Am I missing possible treatments?

[Rebecca Petris]

Has anyone had negative reactions to dwelle? I think its causing Tessa's eyes to be redder and a little swollen, but at other times of the day her eyes are looking better than before I started her on dwelle... Maybe its an initial reaction to the drops that goes away after a bit?

Dwelle has a very high concentration of polymers and it can sting and irritate the surface on first instillation. If it persists, for example, seeing redness etc for hours afterwards, I would certain discontinue (could be allergy or sensitivity to something in it). But if you're seeing improvement and want to keep trying it, one thing you could try is buffering it - put in some saline a few minutes beforehand, then the Dwelle. I do that myself in the mornings sometimes.

I also did some experimenting with heat, and found it causes her eyes to become much redder and quite swollen so I won't be using that. Her eyes were looking really good and I put her in the bathroom with the shower on really hot to steam up the room for some moist heat. Her eyes became quite swollen after. I waited until they looked normal and tried heat on her eyes again and the same response...

I've never heard of warm compresses being used on a dog before. I don't know anything about dog dry eye etiology but it wouldn't surprise me if it's pretty different from people, i.e. predominantly an aqueous issue.

[indrep]

Dani,
Please read the following: http://www.tearfilm.org/dewsreport/p...DEWS-noAds.pdf
and http://www.fdarestasisdata.org/

The first will help you understand the most recent and accepted ideas of what Dry Eye Disease is and how it comes to be and whether there is any consensus at all on how to treat it.

The second will help you understand cyclosporine and how it was approved by the FDA.

Propagating heat application not as simply an additional measure (that might not work well for some patients), but promoting it as universally applicable treatment that is bound to solve any kind/level of inflammation in the dry eye in the long term, might be counterproductive for many patients in need of more serious therapy.

Inflammation is a symptom of a cause. The only way to stop inflammation is to reduce the osmolarity of the tear film. The only way to do that is to increase the volume of water on the ocular surface and to try and regulate its evaporation. Cyclosporin acts only as an antinflammatory.

I am not professing to know all. I do try to read everything related to ocular surface disease and with a skeptical eye toward biased articles or books. I also am in contact 20-40 doctors a week who treat patients and have a good pulse on what works and doesn't.

I am always open to honest debate based on factual information.

[ringo]

Dear Indrep,

Thank you for the valuable links.
I perfectly understand and have mentioned in previous posts that currently available therapy for dry eyes is similar to "firefighting", meaning it cannot cure or completely resolve the inflammation that is causing the neural isolation of the tear glands.
I have also mentioned that the future of treaing fry eye will have to involve nerve growth factors, stem cell therapy, topical hormonal therapy, possibly implants in the eye that slowly release therapeutic agents, etc. This is what will truly help increase tear volume not only in quantity but in quality, and thus decrease tear osmolarity.
for now however,sadly, there are limiited options to control inflammation and its devastating effects on the neural isolation of the glands, which causes dysfunction and subsequent aqueousdeficiency, and also bad quality of any existing tears.
like i have spoken here with people who have a shirmer of 1 or 2-- they have no other options except to resort to the standard available treatments like cyclosporine and secretagogues like pilocarpine; otherwise they will really suffer.
Cyclosporine besides an antiinflammatory, is a potent tear gland stimulant, as it "disarms" pro-inflammatory neurotransmitters and substances that bind to the reseptors in the nerves, and thus allows or partially normalizing the nerv signalling to the glands, which allows them to release the tears and with improved quality. I have explained that in more detail in otehr posts(it is the pathology of dry eye).

You say "the only" way to stop inflammation" and "the only way" to do it is by preventing evaporation and increasing the tear volume-- but how are we going to do that with the medications available nowadays? can we really do that only with hot compresses and artificial tears?

Can that be done by symptomatic treatments only?

Thank you for your openness to discussion.

Dani

[indrep]

This is what will truly help increase tear volume not only in quantity but in quality, and thus decrease tear osmolarity.
for now however,sadly, there are limiited options to control inflammation and its devastating effects on the neural isolation of the glands, which causes dysfunction and subsequent aqueousdeficiency, and also bad quality of any existing tears.

Inflammation is not causing bad quality of tears. Its the osmolarity of the tears that is causing inflammation. Please read the DEWS report to understand the pathology of the disease. It is only possible to stop inflammatory responses when you can bring the osmolarity of the tear film back to normal.

Now once the epithelial cells are in contact with the hypertonic tear film the water is extracted from the cells and they die. This then leads to a disrupted mucin layer exacerbating the issue.

