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  • What you need to know about computer-induced dry eye

    Author's note: I am not a doctor. Do not substitute any of the following for a doctor's advice.

    Abstract
    My Story
    Lessons Learned
    The Tear System
    The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
    Looking For a Doctor
    At the Doctor’s Office
    Treatments, Part 1
    Treatments, Part 2
    Treatments, Part 3
    Get Away From Your Screens
    Final Thoughts

    0. Abstract

    What this post is: This post is my “memory dump” on dry eye caused by computer use. It contains virtually everything I’ve learned about the condition since I first got dry eye, including:
    • Lessons I’ve learned
    • Advice on how to find a good doctor
    • Treatment options available for the two main types of dry eye
    • Ideas for how to minimize computer use
    Who should read this post: This post is aimed at people who’ve recently gotten dry eye from chronic computer overuse, although a lot of information also applies to other causes of dry eye (e.g., Sjogren’s, LASIK surgery). If you’re unsure of what caused your dry eye, the following are some characteristics of people who have computer-induced dry eye. You might have computer-induced dry eye if:
    • You’ve used electronic screens (e.g., computers, phones, or TVs) for 12 hours or more per day on a regular basis over the last few years
    • You have no known allergies that might cause dry eye, or have eliminated allergies as your cause for dry eye
    • You are in your 30s or earlier (though older generations can certainly get computer-induced dry eye as well)
    Keep in mind however, that even if your dry eye wasn’t caused by computers, you might have a lot of the same symptoms and be responsive to the same treatments as those who have computer-induced dry eye.

    What’s in this post: The following is an outline of the content in this thread. There are 10 total sections (including this one) and each section corresponds to a new post in this thread. At the top of each new post (and thus the beginning of each section) is an outline of the 10 sections so that you can easily navigate to a new section. I’ve also attached the entire content of the thread as both a Word and PDF document in this first post, if you prefer to download it.
    1. Abstract
    2. My Story
    3. Lessons Learned
      1. Lesson #1: Dry eye is a progressive disease
      2. Lesson #2: Generally, knowledge about dry eye is poor among doctors, but is steadily improving
      3. Lesson #3: You can’t get better unless you remove the source of your problem
      4. Lesson #4: No matter how much you’ve think you’ve “tried everything,” you haven’t tried everything
      5. Lesson #5: Even with great management, you can get new and/or worse symptoms at any point
      6. Lesson #6: Dry eye is a three-headed monster
    4. The Tear System
      1. The Lacrimal Glands
      2. The Meibomian Glands
      3. Corneal Nerves
    5. The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
      1. Meibomian Gland Dysfunction
      2. Aqueous Deficiency
    6. Looking For a Doctor
      1. Optometrists vs. Ophthalmologists
      2. Your Best Chance
    7. At the Doctor’s Office
      1. Before the Visit
        1. bringing a list of prescriptions and eye drops
        2. a list of questions to ask the doctor
      2. Patient Questionnaires
      3. Tests
        1. Tests for General Eye Health
          1. Vision Test
          2. Eye Pressure
        2. Tests for Aqueous Deficiency
          1. Schirmer Test
          2. Ocular Staining
          3. Tear Meniscus Height
          4. Confocal Microscopy
        3. Tests for Meibomian Gland Dysfunction
          1. Meibography
          2. Meibomian Gland Production Count
          3. Blink Analysis
        4. Tests for Both Aqueous Deficiency and Meibomian Gland Dysfunction
          1. Tear Osmolarity
          2. Tear Break-Up Time
      4. A Diagnostic Checklist
      5. Evaluating Your Doctor As He Evaluates You
    8. Treatments
      1. Treatments for Aqueous Deficiency
        1. Artificial Tears
        2. Prescription Drops (Restasis, Xiidra)
        3. Steroid Drops
        4. Moisture Chamber Goggles
        5. Punctal Plugs
        6. True Tear
        7. Lacrisert
        8. Serum Tears
        9. Scleral Lens
        10. Amniotic Membrane (Prokera)
      2. Treatments for Meiibomian Gland Dysfunction
        1. Blinking Exercises
        2. Warm Compress
        3. Doxycycline
        4. Lid Scrubs
        5. Manual Expression
        6. Lipiflow
        7. IPL
        8. Probing
      3. Treatments for Both Aqueous Deficiency and Meibomian Gland Dysfunction
        1. Diet
        2. Omega-3 Supplements
      4. Treatments for Pain Management
        1. Nortriptylline
        2. Naltrexone
        3. Carbamazepine
    9. Get Away From Your Screens
      1. Exercise
      2. Audio Entertainment
      3. Find a Different Job
    10. Final Thoughts
      1. TLDR
      2. Keeping Hope
    Attached Files
    Last edited by pythonidler; 10-Mar-2018, 23:49.
    What you need to know about computer-induced dry eye
    Dry Eye Survey
    IPL Doctors
    Probing Doctors
    PRP Injections Warning

  • #2
    Abstract
    My Story
    Lessons Learned
    The Tear System
    The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
    Looking For a Doctor
    At the Doctor’s Office
    Treatments, Part 1
    Treatments, Part 2
    Treatments, Part 3
    Get Away From Your Screens
    Final Thoughts

    1. My Story

    Back in September 2012, I was living in the dry, high-altitude environment of Colorado Springs, CO. At the time I was 25 and working at home for an out-of-state engineering company. Since graduating from grad school in 2011, I’d spent a lot of time alternating between looking for jobs online and playing video games. Even though I was also very active outside between hiking, playing ultimate Frisbee, and running, I still spent an average of about 10-12 hours a day on the computer.

    One day while I was sitting at my computer, I began experiencing sharp, intermittent bursts of pain in my right eye that would only last for a couple seconds, but would recur several times throughout the day. One week later, I woke up with a general feeling of dryness in my eye. I discovered quickly that the dryness would go away if I spent an hour or so outside away from the computer. I saw a few optometrists over the next few months, but none of them could help me other than offer artificial tears. It didn’t worry me too much since my dry eye was still pretty mild, and I could make it go away by wearing my contact lenses.

    Then in November I moved to Arizona and starting working for a solar company. My job involved a lot of computer use, though sometimes I got to visit our solar projects in person. Though these projects were often located in dry, isolated patches of desert, I often felt better doing outside work than being inside the air-conditioned office staring at a computer screen.

    Over the course of the two years I worked at the company, my dry eye went from being very mild to being very severe. Within about six months, I couldn’t wear contact lenses anymore. Eventually, I quit my job in October 2014 because my eyes were so gritty and uncomfortable from all the computer use. I haven’t worked at an office job since.

    My story does get better, though. Towards the end of 2014, I started seeking several second opinions from doctors. I stayed in Arizona for one more year to see a doctor at the Mayo Clinic. Just before I moved out of Arizona and back in with my parents in Washington, the Mayo Clinic doctor referred me to a corneal and dry eye specialist in Boston.

    I started seeing the Boston doctor in December 2015. He prescribed serum tears 8x/day, omega-3 2000 mg/day, Lotemax (a steroid drop) 2x/week, and nortriptyline 75 mg/day, among other things. He also advised me to start exercising again (I had stopped after a knee injury in late 2014). From that point forward until mid-July 2017, I greatly improved. I established a routine that I could follow and experienced minimal discomfort.

    However, in 2017 I started using the computer too much as I felt more comfortable. In mid-July, I spent too much time playing video games over the course of a few weeks, and I got actual pain for the first time. I’ve had a constant amount of low pain since then, but perhaps the more severe consequence is that my tolerance for computers and other electronic screens is very low; I can’t spend more than a few minutes on them at a time without my eye pain getting worse. Nevertheless, I know that things will get better for me. I’ll continue to fight this condition until my dying breath.
    Last edited by pythonidler; 10-Mar-2018, 23:43.
    What you need to know about computer-induced dry eye
    Dry Eye Survey
    IPL Doctors
    Probing Doctors
    PRP Injections Warning

    Comment


    • #3
      Abstract
      My Story
      Lessons Learned
      The Tear System
      The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
      Looking For a Doctor
      At the Doctor’s Office
      Treatments, Part 1
      Treatments, Part 2
      Treatments, Part 3
      Get Away From Your Screens
      Final Thoughts

      2. Lessons Learned

      I’ve learned a number of lessons about dry eye over my 5+ years with the disease. Here are some of the lessons I’d like to share with you:

      Lesson #1: There is no cure for dry eye
      Dry eye is very different from other diseases. If you have pneumonia from a bacterial infection, for example, you could take antibiotics for a few weeks to kill the bacteria causing the infection. When the bacteria is gone, you would function normally again and be considered “cured” of your pneumonia.

      With dry eye, there’s no single thing (or even combination of things) that you can do to get rid of dry eye forever. Whatever you do to make your symptoms better, you’ll have to keep doing that thing regularly until some better treatment comes along. Then you’ll do that new treatment regularly. Thus, we don’t talk about “curing” dry eye, but of “managing” it. The better your routine is, the better you are managing your dry eye.

      For most people on this board, they do many things as part of their routine. And medication just might be one part of your routine; other aspects might involve lifestyle changes (such as going on a diet or exercising) or adapting to your environment (such as wearing moisture chamber goggles or using a humidifier). Only you can find out what works for you.

