I was saving this post because dry eye is one of my favourite topics. I have severe dry eye (3 second FTBUT in my left eye, less than 1 second in my right).  I have Meibomian gland dysfunction (MGD) and have a little, distinct notch on my right lower eyelid where that gland has given up the ghost and atrophied.

As well as suffering from dry eye, I have studied it.  My final year project was on Meibomian gland dysfunction and during my time at uni, I invented a handheld device that allows the Meibomian glands of the lower eyelids to be imaged.  It was this little device that won the CooperVision European FORCE final last year, ahead of some really amazing research from all around Europe.  I even got an honorable mention in the BCLA photo competition last year for one of my Meibomian gland pics.  In fact, here’s the photo:

Image

You can really see the acini of the glands (the little dark circles) in this pic.  The parts without the black circles are parts of the eyelid where the glands are missing or atrophied.

I think every optometrist should be a dry eye expert.  It’s the most common non-refractive complaint and, within the realms of dry eye, a staggering 86% is evaporative.  So, for 6 out of 7 patients with dry eyes, lubricating drops aren’t going to do much.  Well, they are going to provide some momentary relief but they are not going to solve the problem.  This is why it’s really important to educate patients on their tears.

As part of my regular slit lamp routine, I look for the signs of dry eye and, if I see something or if the patient reports symptoms, I then look at the FTBUT.

What am I looking for? Well, on a scan of the anterior eye, I look at the eyelashes (any blepharitis? Poliosis? Madarosis?) and then the eyelid margin (any puffiness? Redness? Notches? Capped or blocked glands? Good tear prism height? Is the tear prism consistent along the lid?).  I move onto the conjunctiva – as well as redness,  I’m looking for lid parallel conjunctival folds (LIPCOF), an indicator of persistently dry eyes.  I ask the patient to look up and I pull down the lower lid, everting it with my index finger – here I’m looking for blocked glands, concretions.  All this before I’ve even thought about FTBUT.

You might ask why I’m so thorough when I could just do FTBUT and tear prism height and diagnose dry eye from there but, I’ll let you into a secret: EVERYONE has dry eyes in my room.  I sit in a little, air conditioned box, where the air con is aimed squarely at my patient’s face.  Most of my patients, in this very dry environment, will have a <10s TBUT but they might be absolutely fine everywhere else.  That’s why I look for any and all signs of dry eye, like a lawyer building up a case against their tear quality or volume.

If I’m lucky, my patient will tell me during Hx and Sx that they have dry or gritty eyes.  If they don’t, I will mention it after my slit lamp exam, asking specific questions.

I’m always amazed when someone with MGD, notching, LIPCOF, concretions and a FTBUT under 5s reports no symptoms.  In that case, I’ll always mention it as part of my management but I know, deep down, if it’s not bothering them then they aren’t going to comply with my treatment regime.

As well as using FLUO for measuring FTBUT, we can see any patterns of staining that may help us determine why the eyes are dry.  A lovely line of staining across the middle or lower cornea usually indicates incomplete blinking or lagophthalmos.  A line of staining across the superior corneal implies lid wiper epitheliopathy (LWE), excuse the slightly blurry photo:

UntitledStrangely enough, I had two patients with LWE in one week.  They were both middle-aged ladies with no history of contact lens wear. Weird.

Now we’ve talked about diagnosis, let’s talk about management.

I tested a lady in her 50s last week who had severe dry eye. She reported her eyes “burning” occasionally and she had experienced shooting pains and grittiness.  Her eyes watered constantly when she was outside and this had left her lower eyelids red and sore.

My management of this patient is probably a bit different from what you would expect.  She was using hypromellose QDS and lacrilube ointment in the evenings, she had tried warm compresses followed by lid massage.  I couldn’t see any blepharitis but she was also using Blephaclean wipes in the mornings because of a previous flare up.

I recommended using a little vaseline to help protect the sensitive skin below her eyes and then I did something that might surprise you: I fitted her with contact lenses.

Now, I warned her that the lenses might make things worse and, in that case, I wanted her to discontinue wearing them BUT there was a chance that they might relieve her symptoms.

I’ve mentioned before that the reason I wear extended wear lenses is because my eyes hurt.  My lenses are like bandage lenses, keeping the surface of my eyes protected and comfortable because my tear film can’t.

Anyway, I fitted her with extended wear multifocals and sent her away for a few hours (I love that we are flexible enough to do extended trials).  This lady was going to the cinema near our store so she went to try them out on the new Spiderman film (which she highly recommended).

Now, the cinema is a difficult environment for our eyes.  It’s usually quite air conditioned and I’m sure we stare at the screen in the same way we stare at our computers.  So, after seeing Spiderman, my patient was pretty impressed with her lenses.  Her vision was good with them (in fact, she was seeing slightly better with the lenses than her old glasses as there had been a change in Rx) and they were comfortable.  She hadn’t noticed her eyes for the last couple of hours.

During the I&R, with the lenses out, she said, “My eyes feel so… exposed.  I can’t wait to put them back in.”

Of course, this was a very short time period to test out the lenses so I wanted her to take them away and try wearing them for a while longer.  Maybe 4 hours tomorrow, 6 hours the next day etc.  I wanted her to be wearing them in work by the end of the week, so see if they were still as comfy in her dry office environment while she worked on her PC.  She’s coming back for her aftercare in a few days so, finger crossed, she’ll love her EW lenses as much as I do.

As with all my other patients, I told her that, if she has any problems, don’t worry – there are other lenses we can try.  In this case, if she is getting lots of deposits on her lenses (common for CL wearers with dry eyes) then I would recommend rewetting drops and if all else fails, I would switch her to dailies.

I had another patient recently with MGD. He reported gritty, tired eyes but he had never tried anything to relieve his symptoms (not even over the counter eye drops).  I explained about the Meibomian glands and how they can become blocked over time and then I launched into my “warm compresses and lid massage” speech.  He sat nodding along gamely until I finished.  Then silence – but I could see he was a little confused.

“I’ve got a leaflet with all this written down on it because I know it’s a lot to remember,” I said, fishing in my leaflet drawer.  I handed it to him.

He still looked a bit puzzled.  Finally, he asked, “What’s a flannel?”

“Oh, sorry, it’s just another name for a face cloth.”

“Ok.” Long pause, “What exactly is a face cloth?”

“It’s one of those small square towels, about this size,” I used my hands to do the “about yay big” thing.

It was like a light was turned on. “IS THAT WHAT THOSE DAMN THINGS ARE FOR? My wife keeps buying the bloody things and I find them around the sink, soaking wet and I’m never sure what’s she’s been doing with them!”

Ah, it would be funny if I hadn’t had the same conversation with my own husband when we moved in together (“What are these tiny towels for and why are they always damp?”).

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