Written by Dr. Yuna Rapoport
There are only a few things more frustrating than dealing with constantly burning, itching and irritated eyes. Coworkers and friends ask if you have been crying or are sick. You look tired. Contacts are hard to put in. Figuring out what is causing the chronic irritation can be incredibly frustrating. As a cornea and dry eye expert, I see this type of situation daily: patients who have tried endless drops, have been to multiple doctors, and still find no relief. Curious whether you have dry eye syndrome (DES)? There are a few questions you should ask yourself:
- Do you have a sensitivity to light?
- Do you have burning/stinging of your eyes?
- Do you feel a gritty or scratchy sensation?
- Do your eyes get watery and teared up?
- Does your vision improve with artificial tears?
- Do you find your vision quality fluctuates when blinking?
- Do you have red/infected eyes?
If you answered yes to some of these questions, you may have DES.
Dry eye syndrome is typically caused by an imbalance in the liquid film that covers the ocular surface. It may be caused by an underproduction of tears or a chemical imbalance that prevents the tear film from functioning properly. Typical symptoms can include itching, burning, tearing, foreign-body sensation, redness, blurry vision or episodes of excessive tearing. Many factors affect the health of the ocular surface, including diet, co-existing medical conditions (such as a thyroid disease, Sjögren’s disease, or rheumatoid arthritis), medications, anatomical abnormalities, hormones, and environmental conditions such as high or low humidity and temperatures.
It is important to properly diagnose the underlying cause of dry eye and provide customized treatment with maximum benefit for each patient. I personalize each treatment to every individual and the specific cause of their symptoms. I believe that performing a thorough workup to initially establish the cause of the dry eye is a crucial first step prior to initiating treatment. During this workup, there are specific tests including tear breakup time, Schirmer’s test (amount of tear production) and inflammatory mediators in the tear film.
Treatment then involves addressing the underlying cause. I typically begin with the most conservative and mild approach and slowly add on treatments to determine the minimal amount of treatments needed for the optimum effect. I usually begin with preserved and nonpreserved artificial tears (that come in individual vials), add thicker drops, including those with carboxymethylcellulose, add gel, ointment, prescription drops, and punctal plugs. Below is a description of each of the types of treatments in more detail:
There are two puncta in each eye, one in the upper and one in the lower lid, and the puncta connect to the canalicular and nasolacrimal duct. The tears drain through this system. By occluding the puncta with punctual plugs, we are essentially blocking the drain and allowing the tears to stay on the surface of the eye and thus lubricate it for longer. This improves comfort and minimizes the amount of artificial tears needed throughout the day. Think of this as putting a stopper in the sink drain to allow the fluid to stay on the surface of the eye longer. Punctal plugs are tiny (two by four mm) inserts placed in the office at the slit lamp. The procedure is not painful at all, and you can continue your day-to-day activities afterward. There are two kinds: silicone plugs that are permanent (but may be removed) and collagen plugs, which are absorbed over about three months. If collagen plugs improve symptoms, we replace them. We typically start with two plugs and then proceed to four if there is a benefit. A more permanent solution includes electrocautery of the puncta, which permanently closes the puncta.
Autologous Serum Tears
More aggressive treatments include autologous serum tears, in which a patient’s blood is drawn and centrifuged to separate the liquid and cellular components of the blood and is then turned into tears that are refrigerated for three months. Autologous serum tears are well-tolerated and are composed of substances that artificial tears cannot replicate, such as immunoglobulins, vitamin A, fibronectin and growth factors that promote corneal health. Current indications for autologous serum tears include Sjögren’s syndrome, dry eye, several types of keratitis as well as ocular graft-versus-host disease. They can be costly and time-intensive initially but can greatly help the right patient.
There are several lens devices, such as scleral lenses and specifically the PROSE lens system that provides relief to certain patients. PROSE devices are made out of highly gas-permeable hard plastic that allows oxygen to reach the cornea. They are designed to create a space between the prosthetic device and the eye that is filled with sterile saline. The liquid remains in the reservoir, providing constant lubrication by bathing the eye in a pool of artificial tears.
Another common condition is “epiphora,” or tears pouring down the cheek. This can be the result of various conditions, such as reflex tearing from ocular surface disease, tear hypersecretion, lid abnormalities or nasolacrimal duct obstruction. Reflex tearing is tearing in response to dry eye and an irregular surface. To determine whether there is an obstruction anywhere along the punctal, canalicular or nasolacrimal duct, we irrigate the system through each of the four puncta with saline solution. Obstructions can be partial, intermittent or complete. This procedure is safe and painless and is both diagnostic (it gives us information regarding the location and type of obstruction) and therapeutic (it can open the obstruction partially and improve symptoms). Treatments for obstructions include drops, procedures, and oculoplastic surgery.
Yuna Rapoport received her MD from the honors program at Northwestern University Feinberg School of Medicine, completed an ophthalmology residency at Vanderbilt University, and completed an extra year of fellowship at Harvard Medical School. She performs refractive, cornea, and cataract surgery. Each of Dr. Rapoport’s patients receives individualized and expert care. Her work regarding advances in eye care treatments has been published in many leading medical journals and presented at major ophthalmologic meetings. She is on staff and teaches trainees at New York Eye and Ear Infirmary and Mt. Sinai St. Luke’s Roosevelt.