Is Meibomian gland atrophy reversible? What it the course of treatment?

[eyeneedhelp11]

I have recently been diagnosed with MGD. My doctor says that my MG glands are atrophy on my upper eyelids. Does anyone know if this is reversible and what the course of treatment would be? How do I preserve my lower MG eyelids.

[John C Hagan III, MD, FACS, FAAO]

You would need to ask your ophthalmologist about the pupil size problem. Many people have minor differences in size but 1.4 mm is not minor.  Larger pupils create more visual aberrations.   Expecially if you were not born with such a large difference in the pupil size you should see a neuro-ophthalmologist to work through the various causes of acquired unequal pupils (call aneisocoria)  

[eyeneedhelp11]

Thank you Dr Hagan,  Should I seek an opinion of my primary doctor? My ophthalmologist  suspects it may be secondary to steroid use (i'm on lotemax and xiidra). I will follow up with him next week. Is there urgency in getting this checked out earlier?  

[John C Hagan III, MD, FACS, FAAO]

Not emergency unless you have headache or other major problem.  Lotemax and xiidra don't usually dilate the pupils. Check with your ophthalmologist. I suspect you need to see neuroophthalmologist. They will want you to bring in old facial photos over 10-15 years to document you have not had this in the past.

[eyeneedhelp11]

Thank you Dr Hagan,  I notice my eyes don't dilate and constrict at the same rate when I turn the light in a room on and off.  My right eye will constrict and dilate faster.  Some times, left will remain bigger but other times they will shrink to about the same size. I will follow up with my primary doctor and get a referral to neuro-opto.

Based on my lipiview it seems like most of my upper MG have atrophied.  However, I have a majority of my bottom ones.  Is there a percentage of MG I need to function normally? I've been using AT every 2 hours despite all my treatment.

[JohnHaganMD]

No studies like that published that I am aware of

[eyeneedhelp11]

Thank you Dr Hagan, my doctor advised I get a ct scan due to aneisocoria.  Can dry eye cause sensitivity to cold air or wind.  My eye hurts when I open the fridge now.  

[John C Hagan III, MD, FACS, FAAO]

Don't ask questions just to ask questions. You obviously are intelligent. You have read about dry eyes. Of course you know that dry eye can cause sensitivity to cold, wind.  Please don't post trivia. If you have a major change let me know or ask your MDs.

[eyeneedhelp11]

Thank you Dr Hagan, I had a visit with my primary MD regarding aneisocoria and my sensitivity to light.  He advise that I get a CT scan of the head.  He believes I may be having migraines/ ocular migraines?  A CT scan would not affect my healing process (I'm 5 months post lasik with 4 silicon punta plugs)?  

[John C Hagan III, MD, FACS, FAAO]

No CT or MRI neither one would affect your eyes.  We had our quarterly staff meeting tonight at Discover Vision Centers and they talked about a new device for MGD.  Its called ILUX   link  http://www.tearfilm.com/ilux-device/   I believe our cornea surgeons are enthusiastic about it and will order several.  Much less expensive the lipoflow or ILP (toyos).   But more effective than MG probe/express. Might ask your doctors to look into it.

[eyeneedhelp11]

Thank you so much. I will look into it.  My doctor recently did a MMp9 test on both my eyes which were positive despite being on steroids.  He states that this is indicative of my dry eyes caused by systemic issues.  From what I've read, it seems like if I have "inflamed tears (mmp9+)" it is not advisable to have 4 punta plugs because inflamed tears are trapped in my  eyes. Do you think it would be an option to remove plugs, treat the inflamed tears, THEN put plugs back in? Please advise.

[John C Hagan III, MD, FACS, FAAO]

These decisions must be made by your ophthalmologist but plugs should help not hinder your problem

[eyeneedhelp11]

Thank you Dr Hagan. How do you diagnose ocular rosacea? Is it safe to assume if you have rosacea that you have  or will get ocular rosacea? I've been breaking out bad since my procedure.  Today I have a  large boil on my nose.  I've always thought that I had occasional acne issues, but within the last month the acne has progressively gotten worst. Could this outbreak be caused by Demadex? I've been using hypochlorous acid on my eyelids and area around my eyes.  Do you think  Cliradex would help? Thank you

[John C Hagan III, MD, FACS, FAAO]

I know you see a lot of physicians but you need to put dermatologist on your list and see if you have Acne R.   Demadix does not cause Acne R or severely dry eyes.   Since its unlikely that you have demodix not likely cliradex will help.

