the watery tear layer to adhere to the surface.
The oil layer of the tear film is created by small glands at the lid margin. Oil flows off the eyelid margin onto the tear film surface protecting it from evaporation.
This tripartite, water, mucus and oil, must work together for you to be comfortable. The disturbance of any of these functions, separately or all together, will result in symptoms of dry eye. Treatment varies according to the dysfunctional component.
If the water component is deficient as a result of insufficient lacrimal gland fluid production, eyes get a stringy discharge. The cells of the mucus layer try to produce more mucus to lubricate the eye. But with not enough water, the combination of oil and mucus leads to stringy-like deposits in the corner of the eye and along the lid margins. This feeling of mucus-like greasiness is a direct result of decreased tear production.
The loss of the mucus layer will lead to a feeling of having watery eyes. Without enough mucus, tears will bead, unable to spread over the surface of the eye. Reflexively, the eye calls for more water to be produced by the lacrimal gland, similar to when you first slice an onion, and water rushes to your eyes. You feel of a great deal of wetness and have teary eyes as well as intermittent dryness and burning.
Rare types of tear production issues leading to the destruction of the small glands producing the oil layer can happen in extreme aging, individuals with skin changes secondary to tobacco use and eczema or chronic skin disturbances.
Since any component missing can lead to the symptoms of dry eye, manufacturers of tear replacement products have tried to address each of the components separately and in concert. The simplest type of drops are those replacing the water layer. These are effective for individuals with pure dry eye secondary to arthritis. Tear supplements of this nature are rather watery, characteristically named for their major component and are usually among the least expensive topical drops. There are drops which aid the goblet cell layer by lubricating and protecting the goblet cells, allowing them to rejuvenate and function more effectively. This decreases inflammation or vascular swelling on the eye’s surface. Mucus layer replacements also can be quite viscous, even gel-like and help to resurface the eye. They protect the goblet cells still present and assist them in manufacturing the maximum amount of mucus they can in their damaged state. There are also combination solutions to replace the tear film’s three components: oil, water and mucus. These highly complex tear supplements can be quite effective.
Another way of dealing with decreased tear production is to limit its evacuation. The two small pores on the inner corner of the upper and lower lid are called the punctum. The punctum leads to the tubes called the canalicular apparatus which directs tears into the tear ducts. People may find that their nose runs when they tear excessively. This is because the tear produced in the eye actually runs into the nose through the canaliculi. For individuals who do not produce enough of the water component in their tears, limiting the outflow can result in more comfort, preserving the few tears produced. By blocking the puncta and the tear ducts, fluids can stay more consistently on the surface of the eye without being drained away prematurely. The first product recently available for occluding the punctum is a collagen plug. This is actually just a small section of resorbable suture that is placed in the punctum by your doctor. It blocks the egress or outflow of tears from the surface of the eye into the tear ducts for up to two weeks. This temporary solution is diagnostic and reversible. By inserting the resorbable plugs in place, a patient is more able to determine if punctal plugs might assist them. A more definitive treatment is the placement of small silicone plugs, much like corks, in the punctum which will limit the egress of fluid from the surface of the eye. Most definitively, the tear ducts can be coagulated or closed with the use of laser or cautery. These procedures will definitely close off the punctum and stem the flow of tear fluids from the eye into the nose.
There are now wonderful drops and methods for assisting patients who are uncomfortable and have an ocular sensation of dryness or even intermittently, watering of the eyes. Seeing your ophthalmologist early is key to start you on a regimen that will avoid any irreversible harm to your eyes like scarring and damage to the glands affected by the chronic scraping of dry lids on dry a eye. A good comparison is running an automobile without oil in it. The engine needs lubrication and so do your eyes. Topical drops in the form of tears can assist. In the last 20 years, there has been incredible advances in various types of products available for use in chronic dry eye. A skilled practitioner can often help you select the appropriate care that will bring comfort and relief for this ongoing and chronic problem. Additionally, there are plugs used to stem the flow of tears from the eye and thereby providing more comfort. Your ophthalmologist can direct you to the treatment best suited to your needs.
Dry eye is difficult, common and uncomfortable. Its management is best left to those skilled in improving a patient’s comfort through the modern, careful diagnosis and treatment of tear abnormalities. The physician must identify which of the 3 components in the tear film is not functioning. This differs from person to person.