How Do We Know If We Have Dry Eye Disease?

Segment 5

The components and importance of a good DRY EYE EXAM.

How does my doctor determine the health of these tear/oil glands? Symptoms of dry eye cause the dry eye specialist to look harder than most and they will have equipment to image these glands to see how constipated and/or withered they look. Testing how long a tear holds together before dry spots from evaporation occur and testing salt levels in the tear are both good ways to see how dysfunctional these oil glands are.

Pressing on the lids while looking with magnification allows dry eye specialists to see how much - and what kind of - oil comes out of a gland. Their best performance is thin clear “salad dressing“ oil pouring out with very little pressure. More common is scant, thick, milky or toothpaste-like oils or even as wax. Worst is nothing coming out even with heavy pressure squeezing the lid.

Advanced technologies or careful magnified exams can help us see and/or image how patients blink, so we can see how well - or, more commonly, how poorly the lids come together and then to see and/or image the amount of oil being produced by those blinks.

Since we know there are other causes for Dry Eye disease, other than dysfunctional oil glands, a good exam will also include looking at the volume of tears produced by the “sprinkler system” and if suspected, the function of the “firehose.” This can involve small test tapes or threads, designed to soak up the new tears made over a five minute time frame, as well as to measure the volume resting on the lower eyelid.

Tests for inflammation can involve dipstick test strips or red scale measurements and a special, in-office Lab test can measure salt levels. A good dry eye specialist will also look at the surface and under-surfaces of the eyelids, the lashes and eye’s surfaces - as well as testing with dyes as part of a complete dry exam in order to determine what other issues may be involved.

How Important is Oil to Our Tears?

Segment 4

The importance of oil.

It’s easy to understand one reason why oil is so important to our tears and why it’s been found that as much as 85% of all Dry Eye can relate to dysfunction of these oil glands. This goes back to the fact that water and oil don’t mix - as oil will always “float” on the surface of water. This creates the “liquid plastic wrap” or sealant effect that keeps the water (and its salts and proteins) locked onto the surface of your eye. The lack of oil causes the evaporation or “evaporative dry eye” we discussed in the earlier segment. As I also mentioned earlier, this is called Meibomian Gland Dysfunction or MGD.

But tear oil serves other important functions.

• It serves as good food for living cells.

• It contains our natural antibodies that inhibit germs from eating the oil.

• It’s a great lubricant, so eyelids freely and easily move over the surface of your eyes.

  To make good oil there are several key things you need to know.

• - First it takes good oil to make good oil -
  - the best building blocks in our diet are the Omega‘s 3, 6 and 9. These oils are found, in different degrees, in foods and supplements containing fish, nuts and seeds. The best fish are small, oily fish like sardines, anchovies, herring and wild caught salmon, as the bigger ones like tuna have eaten many smaller fish which causes them to concentrate the pollutants and toxins like lead, mercury cadmium and PCBs in their oil. Nuts would be tree nuts - not peanuts which are legumes like peas and not true nuts. This would include cashews, almonds, walnuts and pecans. Seeds include flax, chia and hemp, pumpkin and sunflower as well as sesame, caraway and black currant seeds. For most of us this is the diet of 1000’s of years ago, since most of us now eat corn and soy derived meats, as well as processed foods like pizza and pasta. These Carb-rich foods can facilitate the inflammatory pathways akin to putting gasoline on a fire and scientists point out that in the last 100 years we Americans now eat 95 times less of these good oils - even as we use our eyes so many times more than we did in our grandparents times.

• Second, oil glands are little accordion-like structures in our eyelids and only work when squeezed– so it takes good blinks to make good oils. This may sound a bit crazy, but watch a child as they interact with digital devices and you can quickly understand why the average age of onset of Dry Eye suffers appears to be steadily shifting from older to younger people. The problem with this digital era is that it encourages us to stare, which is the act of not blinking. The more staring the less blinking and when you finally blink, instead of big strong blinks, we are prone to fast, weaker blinks - so we don’t miss anything! Cell phones, computers, notepads, TV, games - even driving and reading can all teach us poor blink habits. Thinking of the cow’s udder - if we milk a cow regularly it keeps giving good milk but stop milking it and that udder dries up. That is what’s happening to our glands too!!
  

Overly Salty Tears

Segment 3

Too much salt in the salad dressing.