[John C Hagan III, MD, FACS, FAAO]

=

[eyeneedhelp11]

Thank You Dr Hagan.  Can severe dry eye cause recurrent corneal erosion syndrome? Or is this a syndrome cause by systemic issues?  I read an article that states  there is an increase in MMp9 in patients with RCES.  Does the treatment change if I have recurrent corneal erosion syndrome?  My eyes have been a lot more sensitive to wind/cold since tapering off the lotemax.  One of the doctors recommend I tape my eyes shut at bedtime. What are your thoughts? Thank you for all your help

[John C Hagan III, MD, FACS, FAAO]

Yes severe dry eye can cause RCES.   Putting a gel in at bedtime or an ointment such as Refresh PM or duratears is usually enough.   Taping the eye doesn't work tell. The eye tends to open and then can run on the patch and cause cornea abrasion.  The drops and ointment make the tape hard to stick to skin.  Also skin tends to break down after week or so of patching.

[eyeneedhelp11]

Thank you Dr Hagan. Are there any instances where artificial tears are more beneficial then your own tears?  How would you know?  I have (mmp9 positive tears). Can my own tears worsen my dry eyes?  Would xiidra help with mmp9 tears?

[John C Hagan III, MD, FACS, FAAO]

Yes because in dry eyes the tears produced by the eye are poor quality or poor quantity or both. Artificial tears are constituted to mimic 'perfect' tears.  I don't know enough about MMP9 to discuss.  

[John C Hagan III, MD, FACS, FAAO]

I just said that the cornea thickness is not relevant anymore because you had lasik.

[eyeneedhelp11]

Thank you Dr Hagan,

[eyeneedhelp11]

Is there any risk in overusing artificial tears? Despite having four plugs in , I feel a need to instill drops if I'm on the computer every hour.  Will this effect my tear production? Does the body become reliant on drops similar to how it can become reliant on stimulant-laxatives? Thank you for all your help

[John C Hagan III, MD, FACS, FAAO]

You cannot over-use eye drops.  Frequent use does not inhibit your own tears.  Nothing at all remotely like laxative use.   It does get expensive.

[eyeneedhelp11]

Thank you Dr Hagan.  Is it normal to have pupil of different size. My right eye is 6.6 while my left eye is 8.0.  My left eye has a lot more ghosting post-lasik.  Is there any correlation?  

[John C Hagan III, MD, FACS, FAAO]

Look on this page in right hand side the gray box "This Forum's Experts" click on my name in blue which is an active link. It will take you to my home page. Click on "Blogs" and read the article on dry eyes.  Dry eyes, blepharitis and MGD often occur together.  I would suggest you ask your Eye MD ophthalmologist about a prescription for Avenova Eyelid cleaner and use twice daily. This removes the oil plugs that cause the glands to get infected. Warm compresses with a reheatable eye pad also helps.

[eyeneedhelp11]

Thank you Dr Hagan for your insight.  The glands that have atrophied, is it possible to reveres the effects? Ave nova is really expensive. Are there any alternatives?

[John C Hagan III, MD, FACS, FAAO]

Avenova has a discount program that lets no bottle cost more than $40  at least that's the way it is in kansas city and I'm told its a national program. the non-prescription cleaners like Ocusoft platimum are expensive also.   No I am not aware of anything that will 'rejuvenate" MG so the goal is to stop killing them off.

[John C Hagan III, MD, FACS, FAAO]

Follow this link. On the website it says with coupon bottle only costs $35    https://avenova.com/rebate-card-thank-you/    Ocusoft platinum is about $21/bottle and its smaller.

[eyeneedhelp11]

Thanks for your help Dr Hagan

[John C Hagan III, MD, FACS, FAAO]

Sure I have dry eyes and I use Avenova daily with good results.

[eyeneedhelp11]

Dr Hagan, I've been on xiidra for 2 weeks. I notice my left eye can be blurry for up to an hour. My right eye is fine.  Should i continue on xiidra? I currently have 4 silicon plugs in my eyes.

[John C Hagan III, MD, FACS, FAAO]

First of all xiidra is for moderate or severe dry eyes not response to all primary and secondary treatment. It also means using the drops twice/day for the rest of your life and the drops take 4 months to kick in.  It is also outlandishly expensive once the coupon for the first refill is used. It is not approved for MGD.  You need to call whomever prescribed Xiidra and ask your questions. Also ask yourself if you are willing to accept everything I described.  The few times I've tried Xiidra (mainly in patients that did not tolerate the far less expensive Restasis) they have complained of pain, redness, blurred vision.  Of course Jennifer  Aniston likes it but she is paid millions of dollars to advertise on TV.

