In this part of the dry eye series, the goal is to highlight some solutions to combat ocular surface inflammation and its causes. In Part 3 of this series was read, one would know that dry eye caused by inflammation is deeply rooted to what happens on the eyelids. So, much of this discussion will be centered on treating the eyelids, lashes, and meibomian glands. Improvement of the eyelid issues does not happen overnight because they are chronic in nature. Unfortunately, chronic issues take more time and effort to create physiological changes. But while the lid issues are being treated, prescription drops and targeted artificial tears can also be implemented to improve symptoms. And, if possible, finding ways to treat the issue without the long-term use of medications is the primary goal.
Bacterial related Blepharitis
Controlling the bacterial load on the eyelids is key here. There will always be bacteria, but on most occasions, staphylococcus bacteria needs to be targeted. First off, eyelid scrubs should be employed every day. Ocusoft Eyelid Scrubs Plus is a brand that works well because it contains an ingredient that helps target staph bacteria.
If scrubs are bothersome and irritate the lids, another good treatment is with 0.02% hypochlorous acid spray like that found in a HypoChlor. Spraying this solution on the eyelids targets staph bacteria without affecting other naturally occurring species that live on our eyelids. This eventually leads to a reduction in the bacteria that is causing the chronic dry eye symptoms. But remember, with any blepharitis, the meibomian glands are also affected, which means that they will require treatment. More on this later.
Demodex blepharitis is created by mites who inhabit the follicle roots of the eyelashes. It has recently been found that mites inhabit all of us, but their ability to thrive and proliferate depends on the type of skin we have. People with more oily skin tend to have more issues, as well as those that are in contact with mites on a more frequent basis. Mite infested clothing and bedding (pillows) are prime carriers of mites.
Let’s talk about treatment. First, get rid of old pillows or change your pillows more frequently. Second, consistent treatment of the eyelids with tea tree oil kills mites. Tea tree oil contains terpenes, which are substances that have antimicrobial potency. In our office, we perform an eyelash scrub with a solution that contains a high concentration of tea tree oil. It can be caustic to the eyeball, which is why this is best off done in the office. It takes being pretty aggressive to first remove the debris on the base of the eyelashes so that the tea tree oil can get to the follicle base. Once that is done, the patient is sent home with special lid scrubs that contain a lower concentration of tea tree oil. This type of scrub is done on a daily basis for what can be months of time. Sometimes it takes repeating the in-office treatment on several occasions to make progress. Regardless, it is nice that something can be done about mites that will lead to improvement of dry eye symptoms. And as with any blepharitis, meibomian glands are also affected and need to be treated accordingly.
Ocular rosacea can be difficult because so much inflammation is caused by the disorder. Many times Xiidra, a brand new dry eye medication, is prescribed to decrease ocular surface inflammation. Restasis, an older dry eye med, has some effect because it increases in tear production by reducing inflammation of the accessory lacrimal glands. This is different than Xiidra, which reduces inflammation early in the cycle.
One other new treatment of interest is Intense Pulse Light therapy or IPL. This therapy is usually done at medical spas by aesthetician’s or at dermatologist’s offices. IPL sends light pulses through the epidermis into the skin layers beneath it and destroys bacteria, mites, as well as leaky blood vessels created by rosacea. The benefit here is that by removing these problems, inflammatory materials are also stopped from moving into adjacent tissue, thereby reducing inflammation. IPL is usually used to treat the cheeks, nose, and forehead. If ocular rosacea is present, IPL can be done within 2 to 3 mm of the eyelids. The benefit here is that the inflammatory substances released by the leaky vessels will not permeate the eye, and therefore inflammation will be reduced.
There are rumblings that tea tree oil can also be used on the face, and will help with rosacea there too. Perhaps because there is a bacterial or Demodex issue associated with rosacea. Hopefully, we will see more on this in the future.
Meibomian Gland Dysfunction
When blepharitis occurs, inflammation also occurs in the meibomian glands. Because the oil they make is so important to the quality of the tears on the eye, treating is also important. On occasions where bacteria have infiltrated and live in the glands, the antibiotic Azasite, a prescription drop, is a good choice. Azasite is nice because it also helps treat bacteria on the lids. One other antibiotic, doxycycline, taken by mouth, also helps break up the clogging that can occur with chronic inflammation.
Heat works well to restore proper functioning of the glands. A Bruder masks, for example, is heated and placed over the eyes for 8 to 10 minutes each night. This helps reduce inflammation and clogging. Meibomian gland expression can help as well. In-office procedures such as manual expression and Lipiflow help move waxy gland buildup out so that newly formed oil can work its way out easier. Lipiflow is a pretty expensive procedure, but patients say it helps.
One other procedure that works is an eyelid exfoliation. The gland orifices sit behind the eyelashes, and this area can become covered in bio-film which blocks the oil from escaping. Also, if eyeliner is applied too far back, it can also clog the orifices. For eyelid exfoliation, we have a small rotating brush that we use with a special soap that cleans off this area to increase oil outflow.
Nutraceuticals are very helpful for rehabbing the meibomian glands. Omega 3’s, EPA and DHA, that are in a triglyceride form of fish oil are a staple. They help reduce inflammation in the gland, and also help break up clogging.
In the next part of the dry eye series, current treatments for dry eye symptoms will be discussed. This will include more extensive discussion about pharmaceuticals, nutraceuticals, and some nutritional ideas.
Until then, I hope you can use some of these treatments to bring you some relief! It may take some time, but keep working at it!
Mike Morabito, O.D.