Can we change/alter the disease with the right artificial tear and warm compresses? The answer is yes, I am seeing it on a daily basis. It takes longer for some. My wife, as an example, took two years to go from quadraplugged and 13-14 drops a day of PF TheraTears to 1-2 drops of another tear and her sclera are almost white, hasn't had a mucous string in over 18 months.

I appreciate your personal experience and am glad you are finding relief. I am also aware of 1000s of other patients getting long term relief for less money and fewer drugs.

[Lucy]

Indrep, you are an invaluable resource to this board. I always read your posts with interest. Thank you for taking the time to interact with the dry eye "bunch" on DET. Lucy

[irish eyes]

I echo what Lucy has said.

[RobLIC]

This thread blows my mind. Indrep, can you please help me understand a little more about "osmolarity" and your point that cyclosporin (alone) is not likely to influence it? Thanks. Rob

[indrep]

Rob,
The simple answer to understanding osmolarity is that it is the balance of salts in fluids on either side of permeable membrane and the desire for the body to have those in balance.

Imagine a U shaped beaker with a water permeable membrane(epithelial cell wall) at the bottom. There are equal amounts of water on boths sides of the membrane, one side has 1 teaspoon of salt and the other side has two teaspoons of salt. The osmolarity is greater on the side with more salt. The body seeks equal concentrations. The membrane at the bottom does not allow salt to pass and allows ONLY water. The Hypertonic side(side with more salts) pulls water from the other side through the membrane.

On your ocular surface this action kills the cells on your cornea. This causes visual disturbance and discomfort. It also destabilizes the ocular surface exacerbating the problem by disrupting the mucin layer which holds the water on your ocular surface.

Now why can't Restasis/cyclosporine help most patients. First some facts:

Hypertonic tears (increased osmolarity) opens signaling pathways to brain to send inflammatory mediators to the ocular surface. (Research Vascular Permeability and you will know why, serum)
Inflammation is caused by hypertonic tear film.
Inflammation on the ocular surface closes the ducts of the lacrimal gland.

So what does Restasis do?
Restasis acts as antiinflammatory on the lacrimal duct allowing what tears are still produced to be secreted. Unfortunately by the time most people are prescribed cyclosporine their lacrimal glands are in such bad shape that not enough tear can be secreted to make a change in the osmolarity.

Dry eye disease is a progressive disease. Restasis only acts on the inflammation. To really stop the disease, the cause, increased osmolarity, must be addressed.

I hope this helps.

[indrep]

The Dry eye Shop has Oasis TEARS PLUS available, this is the TEAR my wife uses and has been using exclusively for 2 years.
The Glycerin in this product attracts and holds lipids and water, the HA is the delivery vehicle and holds the glycerin and water (1000 times its weight) on the ocular surface.

[cristiandryeyes]

Thanks to indrep and ringo for sharing your deep knowledge on this disease. I have read all your posts and I have reached a conclusion: THERE IS NO HOPE. Both of you have exhaustively tried to explain the underlying mechanisms of this disease, changes on the ocular surface and the role of inflammation and the inflammatory cascade BUT spent little time on the treatment matter which is in the end what we really CARE.


ringo's explanation seems a lot more convincing and REALISTIC to me BUT you leave little room for hope!. Actually I'd rather not have read some of your posts when you get too technical and everything makes so much sense and everything relates to my condition...because then, THEN IS WHEN I KNOW I'M IN TROUBLE.

On the other hand, indrep had a point until he talked about his wife as an example. Man, with all my due respect, artificial tears and warm compresses alone are not gonna cure us. AND I'm not waiting 2 years or more to check if you were right or not. When you've been doing warm compresses for THAT LONG, that's when you've to start thinking about the possible secondary effects of it.

Since you mentioned your wife's case, allow me to briefly tell you mine. Since I've been doing warm compresses, I've noticed MORE AND MORE RED VEINS AND INCREASED DRYNESS SENSATION DURING THE ENTIRE DAY. Of course, I have stopped them, but my eyes never got back to their initial state. I've never got any really relief from warm compresses, not even temporary relief.

So, All in all, I don't if it is good to know the details or simply ignore them. If you know the details you also know exactly how many possibilities you have to get over this. Where I am right now, I cannot assume I'm going to spend the rest of my life in this condition. So, if I'm going to stay like this, I need someone to tell me so I can take a decision whether I shall continue or not.