      Lesson #2: Dry eye is a progressive disease
      If left untreated or undertreated, dry eye will get worse. Not only will it get worse, it will get irreversibly worse to the point that you can’t get back to normal again. Unfortunately, you probably won’t know if you’re at that point until it’s already too late. Therefore, it’s imperative that you attack dry eye as aggressively and quickly as possible to keep it from getting any worse.

      Lesson #3:Generally, knowledge about dry eye is poor among doctors, but is steadily improving
      The first ophthalmologist I saw just diagnosed me with “chronic dry eye,” which as you’ll see later isn’t really a specific diagnosis. If you don’t have a specific diagnosis, your doctor is throwing darts at a dartboard while blindfolded – some treatments might work, but most will probably be ineffective. And the second ophthalmologist I saw, while he gave me a specific diagnosis of meibomian gland dysfunction, he COMPLETELY missed my aqueous deficiency.

      When you combine the fact that dry eye is progressive with the fact that many doctors are largely ignorant about dry eye, it becomes SUPER IMPORTANT that you find a great doctor as soon as possible. In a later section of this thread, I’ll discuss how to increase your chances of finding a better doctor and then how to evaluate that doctor at your initial visit.

      Lesson #4: You can't get better unless you remove the source of your problem
      In the case of dry eye caused by chronic computer use, the sources of your problem are electronic screens. While you may feel better after developing a good routine (usually consisting of one or more medications as well as habitual life changes), it is easy to regress to an earlier, worse state if you continue to use electronic screens as much as you were before you got dry eye.

      The reality of your situation is that you can’t truly improve until you significantly reduce your screen time. If you continue to use computers, smartphones, and tablets at a high rate, you will risk worsening your symptoms, or getting new symptoms altogether. Case in point: I started getting pain in my eyes in mid-July 2017 after spending too much time on the computer over the previous weeks. I ignorantly believed that my symptoms wouldn’t change or worsen as long as I kept up my routine. I was wrong.

      Lesson #5: No matter how much you think you've "tried everything," you haven't tried everything
      It’s easy to believe that whatever expensive treatment you’re trying next is your last possible chance to get better and that there’s nothing else left to try. I felt this way before my first Lipiflow treatment and at various other times in my 5+ years with the disease. And just when I’m about to resign myself to a lifetime of feeling bad, I learn about treatments that I haven’t tried yet.

      I believe no doctor has all of the answers for you. By doing your own online research as well as seeking out second opinions, you can find out about new treatments that might work for you. I’ll share some of the treatments that I know about (many of which I have tried myself) later in this post, but keep in mind this is just a sample of what’s out there.

      Lesson #6: Dry eye is a three-headed monster
      Ever since I had to quit my office job because of dry eye, I’ve thought about how dry eye disease is a “three-headed” monster. It affects you in three negative ways:
      1. Decrease in quality of life
      2. Increase in medical bills
      3. Decrease in future earnings potential

      Dry eye decreases your quality of life because of the chronic discomfort and/or pain in your eyes. It increases your medical bills because you need multiple, regular treatments to decrease your level of pain. Finally dry eye decrease your future income, since you probably won’t be able to work in a high-paying office job as you climb the corporate ladder; most likely you will need a lower-paying hourly job that keeps you away from the computer.

      For these reasons, I STRONGLY recommend that people who have computer-induced dry eye consider other careers that don’t involve as much computer use. If you switch careers early, you may have lower future income, but at least you can minimize the effects of #1 and #2.

      Again, consider my example: right now I’m paying over $5,000/year for dry-eye related medical bills. If I had quit my job within the first year of my symptoms (before they got significantly worse), chances are my current expenses would be closer to $1,000/year. This difference of $4,000/year means that over a 25-year period, I’m paying $100,000 more in medical bills than if I had quit earlier. Given that I was probably was going to have to quit at some point anyway, I should’ve made this decision much earlier. Of course, hindsight is 20/20, but now that you know you’ll need to quit someday, you can use this information as valuable foresight and save your eyes TODAY and prevent your future medical bills from escalating too much.
      Last edited by pythonidler; 10-Mar-2018, 23:45.
      What you need to know about computer-induced dry eye
      Dry Eye Survey
      IPL Doctors
      Probing Doctors
      PRP Injections Warning

      Comment


      • #4
        Abstract
        My Story
        Lessons Learned
        The Tear System
        The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
        Looking For a Doctor
        At the Doctor’s Office
        Treatments, Part 1
        Treatments, Part 2
        Treatments, Part 3
        Get Away From Your Screens
        Final Thoughts

        3. The Tear System

        In order to understand what dry eye is, you first need to know about the various systems that keep your eyes lubricated with tears. The three systems are the lacrimal glands, Meibomian glands, and corneal nerves.

        The Lacrimal Glands
        The lacrimal glands produce two kinds of tears: basal and reflex. Basal tears are tears that are regularly produced by your glands, whereas reflex tears are generated in response to eye irritation, cold outside temperature, or strong emotions. They are different from each other in terms of their molecular content.

        Basal tears are produced by the small “accessory” glands below the eyebrow and above the eyelid, as seen below. Reflex tears are produced by the larger “main” lacrimal gland.
        Click image for larger version  Name:	lacrimalsystem.gif Views:	1 Size:	18.4 KB ID:	210259



        The Meibomian Glands
        Your Meibomian glands are long, tube-like glands located in each of your four lids. There are about 20-30 of these oil glands in each lid. A representation of these glands is shown in the picture below.

        Click image for larger version  Name:	MG.png Views:	1 Size:	120.1 KB ID:	210260

        https://www.centreforsight.com/treat...-eye/lipi-flow

        When you blink, your meibomian glands squeeze (“express” is often used by eye doctors) oil out onto the surface of your tear film. The oil helps the tear film from evaporating quickly.

        Corneal Nerves
        The last part of your tear system is the system which regulates how many tears are produced. In your cornea (outermost surface of your eye), you have a large amount of nerves. The nerves send signals to your brain about how many tears are on the surface of your eye. Your brain then determines if more or fewer tears are needed based on this feedback. If you didn’t have corneal nerves (and many patients with failed LASIK operations have very few functional nerves), your tear production would decrease dramatically.
        Last edited by pythonidler; 10-Mar-2018, 23:53.
        What you need to know about computer-induced dry eye
        Dry Eye Survey
        IPL Doctors
        Probing Doctors
        PRP Injections Warning

        Comment


        • #5
          Abstract
          My Story
          Lessons Learned
          The Tear System
          The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
          Looking For a Doctor
          At the Doctor’s Office
          Treatments, Part 1
          Treatments, Part 2
          Treatments, Part 3
          Get Away From Your Screens
          Final Thoughts

          4. The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)

          There are two main types of dry eye caused by computer overuse. In each case, a little bit of dryness may cause inflammation, which in turn may lead to destruction of tear systems, which may cause more inflammation. It is a cycle of dryness and inflammation which tends to feed upon itself.

          The difficulty is in breaking this cycle and reducing inflammation. Oftentimes, tear/oil production will increase just by controlling the inflammation. And sometimes, lubricating the eyes more (usually with serum tears) will reduce inflammation, which in turn will increase tears.

          One thing to note about each type of dry eye: while you may only have one or the other, it is certainly possible to have both (as I do).

          Meibomian Gland Dysfunction
          As you sit at your computer or phone reading this post, your eyes are not blinking very much. Generally, you blink much less often while at an electronic screen than when you’re not at one. In fact, any activity that forces your eyes to focus on a task lowers your blinking rate (this includes reading and driving). If you don’t blink, then oil will not come out of your meibomian glands. Eventually, the oil in these glands may change from being clear, flowing oil to being thick, toothpaste-like oil. When you’re not getting either the quality or quantity of oil out of these glands that you should, then you have meibomian gland dysfunction, or MGD.

          As you progress with MGD, fewer and fewer glands will produce free-flowing oil. You may eventually develop scar tissue that will completely block oil coming out of the glands. Chronic MGD may also cause many of these glands to completely die off (atrophy) or disappear altogether (dropout); thus, it is important to get a diagnosis of MGD early and manage it aggressively before this happens.

          Aqueous Deficiency
          Aqueous deficiency, or aqueous tear deficiency, occurs when your lacrimal glands don’t produce enough watery tears. For people who use electronic screens, one may “get” meibomian gland dysfunction first and then aqueous deficiency later. Why is this? It may be that MGD initially causes inflammation in the eye, which consequently irritates and deteriorates the nerves. This deterioration leads to aqueous deficiency, since the nerves aren’t communicating with the brain very well.

          One consequence of severe aqueous deficiency is further deterioration of corneal nerves. Your natural tears contain nerve growth factors that help maintain the condition of your corneal nerves. If you’re producing few tears, then your nerves aren’t getting the amount of growth factor that they need every day. The result is that they deteriorate in a condition known as “corneal neuropathy.” With corneal neuropathy, deteriorated nerves send false signals to the brain which are interpreted as a foreign body sensation (grittiness).

