John C Hagan III, MD, FACS, FAAO  
Kansas City, MO

Specialties: Ophthalmology

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2018 General Information on Dry Eyes-Now known as Ocular Surface Disorder

Mar 10, 2018 - 24 comments

Dry eyes are one of the most common conditions seen in the practice of ophthalmology. Collectively dry eyes probably cause more eye discomfort and irritation than any other condition.  The term “dry eyes” will never go way but it’s misleading.  Eye MD ophthalmologists now call this “ocular surface disorder” (OSD) and sometimes “tears dysfunction syndrome.”  There are two forms of the problem. In the first (called by Eye MDs ‘aqueous deficiency’) there are no tears or few tears; it is often associated with dry mouth and is the most severe form. In the second form, the eyes water constantly or often. It is called ‘lipid deficiency’ and is caused by eyelid oil gland (Meibomian Gland Disorder or MGD) problems.  In the first form the eye doesn’t make enough tears; in the second form the tears are of poor quality.  There are many tests for OSD, some of them quite expensive, but the diagnosis can usually be made by a careful symptom review and examination of the eye and eyelids. For persistent problems a complete medical eye examination by an Eye MD ophthalmologist is needed plus telling the Eye MD about your symptoms and how troublesome you find them. Self education on OSD is extremely important.

         If you are menopausal or post-menopausal be sure you and your gynecologist maintain optimal hormonal balance. (Many women with dry eyes have dry mouth and dry vaginal canal). If you have joint pain have that evaluated to be sure you don't have Sjorgren's syndrome or rheumatoid arthritis. You might review your medications with your ophthalmologist. Almost any cold, allergy or sinus medicine can cause or aggravate dry eye and mouth. Oil and debris along the eyelids (blepharitis) can aggravate dry eyes. Blepharitis can also cause eyelid infections such as styes, blocked oil glands (chalazion) or eyelash loss and red eyes and eyelids.  Eye lid cleaners and wipes are very useful. They are non-prescription. The easiest to find, and among the best, are Ocusoft products:   http://www.ocusoft.com/ For recalcitrant cases the new prescription Avenova Eye https://avenova.com/ has worked extremely well.

OSD treatment usually begins with use of preserved and/or unpreserved artificial tears during the day and gels or lubricating ointments at bedtime. Environmental modification is important.  Don't belittle eye drops. They are not ‘all the same”. You would never walk into a restaurant and say “Bring many any type of food, it’s all the same.”  There are over 100 different brands of artificial tears and they can't all be lumped together. Sometimes one will find the perfect drop. That means you put the drop in and your eye becomes comfortable in 5-10 minutes and remains comfortable for at least 3-4 hours. If it stings or burns, write down the name on a list you keep and give it a failing grade. If it helps but only for an hour continue your search for one that lasts 3-4 hours; give it an average grade.   YOU MUST KEEP A LIST OF DROPS YOU HAVE TRIED AND HOW THEY WORKED OR DID NOT WORK FOR YOU.

Because the OSD problem is so prevalent the pharmaceutical companies are coming out with new products all the time. Some of the newest are Systane preserved and unpreserved, Optive, Blink, Soothe, and Retaine. Eye drops for dryness are classified as unpreserved drops (individual vials that must be used within 24-48 hrs.), preserved drops, gels and ointments. The unpreserved drops are more expensive and usually only help the small percentage of people that are really allergic to preservatives. Gels and ointments are normally used at night since regular artificial tears won’t last all night.  Ointments are messy and many people dislike them.  Be sure to try Nature’s Tear’s Eyemist a spray for dry eyes that works for many people. It is available without a prescription.  http://www.naturestears.com/

Tears may need to be used as often as 4-6 times/day.  House brand or generic eye drops may work for the mild forms but moderate or severe OSD usually requires newer brand names.  Omega 3, taken by mouth, has been shown to be helpful. Sources include fish oil (which some people have trouble tolerating), creel oil and flaxseed oil.  Environmental modification means not sleeping under a fan, not blowing air into the face (example in work station, cars, planes) and humidifying home and work and sleep areas during dry winter months.

Some activities aggravate both types of dry eyes because they cause the eye to blink less frequently. These include reading, use of any video screen (computer, iPad, iPhone, video games), watching TV, going to movies.  Discomfort can be helped a great deal by looking away from the screen and focusing on a distant object and blinking forcefully 8-10 times. Do this every 15 minutes during these activities. Because of the increasing amount of time young people are spending on computers/phones/tablets/videogaming there is an epidemic of dry eyes in young people: https://www.nbcnews.com/nightly-news/video/studies-excess-screen-time-could-be-aging-kids-eyes-870691907947  (as an aside young people are also developing impaired hearing at a much younger age due to loud music via headphones/earbuds).