[eyeneedhelp11]

Thank you for your insight, is there any harm to switching to Restastis after a month of treatment? I am on the trial 30 days.  My dry eye is severe.  We have tried amnionic membrane which worked for about 1 month, but then my vision became blurry again.  They then put 4 silcon plugs (upper and lower both eyes) and started me on lotemax drops twice daily, lotemax ointment at bedtime , xiidra twice daily and oasis tears four times a day and as needed.  Am i on the right path?
My eyes still burn when I use the computer and my left eye (has residual myopia) is constantly heavy, I feel like I need to close it or squeeze it shut really hard. Any input would help Thank you

[John C Hagan III, MD, FACS, FAAO]

You would need to discuss this with your ophthalmologist.  Xiidra is supposed to 'kick in' at 4 months whereas restasis 'kicks in' at 6 months. I have posted many times here my wife and I are both on restasis for over 5 years for moderately severe dry eyes with great results.

[John C Hagan III, MD, FACS, FAAO]

You might try 'Retaine" artificial tears. They claim to be the only 4th generation tear on the market.

[eyeneedhelp11]

Thank you Dr Hagan, I've tried Retaine before but notice that it did not last as long. My doctor d/c the Retaine and put me on oasis along with the amnionic membrane.  I will ask him about Retaine at my next appointment and possibly switching to Restasis.

My four silicon plugs makes it difficult for me to use my peripheral vision and turn my head.  Are these symptoms expected with punta plugs? I also came across an article that states that xiidra may be safer with patients with punta plugs?

[John C Hagan III, MD, FACS, FAAO]

No punctal plugs should not cause problems with peripheral vision or turning your head.  Neither Xiida no restasis are especially dangerous with plugs.  Look into the cost of xiidra.

[eyeneedhelp11]

Thank you Dr Hagan, just to clarify. I have a uncomfortable feeling when looking to left or right. I can feel the plugs. Can the plugs do damage to my eyes?

[John C Hagan III, MD, FACS, FAAO]

Yes if they touch the cornea.  Try and move your head to the left or right not the eyes. If it becomes extremely painful you will need to call your ophthalmologist. If you eyes are that dry they may have to permanently close the tear duct openings.

[eyeneedhelp11]

They have consider cauterizing but I am 4 months post-lasik.  They believe my eyes still have a chance to regenerate some nerves. I am 38 years old  so the idea of cauterizing is scary. Initially i had SPK of 3+ in both eyes but they were able to reduce it to SPK +1 via lotemax, 4 plugs and xiidra within a 2 week period. At what point would you consider cauterizing?

[John C Hagan III, MD, FACS, FAAO]

Not a question I can answer from here.   Are you male or female.  Rare to have a 38 year old with this severe of dry eye unless there is some underlying systemic disease like rheumatoid arthritis or other collagen/vascular auto-immune disease.

[eyeneedhelp11]

Thank you Dr Hagan, I am male.  I did not have symptoms of dry eyes prior to Lasik. Should I follow up with my primary MD or ophthalmologist? I did some reading about Sjogren's syndrome, would that present this way?

[John C Hagan III, MD, FACS, FAAO]

Your eye problem is way too severe for your primary care physician and you should see your ophthalmologist.  Yes SS could cause the problem. There is a new simple test that I would suggest you discuss being drawn.

[eyeneedhelp11]

Is it just a blood test? Can you suggest a test so that I can bring it up with my ophthalmologist?  
My left eye constantly feels droopy and heavy.  My Dr says its from dryness.   My left eye was undercorrected from Lasik, can it be strain from constantly trying to accommodate.  They aren't able to do a MR for glasses yet due to dryness. Do you think glasses will fix this issue?  
Thanks for your help, I'm a mess

[John C Hagan III, MD, FACS, FAAO]

New SS tests are by B&L  here is link  http://www.bausch.com/our-products/diagnostics/sjo-diagnostic-test     No eye strain would never cause dryness as severe as you.  Glasses may help you see better but not help dryness or have less dryness related pain.  Are you on omega 3? takes about 30-60 days but can help dryness.  Fish oil, flaxseed oil, creel oil or a compound made just for dryness  e.g. https://www.walmart.com/ip/Thera-Tears-Eye-Nutrition-Omega-3-Supplement-1200mg-Soft-Gels-90-ct-Bottle/10532780?wmlspartner=wlpa&selectedSellerId=0&wl13=1120&adid=22222222227000015632&wl0=&wl1=g&wl2=c&wl3=40753431632&wl4=pla-56971569545&wl5=9023228&wl6=&wl7=&wl8=&wl9=pla&wl10=8175035&wl11=local&wl12=10532780&wl13=1120&veh=sem  

[eyeneedhelp11]

Thank you Dr. Hagan.  I am taking 2000mg of fish oil and 1000mg of flaxseed daily for about 5 months.  My job requires me to use a computer 8 hours a day. Can the computer use worsen my condition.  Should I consider decreasing my workload.  Work is important, but I want to do whats best for my health.  