          Since patients with corneal neuropathy have fewer working nerves, the brain isn’t getting sufficient information about how many tears are on the surface already. This results in fewer tears being produced and leads to more inflammation.
          Last edited by pythonidler; 10-Mar-2018, 23:46.
          What you need to know about computer-induced dry eye
          Dry Eye Survey
          IPL Doctors
          Probing Doctors
          PRP Injections Warning

          Comment


          • #6
            Abstract
            My Story
            Lessons Learned
            The Tear System
            The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
            Looking For a Doctor
            At the Doctor’s Office
            Treatments, Part 1
            Treatments, Part 2
            Treatments, Part 3
            Get Away From Your Screens
            Final Thoughts

            5. Looking For a Doctor

            As discussed in the “My Lessons Learned” section, because dry eye is a progressive disease that will become irreversibly worse with time, it’s critical that you find an excellent doctor as soon as possible. I believe that finding such a doctor is a two-step process: first you need to make appointments with several (at least 4-5) doctors; then, go to these appointments and evaluate each doctor based on a number of criteria. This section explains how to make those initial appointments, while the following section will explain how to evaluate the doctor while at the office.

            Optometrists vs. Ophthalmologists
            Before making any appointments, you should first realize the difference between an optometrist and an ophthalmologist. Generally speaking, an optometrist deals with your vision (e.g., prescribing contact lenses and glasses) and doesn’t deal with medical issues often. Conversely, an ophthalmologist probably has better knowledge about a few specific eye diseases and conditions. Because of this, I think you’re more likely to find a good dry eye doctor who is an ophthalmologist instead of an optometrist. That being said, you can still see ophthalmologists who know very little about dry eye.

            Your Best Chance
            So where can you go that gives you the best chance of finding a great doctor? In my experience, the best doctors are not located in your average run-of-the-mill eye clinic, but in research institutions such as the Mayo Clinic or a university medical center. The reason is because standalone eye clinics mainly exist to make money, whereas clinics located in research institutions are mostly there to do research. Because of this difference, doctors in research hospitals will generally be more knowledgeable, have better diagnostic tools, and most importantly will probably have more treatment options at their disposal. It is also more likely that a doctor at a research institution will refer you to another doctor that they know is more knowledgeable about dry eye. This will usually not be the case at a for-profit eye clinic, since they don’t want you to take your business elsewhere.

            When you call to make an appointment – regardless of where that may be – don’t hesitate to ask the scheduler who would be a good dry eye doctor to see. As long as they’re not completely new, they should have a good idea of which doctor has a lot of dry eye patients. If the scheduler isn’t sure, make an appointment with the doctor who is available the soonest. When you see that doctor (especially if they do not specialize in dry eye), you can ask for a referral to a specialist who is more qualified to treat you.
            Last edited by pythonidler; 10-Mar-2018, 23:46.
            What you need to know about computer-induced dry eye
            Dry Eye Survey
            IPL Doctors
            Probing Doctors
            PRP Injections Warning

            Comment


            • #7
              Abstract
              My Story
              Lessons Learned
              The Tear System
              The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
              Looking For a Doctor
              At the Doctor’s Office
              Treatments, Part 1
              Treatments, Part 2
              Treatments, Part 3
              Get Away From Your Screens
              Final Thoughts

              6. At the Doctor's Office

              Once you’ve scheduled enough appointments (and you won’t know if you’ve scheduled “enough” until you’ve found a doctor that you like), it’s time to take your visits. Selecting a doctor is kind of like dating – you’ll have to meet a bunch of candidates to know which one is best for you. And like dating, you’re not obligated to “marry” the first one you meet. Or the second, or the third, and so on.

              Before the Visit
              Before your appointment, you should do a couple things to make sure your appointment goes better:
              • Bring a list of prescriptions and eye drops you currently use. This will really help the doctor understand what might be working for you, and what other things you still need to try.
              • Write down a list of questions to ask the doctor. You’ll no doubt have questions to ask the doctor before you come in, so write them down before you forget any of them. You can also add to this list while you’re at the office, if any questions arise there.
              Patient Questionnaires
              One way that doctors measure and track the severity of a patient’s symptoms is by having the patient fill out patient questionnaires. These questionnaires may consist of many questions, including:
              • What are your current symptoms? Are you having pain, sensitivity to light, grittiness, burning sensation, excessive tearing, etc.?
              • Rate your pain on a scale from 0-10 over the last 24 hours. Rate your pain over the last 2 weeks.
              • How much worse are your symptoms in an air-conditioned building? How much worse are they during very windy days?
              • How much has your dry eye interfered with your ability to use a computer? How much has it interfered with your ability to read? How much has it interfered with your day-to-day activities?
              • (For follow-up visits) How much have your symptoms improved since the last visit?
              Tests
              At both your initial visit and follow-up visits, your doctor will (or at least SHOULD) perform a battery of tests on you. Don’t expect a single doctor to do all of these tests on you – but a good doctor should do a lot of them.

              Personally, the more tests a doctor does on me, the more confident I feel in his diagnosis. And if a doctor doesn’t take at least ONE image of your eye (e.g., meibography or confocal microscopy), then that doctor probably isn’t worth keeping.

              Tests for General Eye Health
              Two tests your doctor will do for general eye health are a vision test and eye pressure test.

              Vision Test
              One of the first things the doctor (or his assistant) will do is to check your visual acuity (i.e., can you see 20/20). Thus, you should bring any vision-correcting glasses or contact lenses to this appointment.

              Eye Pressure
              Taking steroid drops too frequently increases your intraocular (inner eye) pressure. Chronically high eye pressure increases your risk of glaucoma, a condition which causes blurry vision and may eventually lead to loss of vision. If you take any steroid drops at all (and even if you don’t), it’s a good idea to get this checked. You can take steps to lowering your eye pressure (including diet and exercise), but it’s best to do this before glaucoma sets in.

              Tests for Aqueous Deficiency
              There are a few tests for aqueous tear deficiency, but the gold standard is the Schirmer test since it is a direct measure of how many tears you are producing.

              Schirmer Test
              There are two versions of the Schirmer test, but both are very similar to each other. In a Schirmer test, a small strip of filter paper is placed on top of the lower eyelid and the patient is asked to close his eyes. While the eyes are closed, tears produced will either drain through the lacrimal ducts or be absorbed through the filter paper. After 5 minutes, the patient opens his eyes and the doctor measures the length of paper (in millimeters) that is soaked by the tears. Generally speaking, anything above 15 mm is considered normal, whereas anything below 15 mm is considered aqueous deficient.

              Click image for larger version  Name:	Schirmer.jpg Views:	2 Size:	52.1 KB ID:	210261


              In a Schirmer I test, anesthetic drops are put in the eyes before the test in order to prevent reflex tears from being generated (due to irritation from the filter paper). Thus, a Schirmer I test measures basal tear secretion only.

              In a Schirmer II test, anesthetic is NOT used. Therefore, reflex tears are produced and a Schirmer II measures basal tear production PLUS reflex tear production. One can expect your values from a Schirmer II test to be higher than your values from a Schirmer I test.

              Corneal Staining
              To gauge general eye health, a doctor will put lissamine green drops into the eyes and examine them through a slit lamp (a microscope an eye doctor uses to look at your eyes up close). Areas of the eye that are damaged will appear different than the normal, healthy parts of the eye. Although many things may cause cells to be damaged (e.g., poor-fitting contact lenses), in the case of aqueous deficiency the cause is not enough tears getting to a certain area of the eye

              Tear Meniscus Height
              The tear meniscus of your eye are tears that collect in a small pool above your lower eyelid (seen as green in the photo below). A normal person has a tear meniscus height of about 0.45 mm, whereas someone who is aqueous deficient (and thus producing fewer tears) has a tear meniscus height of about 0.25 mm or lower.

              Click image for larger version  Name:	Tear Meniscus.jpg Views:	1 Size:	79.1 KB ID:	210262


              Your doctor will probably not measure your tear meniscus height exactly (as it is difficult to do this when observing the eye through a slit lamp), but they can get a rough estimate. You can get a rough estimate of your tear meniscus height as well by doing the following:
              • First, find someone who you know does not have dry eye and has about the same size eyes that you do
              • Stand with this person in front of a bathroom mirror, or other mirror that is large enough for both of you to see each other in
              • Put your faces about 2 inches from the mirror
              • Compare your tear meniscus to that of the person standing next to you. If your tear meniscus is about the same, you probably are not aqueous deficient. If your tear meniscus is significantly different from the other person or is otherwise non-existent, you are probably aqueous deficient.
              Confocal Microscopy
              A confocal microscope, or HRT (Heidelberg Retina Tomograph), is a device used to take high-resolution images of the corneal nerves. It is a somewhat rare device that you probably won’t find at your average doctor’s office. Below is an example of an image taken with a confocal microscope.

              Click image for larger version  Name:	HRT.png Views:	2 Size:	756.9 KB ID:	210263


              With HRT, a doctor can determine the quality and quantity of nerves in your eye. Since nerves are critical for tear production, nerves that have been damaged aren’t helping to produce tears. Only when those nerves have been repaired can tear production increase. A patient who has many damaged nerves is diagnosed with corneal neuropathy, and may have eyes that feel gritty when blinking.

              Tests for Meibomian Gland Dysfunction
              The following are common tests performed to diagnose MGD. The gold standard here is meibography, which provides a detailed view of the meibomian glands.

