How many drops a day are too much?

[Elegiamore]

I was saddened to see how many people needed to put drops in hourly in the daily routine thread. What a challenge!

However, I read an article by Dr. Holly on the Dry Eye Institute site that says

"In general, many types of artificial tears have been tried by the dry eye patients without noticing much beneficial effects. Frequent and heavy doses (flushing) were occasionally suggested with often harmful results, (punctate staining, burning sensation) resulting from the leaching of the mucin layer coating the ocular surface."

Rebecca and other smart folks - how often is "frequent" drops? I have dry eye spots on my cornea, probably from cornea damage from contacts in the past, and my eye doctor said to put in drops every two hours at least, to rush up the healing, but after reading the above, I dropped to four or five times a day.

As I am health insurance/cash handicapped now that I am presently unable to work, I'm not going back to the eye doctor for an update. So any thoughts or comments?

Many thanks and good luck, Elegiamore

[cristinalatina]

Elegiamore,

I have committed the same mistake since I had Lasik surgery. My surgeon's recommendation was to use drops hourly. That led to real pain and worse irritation. Now I use longer-duration drops (Dr.Holly's) every 2.5 to 3 hours, for a total of 5-6 times a day. In bad days I've used them more often, and in the end my eyes burn more than before. I really believe in limiting drops to up to 6-7 a day.

[Silverlady]

Some times more

For people with system and autoimmune diseases it is necessary to use drops more often. I have Sjogrens and have very little natural tears. I've been tested and test 1-3 on the Shrimmers test (not sure I spelled that right. So it is necessary for me to use drops sometimes as often as 35 times a day. We go thru a box of Bion tears bi-weekly. I try to use it less but it just isn't possible.

Billye

[indrep]

Hypertonic tears (Refresh) can actually reduce the goblet cell density on your eye. So, yes, depending on the type of drop you are using it can be harmful to an already compromised eye.

[cristinalatina]

Indrep,

my understanding is that you would suggest TheraTears to your patients based on its hypotonicity, which indeed would make a tear substitute very friendly to the eye, even with frequent dosing.

However, I read on this paper http://www.iovs.org/cgi/reprint/20/2/236.pdf by Dr.Holly that the tonicity of the tears can be lowered for about 1 minute after using hypotonic solutions - after that interval it quickly returns to baseline.

Does TheraTears work differently that you know of? Thanks for your time.

[indrep]

There are two studies that I am familiar with that show saturation dosing(every hour) lowers osmolarity and elevates goblet cell density. I think Neil posted a link to one of the studies (NIH, Gilbard). The other was from a Dr. Pfister in Birmingham, AL. Dr. Gilbard has an interest in proving this, Dr. Pfister is an independent ophthalmologist.

PS I have no patients I am just a lowly industry person.

[Rebecca Petris]

There are definitely multiple schools of thought on this topic, at a scientific level (Dr. Gilbard/Dr. Holly), clinical level (some doctors are in favor of frequent dosing, others warn patients against it) and practical level (this board itself over the years having given a lot of anecdotal evidence that frequent dosing is outright bad for some people but may be OK for others).

Clearly, if a cornea is in danger of erosions or ulceration, you have to keep it wet. (In that sense I agree with Silverlady.) On the other hand, what worries me sometimes observing the discussions here is that tears/gels/ointments get used (abused?) for pain management purposes rather than used for safety purposes.

Personally, I think that where alternatives to frequent dosing are possible, they are a good idea - including better environmental control, eyewear, humidification, compresses, etc. There are some "common sense" arguments about overdosing that have always made reasonable sense to me, including the idea that overdosing will wash out what little remaining good stuff we have in our tears - all the components that help protect our eyes from bacteria, allergens etc.

[indrep]

I agree with Rebecca on trying to control environment as much as possible.

The symptom of dry eyes is caused by so many different factors and there is no one answer for all of them. The one thing each individual can help control is the environment around their eyes.

Rheumatoid patients can minimize their meds by getting rest and watching their food intake. Dry eyes are the same way, rest warm compresses, etc. All of these disrupt your life but minimize what has to be put on the eyes.

[cristinalatina]

With the exception of people suffering from autoimmune disorders, like Silverlady correctly pointed out, I agree that limiting eye drops and increasing environment control is the best solution. I am not approaching the issue from an academic standpoint, but from personal experience - too much of any drops make my eyes hurt unbelievably. I use the ThermoEyes goggle to skip doses of drops, more inconvenient but in the end, worth it.

However, I couldn't stop using eye drops. I've tried that occasionally, and after 3-4 hours or after sleep I'm frantically looking around for a bottle.

[calli66]

Eyes Drops and Bandage Lenses

Drops:
I agree with Rebecca--based on what works for me. My dry eyes were greatly exacerbated by using too much saline solution. In the past, I used it to keep my contacts hydrated, and then at night--repeatedly--to relieve dryness. None of the thinner commercial eye drops work for me, either. Anything "watery"--even Soothe (which has a bit of oil) seems to leave my eyes drier than ever.

