My Inexplicable Night-time Redness

[Rhuidean]

Hello All, I joined this forum a few weeks ago and have been very impressed with the depth of knowledge the board veterans seem to have regarding eye issues. I'm hoping some of you can help to find an answer for my problems. First, a little backstory.

I had LASIK in July 2009, specifically an Intralase treatment for my myopia. The results were excellent; my vision has been brought up to 20/15 with a small degree of induced astigmatism in my right eye which I have mostly come to accommodate since. Shortly after my treatment I started to have problems at night-time, specifically I will wake up in the middle of the night with red, irritated-looking eyes. At first I thought nothing of it and concluded that it was a normal symptom of the post-LASIK dry eyes, however it then persisted for the full 18-month expected healing time without seeming to improve at all.

Subsequent visits to the clinic where I was treated have been frustrating to say the least. I'm very happy with the treatment I've received there, however every attempt at alleviating my symptoms has failed.

The ophthalmologists I've seen insist that I don't have dry eye; TBUT and Schirmers tests have consistently given similar results to what I had before treatment. I don't recall the Schirmers but my TBUT is generally 12-14 seconds which I'm given to understand is quite good. I know this isn't a conclusive test as the tear cycle is complex, however I also don't experience dry eye symptoms during the day at all; I don't need any drops and can be outside in any weather without issue.

At night though, I wake up consistently after 3-4 hours with red, irritated eyes. They're soothed by eyedrops but seemingly can't be prevented by anything. Here's a list of what I've tried:

• Eyedrops ( preservative-free ) during the day
• Gel-based products at night ( geltears, lacrilube and viscotears )
• Blepharitis treatment including baby shampoo and blephasol
• MGB treatment including hot compresses 3x daily for a week
• Steroids ( worked for one day, then back to red ), however I have an adverse IOP reaction to these so I can't stay on them
• Tranquileyes, sleep masks, moist gauze
• Cold compresses before bed
• Anithistamine eyedrops and pills in case of allergies
• Eyelid taping

The latest development is a visit to a private ophthalmologist for a second opinion. He suggested trying punctal plugs just in case it was some form of dryness. He installed them last week but so far there has been no improvement in my condition. The ophthalmologists at the clinic where I was treated seem to think that this is a hypersensitivity condition brought about by the LASIK surgery and that it will abate over time, however it's now been 2 years since my treatment so I'm not sure I believe this.

So at this point I and my doctors are completely stumped as to what is causing this. I feel like I've tried everything and nothing seems to work. If anyone has any suggestion on what this might be or what I can do to stop it, I'd appreciate it.

Thanks,
Rhuidean

[Rebecca Petris]

Hello and welcome.

Very interesting situation... must be very frustrating!

Nothing improves it, right? But does anything seem to make it worse? Or are these night symptoms pretty much totally static?

Have you been through any lengthy periods (e.g. couple of months or more) where you were using absolutely nothing with a preservative, whether Rx or OTC?

Why did you do all those bleph/MGD treatments: Were your doctors seeing signs of MGD that they felt needed addressing, or were they just things to try "in case"? The reason I ask is, sometimes people get on a treadmill of sorts with dry eye treatments in general and inadvertently prolong or worsen symptoms... hard to avoid, and hard to detect if this is the case when you're trying to solve a tear-related problem, for sure. So I'm just curious.

Have you been using the geltears/lacrilube/viscotears type products at night ALL along, or did you start these much later than the symptoms?

Has anyone evaluated whether you might have a little nocturnal lagophthalmos? One would think not if taping doesn't help but hard to be sure.

This comment from the clinic "The ophthalmologists at the clinic where I was treated seem to think that this is a hypersensitivity condition brought about by the LASIK surgery" certainly seems spot on, not that it helps particularly to know! But the way I'd think of it is surgically induced tear dysfunction of some kind. Anytime you do not have a healthy tear film, your eyes are more vulnerable to all kinds of things that would never affect you under normal conditions, be it allergies, lagophthalmos etc. There are so many possibilities. Your reaction to the steroid for example (VERY brief relief, which is surprising) MIGHT suggest - again I'm just voicing possibilities not probabilities! - sensitivity to BAK in the steroid which could then explain why the antihistamine drops don't help iF the night stuff is due in part to ocular allergy.

Ever tried something like a swim goggle at night, with either no lubricant or PF-only? Might be useful as an experiment - excluding all irritants, increasing moisture and excluding chemicals as much as possible.

Then there's all the environmental stuff - pillow, pillowcase, laundry detergent, any possibility of mold in the bedroom etc.