              Meibography
              Meibography are images of the meibomian glands taken using an infrared camera. These images can be taken with a LipiView or LipiScan device, or other comparable IR imager. Your doctor will flip each of your four lids in order to take the pictures. An example image is shown below – the meibomian glands are the tube-like structures in the lid.

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              As the saying goes, “a picture is worth a thousand words,” and this is certainly true for meibography. A meibography image can reveal many things about your glands, including:
              • How many glands there are in the lid
              • How much gland dropout (disappearance) there is
              • If there is any scar tissue blocking your glands (very important to know before doing IPL or Lipiflow)
              Any doctor worth his salt should be able to answer all of the above questions with a meibography image.

              Using the images, the doctor will “grade” your meibomian glands on a scale from 0 to 4, where 0 means your glands are completely normal and 4 means virtually all of your glands have died. The below picture shows MGD progressing from “mild” to “severe.” Any area which appears empty of glands (where there would normally be a gland) is a gland that has atrophied and died.

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              Meibomian Gland Production Count
              In addition to meibography, one other way of measuring meibomian gland health is to count the number of glands that are producing oil. The doctor does this by pressing against your lids with either a special tool (looks like a USB flash drive) or their own fingers. By pressing against different parts of the lid, they can get an idea of the total number of oil-producing lids.

              Blink Analysis
              If the doctor has a LipiScan or Lipiview machine, he can also determine how often you blink as well as how well you blink. Partial blinking (when the upper lid doesn’t completely meet the lower lid) is a potential red flag for MGD.

              Tests for Both Aqueous Deficiency and Meibomian Gland Dysfunction
              Some tests may not look for aqueous deficiency or MGD specifically, but they may signal a dry eye problem nonetheless. Here are some examples of those tests.

              Tear Osmolarity
              A person without dry eye has a normal “osmolarity” (saltiness) to their tears. As dry eye worsens and the quality of your tear film decreases, your tears get higher and higher osmolarity. This high osmolarity causes cell death at the surface of your eye.

              When a doctor does a tear osmolarity test, he will take a small sample of your tears and run it through a machine to calculate its osmolarity. The following is an approximate severity scale for dry eye based on the osmolarity of the tear film:
              • Less than 300 - Normal
              • Between 300 and 320 - Mild
              • Between 320 and 340 - Moderate
              • Greater than 340 – Severe
              Aqueous deficiency almost certainly causes tear osmolarity to increase. However, it is not known whether meibomian gland dysfunction increases tear osmolarity – some studies have not shown a clear link between MGD and tear osmolarity. Thus, a high tear osmolarity may only indicate aqueous deficiency as opposed to meibomian gland dysfunction.

              Tear Break-Up Time
              A tear break-up time (TBUT) test measures how long it takes for your tear film to develop a dry spot after blinking. A doctor puts a fluorescein drop in your eyes, tells you to blink, and then counts the number of seconds until a dry spot appears on your eye. Anything less than 10 seconds is considered to be abnormal and indicative of dry eye.

              Since your break-up time depends on both the thickness of the oil layer as well as the thickness of the aqueous layer, a TBUT test will not tell you if you have specifically aqueous deficiency or meibomian gland dysfunction; instead, think of it as a test to measure how “bad” your dry eye is.

              A Diagnostic Checklist
              The following is a checklist of all the tests that were mentioned above. I encourage you to print out this checklist (or make one of your own), and mark off the tests that are done while they are performed on you. The tests that have asterisks (*) next to their name I consider to be essential tests. If your doctor skips one of those, that’s a red flag for me.
              Test Done?
              Vision Test*
              Eye Pressure Test*
              Schirmer Test*
              Ocular Staining*
              Tear Meniscus Height
              Confocal Microscopy
              Meibography*
              Meibomian Gland Production Count
              Tear Osmolarity
              Blink Analysis
              Tear Break-Up Time*

              Evaluating Your Doctor As He Evaluates You
              While you’re primarily at the doctor’s office to seek an evaluation and second (or third or fourth) opinion, you should also be judging the doctor as “the one” to treat you regularly. In addition using the diagnostic checklist printed above, you should also consider the following:
              • General temperament – is he easy to be around, or does he seem aloof and unconcerned?
              • Patience – does the doctor seem to be in a hurry? Is he willing to answer any and all of the questions you prepared to ask as well as any others that might arise?
              • Knowledge – does the doctor seem to be very knowledgeable about dry eye? It’s a bad sign if you know more than the doctor just by reading this post.
              • Follow-up appointments – is it easy to make follow-up appointments, or does he take so many patients that follow-up appointments are hard to schedule?
              • Location – Is the doctor nearby, or do you have to fly across the country to see him? Note that I think this is probably least important when considering a doctor. IMO, it’s worth it to travel far for a great doctor.
              Last edited by pythonidler; 10-Mar-2018, 23:55.
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              • #8
                Abstract
                My Story
                Lessons Learned
                The Tear System
                The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
                Looking For a Doctor
                At the Doctor’s Office
                Treatments, Part 1
                Treatments, Part 2
                Treatments, Part 3
                Get Away From Your Screens
                Final Thoughts

                7. Treatments, Part 1

                The following is a list of available treatments that address both aqueous deficiency and meibomian gland dysfunction. It is NOT a comprehensive list, and I don’t claim to know everything about all treatments available. That being said, I’ve tried most of the treatments on this list. Treatments are listed generally from least aggressive to most aggressive.

                Treatments for Aqueous Deficiency
                The following treatments are for aqueous deficiency only. One may try any combination of treatments listed below.

                Artificial Tears
                Artificial tears, also known as over-the-counter eye drops, will help lubricate your eye if you aren’t producing enough tears. However, there is a delicate balance between using too few drops and using too many drops; oftentimes, using too many drops will irritate your eyes and make you feel worse than if you hadn’t used any drops at all.

                Which drops you use depend on the kind of dry eye that you have. Most eye drops on the market are geared toward those who are aqueous deficient. There are many brands and types of these eye drops – from those with preservatives to those in preservative-free vials (see image below). Only you can discover which artificial tear works best for you.

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                If you have meibomian gland dysfunction (and not aqueous deficiency), your problem isn’t lubrication but evaporation. For those with MGD, there are three competing eye drops which contain oils to prevent evaporation: Retaine MGD, Refresh Optive MEGA-3, and Soothe XP. The first two brands come in preservative-free vials that are single-use (though you can try to re-cap the opened vials and re-use them later), whereas Soothe XP is preserved in a single bottle.

                Prescription Eye Drops (Restasis, Xiidra)
                Prescription eye drops such as Restasis (cyclosporine 0.05%) and Xiidra (lifitegrast 5%) are designed not to lubricate your eye, but to reduce inflammation associated with dry eye.

                Unfortunately as is the case with a lot of dry eye treatments, Restasis and Xiidra are not cure-alls, especially if your dry eye tends to be more severe; you will need to supplement them with other medications or treatments. That being said, you will probably notice at least a small improvement in your symptoms while using them. As a bonus, Restasis may also increase your tear production by a few points on the Schirmer scale (e.g., going from a Schirmer score of 3 to a Schirmer score of 4).

                Like some over-the-counter, preservative-free artificial tears, both Restasis and Xiidra come in single-use vials. The instructions tell you to tear open the vial, put one drop in each eye, and then discard the vial. However, there are enough drops in the vials for Restasis and Xiidra (especially Restasis) to re-use these vials until they are empty. You only need to either re-cap the vial (only Restasis can be re-capped) or set the opened vials up against your bathroom mirror or other vertical surface to prevent the contents from spilling out.

                Steroid Drops
                Steroid drops such as Lotemax (loteprednol etabonate 0.5%) are another means to reduce inflammation, but they can’t be taken every day. As mentioned in an earlier section, frequent use of steroid drops can increase inner eye pressure, which increases the risk of glaucoma. Such steroid drops should probably not be taken more than twice per week on a regular basis; more frequent use may be allowed on certain occasions (such as after a major procedure which may cause a spike in inflammation).

                Moisture Chamber Goggles
                To better manage dry eye pain, you might want to consider moisture chamber goggles. These are usually sunglasses modified with foam lining (see image below) to create a small pocket of air around each of your eyes. Humidity increases in the air pocket, thus slowing the evaporation of your tear film and making you more comfortable.

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                Popular brands of moisture chamber goggles include 7eye and Wiley X. Both 7eye and Wiley X can be found at your local optometrist (visit their websites to find which optometrists carry them), while only Wiley X is carried at Harley Davidson stores. You can order them from any number of sources, including:Punctal Plugs
                Tears that are produced by your lacrimal glands do one of two things: they either evaporate off the surface of your eye (especially more rapidly if you have MGD), or they drain through the lacrimal ducts. The lacrimal ducts are located on the inside corners of your eyes, and there is an upper and lower duct for each eye (see image below).

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                If you are aqueous deficient, one way to keep more tears on the surface of your eye is to block off the ducts by inserting a small silicone plug into each of the puncta, called punctal plugs. This can be done in a relatively straightforward procedure that virtually any optometrist or ophthalmologist should be able to do. The more puncta that are blocked off, the more tears that you will keep on the surface of your eye.

