Had the TearLab test with new doc--my tears are too salty.....

[tiff]

This new doc was amazing! Turns out I don't have ocular rosacea, just some redness on the lid margin. The tearlab test couldn't be performed on one of my eyes because there was no moisture, but the other eye registered a very high number and he said my tears are very much like saltwater. He is lowering my doxycycline to once per day, told me to stop restasis, use systane and blink tears instead of the oasis, genteal, refresh and theratears. I was also prescribed an antibiotic drop (form of zythromyacin I think). I asked him about meibomian gland expression and he said it's not necessary, just to do warm compresses. I am a little skeptical about this. In all, he was great and the staff was much more willing to educate me on all of this than the other prestigious, but not helpful places I've gone. Any thoughts on the antibiotic drops or the diagnosis of salty tears?
Thanks,
Tiffany

[SimpsonDesert]

Hello Tiff,

If your doctor has a Tearlab then that is a good indication he takes dry eye seriously. Osmolarity or 'saltiness' is a good indicator of tear film health and I had the pleasure of watching mine gradually come down from 350-odd to under 300 over a period of some 6 months, with corresponding improvements in lousy TBUT to the point of being close to normal readings.

The treatment was for inflammation (pred steroid drops, doxy) with omega-3 supplementation and hot compresses. It took ages and I had to stick to the treatments like glue. So persevere.

I tailed off all treatments and enjoyed months of wonderful normality, but am now having a nasty little setback that I expect to see reflected in the figures at my next appointment. The idea is to get as close to normal as possible, then go with a minimal regime to maintain the gains. Clearly I need to do a bit more than I was doing - we live and learn with this condition.

Wishing you the best - you sound as though you're in good hands.

Regards, Simpson Desert

[tiff]

Dear Simpson Desert,

Thank you so much for your helpful and kind response. I'm so encouraged to hear things improved for you! Did you also have dry eye issues (forgive me if this is a silly question)? If so, is it possible to get your eyes to make more tears without Restasis--it didn't work for me. Do salty tears also mean too few tears are being made or just that their osmolarity is not good?

I am looking forward to my next visit in 6 weeks to see if I've improved at all.

Tiffany

[indrep]

tiff,
The tears can be too salty (hypertonic) for two reasons: not enough aqueous production or aqueous evaporating too fast. The first issue is a lacrimal gland issue and the second can be related to the meibomian glands not secreting enough lipids to properly regulate evaporation or/and not enough goblet cells producing mucin to hold the aqueous on the ocular surface.

I would look into the Oasis TEARS. Its molecular structure holds over 1000 times its weight in water on the ocular surface. In order to lower the osmolarity water needs to be held on the ocular surface for long periods of time.

[SimpsonDesert]

Hi Tiffany,

Indrep has summed up the osmolarity issue much better than I could. Dry eye (which I do have) is not just about watery tears, it's about whether or not your entire tear film, which consists of aqueous tears, mebomian gland secretions, and the bottom or mucin layer is sufficiently stable (ie doesn't break up) between blinks to protect your eye surface. So you may not be producing enough watery tears, and/or deficiencies elsewhere in the system are allowing the tears to evaporate too quickly. A decline in your osmolarity counts is an excellent indicator of improvement, as is an increase in your TBUT (tear break up time) which measures both the stability of your tear layer, and shows the amount of pitting, or dead cells on the surface of your eyes.

Check my post under "Intl Plug a Doc" for the Dry Eye clinic in Sydney - it gives an outline of the tests done and the treatment philosophy for comparison with your clinic.

Steroids - they can be great for inflammation control but can cause CATARACTS or GLAUCOMA !!! so must be very strictly monitored. Eye pressure should be checked regularly if you are on them - apparently some people are steroid responders, and get elevated pressure, while others do not. I was on them for 5 months with no increase; Dr said 6 months was about the limit. A longish course of steroids and doxy did wonders for me - from torment to near normal, but along the way I actually felt even worse and drier, with grittiness and stinging from the drops, and the hot compresses which had felt so beneficial earlier seemed to stop working their magic. So don't give up too easily if having adverse reactions unless they're truly awful as the treatments are limited.

Can't comment on Restasis - some have found it helpful, and it is reputed to sting like crazy.

Tears - important to use the non-preserved individual vials, bottled ones have preservatives that are bad for long term use. Alas more expensive. I use Theratears, but I'd take up Indrep's suggestion if possible.

Even the experts seem to have a lot of trouble determining what part of the system is at fault, as once the tear film destabilises (for whatever reason) and the eyes become inflamed, everything seems to give trouble - glands block up etc. Ask your Doc what he thinks is the main cause of your problems. Mine were induced by necessary surgery.


If you're having a lot of pain, sometimes a low dose of an anti-depressant (in my case Endep) will be prescribed. In my experience, the pain relief was considerable and that makes such a difference - they work by raising the pain threshold in general. Some complain of feeling even 'drier' on them but I've found that while you're in the grip of an inflammatory bout, practically anything feels as though it's making matters worse in the short term.

It actually took about 2-3 months from starting proper supervised treatment to feeling real improvement and having no more staining; the cells on the surface of the eye regenerate on a 90 day cycle, and I do think people get impatient (understandably) and abandon treatment options too soon.

Here's a hint - keep a dry eye diary. Just an ordinary exercise book will do. For every visit, record your dry eye test readings, with a column for each eye. Note between visits how you felt, what your regime was, any conditions that seemed to help or hinder.

I recorded mine like this:

Date of visit -
Schirmers:------------(R) 6------------(L) 5
TBUT------------------(R) 4------------(L) 5
Osmolarity-----------(R) 310----------(L) 295
Staining--------------(R) 4/10---------(L) 2/10

Regime: Minims x 3 daily, Doxy 100 mg, 6000 mg Omega-3 etc...
Any other comments or recommendations Dr makes (so you don't forget), then record if they helped.
Observations - eg water in eyes didn't sting for first time, air cond more tolerable, drops made eyes feel even dryer, stung etc.

I found this invaluable in giving perspective, as I'm having an uncomfortable and worrying setback, and can compare current symptoms and measures with previous ones without recourse to memory, which can be terribly unreliable.

Stick to your treatments, be systematic, record everything and be prepared for discomfort enroute to (hopefully) improvement. My suggestions are non-professional and based on personal experience and reading, so do be aware your own treatment needs and responses may be different - eg due to allergies, other health issues, medications etc.

Good luck with your next visit!

Regards, Simpson Desert