[Rhuidean]

Hi Rebecca, thanks for your reply. To answer your questions in order:

The only variability I've seen is in location. If I'm in my apartment it's at its worst, if I visit my parents it's a little better. I noticed a great difference one night only when I was there, I woke up and went to the bathroom and my eyes felt and looked fine, since then it's been largely the same so I don'to what I should attribute the improvement to. This pattern led me to pursue allergies as a cause but that went nowhere. I occasionally see an improvement if I sleep on my back rather than my side or stomach but it's never consistent or completely successful.

I've been using preservative-free eyedrops in the middle of the night for a number of months, with periods of several weeks in that time where I was using nothing else.

The Bleph/MGD treatments were just things to try that my doctor thought might help to narrow the possibilities. I've never tried any of these treatments past the 2-week mark due to their lack of effect and the fact that my TBUT is good.

I started using lacrilube, etc. over a year after my surgery and again only tried them for a week or two before stopping due to a lack of any effect.

I've had my girlfriend check during the night whether my eyes appear to be open in my sleep, she's told me they don't appear to be. My attempts at taping were difficult to say the least and I'm not sure if they actually kept my eyes completely closed, however I would have thought that if lagophthalmos was the culprit, the gels and goggles would have some effect; which they haven't.

The hypersensitivity explanation is fine, but unverifiable so I continue to look for alternatives; I'd prefer not to give before being sure there's no other explanation. I haven't tried swim goggles, however I have tried sleeping masks, saran wrap, Tranquileyes and gauze and they seem to do nothing.

In terms of environmental factors, as I said above I do notice a small difference when at my parents' house but it never actually stops happening. It also happens in different countries including Germany and Poland. I've yet to try hypoallergenic bedding but it happens even if I sleep on a leather couch for a short time ( 30 mins or so ) without any bedding so I'm not sure if it could be a dust-mite allergy or something similar.

Again, thanks for your reply. I don't expect to find any answers given everything I've already tried myself but I appreciate the effort

[NeedMyEyes]

Nocturnal redness / dryness

This is probably my biggest issue (dryness not redness) and I am not post-LASIK. I have a component of nocturnal lagopthalmos and is probably the reason for my becoming symptomatic 12 months ago.

When you said it depends on your sleeping position, this makes me think you are digging your head into your pillow when you sleep on your side and it forces your eyelids open a little.

Also, taping is really difficult - 2 methods I'm aware of: 1) tape to the cheek and then keep the tape tight to the forehead. this elevates the lower lid and the upper lid can rest easily on it. 2) tape on the upper lid and tape down and onto the lower lid (or reverse). This is the only way I can get an "airtight" seal. I am unable to see anything until I take the tape off in the shower in the AM. If I put in a drop of unpreserved saline before the taping, some mornings I feel close to "normal" and have a good night's sleep. I recommend trying this. If it helps, there is a component of lagophthalmos.

I have tried almost every ointment out there. I can say that they *mostly* solve my nighttime dryness issue, but several of them cause redness. They also cause a foreign body sensation, especially in my worst eye.

The worst for me is Refresh PM. Refresh has lanolin alcohols, I think, and lots of mineral oil, but no preservatives.

The best for me is Genteal PM ointment. Just a little redness in the AM and just a little FB sensation.

Okay, actually, the best for me is FML ointment which is a steroid plus mineral oil, petrolatum, lanolin alcohols and a preservative (thimerasol, I think). I wake up in the AM with absolutly NO redness, no FB sensation, no dryness, etc. My eyes basically feel normal (like they did a year ago before this all started).

So, I don't know if a steroid is an option for you, but sometimes I use it in emergencies when I have had a rough week or few days etc.

[Jesslin]

I have the same problem, I didn't have LASIK but the night time dryness isn't made better by anything really. Goggles or ointment don't really help at all but I use the ointment in an attempt to minimise any further damage to my eye. Like you I get problems anywhere not just at home. Even if I close my eyes outside or on the sofa or anywhere my worst eye sticks to the eyelid in about 10 seconds and when I open it again it really smarts and blurs. Apparently mine is caused by abnormal meibomian secretions, not had any luck fixing it as if yet but also like you I once had one good night and can't, however hard I try manage to recreate it. If I have any luck I'll post here.

[NeedMyEyes]

nighttime dryness with Meibomian Gland Dysfunction

Jesslin, this is my biggest struggle and I can't seem to figure it out...

Before all this happened, it didn't matter what i did to my eyes during the day - at night I would go to sleep, wake up and in the morning, my eyes felt good again.

Why now that I have meibomian gland problems do my eyes get EVEN DRIER at night? Just doesn't make any sense to me. I should be able to go to sleep and when I wake up, everything feels good again.