We talk about dry eye all the time to patients, but are we diagnosing
dry eye correctly?
I will share my protocol for treating evaporative dry eye associated
with meibomian gland dysfunction (MGD) or posterior blepharitis, which I have
refined over the course of 10 years.
Most optometrists treat dry eye with artificial tears, indicating that
they believe most dry eye is due to an aqueous deficiency. I have found that
about 80% of my patients with dry eye complaints have an evaporative component
(meibomianitis) and many have a combination of evaporative and aqueous
deficiency. However, if you treat the MGD first, the artificial tears work much
better because the patient will have a sufficient lipid layer to prevent
evaporation of the tears.
Determining type of dry eye
by Quantum Heat are applied
with the lids closed for at least 15 minutes.
Image: Lee J
Patients have a variety of subjective complaints when the eyes are dry.
Based on the symptoms, the doctor can easily predict which type of dry eye a
patient has before clinical testing is performed. The accompanying table shows
the common symptoms associated with each dry eye deficiency.
When a patient has MGD, the pores are moderately to severely blocked and
can also have an oil deficiency. Various factors such as dust, make-up, pollen,
blepharitis scales or wearing contact lenses can block these pores. No matter
what factor caused the pores to be blocked, opening them can greatly reduce the
dry eye symptoms.
Biochemical changes in the body due to hormonal changes, medications or
stress can cause an oil deficiency. The quality of oils secreted becomes
thicker and the quantity can be affected. Oil deficiency is addressed through
nutritional supplements. I recommend ProOmega capsules from Nordic Naturals.
How to assess MGD
When diagnosing MGD, first assess the lids and look at the lid margins
to note redness, inflammation or fatty acid build-up. The most important
component of the dry eye exam is the manual expression of the meibomian glands.
Place the thumb against the lid margin and press firmly against the
eyeball to determine the percentage of meibomian pores that are blocked. This
assessment is performed on both the upper and lower lid of each eye. Refer to
the accompanying table to grade the MGD. Normally, the meibomian secretions are
easily expressed and are thin and clear in consistency. Lipid secretions become
more milky and thicker as more pores are blocked.
First treatment phase: open meibomian pores
There are two phases of treatment: Open up the meibomian pores and
recommend daily use of nutritional supplements.
The key to my success of this dry eye treatment was finding a heat pad
that sustained its temperature for about 15 minutes. I use the heat pads made
by Quantum Heat. Warm compresses cannot work without massage therapy of the
lids to release the blocked contents. For patients to have minimum dry eye
complaints, the pores must be 65% open on both upper and lower lids. My goal is
to get the pores more than 80% open so patients can remain asymptomatic without
repeating this dry eye treatment. I have set this goal as a result of
fine-tunning my treatment plan for nearly 10 years.
Use two heat pads, one for each eye, with the lids closed for a minimum
of 15 minutes. The more heat the lid can take, the more the pores open up and
the more the blockages dissolve.
Remove the heat pads and immediately massage each eye (upper and lower
lid) for 5 minutes. Place the index finger against the edge of the lid margin.
Massage in a circular motion and begin on the nasal side and then move across
the lid to the temporal side. Repeat this again, but go from the temporal side
to the nasal side. The patient may experience temporary blurred vision due to
the blocked oils being released into the eye.
Clean the base of the lids and lashes with lid scrubs, preferably
pre-moistened pads. I use OcuSoft Lid Scrub Premoistened Pads. This prevents
all the debris and expressed contents from re-blocking the meibomian glands.
The patient should perform these steps before bedtime for up to 6 weeks.
Patient understanding and recognition that they have dry eye is vital to
the success of the dry eye program. Patients with grade 1 MGD are generally
asymptomatic and will not acknowledge that they have dry eye even if clinical
findings determine otherwise. However, those with grades 2 to 4 of MGD will
greatly benefit from the treatment.
Perform medical visits every 2 weeks to reassess the percentage of
blocked or open pores. Patients cannot tell if they are massaging correctly,
but the doctor can guide the patient during theses visits. If patients perform
this treatment daily and correctly, they will complete the regimen within 6
weeks by reaching more than 65% opening of the meibomian gland pores. For
maintenance, patients should continue with massaging the lids (without heat
pads) daily in the shower to keep the pores unblocked.
Second treatment phase: nutritional supplements
Research has shown that essential fatty acid supplements, omega-3 and
omega-6, aid in the treatment of dry eye. I recommend front-loading the first
month with omega-3 fatty acid supplements (one capsule = 1,000 mg), two
capsules twice daily for the first month, then one capsule twice daily
continually. This greatly enhances the quality and quantity of the lipid layer.
Before beginning treatment, make sure this supplement does not interfere with
Completion of the two-phase treatment will heal most patients’ dry
eye symptoms. If needed, patients may require more dry eye treatment. It is
amazing how patients can have dry eye problems most of their life, but this
simple drug-free treatment can cure this problem within a few weeks.
For more information:
- Jeanette Lee, OD, can be reached at 20/20 Optometry of Silicon
Valley, 2555 North First Street, San Jose, CA 95131; (408) 433-0800; fax: (408)
577-0849; e-mail: firstname.lastname@example.org. Dr. Lee has no
direct financial interest in the products mentioned in this article, nor is she
a paid consultant for any companies mentioned.
- Heat pads are available from Quantum Heat, (760) 429-3380; Web
- OcuSoft Lid Scrub Premoistened Pads are available from
Cynacon/OcuSoft, P.O. Box 429, Richmond, TX 77406-0429; (800) 233-5469; fax:
(281) 232-6015; Web site: www.ocusoft.com.
- ProOmega is available from Nordic Naturals, 94 Hangar Way,
Watsonville, CA 95076; (800) 662-2544, ext. 1; (831) 724-6200, ext. 1; fax:
(831) 724-5263; e-mail: email@example.com; Web