What is Dry Eye

What is Dry eye and Dry Eye Treatment in Katy and Fulshear: Why Your Eyes May Still Feel Dry

I get told almost every day at work, “My eyes are tired at the end of the day,” “My eyes are irritated from looking at the computer all day,” and “My eyes feel gritty.” Most of the time, I will say that it is probably due to dry eye. When I ask what they are doing for it, they usually say, “Nothing,” or “I put drops in my eyes.” Which does nothing but treat the symptoms, not the cause.

That drives me crazy because whenever my eyes burn from dryness, which is very rare now with the newer treatments I use, but I will circle back to this later, I feel like I have to suffer or put enough eye drops in my eyes over the next hour to flood the Sahara Desert just to feel slightly normal. So, let’s actually talk about what dry eye is.

What Is Dry Eye?

A lot of people would say you are not producing enough tears. Which is somewhat correct, but there are actually three major parts to your tear production. The first one is the oil layer. This is the one I want to talk about the most because it is probably the most important part of dry eye for a lot of people. The oil glands in your eyelids are called the meibomian glands. Their job is to produce the oil that helps keep the tears you produce on your eye instead of allowing them to evaporate immediately. When these glands are not working correctly, you have meibomian gland dysfunction, or MGD (I will use MGD a lot so just remember this acronym). This is one of the most common causes of dry eye, and it is a big reason why some people can put drops in their eyes all day and still feel miserable.

How Do We Measure Dry Eye?

We measure this with what we call TBUT, or Tear Break-Up Time. Basically, we are measuring how long your tears stay on your eye before they start to break up. We do this by putting dye in the eye and using a blue light to look at the tears. The dye is technically yellow-orange, but with the blue light it looks green. Then we count until we see the tears break up. Generally, if it is over 10 seconds, that is considered normal. If it is under 10 seconds, that is considered dry eye. And if it is under 5 seconds, that is generally considered severe dry eye. So, when someone tells me their eyes feel terrible, I do not just want to give them another bottle of drops. I want to know why their tears are not staying on their eyes.

Example of the tears breaking up on the eye.

Why Do the Meibomian Glands Become Damaged?

The thing is, these glands are very susceptible to damage because there is a very thin layer of skin around them and not a lot protecting them. We know that inflammation is one of the things that can trigger these glands to die over time. They are also constantly exposed to the environment and are moving all the time because you blink approximately 15 times a minute. If you have allergies, it can make things even worse because of the immune reaction and the physical act of rubbing your eyes. Other things that can damage the oil glands include, Eye makeup, Skin issues, such as rosacea, Blepharitis (which is debris and inflammation around the eyelashes), contact lens wear, Hormones, Certain medications, and Aging. This is why meibomian gland dysfunction (MGD) is 86% of the time the cause of dry eye.

This damage from inflammation can cause the glands to make oil that is more like cold butter instead of the nice, fresh oil which is like warm butter consistency that is supposed to come out. That thicker oil can cause the glands to become blocked and can contribute to things like styes. That is one reason some people get them more than others. The other two major parts of tear production are the aqueous layer and the mucin layer.

All three of these layers can decrease with age, but the oil layer is normally what is affected the most.

The Aqueous Layer

The aqueous layer is the watery part of your tears. It is made by the lacrimal gland, which is located deeper around the eyebrow area. This is responsible for about 10%–20% of dry eye cases, although there can be some overlap with a lack of oil production. This layer is made up of proteins, electrolytes, small amounts of glucose, urea, and hormones, but it is approximately 98% water. To put it simply, this is the part that allows your tears to be liquid.

The aqueous layer can be affected by aging, Hormones, Autoimmune diseases, especially Sjögren’s syndrome, Certain medications, Nerve damage which can be caused by Contact lens overuse and Surgery, such as LASIK.

The function of this layer is to wash out debris and bacteria, provide nutrients and oxygen to the eye, and provide the wet surface that helps your eyes see clearly.

The Mucin Layer

The last layer we are going to talk about is the mucin layer. This is made by goblet cells on the front surface of the eye. It helps spread the tears across the eye evenly.

The amount of dry eye caused by a deficiency in this layer is very small and is normally not major player compared to Aqueous and Oil layers of the tears. Things that can damage the mucin layer include inflammation, normally due to dry eye, Diseases such as Stevens-Johnson syndrome, Chemical burns, Severe vitamin A deficiency, and Aging

I am just going to put this here, but there is not really a good way in the United States to specifically treat the mucin layer of the tears. Some pharmaceutical treatments may or may not help.

Sometimes Your “Dry Eye” Is Not Actually Dry Eye

I also want to mention that sometimes your “dry eye” is not actually dry eye.

It could be due to floppy eyelid syndrome, ectropion (eyelid turned out), or entropion (eyelid turned in). These can give you almost the exact same signs and symptoms as dry eye. If someone does not look at your eyelids and how they rest on your eye, or does not know how much tension your eyelid is supposed to have, you can easily be diagnosed with dry eye when your tears are actually working fine. The problem may be that your eyelids are not spreading tears out correctly.