                True Tear
                In 2017, Allergan (the maker of Restasis) was approved by the FDA to start selling a small device called True Tear (see image below). True Tear is an intranasal tear neurostimulator, meaning it forces tear production by stimulating a nerve in your nose with a small amount of electrical current.

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                To operate, you first attach a disposable tip to the base of the unit. Then, the device is turned on and the tip is inserted into each nostril. The power level (amount of electricity being delivered at the tip) is increased until the nerve that stimulates tear production is felt to be mildly massaged. Electrical current is delivered for one minute until the device shuts off. The device can be used for up to 3 minutes at a time in a single treatment, with each treatment separated by at least an hour. This procedure can be done anywhere between 2 and 10 times per day – whatever is most effective for the patient.

                True Tear causes tear production to increase immediately after using it for the first time (whether these are basal tears, reflex tears, or some combination of both is unclear). As True Tear is used more and more, the benefit gotten by using it decreases; for example, the increase in tear production a month or two after first using it may be half of what it originally was. In my case, after a few months of using it I didn’t really notice any tears being produced at all (this despite using it at the highest possible power setting). Of course, everyone is different and some patients may realize greater benefits than I did.

                True Tear is currently only available by prescription from a few doctors’ offices across the United States, though I expect that it will become more widely available in the next year or so. True Tear currently costs $395 with certain insurance plans, and costs about $300 more than that if you don’t have insurance or don’t have an accepted insurance plan. You will initially receive a 30-day supply of disposable tips (each of which supposedly only last 24 hours) with your device. The reason the tips must be disposed after 24 hours is because the tips contain hydrogel at the ends, which dries out over the course of the day. A new 30-day supply of tips costs about $45.

                Lacrisert
                Lacrisert is the only treatment for aqueous deficiency on this list that I haven’t tried personally, so what I write about it will be from articles that I’ve read.

                Lacrisert is a small, preservative-free piece of solid lubricant that is inserted below the lower eyelid daily and dissolves over the course of the day to thicken the tear film. To insert, the lower eyelid is pulled down and to the outside and the piece is tucked inside the eyelid. This video shows how this is done. Since I haven’t tried Lacrisert personally, I don’t know how much relief people get by using it.

                Lacrisert is only available as a prescription. If you don’t have insurance or your insurance won’t pay for it, a 30-day supply will cost about $500.

                Serum Tears
                If you are severely aqueous deficient and have a gritty sensation in your eyes, then serum tears may be helpful for you.

                When tear production decreases significantly, the corneal nerves aren’t getting enough nutrients from your basal tears to maintain themselves. As a result, corneal nerves deteriorate and begin to send false signals to the brain that are interpreted as grittiness. And since the nerves aren’t communicating well with the brain, fewer tears are produced. So lack of tears causes nerve degradation which causes lack of tears – it’s a vicious cycle.

                Fortunately, your blood serum contains a lot of growth factors that can help your corneal nerves regenerate. Serum tears, also known as autologous serum tears, are simply blood serum mixed with saline. As you use serum tears more often, your nerves regenerate and you start to produce more basal tears. When the nerves are almost healed, the grittiness sensation goes away.

                To make a supply of serum tears, you must first find a compounding pharmacy near you that can make them. This compounding pharmacy must have a sterile facility that is capable of making serum tears. Although you may find many compounding pharmacies near your town or city, only a small percentage of them have a sterile lab. Thus, the bigger the city you live in, the more compounding pharmacies there will be and the more likely it is that one of them can make serum tears.

                The compounding pharmacy will require a prescription for serum tears that typically lasts one year. Although virtually any doctor can write a prescription for serum tears, it’s best that you have an optometrist or ophthalmologist write this for you. The compounding pharmacy will work with a local lab to make serum tears for you. The lab will draw a relatively large amount of blood from you (anywhere between 10 and 15 vials) and send it to the compounding pharmacy. Your doctor will need to send a lab order to the lab every time you want to draw blood.

                Once the compounding pharmacy receives the blood from the lab, they will centrifuge (spin) the blood in order to separate the blood cells from the serum. They may centrifuge the blood more than once to make sure that the serum is fully separated. When the separation is complete, the pharmacy will extract the serum from the vials and mix it with an appropriate amount of saline, depending on the concentration of serum tears prescribed by your doctor (a typical concentration is 20% serum). This mixture is then inserted into individual bottles for you to use.

                Some pharmacies may give you 5 ml bottles and tell you to use them over the course of a few days until they are empty; other pharmacies may give you smaller 3 ml bottles and tell you to use one bottle per day and discard any leftover tears in that bottle. Personally, I think throwing away perfectly good serum tears is extremely wasteful, so I use all the serum tears given to me.

                A typical supply of serum tears will last you anywhere between 1-3 months (but never more than 3 months), depending on how much serum tears the pharmacy gives you. Since the growth factors in the serum deteriorate quickly at room temperature, serum tears need to be kept cold at all times. Unused bottles are kept in the freezer until needed. When you need a new bottle, take it out of the freezer and put it into the fridge to let it thaw out. Bottles last up to 7 days in the fridge. If you need to travel or get out of your house for a long period of time, I recommend using a vacuum insulated bottle such as Hydro Flask to store your serum tears in. Simply put a few ice cubes in the bottle and you’re good to go.

                How often you’ll need to use serum tears depends on both the concentration of the serum tears as well as how severe your aqueous deficiency is. Some people may only need to put in a few drops per day; others may need much more than that. My doctor prescribes serum tears for 8 times per day.

                The major downside of using serum tears (besides needing it to be kept cold at all times) is that insurance companies in the U.S. don’t cover them; this is generally true of any compounded medication. So you’ll have to pay out of pocket for your serum tears every 1-3 months. The cost may vary significantly depending on which compounding pharmacy you use. The more compounding pharmacies in your area that make serum tears, the more competition they have for your business and thus the lower the cost of the prescription. For a three month supply of serum tears, I’ve paid anywhere between $275 and $400.
                Last edited by pythonidler; 10-Mar-2018, 23:57.
                What you need to know about computer-induced dry eye
                Dry Eye Survey
                IPL Doctors
                Probing Doctors
                PRP Injections Warning

                Comment


                • #9
                  Abstract
                  My Story
                  Lessons Learned
                  The Tear System
                  The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
                  Looking For a Doctor
                  At the Doctor’s Office
                  Treatments, Part 1
                  Treatments, Part 2
                  Treatments, Part 3
                  Get Away From Your Screens
                  Final Thoughts

                  7. Treatments, Part 2

                  Scleral Lenses
                  If you have severe dry eyes and have already tried a lot of the previously mentioned treatments with no relief, a scleral lens may help you.

                  A scleral lens is essentially a bigger version of a contact lens (see below image). The main differences between them are:
                  • Whereas a contact lens covers only part of your cornea, a scleral lens is meant to cover all of your cornea
                  • Whereas a contact lens is mainly used to correct vision, a scleral lens is mainly used for medical purposes
                  • Whereas a soft lens allows liquid molecules to permeate it, a scleral lens is a hard lens that does not allow liquid to go through it
                  • Whereas a contact lens sits directly on your eye, a scleral lens is filled with a reservoir of fluid (perhaps of serum tears) before it is inserted into the eye
                  • Whereas a contact lens usually only lasts either one day or two weeks, a scleral lens can last about 1-3 years (or more if you have a custom fit lens) depending on how often you wear it
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                  To get fitted for a scleral lens, you must visit an optometrist or ophthalmologist who does scleral lens fitting. At your fitting, the doctor will try several different lenses on you to find the most comfortable fit. The doctor will also do a refraction test on you to determine the strength of prescription to put into your lenses (if any). After you’ve been fitted, the doctor will send your information to the company that will make your lenses, and you’ll get the lenses within 1-2 weeks of your visit. It will cost between $2,000 and $4,000 to get fitted this way. Insurance may help cover some of the cost of scleral lenses.

                  As another (more expensive) option for fitting, you can also get lenses that are custom made to exactly fit your eye shape. Custom lenses generally have a better fit and may last longer than other scleral lenses. Various companies can do this kind of custom fitting, and the methods they use for fitting vary; some may use solid molds of your eye (EyePrintPro), while others may use a 3D computer model of your eye determined by a laser scan (LaserFit). According to this thread, Laserfit lenses cost about $3,500 while EyePrintPro lenses cost about $7,000. Again, insurance may help with the cost of these lenses – according to one poster, patients who buy EyePrintPro lenses pay an average of $3,000 for their lenses after insurance pays.

                  Two different tools are used to handle scleral lenses – one to insert the lenses and the other to remove them. To insert, the lens is placed upon an insertion tool (middle tool in picture below) and filled to the brim with fluid. You bend over at the waist so that your head is looking down, and then the lens is brought up to the eye and carefully placed on the eye. The lens must be inserted quickly but carefully. If the lens is inserted and an air bubble is seen behind the lens, the lens must be taken out and inserted again so that there is no air bubble.

                  To remove, the suction tool (right tool in the image below) is placed on a part of the lens close to the outer edge and pulled at an angle so that the lens slides off as it is coming out. The fluid in the lens will have to be replaced after about 8 hours, so that the lens can be worn for longer.

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                  If you had to use serum tears prior to being fitted for scleral lenses, you will need to fill the scleral lenses with serum tears prior to putting them in. The lenses may not need to be 100% serum tears; you may be able to get away with mixing 50% serum tears and 50% saline or some other solution.

