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Dry Eye Triumph over Lagophthalmos and non-obvious MGD

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  • Dry Eye Triumph over Lagophthalmos and non-obvious MGD

    Summary:
    • Presentation: Young male, contact lens wearer, experiencing two years of dry eye symptoms including eyelid inflammation, stinging, eye dryness, blurriness
    • Diagnosis: Dry eyes due to non-obvious MGD, which in turn is caused primarily by exposure of eyes and eyelid due to daytime insufficient blinking and nocturnal lagophthalmos
    • Treatment: Lotemax to reduce and treat inflammation, Hylo preservative-free eye drops for dry eyes and daily use, night time use of eye goggles, daily Omega 3



    Details:

    Hi everyone,

    I wanted to lend some insight into how I have been overcoming my dry eyes. I spent a lot of time reading on this forum and getting a lot of good tips, and now I feel the obligation in sharing my past and current experiences to help others. For me, this condition is incredibly annoying, frustrating, and chronic - but I feel I am turning a corner and taking the fight back! So, without any more introduction, here is my story:

    Overview:

    I am a 29 year old male, living in Toronto, Canada. I am quite healthy - I am a very good weight for my height, I have a very nutritious and consistent diet with lots of vegetables, I generally sleep well, I weight lift 2-4 times a week and also love to run and bike, and have a great work-life balance and social life. I work on a computer for much of the day at my job, but I try my best to get up often and walk around. I have myopia and have been wearing corrective lenses since the age of 6, and since the age of 13 I have been wearing monthly disposable contact lenses. I do not have any other bad chronic conditions except for exercise-induced asthma, mild environmental allergies, and chronic rhinitis - all of which are treated on an ad-hoc basis with medications and have seemed to have gotten better the older I get.

    History:

    I always had some dry eyes whenever I wore my contact lenses for long periods - usually 10-12 hours a day. But I never had dry eye symptoms as a chronic nature - rather, it was always with contact lenses after wearing them for a long time.

    However, about two years ago, I started feeling dry eyes even well after my lenses were off. Eventually, my eyes got worse - I noticed redness and inflammation on my eyelids, stinging, and crusty eyes. I went to my optometrist, who said I had blepharitis but also noticed my cornea was scratched. She put me on meds and I went away to treat it. A few months later, it was still bad, and I then realized I was suffering from Dry Eye Syndrome (DES). My optometrist, although she tried, was not entirely confident in treating the DES. I insisted she refer me to an opthamologist, which I saw in June of 2013. The ophthalmologist told me much the same - that I had chronic blepharitis and MGD, and that I need to take artificial tears and get on Maxidex (a strong ocular steroid ointment). I did all that and indeed, after one month, I felt much better, but on follow-up I was told this my DES is chronic and lifelong, and I need to continue with artificial tears indefinitely. I was also told to begin taking Omega 3ís, which I did sporadically.

    Fast forward to May of 2014: DES strikes again, and in a big way. My eyelids were very red, inflamed, and I had constant dry spells. Wearing contact lenses, even for just 2-3 times a week at that point, was making it worse. I went full throttle on warm compresses, but they didnít help. In fact, I felt my eyes worsened with warm compresses. I then tried cold compresses, and although that helped, it was only temporary. I stared at my eyes constantly, trying to zero in on my eyelids and see what was wrong. I expressed my meibomian glands and to my surprise, I saw that in fact there was a clear, consistent oil coming out - I surmised at that point that my glands were fairly good, but was still stuck at what the problem was.

    Once again, I went to see my optometrist, who was completely lost with what to do. I insisted on being prescribed a steroid once again, and I went on Tobradex. At around the same time, being very frustrated with both my optometrist and the previous ophthalmologist, I began to search for another person to speak to. Not long after I started my search, I found a great optometrist in the Greater Toronto Area (personal message me for his contact). I booked an appointment with him, and next week was in his office. Diagnostic tests were run on me (most of the tests were done for the very first time, mind you) and included a TBUT, flurouesnece, blinking, and meibography (using infrared to see the meibomian glands). I then sat with the optometrist to go over the results and discuss next steps.

    Diagnostics and treatment:

    My TBUT was bad - about 5 seconds. There was obvious superficial damage to my cornea. My blinking was not entirely full either - my upper lid didnít go all the way and close down with the lower lid. And my meibomian glands were in a bad shape - he estimated they were nearly 60-70% atrophied! Interestingly, however, was when he examined my meibomian gland, they were working ok, letting out clear oil, although probably not in the quantity that was normal. In short, he said I have ďnon-obvious MGDĒ - in that the glands are not blocked and in fact secrete oil, but are still atrophied. Their atrophied state was causing less oil to flow out, thus causing evaporative dry eye.

    So what was causing the atrophy? At this point, it was hard to tell. There was a suggestion of possible androgen insufficiency, even though I had none of the symptoms to suggest so. But because of my demographic, he suggested I test for free testosterone, just to be comprehensive and rule it out. He also pointed out my insufficient blinking, to which I also mentioned to him how my girlfriend noticed that I was sleeping with my eyelids open. She noticed it on several occasions and even snapped a photo to prove it!

    In any case, the first step in my treatment was to get my eyes under control, to stop the inflammation and get rid of it, and get my eyes feeling better again. So, he put me on Lotemax, use Hylo preservative-free drops three to four times a day, and continue taking the PRN Omega 3 tablets that I had started a few weeks earlier. He also suggested I purchase the tranquil eyes googles, and begin wearing them at night, I was to follow-up one month later, with a decision point of either using testosterone cream on my eyelids, or punctal plugs, for further treatment.