While the recipe of the salad dressing is critically important - just like the recipe of our blood is to our body - the more common problems relating to dry eye come from

#1: too little oil - or to less healthy oil - also called Meibomian Gland Dysfunction or MGD and

#2: too little water, also known as Aqueous Tear Deficiency or ATD.

Less common is a lack of protein but very common is the excess of salt which is rarely related to your dietary salt intake - but most commonly affected by too little water to dilute it. The lack of water can occur for many reasons, not the least of which may come from not drinking or retaining enough water in your diet. However most happens from evaporation - when the warm water of our tears evaporates into the dry air around us because of insufficient oil floating on top. This leads to what is called evaporative dry eye due to MGD - the leading cause of all dry eye.

As the water leaves, the salts and proteins remain, gradually concentrating the dry spots left when the water evaporates. These dry patches are like little open sores on the surface of the eye - and the concentrated salts get rubbed into the sores with blinking. This leads to the burning, scratching and then reflex tearing - as the fire hose turns on - to wash the excess salts away.

This is also why many people with Dry Eye will complain of the opposite symptom - as in tearing, but remember that saltwater is not a great substitute for salad dressing and this tearing tends to create more burning and stinging, which leads to more irritation and more tearing.

This cycle of recurring open sores on the surface of the eye and the concentrated salts getting rubbed into the sores - with further evaporation and blinking - leading to yet more burning, scratching and then reflex tearing - results in increasing inflammation (your body’s response to irritation) and the vicious cycle of evaporative dry eye disease. When the salts and proteins concentrate and combine, we can get stringy strands or white mattering on the lids and lashes (from excess proteins and salts left when the water leaves from evaporation). And all because you need an oil change!

Why Tears Are Important

Segment 2

Why are tears important? Perhaps we should ask - why should we even worry about our tears?

Well, first we need to remember that the surface of our eyes is covered in a sheet of living cells and like every living part of our body these cells need support - things like water, food, oxygen and protection. Every living cell in our body can generally get this from blood, but if we had blood over our eyes we would have a hard time to see - so instead of blood we have tears - which means that tears need to be as complex as blood, but without the red cells that would get in the way of our vision.

Moisture is job number one and tears are so important that we have two ways to make tears - what I like to call a sprinkler system and a firehose. The firehose makes a saltwater tear that is good for flushing a loose eyelash out of our eye or helping us with our emotions - but being mostly salt and water it isn’t much like blood, so we should think of it more like an emergency back up system. The best tear comes from our sprinkler system made of many cells and glands that together make the best tears from water, salt, protein and oil - think salad dressing - and like salad dressing the water and oil don’t mix - with oil floating on the surface. Either system can wet our eyes, but only the salad dressing of the sprinkler system has all the good stuff to keep our eyes happy and healthy.

Introduction To Dry Eye Disease

Hi, I’m Dr. Edward Jaccoma - a “Dry Eye Guy”. I’m also a board-certified Ophthalmologist or “Eye MD,” with over 30 years of experience in dry eye and related eye care. In the following segments I’m going to address issues common to diagnosing and fixing most dry and related eye surface diseases. These segments include videos and diagrams simplifying what are often complex medical problems and are not designed to replace the care from your eye doctor.

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It’s estimated over 40 million Americans have this common disease and if you have any doubt if you may have dry eye, then this could be a simple test to see if you might have it.

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Blink Test

For the next 20 seconds, starting on my cue, you should try to stare - without blinking - to see how you will feel, but first I want you to set a 20 second timer and then blink two times. So it will be 2 blinks and then start your timer and no blinking for the 20 seconds the clock will measure for you.

Ready, 2 blinks and Go! (20 seconds).

Ok, blink all you want but remember how your eyes feel now or at anytime over the last 20 seconds.

• Any sense of stinging, burning or scratchiness?

• Sensitivity to light?

• Watering?

• Blurry vision?

  —- Are you now or commonly finding:

• Strings of eye mucous?

• A sense of eye fatigue?

• Redness of the eye whites?

If you’re not sure - then even if you don’t have it now, there’s a good chance that somewhere in your lifetime you will - because this is a common, chronic and progressive disease. If you think - or know - that you or someone you’re close to has dry disease, then I’ve got more information to share in the following segments.