                  Amniotic Membrane (Prokera)
                  Those with chronically severe dry eye may have caused damage to their corneas. Eventually, a corneal ulcer may develop over the surface of the eye, which may be accompanied by blurry vision and pain. For those with corneal ulcers or other types of eye damage, an amniotic membrane may help the wound heal.

                  An amniotic membrane is a small piece of tissue taken from the innermost layer of donated placenta. During pregnancy, the placenta plays an important role in protecting the fetus from infection. The inner layer of placenta has natural anti-inflammatory properties that promote healing when there may be an overabundance of inflammation.

                  There are two types of membranes for ophthalmic use: cryopreserved (preserved by being kept very cold) and dehydrated. Prokera (see image below), a brand of cryopreserved amniotic membrane, is one of the most popular membranes used to heal damaged eyes. To use it, the doctor inserts the membrane into one of the eyes of the patient and secures it to the eye. The doctor probably won’t insert the membrane into both eyes, since the patient’s vision will be blurry in the eye which has the membrane in it.

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                  The patient keeps the membrane in his eyes for one week. After a week, the membrane is removed by the same doctor that inserted it. Sometimes, a Prokera for the second eye won’t be necessary since having it in one eye may promote healing in the other. If the second eye is still damaged after the membrane from the first eye is removed, the doctor will insert a new Prokera into the second eye.

                  The cost of an amniotic membrane depends on the type of membrane used and the doctor who inserted it. As a general rule, expect a single membrane to cost around $1,000.

                  Treatments for Meibomian Gland Dysfunction
                  The following treatments are for meibomian gland dysfunction only.

                  In my opinion, there is a clear distinction between the first three treatments mentioned below (blinking exercises, warm compress, doxycycline) and the latter three treatments (LipiFlow, intense pulsed light, probing). The first three treatments are relatively inexpensive and may be very effective for those with mild MGD; conversely, the latter three treatments can be very expensive and only those who can’t get relief from the first three options should try them.

                  As a general rule, all MGD patients should incorporate each of the first three treatments into their routine. Those with more severe MGD should also do one or more of the latter three treatments on a regular basis.

                  Blinking Exercises
                  As mentioned in a previous section, one problem that leads to MGD is either a low blinking rate or incomplete (partial) blinking. If your MGD is still fairly mild, you can treat it by practicing blinking exercises; these exercises will strengthen the muscles used to blink.

                  This video gives a good example of how to do these exercises. To start, place your forefingers at the outside corner of each of your eyes – this will ensure that you’re performing the exercises correctly. Then, squeeze your eyelids shut without “scrunching” your eyes (the below image shows how NOT to do this). If you did the move correctly, you won’t feel any movement on your fingers. After two seconds of closing your eyes, you can open them again. Repeat the closing-opening sequence two more times for one “set”. If you’re using a computer, these exercises should be done about every half hour.

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                  Blinking exercises should be done indefinitely until it becomes second nature to blink more often and more completely. As a reminder to do blinking exercises when using the computer, you can install a Chrome extension called eyeCare, which gives you an alert every 30 minutes or how ever often you wish; there are also several iPhone and Android apps which serve the same function. After doing the exercises, rest your eyes by taking a 2-minute break from your computer. Walk around, talk to a friend, or doing anything to avoid staring at your screen for those few minutes.

                  Warm Compress
                  Warm compresses are one of the cheapest ways (about $10) to manage your MGD; I think everyone (not just people suffering from MGD) should incorporate them into their daily routine.

                  A warm compress (see image below) is an eye mask filled with beads that heat up when microwaved for about half a minute. When applied to the eyelids, the heat from the eye mask melts oils that are still liquid-y but may be slow to get out of the glands.
                  Click image for larger version  Name:	compress.jpg Views:	1 Size:	19.5 KB ID:	210277


                  Typically for a single treatment, it is recommended to keep the compress on the eyelids for about 5-10 minutes. After removing the compress, you can work on massaging your lids in order to further express the oils – simply put mild pressure on your eyelids and work your way from the base of the eyelid to the lid margin. This combination of heating and massaging I do about 1-3 times per day.
                  Last edited by pythonidler; 10-Mar-2018, 23:58.
                  What you need to know about computer-induced dry eye
                  Dry Eye Survey
                  IPL Doctors
                  Probing Doctors
                  PRP Injections Warning

                  Comment


                  • #10
                    Abstract
                    My Story
                    Lessons Learned
                    The Tear System
                    The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
                    Looking For a Doctor
                    At the Doctor’s Office
                    Treatments, Part 1
                    Treatments, Part 2
                    Treatments, Part 3
                    Get Away From Your Screens
                    Final Thoughts

                    7. Treatments, Part 3

                    Doxycycline
                    Sometimes the primary reason for lid inflammation is bacteria hanging around the lid margin. The inflammation restricts the gland openings and limits the amount or quality of oil coming out of the them. In this case, some MGD patients may have most of their MGD symptoms resolved simply by taking the antibiotic doxycycline. Unfortunately, MGD can’t be “cured” by taking just one bottle of doxycycline – the medication will have to be taken indefinitely to ensure the bacteria don’t re-establish themselves. The good news is doxycycline – even without insurance – is one of the cheaper treatment options for MGD.

                    Lid Scrubs
                    Taking doxycycline can be great lid hygiene in and of itself. Using lid scrubs is another great way to further remove lid debris. A major brand of lid scrubs is OcuSoft, which may come in a variety of forms such as a spray bottle or as pre-moistened wipes. Personally, I prefer the pre-moistened wipes as they are most convenient; if buying a spray bottle, you’d need to buy separate applicator pads as well.

                    I honestly don’t know the difference between the various lid scrub products. I’d think as long as your lids are getting cleaned down to the base of your eyelashes, that’s all that really matters. Look for tea tree oil in whatever product you decide to buy – but make sure if you buy 100% concentrated tea tree oil that you first dilute it to 50% concentration with distilled water before using it.

                    Manual Expression
                    Manual expression has long been a staple of MGD treatment. Expression is simply the doctor squeezing the eyelids with either a special forceps tool or with a combination of two q-tips, in order to get stubborn oils out of the glands. The picture below shows a doctor expressing glands with the forceps tool, while this video shows a doctor using the two q-tip method to express the glands.

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                    Manual expression can be done alone, but it is most effective when performed in conjunction with another, more aggressive treatment (e.g., IPL or probing). This is because the more aggressive treatment options open up the glands and allow more oil to be expressed than if expression were done “cold”.

                    LipiFlow
                    LipiFlow is the first of the more aggressive MGD treatments. LipiFlow was developed by TearScience (also the manufacturer of LipiView and LipiScan machines) in 2011 to treat meibomian gland dysfunction. Because of TearScience’s effective marketing to doctors and its perceived relative safety compared to other, more aggressive treatments, LipiFlow is one of the most popular treatments for MGD.

                    The LipiFlow system consists of a machine with two electrical cables connected to two disposable eye pieces (see image below). The treatment procedure is as follows. Watch this video to see how it’s done.
                    • First, anesthetic drops are put into each eye
                    • The upper and lower lid margins of each eye are scraped (called debridement) to remove debris
                    • The eye pieces are then fit into each eye. One part of the piece contacts the underside of the lids and the other part contacts the outside of the lid
                    • The treatment program is run. The eye pieces will take about 30 seconds or so to warm up. During the program, the eye pieces will alternately contract and expand to express oil out of the glands. The program itself lasts for about 12 minutes
                    • After the treatment program is complete, the eye pieces are taken out of the eye. Some doctors might also choose to perform manual expression at this time
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                    The above procedure describes one session of LipiFlow. Unfortunately as with many other MGD treatments, you must get regular LipiFlow treatments in order to maintain the benefit. How often you get treatments depends on the individual; doctors have told me to get repeat treatments every 6-12 months, though some people may need it more frequently.

                    Because a doctor can only use an eyepiece once before having to discard it, the doctor must purchase new eyepieces from TearScience in order to do additional treatments. And because TearScience charges an office a few hundred dollars per eyepiece, the company ensures that the cost of a Lipiflow procedure will remain very expensive (at least $1,000 to do both eyes) into the foreseeable future.

                    Part of the reason I dislike LipiFlow so much is because of this “money grab” scheme by TearScience. It would be justifiable to do this, in my opinion, if LipiFlow were considerably more effective than the other aggressive treatments; however, as a matter of fact, it may be the least effective of all of them. For these reasons, LipiFlow seems to me less of a viable treatment option and more of a giant black hole where money goes and doesn’t come back.

                    Intense Pulsed Light
                    Intense pulsed light (IPL) is a relatively new treatment for meibomian gland dysfunction. As the name implies, IPL applies short bursts of powerful light (in both the visible and infrared part of the spectrum) to the area around the eyelids in order to melt thick oil in the glands. Unfortunately, since IPL produces a lot of energy in each pulse and darker skin pigments absorb more energy (not good), only people with lighter skin can get IPL treatment.