[mary kenny badami]

Cristian:

Artificial tears CURED ME, in a matter of weeks. That's my truth.
In my case, "Dr. Holly's drops," as I have written about many times before.
If not defined as a cure, one might call it a strategy to manage my dry eyes sufficiently and satisfactorily with a minimum of daily effort.
But only after several years of trying other alleged remedies with zero success.

However, I don't presume that what helped me will necessarily help other people.

My profile is/was different from yours: aqueous-deficient dry eyes.
Background: age-related/ post-menopausal female; problems made much worse by Lasik ten years ago; and with recurrent yearly episodes triggered in springtime whenever the pollen started drifting off the trees.
Remedy: nowadays I use eyedrops faithfully every morning and evening (and more in the springtime or if my eyes feel dry and itchy).
Duration: my dry eye problems have been fundamentally under control for several years now.

indrep's (and well before his time, Dr. Frank Holly's) posts about "osmolarity" were sometimes tough for me as a non-scientist, non-technically-oriented person, to understand
-- although indrep's wonderful analogy today, the one which starts "Imagine a U shaped beaker . . . " with the teaspoons of salt, made a lot of sense to me.

My opinion is that people who post on this board likely have a variety of physical and environmental reasons for our dry eye problems.

Therefore I am always wary when a poster -- any poster, whether doctor, patient, professional, family, or friend -- claims that any one solution will fit all.

Personally, I think that we do need the theoretical researchers and interpreters of research information to explain the MECHANISMS by which dry eyes occur,
so that their scientific explanations will guide the practical scientists and physicians who will help us discover, in each of our individual cases, RELIEF and CURE.
However, it sounds to me as though you are less interested in reading posts about the THEORY, and more interested in reading posts about the SOLUTIONS.

Cristian, you have eloquently expressed your sense of frustration today, which is one of the purposes of this bulletin board.
I hope and trust one day you will find a strategy -- whether from your own efforts, or recommendations by a doctor who really understands your situation -- to feel better for the rest of your life.

[Guest]

Indrep,

I was wondering what your thoughts are on Thera Tears (which is supposed to address the issue of hypertonic tears) vs Oasis Tears Plus. Which one do you think is the superior product and why. (presumably you believe Oasis is the better one since your wife had such good success with it, but I'd like to know WHY it is better)

Thanks a bunch!

[Guest]

Cristian,

I doubt that anyone will be able to give you a guarantee of if you will for sure get better or not... BUT, many here have improved dramatically after years of suffering once they finally found the right treatment - I know it's hard, but hang in there, and keep searching for solutions!

[indrep]

SAAG,
Before Oasis TEARS were available I thought TheraTears were the best available tear. I will try to explain.

Remember, we are trying to reduce the osmolarity of the tear film on the ocular surface to stop the signals to the brain for inflammation.

TheraTears attempts to do this by being a hypotonic solution. So if the tear film has a reading of 320 and you add a drop of Theratears at 280, theoretically you get a reading of 300, well within the normal range. Unfortunately the carboxymethylcellulose is a branched rigid moelcule and is easily moved off the ocular surface with blinking. The result is the water doesn't stay on the surface long enough, in most cases, to make a meaningful change in osmolarity.

Oasis TEARS PLUS has two ingredients, the active ingredient is Glycerin and the inactive delivery molecule is Sodium Hyaluronate(HA). Glycerin is also a branched molecule and would be blinked off the eye as quickly as the carboxymethylcellulose in TheraTears. The HA molecule is a viscoadaptive molecule and stays on the ocular surface for hours. Viscoadaptive means that under stree, when you blink, the molecule is long and linear. The lids move right over it. Then when the stress is removed the molecules intertwine and form a spongelike matrix holding the water, lipids and glycerin on the ocular surface. In layman terms the HA acts as a mucin layer holding the aqueous(water) and the lipids to form a more natural tear film. This process allows up to a 1000 times the molecule's weight in water to be held on the ocular surface. This is how TEARS PLUS lowers osmolarity and other tears can't.

I hope that helps and was easy to understand.

[Guest]

Thank-you for the explanation Indrep! It is perfect!

I've started using the Oasis Tears Plus again recently - now that I have my uppers cauterized, and the lowers plugged, plus the Lacriserts, I am finding that either the Oasis Tears Plus or Thera Tears give me the most comfort, depending on how my eyes are doing at the time.

I love this thread by the way - I crave some of the more technical info and debates! Not that understanding things better will always "fix" us, but it's very interesting all the same!

Sheralyn