      Warm compresses are often helpful.  Hot washcloths may suffice but a much better way is with re-heatable, eye pads available at any drug store. They are relatively inexpensive and way more efficient that hot washcloths. Follow the directions carefully to prevent damage to the eye. Additional things that can help include a diet rich in fatty fish (e.g. salmon, sardines, etc.). Fish oil taken by mouth usually 2 to 4/day has been show to help some patients. Do not start with this many fish oil/day. Start one per day with a meal and every 2 weeks as another to the amount recommended on the bottle. Ask your physician before beginning fish oil.  In addition, there are non-prescription pills for dry eyes available at most major drug stores or by direct order from the companies. Thera-tears formula for dry eyes is probably the most widely used. You can use any search engine to pull up the websites of the companies that see these.

For people that exhaust all these first and second level treatments, whom are still moderately or severely symptomatic and/or who are using drops 4 or more times/day, they might consider Restasis or Xiidra.  These are not artificial tears but prescription eye drops that over a period of 4-6 months: 1. reduce inflammation on the surface of the eye and 2. promote the formation of more efficient, high quality tears.  It is important to realize the commitment one is making when considering these:  1. twice/day for the rest of your life (or until something better comes along) 2. waiting 4-6 months for them to start working 3. expense associated with them (although in the long run may be less expensive than purchasing brand name eye drops to use 4-6 times/day).    You can read about them on their websites:  https://www.restasis.com/  and https://www.xiidra.com/

This is sort of a personal testimonial. I do not receive any money from any drug company for anything.  My wife and I have moderately severe dry eyes. I have aqueous deficiency, classic ‘dry eyes” and my wife ‘lipid deficiency’.  When we did not respond to first and second level treatment we went on Restasis. After 3-4 months we saw some improvement and after 6 months were entirely comfortable with only occasional use of artificial tears. Both of us have been on Restasis over 5 years.  There is a way of using Restasis in non-preserved vials that can dramatically reduce the cost. This method does not work with the multi-drop Restasis bottle introduced the past year. We always ask for the non-preserved vials.  Xiidra is relatively new. They are advertising heavily now using Jennifer Aniston as spokesperson. It is not better than Restasis and in the testing phase in some areas was not as good as Restasis. The company is marketing that its full onset comes 4 months after starting drops whereas Restasis is 6 months. I have not used a great deal of Xiidra in my practice for several reasons:  1. when patients hear how well Restasis did for me and my wife they want to try it. 2. In the few cases I have tried it the patients did not like it and especially 3. when the Xiidra first refill discount cards and samples are exhausted the patients have found it way too expensive.  

New treatments also include pulsed laser to the surface of the eyelids https://www.reviewofophthalmology.com/article/intense-pulsed-light-for-treating-dry-eye  and heat/compression to the eyelids https://tearscience.com/lipiflow/   I do not have much experience with these but patients treated elsewhere have told me they are quite expensive and may or may not prove helpful.

      If you reach a point of exhausting all the above see an ophthalmologist that specializes in "Cornea and External Disease". This is their special area of expertise. A final new treatment that they can often do is “Autologist Platelete-rich plasma” therapy. This uses eyedrops made out of your blood products. (reference Ocular Surgery News: November 1, 2007 page 46 lead author Jorge Alio MD.

     While dry eyes-ocular surface disorder cannot be cured, it is a chronic problem, is can almost always be helped a great deal. The Eye MD can only do so much and much of the success of treatment is determined by the willingness of the patient to learn about the problem and systematically work towards relief of their symptoms.

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Avatar universal
by dustinalvillar, Mar 11, 2018
(posting for girlfriend)ive suffered dry eyes for i guess the past year. im 28 female with type 1 diabetes. have had corneal abrasion and cataracts for the past year and have been through 3 different specialists out here who just refer me to the next once they figure out that they cant figure out whats wrong with me... ive had patches put on my eyes with gel underneath, been thru many eyedrops, had plugs put in my eyelids, had amniotic membranes placed on my eyes, now they are at the point of wanting to stitch eyelids together (i think called Tarsorrhaphy) not 100 percent sure i have it written in car.. they say that the stiches may be permanant. and blood sugar is very well maintained, drink lots of water, count carbs, i dont know what to do or who to talk to. if it helps i have medicare part a b and d and i also have transportation to wherever someone thinks they can help me

Right off the bat that puts the person with this problem in the worse 99.2% of dry eyes. Having been through all of that its likely  that the advice you have been given is appropriate. You are working your way up the referral ladder and its likely that the Eye MD ophthalmologist that is treating you is a cornea/external disease specialist with the appropriate training. Also you have a chronic problem that is not going to be cured so you need to go to an ophthalmologist that you can easily get to many times per year. You also should have a retinal Eye MD ophthalmologist on your team to examine your 'better' eye for diabetic retinopathy.   another option would be if you have a medical school department of ophthalmology that is close enough to go to regularly would be to get a second opinion from the cornea/external disease eye MD there. This is a terribly severe problem that is atypical of 'average" case of dry eyes.