                    Long before IPL was used to treat MGD, many dermatologists were using it to treat various skin conditions such as rosacea and acne. Then in the early 2000s, some patients of Dr. Rolando Toyos in Memphis, TN reported that their dry eye symptoms improved after getting an IPL treatment. Dr. Toyos investigated this phenomenon on a large sample of patients and in 2015 published a paper describing the effects of IPL in treating meibomian gland dysfunction. To this day Dr. Toyos continues to treat MGD patients with IPL, as well as train other doctors around the U.S. in how to perform IPL for dry eye. As IPL becomes more popular as a tool to treat MGD, new IPL machines are being designed to specifically treat dry eye (such as the Lumenis M22, seen below).

                    The paper published by Dr. Toyos details the many benefits of IPL. It turns out that the wavelength of light used in IPL has many positive effects, including:
                    • High heat generation – the meibomian glands absorb a lot of the energy emitted by IPL, which is manifested as heat. This results in the oil being heated to a point where it can be more easily expressed out of the glands
                    • Anti-inflammatory – the heat generated from IPL also closes abnormal blood vessels which produce inflammatory cytokines. By closing these vessels, IPL has an anti-inflammatory effect
                    • Stimulation of oil glands – the wavelength produced by IPL stimulates cell activity, a process known as photomodulation
                    • Antibiotic – The combination of heat and specific wavelength of light used also works to kill bacteria which grow along the lid margin and cause inflammation
                    Only a few negative effects have been reported from IPL. Some potential downsides are:
                    • Increased skin sensitivity to sunlight – The area of the skin that is treated by IPL is more sensitive to sunlight for about 2 weeks following treatment. Patients must use liberal amounts of sunscreen to avoid getting sunburned when spending time outside
                    • Redness of skin – Because of the large amount of energy contained in a single pulse, IPL may cause the skin to redden
                    • Swelling or blistering – Again due to the large amount of energy being delivered to the skin, some patients may experience swelling or blistering
                    Some posters on this forum have warned about IPL causing major damage to the eyes. In my opinion, this is due to doctors not taking appropriate safety measures (such as putting on protective eye patches or corneal shields). Patients should not experience any negative effects from IPL besides the ones listed above.

                    An intense pulsed light system (see below) consists of a flash-lamp (or as I call it, a “zapper”) connected via large cable to a machine. The machine has an interface where the doctor can change certain parameters of the treatment such as pulse power and duration.

                    Click image for larger version  Name:	M22.jpg Views:	1 Size:	50.8 KB ID:	210280


                    The treatment procedure lasts about 15 minutes and is described as follows. Watch this video from Dr. Toyos himself to see how it’s done.
                    • First, the doctor either adheres disposable eyepatches to the eyelids or inserts metal corneal shields underneath the eyelids to protect the eye from receiving too much energy from the pulse. If a corneal shield is inserted, anesthetic drops will be given beforehand
                    • The doctor will spread a layer of cooling gel onto the areas of the face that will receive IPL pulses. This is to prevent the skin from being burned by the pulses
                    • After protection has been given to the eye and skin, the doctor will start the IPL treatment. The doctor will administer short pulses one at a time, in an area that spans from temple to temple. Each pulse will be administered in a different location on the face and feel like a rubber band has been snapped at that spot. The pulses are somewhat uncomfortable, though tolerable
                    • After all pulses have been given, the doctor will power down the machine and remove the eye patches and/or corneal shields
                    • As a final step, the doctor will perform manual expression on all four lids. This is an ideal time for manual expression since many of the thicker oils have been softened by IPL pulses
                    The procedure above defines one treatment session. When IPL is initially done, it must be done once per month for the first four months. Thereafter, IPL must be done on a regular basis every [x] number of months, where [x] is a number unique to every individual; some people may only need IPL every 12 months, while other may need IPL every month or month and a half.

                    IPL is more affordable per session that LipiFlow – a typical session of IPL can cost anywhere between $250 and $500. As a bonus, your insurance may also cover the cost of IPL. I discovered this by accident in 2015, when I was seeing a doctor at the Mayo Clinic in Arizona. My doctor told me that I would need to pay out-of-pocket for the treatment, so I did for my first couple sessions. But the Mayo Clinic billing department ended up submitting IPL charges to my insurance company – and they were approved! Since then, I’ve been able to get IPL covered despite now seeing a different doctor with a different insurance plan. When I met my deductible, my IPL treatments became ridiculously affordable, ranging from $40 to $70 per treatment.

                    Meibomian Gland Probing
                    Perhaps the single most aggressive treatment for MGD is probing. If you have glands that are still visible on meibography (i.e., not dropped out), but no other treatment option has worked for you, then meibomian gland probing may help you.

                    Probing was pioneered by Dr. Steven Maskin in Tampa, FL and involves using small needles (called probes) to open up glands that have been blocked by scar tissue; this scar tissue is normally too tough to be cleared by LipiFlow or IPL. Thus, patients that have a lot of scarring but still have most of their meibomian glands stand to benefit the most from probing.

                    The procedure is as follows. Watch this video to see how it’s done. Even with anesthetic, the procedure can be quite painful. However, if it’s done well enough you might not need to do it again.
                    • First, the lids being probed are given topical anesthetic. The doctor may also put in numbing drops
                    • After the lids are numbed, the doctor will start probing on one lid. When a gland is probed that has scar tissue over it, a “crunching” sound will be heard
                    • Once the doctor finishes probing one lid, he will move on to another lid
                    • After all lids have been probed, the doctor will perform manual expression on the lids using either a special forceps tool or using the two q-tip method
                    Note that some doctors may perform probing in a slightly different way; for example, some doctors may perform manual expression on a lid immediately after that lid has been probed instead of waiting until all lids have been probed.

                    Following the procedure, the patient will be given some combination of steroid drops and an antibiotic ointment to help control the temporary increase in inflammation caused by probing. Some doctors may prescribe Blephamide, which combines steroids and an antibiotic into a single ointment. A patient should expect his symptoms to improve between a few days and a few weeks after the procedure. A follow-up visit may be scheduled for one month after probing.

                    Assuming probing worked for the patient, treatments like LipiFlow and IPL will now be effective for the patient since the scar tissue has been broken up. As long as these treatments are administered on a regular basis, there is a good chance the patient won’t need probing again.

                    There are two downsides about probing. First, it can be very difficult to find a doctor; for example, I live in the Pacific Northwest and the closest doctor who can do probing is in California. That means that I’d have to fly out of state to get it done. Because there is no published list of doctors who do probing, you’ll have to do some research to find one near you. I recommend calling the manufacturer of the probes, Rhein Medical, and asking about doctors who have purchased their probes.

                    The second downside is that probing can be very expensive. I’ve heard that Dr. Maskin charges between $7,000 and $8,000 to do probing on all four lids. But I also know of three other doctors who do probing, and each charges a fraction of what Dr. Maskin does. That said, expect to pay about $2,000 at minimum for probing. For something that is only slightly more expensive than LipiFlow, however, I consider it to be a very good investment of your money.

                    Treatments for Both Aqueous Deficiency and Meibomian Gland Dysfunction
                    The following treatments target your entire body and can address inflammation both on the ocular surface as well as in the eyelids. They therefore may help improve both aqueous deficiency and MGD.

                    Diet
                    One of the cheapest ways (though also one of the most difficult) to reduce inflammation in your body is to change the foods that you eat. There are many conflicting theories about which foods are anti-inflammatory and which foods are pro-inflammatory. However, there is a general consensus that foods high in omega-3 fatty acids are anti-inflammatory and are good for your heart as well as dry eye.

                    Foods high in omega-3 include:
                    • Certain types of fish (mackerel, salmon, sardines, tuna, anchovies)
                    • Certain nuts and seeds (walnuts, flaxseed, chia seeds, hemp seeds)
                    • Eggs
                    • Spinach

                    You can also try the opposite approach of avoiding foods that are pro-inflammatory. There is less agreement here about which foods are pro-inflammatory, but according to eatthis.com, some purported pro-inflammatory foods are:
                    • Anything with a lot of sugar
                    • Fried foods
                    • Foods with refined flour
                    • Dairy
                    • Processed meats
                    • Fast food
                    By a happy coincidence, those foods listed as pro-inflammatory are probably foods you should be avoiding anyway.

                    Additional foods that are commonly listed as inflammatory include anything with gluten in it. Although I personally don’t seem to react negatively to gluten, other people would probably say it definitely affects them in a negative way. The only way to find out is to experiment with gluten-free foods.

                    Omega-3 Supplements
                    Another way to increase your omega-3 intake is to take fish oil or seed oil supplements. Doctors have personally recommended to me three different supplement brands:The main difference between these supplements is that HydroEye is made from black currant seed oil, whereas Nordic Naturals and PRN are made from fish oil. The difference between the two fish oil brands is that they have differing amounts of EPA and DHA. To me there is no noticeable difference between the three in terms of symptom improvement, though other people may feel differently about how the above three products affect them.

                    A good starting point with omega-3 supplements is to take about 1000 mg per day, spreading out when you take the supplements as much as you can. If 1000 mg are not effective, increase your dose to 2000 mg; again, make sure you are taking one capsule at a time spread out throughout the day. If neither 1000 mg nor 2000 mg seem effective, increase your dose to 3000 mg per day. This is probably the upper limit in terms of how much omega-3 your body can actually use in a single day.