Your eyelids work kind of like windshield wipers. When you blink, they spread and move your tears across your eye. If they are not attached to the globe of your eye correctly, they can cause your tears to streak across your eye instead of spreading evenly. That is why I think a comprehensive dry eye evaluation is important. We need to look at the whole system, because this the signs and symptoms are identical to dry eye besides just the lids. Now let’s circle back to what the treatments are for dry eye.

Treatment for Aqueous Deficiency

If you have aqueous deficiency, there are really not a lot of options. We either have to add more tears to the system or try to improve the function of the lacrimal gland. If you are dehydrated, drinking water can help a ton. But for the majority of people, dehydration is not the cause of their dry eye. If we have damage to the cornea that is causing a lack of corneal sensitivity, then we need to increase corneal sensitivity. This is a weird game, though, because as the cornea improves, the symptoms can actually get a lot worse before they get better. One treatment for corneal sensitivity is a drop called Oxervate, which works great if we can get insurance to cover it, but it is very expensive. The other treatments for corneal sensitivity, Autologous serum drops, and Amniotic membrane treatment. Different treatments work for different people, and sadly, some will not work for others depending on what caused the corneal sensitivity issue.

When it is not due to corneal sensitivity, we are usually looking at adding artificial tears or using punctal plugs. Possible supplements that may also help I’m not sold on but for some people it works well on.

Treatment for MGD: The Most Common Cause of Dry Eye

Now let’s talk about the treatment for dry eye caused by a lack of oil production. This is the one where a lot of the research goes. We talked about how the glands get damaged. Now let’s talk about what we can do about it. There are studies on heat masks and omega-3 supplements. I still recommend omega-3s, but the research, especially on omega-3s, is very mixed. There are also some in-office procedures we can do like

• IPL (Intense Pulsed Light)

• Tixel

• LLLT (Low-Level Light Therapy)

• LipiFlow (any other heat treatment there are ton of them)

• RF (Radiofrequency)

LLLT

LLLT is nice because it provides heat to the system to help melt the oil in the glands and let new oil come in. It is also supposed to help the glands work harder by having the mitochondria produce more ATP. Most studies on LLLT also used IPL and showed that it was effective. Fewer studies have been done with just LLLT, but I will not lie, there are some decent studies with just LLLT.

Radiofrequency

Radiofrequency, or RF, adds heat to the system and produces collagen. But there are some downsides of this treatment are two things. First, most studies of RF for dry eye are almost always done with IPL, so it is hard to know how much of the benefit is coming from RF alone. Second problem, when it comes to RF and the face, it can remove fat and cause deeper scarring, which can make other problems in the future. The last place anyone wants to lose fat is around the eyes and make the face look more hollow.

Heat Therapy (LipiFlow)

There are a ton of different devices on the market now that provide heat to the glands, things like LipiFlow. They all work a little differently, but the general idea is to provide heat to help improve the oil flow. Then either the machine or Doctor express the glands. My big thing with this how is this better then doctor using a heat mask and doing general expression himself. I don’t know for sure. When the instruments are thousands of dollars and heat mask is $30 means the cost for the patient is significantly higher without much improvement.

IPL for Dry Eye

Let’s go to IPL, or Intense Pulsed Light. This one is definitely one of the most researched dry eye treatments, and it has some added benefits that I love. IPL works by targeting inflammation, which is one of the underlying causes of MGD. It can also treats rosacea, which can cause MGD and dry eye. It has the added benefit of treating blepharitis and demodex, which are things that can also cause dry eye. The OptiLight system, which is FDA-approved for dry eye, has been shown to double tear break-up time. So, to put that into perspective, 5 seconds is severe dry eye and above 10 seconds is generally considered normal. That means that, in some patients, you can go from severe dry eye to normal tear break-up time with just this treatment.

A lot of other dry eye treatments have been studied in combination with IPL, and that is one of the reasons IPL was one of the first machines we got for dry eye. At Eyecare Redefined in the Katy and Fulshear area, we use an FDA-approved IPL system specifically indicated for dry eye. The nice thing about IPL is that it can attack dryness directly and indirectly. The aesthetic benefits are also something I really like. IPL can help with fine lines, dark spots, and red spots. Personally, it makes my skin slightly less red and just overall more even in skin texture.