If I do have SS and MGD, what is my prognosis.  Will this be a lifetime problem?  Im still holding out hope for nerve regeneration post-lasik.

An optometrist friend of mine recommended Clindarex for MGD because Ive had bad acne breakout post surgery on my forehead. Is this a plausible option

As always, thank you so much for your input. My wife and I appreciate it.

[John C Hagan III, MD, FACS, FAAO]

Yes computer works drys the eye because it reduces the blink rate. Part of the reason why dry eye becoming more common in young people. Do the 10/10/10 rule. Every 10 minutes look away from your screen focus on something as far away as possible and blink firmly 10 times. Use artificial tears at least every 30 minutes.  SS is a lot worse for prognosis than MGD.   You would need to ask your ophthalmologist about oral antibiotics.  SS would be a bigger set back than MGD.  Both of those are chronic problems.

[eyeneedhelp11]

Thank You Dr Hagan.  Is it normal to have lasik scar? They noted that I had lasik scar.  Can this be contributing to my light sensitive and do these scars heal?

[John C Hagan III, MD, FACS, FAAO]

All "flap" lasik leaves faint scars that are outside the visual axis and don't normally cause a problem. Surface lasik PRK  may or may not leave a scar.  I doubt laser scars are causing the problem

[eyeneedhelp11]

Thank you Dr Hagan, what else can contribute to the light sensitivity? I notice the light sensivity has gotten worst since I had the 4 plugs put in. I periodically see more of a haze around lights at night in my left eye. Not sure if thats a side effect of lotemax/xiidra or if its an underlying cause of my condition.  I also notice a film that covers my cornea from time to time. Is this cornea haze? As always any input is greatly appreciated. Thank you

[John C Hagan III, MD, FACS, FAAO]

You have extremely severe dry eyes. That is by far the most likely cause of your light sensitivity.  A cornea haze is loss of clarity and it pretty much always there. If it comes and goes not likely that.

[eyeneedhelp11]

Thank you Dr. Hagan. My left eye constantly has a a lot of mucous when I wake up which blurs my vision for about 5 minutes.  Should I try to fish this out? I just add lubricant drops and blink until it goes away.  

[John C Hagan III, MD, FACS, FAAO]

"Fishing" will only make it worse. read about "mucous fishing syndrome"   rinse out with warm water then use your favorite artificial tears.

[eyeneedhelp11]

Thank you Dr Hagan, my doctor advise me not to get any water in my eyes because I had Lasik in december.  Should I flush it out with artificial tears instead?

[John C Hagan III, MD, FACS, FAAO]

Yes tears.  Water is hypotonic and can make the lasik flap swell.

[eyeneedhelp11]

Thank you Dr Hagan, my dry eye causes my vision to be extremely blurry at times.  Is this dangerous? What are the long term effects of dry eyes if I can't manage it? Today my right eye (normally stable) has been blurry the whole day despite using lubricant drops.  Vision not improving with blinking. Should I see MD asap or wait until my follow up next week. Please advise

[John C Hagan III, MD, FACS, FAAO]

I think you should at least call your ophthalmologists office and report your observation.  Dry eyes can run the gamut from extremely mild rarely causing a need for artificial tears to ultra severe that destroys the cornea and leads to visual loss or blindness. It's obvious from your posting yours is not an 'average' case.

[eyeneedhelp11]

Thank you Dr Hagan, is it possible blur vision can be from lotemax. I've been using lotemax susp bid for 3.5 weeks along with lotemax ointment qhs and xiidra bid.  I am afraid with my 4 silicon plugs it is not getting the proper drainage.

[John C Hagan III, MD, FACS, FAAO]

Possible yes, likely no.

[eyeneedhelp11]

Thank you Dr Hagan, my doctor mention sclera lens.  Is this a good option for dry eye?  He also mention the possibility of placing an amnionic membrane again in my left eye.  Is it ok to have multiple treatment of amnionic membrane? My first membrane was placed in January.

On a side note, I notice you are a graduate of Loyola Chicago.  Your basketball team is doing amazing!!

[John C Hagan III, MD, FACS, FAAO]

Trying an amniotic membrane again, or autologous serum or a scleral lens are all acceptable options.  Yes  I am a Loyola University Rambler fan and who I will be cheering for.