Avatar universal
by mahniah, Apr 04, 2018
With regard to MGD (meibomian gland disease), there's a new treatment developed by a doctor in Florida and it seems to work, at least it did for me.  Meibomian gland probing isn't covered yet by insurance and there aren't a lot of docs doing it yet, although younger docs are more likely to do it.  I had it done and it changed my life.  It's basically clearing out the glands by probing.  Check it out.

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by JohnHaganMD, Apr 04, 2018
The treatment developed by Dr. Steve Masket  MD of Tampa is not new. This is a reference dating to 2010  https://www.healio.com/ophthalmology/news/blogs/%7B05533875-6996-4b98-aae3-13315cc9c5e5%7D/john-a-hovanesian-md-facs/squeezing-and-probing-those-meibomian-glands--does-it-work     There are a lot of things that work for some people.  I have not found it particularly effective and most people find it very uncomfortable. Glad it helped you.  

Avatar universal
by MjCg, Jun 06, 2018
Hello, Dr. Hagan - I'm so glad to have come across your article about dry eyes.  Under care from my optometrist, I had actually begun using Restasis two months before my detached retina occurred.  Although my optometrist and my retinal specialist have both told me that Restasis did not cause my RD, psychologically I can't bring myself to start using it again (aaack!).  What do you think?  Is it even slightly possible that Restatis could cause a tear/detached retina?    

Not not even remotely possible. My wife and I both take restasis very successively for over 5 years for dry eye.  There is only one eye drop that has been associated with RD and its almost never used anymore (pilocarpine).  Restasis just reduces inflammation on the surface of the eye and helps the eye make a higher quality tear.  You could try Xiidra but it is outlandishly expensive.

Avatar universal
by Tiigerlily, Jul 09, 2018
Since about last 3-4 wks.I have been experiencing dry eyes from time to time. As of 5 days ago I began to notice a sort of smudged view from the lower right area of my left eye; it seems to come and go, although when I cover my right eye it seems to go away... What are your thoughts?

See your ophthalmologist about this complaint.

Avatar universal
by jnowak_1, Aug 19, 2018

Dr. I had stevens Johnson syndrome  and the mucus lining in my eyelid were' burned out' so I only have tears to lubricate my eyes. Others I have corresponded with who have also had sjs or TENS syndrome have found a stem cell procedure to cure and restore the eyes from dry eye syndrome and scarred cornea's . the procedure is being done in California if my memory serves me correctly and you can get more information about it by contacting the Stevens Johnson Foundation (Julies) and contacting Jean the Founder as her daughter had sjs as well. very nice helpful people. hope this helps someone. The boston foundation for sight also makes custom fitted scalera len's which takes 5 days there to develop and fit if that route isn't an option which in on a link in the prior webpage. people I correspond with there have had great success.

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by JohnHaganMD, Aug 19, 2018
Stem cell transplants for cornea disease are relatively simple and widely available across the United States.  There is also a new blood test for Sjorgren's Syndrome from Bausch & Lomb.   For Steven's Johnson Syndrome treatment should be available at tertiary ophthalmology centers across the United States. Thanks for the comments

Avatar universal
by judithmhol, Aug 23, 2018
So very very helpful. And as I sat and read in it’s entirety,  I kept thinking about the days gone by when my eyes looked rested and didn’t bother me all the time.  They sting, always watering or feeling dry.  And I look so tired all the time.  Can’t use eye make up anymore, and if I make the mistake of rubbing my eyes....well I pay for it.
Anyhow, thank you for taking the time to send this out.  Will get back on my Restasis

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by JohnHaganMD, Aug 23, 2018
If you use the Restasis vials and use one up completely before opening the next (my wife and I both do this for our restasis)  it reduces the cost by 5/6 since one vial lasts about 3 days and normally if used as directed would use 6. The multidrop bottle is much more expensive.  Xiidra is out of sight expensive.

Avatar universal
by Paulaedwards, Nov 18, 2018
Great general Information on Dry Eyes-Now was known as Ocular Surface Disorder. Thanks for sharing with us. Your this kind of information was very helpful for all those people who suffer dry eye disease. Keep sharing more & more

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by JohnHaganMD, Nov 19, 2018
There is a new double strength Restasis just released called "Cequa"  should be very effective for Restasis failures. Since it's new have no experience with it yet and not knowledge of the cost.