Tixel for Dry Eye

The last treatment I am going to talk about is Tixel. This is another heat treatment, but it also has collagen improvement. It can help melt the glands because of the amount of heat you are putting into the system. Collagen around the eyes is important because of the skin around the eyes, and this treatment may also help with the blink reflex. As we discussed above, blinking helps spread the tears. If you have extra folds of skin on the upper lid (dermatochalasis/hooded eyes), it can disrupt the blink and cause problems. This can cause mechanical ptosis, or a droopy eyelid, and the extra weight of the skin above the eyes is causing the eyelid itself to become droppy. Example below

The nice thing with Tixel is that it is also one of the few devices that is FDA-approved for dry eye and has been shown in an FDA-approved study to double tear break-up time, similar to IPL. The other nice benefit to Tixel is that it helps with Wrinkles, as discussed before, Hooded eyes, also called dermatochalasis,  Bags under the eyes, and many more other aesthetic concerns. Examples below

My personal results were that it helped lift the skin. It acts almost like a mini facelift, and I feel like my eyes look less hollow. As someone with deep set eyes I love less hollowness I have gotten filler in my cheeks earlier this year and I felt like one treatment was better then filler for doing what I wanted it to do. I say I look about 5 years younger around the eyes. My mom who I also ran it on said here smoker mouth lines (my mom never smoked in her life but her and my grandma both got them) said after one treatment she doesn’t remember them being that good in a long time. My mom has had microneedling done with PRP specifically to get rid of those lines.

Why I Chose IPL and Tixel for My Patients

The reason why I chose these treatments for my patients in the Katy and Fulshear area is because I think they are two of the best options. IPL is one of the best procedures when it comes to research and helping with dry eyes. Tixel gives us a huge area to treat a lot of dermatological things, including wrinkles, hooded eyes, and baggy eyes, along with helping increase lid collagen that the IPL doesn’t and also providing help to dry eyes. So two devices working in two completely different ways to help one problem dry eye.

Both treatments are also two different FDA-approved method. Is the FDA perfect? No, it is not. But when I look at the research behind IPL, the studies on Tixel, and the way these treatments work for dry eye and the amazing dermatological effects, to me, it was a no-brainer to bring these treatments into the office.

What About prescription medicine for dry eye?

Let’s talk about the current dry eye drops we have:

• Xiidra

• Cequa

• Restasis

• Tyrvaya

• Miebo

Sadly, the thing is that most of these medications do not directly treat the underlying cause of MGD.

Miebo

Miebo is the one that is specifically designed to address the evaporative component of dry eye. It helps reduce evaporation and keeps the tears on the eye longer. So, it can help with symptoms, but it does not repair or improve the meibomian glands themselves. It basically very fancy artificial tear.

Tyrvaya

Tyrvaya is a nasal spray that works on the lacrimal gland to make more tears. For lacrimal gland problems, it can work. But in my experience, for most people with MGD, it does not help very much. Sometimes the glands are just too weak to really help. Plus anywhere to 17 to 44% of people stop taking the nasal spray after the 1st bottle do to side effects/not working for them. Honestly, I think doing a punctal plug makes more sense for some of these patients. Especially when adding the treatments listed above.

Restasis, Xiidra, and Cequa

Restasis is supposed to lower inflammation in the eye and help with the cycle of dry eye. The problem is that it can take around three months to work. These medications can help the right patient, but the problem is that a lot of patients stop using them because they do not feel like the results are worth the effort. 70% of Restaisis user stop before end one year, 60% of Xiidra stops within a year (over 10% of people stop using xiidra because side effects within 3 months), Cequa average time of stopping is also before one year. And that is the thing we have to remember. It is not just about whether a medication works in a study. It is also about whether the patient is actually going to use it. With the medication taking 3 months to work what happens when you are inconsistent with the drops. If you take week off it may take another month to have the treatment from the drops.

The Problem With Compliance

One thing we have known for years from studying glaucoma drops is that patients do not always take their medications consistently. 50% of glaucoma patients don’t take there drops on regular basis. Glaucoma drops are normally once a day, and dry eye drops are often twice a day or more. Even with glaucoma drops, a lot of patients do not use them regularly. Even though not using them could mean they go blind.  When you stop taking the medication, it stops working. This is why I am not a huge fan of drops alone. But if the goal is to treat the underlying cause of dry eye, I think there are better options for a lot of patients.

Why I Prefer In-Office Dry Eye Treatment

Tixel treatment in our office is slightly more than $80 a month when you look at the treatment cost over the course of a year. To me, that actually makes a lot of sense when you compare it to the cost and effort of using drops every day. I am not saying drops are useless I recommend drops. I have prescribed drops. But honestly, I feel like there are just better options for most patients. When we can use a treatment that helps the body improve its own function, that makes so much sense to me. And that is why I am so excited about these newer treatments. They give us the ability to treat the underlying causes of dry eye instead of just treating the symptoms. And for patients who have been suffering for years, that can make a huge difference.

Looking for Dry Eye Treatment in Katy or Fulshear?

If your eyes are constantly burning, gritty, or tired, you do not have to assume that you just need another bottle of eye drops.

At Eyecare Redefined, we look at the underlying causes of dry eye and help determine which treatment options may be appropriate for you.

Whether your symptoms are related to meibomian gland dysfunction, inflammation, inadequate tear production, or eyelid problems, the first step is understanding what is actually happening.

If you are looking for a dry eye doctor in Katy or Fulshear, schedule a comprehensive dry eye evaluation with Eyecare Redefined.

We can help you understand your options and develop a treatment plan that fits your needs.