[eyeneedhelp11]

Hi Dr Hagan, hope you enjoyed your Easter weekend. I had an appointment with my doctor and he ran a HD Analyzer test on me.  He ask me to keep my eyes open and not blink for 20 seconds while it analyze my scatter index?  Can you help me understand this test?

He also did a Tear lab test. My left eye (bad eye) was not able to detect a reading.  My right eye was below 300 which he said was normal.

[John C Hagan III, MD, FACS, FAAO]

No I don't use the first test and can't help you. Last test measure "tear osmolality"   High numbers >320 indicate dry eyes.  Less than 300 indicate normal tests. Can be affected by use of artificial tears.

[eyeneedhelp11]

Thank you Dr Hagan, my one month trial of Xiidra expires this week and I will probably switch to Restatis.  However, I read on the website that Restatis did not generate new tears with punctual plugs.  I currently have four permanent silicon plugs in for 3 weeks and have been on lotemax for three weeks.   My doctor is tapering me off the steroid, but should I start restasis with 4 plugs or remove plugs then start restasis? Sorry for loaded question.

[John C Hagan III, MD, FACS, FAAO]

I can't see any reason in the world why you were started on Xiidra and are now switching to Restasis? Better run that by your ophthalmologist.   If you do switch as I told you ask for the droppertte form of restasis and not the multi-drop bottle. My wife and I use up one dropperette completely before opening another. One used both eyes twice/day lasts 2-3 days and reduces your cost by 400-600%    In severe dry eyes we leave plugs in.   Neither restasis nor xiidra generate new tears. they reduce inflammation on the surface of the eye by inhibiting mast cells and promote a higher quality tear.

[eyeneedhelp11]

Thank you Dr Hagan, He believe the xiidra would work faster and I can transition to Restates once the 1 month trial ran out.  Is there any harm in switching?

Would 4 plugs prevent medication from draining properly and leading to problems? I will see my ophthalmologist later this week and ask.  As always, thanks for your insight

[John C Hagan III, MD, FACS, FAAO]

Restasis.   No but that logic is flawed.  Might as well get the restasis on board ASAP.    The plugs are there to prevent drainage.  Hopefully all the few tears you make and the artificial tears you put in stay in your eye rather than go down the tear duct into the nose.   Also its incorrect to refer to them as permenant. They usually fall out after a variable amount of time. What is permanent is closing the ducts completely with cautery or laser.

[eyeneedhelp11]

Thank you Dr Hagan, is there a risk of the medication staying in the eye too long due to the four plugs?

[John C Hagan III, MD, FACS, FAAO]

None that I have ever seen reported nor in my experience.

[eyeneedhelp11]

Thank you Dr Hagan, my doctor is switching me to Restasis due to cost.  She recommends I use both for 1 month, then d/c Xiidra.  She wants to give Restasis some time to work. I've only been on Xiidra for 3 weeks.  Your thoughts?

[John C Hagan III, MD, FACS, FAAO]

we've been over that before.

[eyeneedhelp11]

Thank you Dr Hagan, she actually wants to use both simultaneously.  Is there any reason to use both?

[John C Hagan III, MD, FACS, FAAO]

The data on using both is very limited, and would only be used in the most severe cases of dry eye.  I have tried it on only one patient and they complained of pain and burning on Xiidra and would not continue it.  You need to discuss this with your ophthalmologist. I can't make these types of decisions for you.

[eyeneedhelp11]

Thank you Dr Hagan, Dr has me on lotemax drops twice a day and lotemax ointment at bedtime for 3.5 weeks.  Recently he decrease to lotemax drop once a day & lotemax ointment at bedtime.  How long is it safe to use steroids without causing problems.  My eye pressure is below 20 for both eyes. Thank you for insight

[John C Hagan III, MD, FACS, FAAO]

There is no way to answer that question. Some people have trouble with steroids as soon as they go one them and others are on for years and years (such as after corneal transplant) without problem.  The higher the dose and the longer you are on them the more chance of complications.

[eyeneedhelp11]

Thank you Dr Hagan. They did a pachymetry reading on my eyes and the reading were 510 and 560.  I did some research and it stated that this may be a risk factor for glaucoma?  Can you help me understand these results? Thank you

[John C Hagan III, MD, FACS, FAAO]

Average cornea thickness in center is 540 microns.  Thicker than that means less likely to get glaucoma and a chart is used to SUBTRACT number from Goldman tonometer reading because it will read high.  Thinner than that increases risk of glaucoma and numbers are ADDED to tonometer reading.   Since you have had lasik these numbers don't mean much and the important number was pre-lasik numbers.

[eyeneedhelp11]

Thank you Dr Hagan for the information.  Isthere increase risk due to the variability between the two eyes?