    And so began my first month of treatment. During this month, I was judicious in keeping a dry eye journal. Each day, I would write how I felt, what happened, my diet, and as well I would write a score out of 5 of how I felt. This way, I could track the good days, the bad days, and maybe see if there was a pattern. Real detective work here! And of course, there were good days and bad, and I noted them all. At one point, nearly two weeks into this treatment, my eyes once again got worse, and I grew very frustrated. The inflammation and burning was back, but I kept on going with the treatment as told to me. Eventually the tranquil eyes goggles came in, and I started wearing those at night.

    And then, nearly four weeks later, my eyes started to feel better. Firstly, the redness went away, then the inflammation and burning feeling also subsided. I also crucially realized that my ďdry spellsĒ - those times in the day when all of the suddenly my eyes got dry - began to lessen. A few days before my one month follow-up, I was really beginning to feel better more consistently.

    At the one-month follow-up, my eyes were examined and progress was noted. At the first appointment I had, we were considering either testosterone cream applied to the eyelids, or punctal plugs. In the end, based on my good blood test results and no symptoms of androgen deficiency, we went with the punctual plugs. He put them in, and voila! Things got even better. I noticed right away how my eyes were more fluid and less dry - I got used to the feeling very quickly, and itís now been one week with the temporary plugs and I am feeling great.

    Itís still too soon for me to claim a substantial and sustained victory - I will need months of feeling good to claim that. I also know that there is more to accomplish here. For one thing, my goal is to wear daily disposable contacts 2-3 times a week, and I need to start slowly on that path. I also know there will be bad days ahead, and I need to prepare for those as well.

    In the end, we both feel that a probable cause of my non-obvious MGD is exposure due to insufficient blinking and sleeping with my eyes open at night. To think, if this really is the cause of my dry eyes, just how preventable it could have been earlier on.

    My tips:
    • Do not settle with an average doctor - go for the best in your area. Dr. Maharaj, on the two occasions I saw him, was great. He listened to me, answered all my questions, and suggested a very sound and accurate diagnosis and treatment.
    • Get proper diagnostic testing done. The tests I mentioned were key, and helped with the decision-making process.
    • Seriously consider improper blinking or sleeping with your eyes open at night! If you are like me, and your meibomian glands are functioning well, youíre young, you eat healthy and take Omega 3 pills, and still have dry eyes - it may be a physical problem. I have no idea why I sleep with my eyes open - I happen to have big eyes and long eye lashes - but regardless, I do. It sucks sleeping with the googles, as they are not very comfortable, I wake up blurry eyed since they press on my corneas, and letís face it, theyíre not sexy either! But ever since I have been wearing them, my dry eye symptoms have cleared up a lot.
    • Wear your contact lenses correctly and sporadically. I donít yet have enogh evidence to prove that my prolonged contact lens wear over many years is the cause of my DES. Regardless, having a piece of plastic over your eye for 12 hours a day, every day, is obviously not healthy - and you donít need an MD degree to know that. Limit your contact lens wear. My goal is 2-3 times per week, and only really on weekends or when I do extraneous sports. While at work, staring at a computer for much of the day, I donít need CL. You should think the same.
    • Sleep, eat, and live well. Itís obvious, we hear it all the time - but itís so true. Sleep in particular is important, and I realized that I need at least 8 hours a night to feel really good. My eyes benefit especially.
    • Donít give up. Try and try again, and seek our new theories and treatments. But also recognize that DES is really chronic and may be lifelong. When I heard atrophic glands almost never grow back, I was disappointed. I even though damn, if only I knew this a year ago, I could have saved some more of them! But whatís done is done, and vision is critical and I have that.


    Hope this helps! Itís a lot to take in, and like I said, I feel like I owe this community a potential solution that can help so many others. I am open to all questions and comments.

    Take care
    -JK

  • #2
    Are you still taking Lotemax? It is the only thing that has ever given me significant relief. However I was told you cannot take it long term due to risks of developing glaucoma.

    Comment


    • #3
      Hi,

      Glad you read my post!

      As it happens, I actually contacted my optometrist yesterday to ask about Lotemax. I've had a bit of a flareup over the past two weeks with my eyelids - they feel dry an itchy, but no serious inflammation. I will see him in a few weeks, but it could be that I will need to take Lotemax for flareups on a limited basis - like one week. The lotemax may be able to solve the minor flareups within that time; if it doesn't, it suggests something else stronger may be needed.

      But yet, long term, you should not take Lotemax, even though it's the mildest of the steroids out there.

      Update on my plugs: they have/are working great. I don't know if they are disolved yet, but it's been about 2.5 months so it could be so. Next step may be permanent plugs.

      Comment


      • #4
        Great to hear jk23, what do you think helped you the most?

        Comment


        • #5
          This is awesome news. What kind of diet do you follow?

          Comment


          • #6
            Any updates on this? I'd love to hear if you found more improvement , I have this type of mgd also, where
            Everything should be working as intended but just....isn't.
            it's so frustrating, this is the first post I've come across that's touched on the subject, very helpful reading.
            People have recovered, so can we.
            www.twitter.com/EyeGirlfriend)

            Comment


            • #7
              Hi, I would be happy to have updates from you as well. Mainly about your nocturnal lagophthalmos.

              Comment

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