Avatar universal
by Jim_in_Italy, Jan 14, 2019
Dr Hagan, first, thank you so much for your incredibly helpful info posted on medhelp. I have learned so much. Just for info, in Europe, where I live,  there is a drug Ikervis by Santen which is also double strength 1mg/ml. But whereas Cequa is dosed twice daily, Ikervis is once daily. (Both are about same strength I believe.)  Also Ikervis is incredibly expensive. I have yet to go to pharmacy but I believe it could be $300 for 30 vials !!!! Thanks for your tip to use vials more than once.
New question: have you heard of LO2A by Wize, also for OSD. If so, could you comment on it?

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by JohnHaganMD, Jan 14, 2019
Thanks for the information. Because of the US  Food & Drug Administration and the rapacious US tort lawyers we have a huge 'drug lag' in the USA.  The new head of the FDA is Scott Gottlieb MD and he is working hard to try and help the problem.  I have no experience with LO2A, sorry.   Xiidra and Cequa are very expensive in US also

Avatar universal
by HamzaRanjha, Jan 15, 2019
Can you reverse irregular astigmatism from dry eyes?

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by JohnHaganMD, Jan 15, 2019
Irregular cornea astigmastims is due to surface dryness so use of artificial tears, gels, ointments or the superstrong meds: Restasis, Xiidra, Cequa  make the cornea regular.    True irregular astigmasims is due to structural corneal disease such as scarring or keratoconus.

Avatar universal
by Jim_in_Italy, Jan 17, 2019
Dr Hagan, ref my comment above, here is the web page for LO2A. It is sold in a few European countries under different brand names
I would be interested in your opinion.  Much less expensive than Restasis Xiidra Cequa, but I wonder if it “does the same the same thing”.  

Also regarding how many drops you get in a vial of Restasis, I have seen on the internet that a “drop” is generally measured as .05mL.  Restasis vials contain .4mL, so should be good for 8 drops. But that is only 2 days worth @ 2 drops/eye/day.  Am I calculating correctly? the reason I ask is to calculate how much the Ikervis (available to me here) would cost monthly. Each vial contains .3mL so theoretically should be 6 drops and last 3 days @ 1 drop per eye per day. That means the $300 pharmacy cost for 30 vials would be closer to $100/month.  Still not cheap of course, but a lot better until I can get to the US and get help with Restasis via Medicare.

many thanks

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by JohnHaganMD, Jan 17, 2019
LO2A is a proprietary molecule with an action completely different than Restasis, Xiidra or Cequa.  The study was small. It is not available and I only know what I have read so I cannot make a comparison to the latter 3 that I have used on patients.   Also your calculations on how long something will last is only theoretical and not practical. You are comfortable with internet searches.   Search a paper by Charles M. Lederer, MD  I think Archives of Ophthalmology on drop size. It demonstrates the average drop is not 55 microleters.  Also other studies show that same medication, same purported volume from different manufacturers (latanoprost) have different size drops and different number of drops. My wife and I use restasis in vials for many years successfully. One vial lasts me 3 days (12 drops)

Avatar universal
by Jim_in_Italy, Jan 17, 2019
Many thanks, Dr Hagan, for fast response. I have always wondered is a liquid’s viscosity was one factor in drop size. (I have a swimming pool and do my own maintenance, so I am constantly testing with chemical drops. Hence my comment on viscosity)
Since the LO2A is available here, and OTC, and relatively inexpensive, I will try it and post if I have anything of interest to report

Again my thanks to you for your patience and diligence

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by JohnHaganMD, Jan 17, 2019
Yes viscosity would be a factor however the studies I was talking about are all solutions not gels.

Avatar universal
by Alfreda123, Feb 01, 2019
Hello! I've been diagnosed with Graves Disease. My numbers are off the charts. I'm experiencing severe dry eyes, bags under my eyes with swelling , pain and dark circles. I use the drops for moisture and it only helps a little. What else can I do?

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by JohnHaganMD, Feb 01, 2019
You need to be under the care of an ophthalmologist.  If you have ‘bug eyes’ from the Graves Disease you need to see an oculoplastic surgeon about orbital decompression. You also likely need to go on Restasis or Xiidra or Cequa.    My wife and I both use restasis with great success for many years for severe dry eyes (ocular surface disorder)  If you go on restasis get the non-preserved vials (not preservative free multidrop bottle) and ask your ophthalmologist about using up all the drops in the vial before opening another. DRASTICALLY REDUCES THE COST.

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