                    Treatments for Pain Management
                    The following treatments are for pain management. These treatments will only be effective if you have eye pain; if you only have discomfort (e.g. grittiness), they will not work.

                    Nortriptyline
                    Nortriptyline is an anti-depressant drug that can be prescribed for eye pain. Nortriptyline works by altering how the brain interprets pain signals from the nerves in your eye. Fortunately for dry eye patients and unlike most anti-depressants, nortriptyline does not decrease tear production.

                    When I was prescribed nortriptyline, I was told to ramp up my dosage from 25 mg to 75 mg over the course of three weeks (25 mg the first week, 50 mg the second week, 75 mg the third week). At my follow-up appointment, my doctor asked if I had any side effects from taking the medication. When I said I hadn’t, he told me I could increase my dosage to 100 mg. Since then, I’ve further increased my dosage to 150 mg /day without experiencing any negative side effects.

                    Naltrexone
                    Naltrexone is normally a drug given to rehabilitated alcoholics or narcotics abusers to keep them from using again. When prescribed in a lower dose form, it can also help with eye pain.

                    In lower doses, naltrexone has been shown to alleviate chronic pain associated with certain auto-immune conditions, such as fibromyalgia. This article does a good job of explaining exactly why that is the case.

                    My doctor prescribes me naltrexone in 4.5 mg capsule form (though I’ve also heard of people using naltrexone eye drops). Because naltrexone isn’t normally manufactured in such a small dose, it needs to be made by a compounding pharmacy. Unfortunately for many patients in the U.S., insurance plans are very reluctant to cover any compounded medications. Thus, you will probably pay out-of-pocket for naltrexone.

                    One way to reduce the cost of naltrexone is to have your doctor prescribe as many refills (1 refill = 30 day supply) as possible. Then, instead of having the pharmacy give you a one-month supply of naltrexone, ask for as much as they can give you; the more refills your doctor has prescribed, the more capsules the pharmacy can give you in a single order. The cost per capsule is much less if you order your naltrexone this way as opposed to ordering it on a month-by-month basis.

                    Carbamazepine
                    Carbamazepine is a medication used primarily to treat seizures in those with epilepsy as well as those who have nerve pain.

                    Since I haven’t used this drug personally (yet), I can’t report on its potential effectiveness. I can tell you about its potential side effects, which according to WebMD include: nausea, vomiting, drowsiness, constipation, dry mouth, or unsteadiness.

                    Carbamazepine has been available in the U.S. since 1968, and as such is widely available as a generic drug. It is inexpensive even for those without insurance.
                    Last edited by pythonidler; 11-Mar-2018, 00:00.
                    What you need to know about computer-induced dry eye
                    Dry Eye Survey
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                    • #11
                      Abstract
                      My Story
                      Lessons Learned
                      The Tear System
                      The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
                      Looking For a Doctor
                      At the Doctor’s Office
                      Treatments, Part 1
                      Treatments, Part 2
                      Treatments, Part 3
                      Get Away From Your Screens
                      Final Thoughts

                      8. Get Away From Your Screens

                      As I mentioned in the “My Lessons Learned” section, you can never truly get better until you remove the source of your problem – computer and phone screens. Here are some ways to do that.

                      Exercise
                      Being active is a great way to treat your dry eye, for a couple reasons. First, when you are physically active and working hard, you tend to focus more on the exercise than your eye pain. In this way you can give yourself a mental break.

                      Second, your body releases endorphins when you exercise. Endorphins are naturally occurring hormones in your body that reduce your perceived level of pain. In order for endorphins to be released, you must do moderate physical work (either cardio or weightlifting) for at least 20-30 minutes at a time. The endorphins will remain in your system for an extended period of time even after you’re done working out.

                      Audio Entertainment
                      In your free time, you can occupy yourself by listening to music, audiobooks, or podcasts. I’m sure everyone has put at least some music on their phones, so I’ll just tell you how you can listen to audiobooks and podcasts.

                      When I first got eye pain in July 2017, I realized I probably wouldn’t be able to watch TV anymore. So I immediately cancelled my Netflix subscription and started subscribing to Audible.com. Audible has a large selection of audiobooks for sale. If you subscribe to their “Gold” plan (about $15/month), you get 1 credit per month, which you can use to buy an audiobook at any price. You can also choose different plans which give you either more or less credits per month. You listen to an audiobook using an app on your smartphone, tablet, or certain Kindle models.

                      Podcasts are audio-only shows that you listen to on your phone or other device. There are many different categories of shows, including:
                      • News
                      • Talk
                      • Sports
                      • Comedy
                      • Informational
                      You download podcasts through a podcast app. If you have an iPhone, a podcast app is included by default. If you have an Android or other phone, you can download a podcast app such as “Podcast Addict” for free through your app store. To listen to a podcast, you first subscribe to the podcast. Subscribing to the podcast will give you information about all recent episodes of that show. You can then download any individual episode that interests you, or set it so that all new episodes of the show are downloaded automatically.

                      Find a Different Job
                      Lastly, but certainly not least, the biggest thing you can do to avoid computer screens is to find a different job that doesn’t require as much screen time.

                      Before you tell me that you can’t possibly give up your career that you’ve spent so long preparing for, let me tell you about your only other option – should you decide not to quit your job, you WILL continue to deteriorate further. As your condition continues to decline, your tear system will become irreversibly worse, and to a point that you guarantee yourself more expensive medical bills in the future. Then you will be FORCED to quit when your condition becomes more severe, and it won’t be a question of “if” but “when”. In this way, it actually is cheaper to quit your job while your dry eye is still relatively mild. You can take a chance that you won’t be one of those people who has to quit – but that’s a hell of a gamble.

                      As for what jobs you can do that don’t involve a lot of computer work – I wish I could give you an example of a job I have, but I’m still in the boat of people trying to figure out how to move on with their lives. One thing I will say is that there ARE jobs out there that require little to no screen time. You may not have much interest in them, but they exist. If you do some digging, I’m sure you can find something that interests you at least a little bit.
                      Last edited by pythonidler; 10-Mar-2018, 23:48.
                      What you need to know about computer-induced dry eye
                      Dry Eye Survey
                      IPL Doctors
                      Probing Doctors
                      PRP Injections Warning

                      Comment


                      • #12
                        Abstract
                        My Story
                        Lessons Learned
                        The Tear System
                        The Two Main Types of Dry Eye (And How Electronic Screens Cause Them)
                        Looking For a Doctor
                        At the Doctor’s Office
                        Treatments, Part 1
                        Treatments, Part 2
                        Treatments, Part 3
                        Get Away From Your Screens
                        Final Thoughts

                        9. Final Thoughts

                        TLDR
                        This has been a long post and I don’t blame you for not wanting to read every single word of it. So if there’s one thing I want you to take away from it, it’s this: for many reasons, it’s very, very important to treat dry eye as quickly and aggressively as possible. This means finding the best doctor in your area and asking him to give you the more aggressive treatments sooner rather than later. By doing this, you will keep your eyes from getting significantly worse and have a much higher quality of life. And although you may spend more money in the short-term, in the long-term you will save lots more money than if you had been less aggressive with your treatment.

                        Keeping Hope
                        To borrow a line from one of Rebecca’s posts, “you are NOT going to feel like this forever.” For new dry eye patients especially, there are ALWAYS better doctors to see and treatments to explore. And even if you’re a dry eye veteran with a top-notch doctor, there are still treatments you haven’t tried.

                        Dry eye is a frontier in ophthalmology right now, and that’s both good news and bad news for patients. The bad is that there aren’t a lot of super-effective prescription drops out there right now (I consider Restasis and Xiidra to be only mildly potent). The good news is that demand for dry eye medications is expected to skyrocket as more and more people get diagnosed with dry eye (the number of diagnoses increases both as a function of the total number of people having dry eye as well as doctors being able to better diagnose it). As demand for dry eye drugs increases, so does the number of medications or other treatment options in development. The website dryeyeawareness.info has a great page dedicated to the “pipeline” of drugs currently in FDA clinical trials. One only need look there to realize the future of dry eye is bright.
                        Last edited by pythonidler; 10-Mar-2018, 23:48.
                        What you need to know about computer-induced dry eye
                        Dry Eye Survey
                        IPL Doctors
                        Probing Doctors
                        PRP Injections Warning

                        Comment


                        • #13
                          Pythonidler, I've been looking forward to you posting this complete document. My first two thoughts are WOW and THANK YOU!! I will look at it in more detail in the coming days, but glancing over it, I know it will be an invaluable reference for me and others in this forum for many years...lots of info for those without computer-induced dry eyes too. It is so complete and and well written, I really think it should be officially published somewhere.

                          Thanks again for sharing all your experience and knowledge you've accumulated over the years. Hopefully your MGD did not get worse from working on all this!
                          Last edited by Hokucat; 11-Mar-2018, 03:45.

                          Comment


                          • #14
                            Pythonidler, this is an amazing resource. Thanks so much for taking the time to put this together!

                            Comment


                            • #15
                              Hokucat m4shore thank you both for your kind words. My goal is to raise awareness for dry eye, and the more people know about it the better.
                              What you need to know about computer-induced dry eye
                              Dry Eye Survey
                              IPL Doctors
                              Probing Doctors
                              PRP Injections Warning

                              Comment

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