Right now, what works is Genteal Gel and TranquilEyes goggles at night. I have to use the gel with eyes closed--it's irritating with eyes open, so I can't use it during the day. The night treatment--over a period of months--has seemed to keep my corneas from getting dry spots, and that maintains itself during the day.

Too much dryness and watery drop treatment causes my eyelids to swell up--congestion and inflammation.

During the day, I wear contacts. Before insertion, I put a drop of Aquify rewetting solution in the lens, and I use Aquify or Blink during the day. The lenses keep my eyes hydrated. Without them, I'm pretty uncomfortable.

I feel pretty lucky to be able to wear contacts because my Schirmer score is 2-3 mm, and I live in New Mexico USA where the humidity is very low. I do field work in high altitude and harsh conditions for 5 months of the year, wearing contact lenses.

Bandage Lenses:
Dr G mentioned in a recent post that he was treating a dry-eye patient with a soft "bandage lens" (he was using the Focus N&D). I think there is great hope for dry eye sufferers in the use of bandage lenses. Right now, the choice of lens materials is a bit limited. But companies are continually improving materials and lens design.

I think this treatment technique deserves a lot more attention.
This could be something people could try before going the route of the Boston Scleral Lens. For those without refractive error, plano lenses are available, and for those with astigmatism, the "glasses over contacts" approach is a possibility, if no toric lens is available. And another thing: most doctors will say that it is better to wear a low water content lens (~30%) if you have dry eyes. But here in New Mexico, my eye doctors have always recommended a high water content lens (50%) which works well for me. But each person and lens is different, and the best fit can be found with trial and error. In the case of dry eye, the priority should be symptom relief and fit, before vision correction.

More attention needs to be paid to contact lens solution irritants. The most commonly available solutions are the "no-rub" type, which have detergents in them (very irritating to dry eyes). This COULD be the source of lens intolerance for dry eye sufferers. These solutions should be avoided, and only the "disinfect and soaking" type used. Even the hydrogen peroxide type solutions have to be thoroughly neutralized, or they are very irritating to the eye.

C66

[YGB]

Calli66 - you bring up an excellent point that has perplexed me from the beginning of my DES situation. I thought that maybe a special type of contact lens with moisturizer could help some folks with dry eye. Thus far, most feedback is that it's all (i.e. Boston Scleral Lens) or nothing (i.e. no lens at all).

As you stated, Dr. G. mentioned that he was treating a dry-eye patient with a soft "bandage lens" (he was using the Focus N&D).

Dr. G. ... if you are out there and don't mind sharing your trade secrets, are there certain lenses aside from the Focus N&D that we DES sufferers should consider before taking the BSL plunge?

[20/20_Hindsight]

My eye doctor, not knowing what else to try, decided to have me try a Focus N&D bandage lense thinking it might help protect my eyes from air movement. Well, it dried up on my eyeball in 30 minutes. It wasn't too bad while I was in my own house, but I had to take a trip to the vets that morning and 2 minutes after entering the vets office, with the central air going in the building, the lenses became dry and adhered to my eyeballs causing extreme pain. I had to make an emergency trip to the car to get them out. Maybe I am just too dry for these to work. I am in the "severe dry eye" category with corneal erosions on a weekly basis.

[DrG]

My eye doctor, not knowing what else to try, decided to have me try a Focus N&D bandage lense thinking it might help protect my eyes from air movement. Well, it dried up on my eyeball in 30 minutes. It wasn't too bad while I was in my own house, but I had to take a trip to the vets that morning and 2 minutes after entering the vets office, with the central air going in the building, the lenses became dry and adhered to my eyeballs causing extreme pain. I had to make an emergency trip to the car to get them out. Maybe I am just too dry for these to work. I am in the "severe dry eye" category with corneal erosions on a weekly basis.

Did you use rewetting drops?

[DrG]

Dr G mentioned in a recent post that he was treating a dry-eye patient with a soft "bandage lens" (he was using the Focus N&D). I think there is great hope for dry eye sufferers in the use of bandage lenses. Right now, the choice of lens materials is a bit limited. But companies are continually improving materials and lens design.

Sorry, this almost got by me and deserves a comment, especially in view of 20/20 Hindsight's recent experience. First of all, this should only be done under a doctor's supervision, and then it will almost always be necessary to use some type of rewetting drop to keep the lens hydrated. But, the lens will retain the moisture on the surface of the eye longer as opposed to having it dissipate immediately after the blink. It's an old technique that still seems to have utility for some patients, but certain precautions are necessary.

When I placed an RGP lens in this patient's eye, her tears did not coat the surface well.

[DrG]

Dr. G. ... if you are out there and don't mind sharing your trade secrets, are there certain lenses aside from the Focus N&D that we DES sufferers should consider before taking the BSL plunge?

Low water lenses have always performed better on dry eyes than high water lenses. Focus N&D has a very low water content, and so the lens dimensions aren't as likely to change as much when it dries on the eye...although there is certainly still that possibility. Unfortunately, it only comes in limited parameters, which may restrict the use of the lens to patients whose corneas aren't too flat.

One interesting note is that Ciba is going to be coming out with custom parameters in the O2Optix material...more diameters, more base curves, and more prescriptions.

I have seen more adherence problems with Proclears, probably because it is a high water lens.