New with some questions

[transientcat]

Hello all,

I have been lurking around for a month or so but this is the first time I posted. I have been having problem upon problem with my eyes (especially the right one) for 4.5 months. Before May this year, I had worn contacts for 12 years (Proclear compatibles) with realtively no problems except mild dry eye. Sometimes I used Systane 2 times a day and that was it. Then 4.5 months ago I developed a severe foreign body sensation in my right eye. I went to the OD and he same a small abrasion. I stopped wearing contacts and he checked it again in a few days and pronounced me healed. Problem is...The foreign body sensation never went away! I still have it, though it is better than it was. I saw 3 eye doctors including a specialist. They all agreed the sensation was from GPC, and it was the bumps that were causing the sensation. However, they saw GPC on both eyelids, and I only was symptomatic in the right. I tried so many brands of artificial tears (all preservative free only) and stayed out of contacts, with no help. Finally I tried a week of FML steroids (made it worse) and a week of Patanol/Pataday (made my eyes burn).

During these 4.5 months, my eyes have also gotten super dry, way worse than they were before the GPC. After reading this forum, I went to the eye doctor today and asked to be evaluated for dry eye, as probably this was also attributing to my discomfort. I had a Schirmers and a tear film break up test.

The results:
10 on Schirmers on left, 8 on right (I knew the right one was worse)
Tear film break up showed great lipid and water layer, but almost NO mucin!

He wants to plug my upper ducts with Smartplugs, and says that it will help both my dry eye and my GPC, and get me back to being able to wear contacts again (which I really can't wait for...I really don't like wearing glasses.)

But...I am kind of leery about the idea of getting plugged, and want advice.
Is a deficient mucin layer but good lipid and water layer "normal" for DES? Are my Schirmer's scores really bad, or just marginal? What do you all think about Smartplugs, and what do you think about getting uppers plugged only?

I told him that I would be researching before I tried the plugs, and he said that I should take my time. So I wanted to ask you all here what you think. For a newbie, this is all very overwhelming. I still am working on even finding an artificial tear that I like! After 4 months, I still haven't found one that "works" for me.

Thank you,
Emily

[Rebecca Petris]

Hi Emily and welcome.

Is a deficient mucin layer but good lipid and water layer "normal" for DES?

Not as far as I know. In fact, reading your post, I am really curious to know on what basis they're proclaiming your mucin non-existent.

Are my Schirmer's scores really bad, or just marginal?

Pretty close to normal - BUT depending how they performed the test this does not mean your basal tears really are normal. Lots of false positives with Schirmer.

What do you all think about Smartplugs, and what do you think about getting uppers plugged only?

Smartplugs are just about the most comfortable kind of plugs. Personally, I am not in favor of any durable material plugs inserted all the way into the canalicula because of the complications associated with them - relatively rare of course but when they DO happen they can be very serious. From a safety standpoint and especially for someone trying plugs for the first time, I prefer punctal plugs. On the other hand... punctal plugs may be very uncomfortable in the uppers. - Plugging only uppers is not common but there's nothing wrong with the idea.

I still am working on even finding an artificial tear that I like! After 4 months, I still haven't found one that "works" for me.

If no artificial tear 'works' for you then my guess is you don't have a problem that artificial tears can address sufficiently.

You might want to try some of the basic maintenance things many of us do here - despite having your oil glands given the all clear - like warm compresses and lid hygiene and Omega 3s. Can't hurt and may help.

A question: When is your foreign body sensation worst? Is it bad in the morning when you get up, or more late in the day?

[Eli]

Impression Cytology is the only test that I aware of to determine if you are mucin deficient or not. Actually, the test measures goblet cell density, which are the cells on your conjuctiva responsible for producing the mucin. If your OD didn't do this then I'm not why he feels that you have "no" mucin. Tear break up tests look more at the element of time; i.e. how fast your tear film will remain stable on your eye without blinking. I do not believe (I could be wrong) that it is possible to distinguish between the three layers of the tear film using only flourescein dye (the orange colored drops) and a blue light. There is a test (not widely available) that allows a doctor to observe the lipid layer, but requires special equipment. Also, I agree with Rebecca on the plugs. You might want to try something that is easily removable first, if only to make sure that you see some benefit to them. Lower plugs tend to be more comfortable than uppers, by the way.
Hope this helps

[transientcat]

Thanks for your replies. I am glad to know your feelings on the plugs. I am hesitant about trying them, as even though the eye doctos said they are relatively w/o complications, you seem to allude to the fact that they might cause some problems. Could you elaborate on what they may be? This is why I want to research it more before deciding. I really don't know why my eye doctor said these things about the mucin layer. He seemed so sure! Maybe I should try a new eye doctor? What do you think? Anyway, when I said that I couldn't find an AT that "works" for me, I meant one that 1.) Takes away the foreign body sensation and 2.) Gives me any relief of the burning and dry feeling that lasts longer than maybe 1-2 minutes.

The foreign body sensation doesn't seem to be worse or better depending on the time of the day. The eye doctor says it is from the bumps from the GPC under my eyelid rubbing on my dry eye.

Also, I am doing Omega 3s, but not the other things. I have been doing cold compresses due to the allergic nature of the GPC, but you think hot is better? How many times a day/for how long? Also, what is lid hygene and why would it help?
Thank you very much for your replies, I appreciate it greatly.
-Emily

[indrep]

Transient,
I rather doubt you are mucin deficient based on exam. As Eli said goblet cells produce the mucin and if he had done the test to determine goblet cell density he could make that statement regarding your mucin levels. Keep in mind that while people refer to three layers to a tear film it is actually more complicated. The mucin is more a gel that is thicker at the cornea and thins as its distance from the cornea grows.

Technically your schirmer scores could be normal but they may also reflect a quantity of reflex tears which then makes the scores unreliable for a diagnosis.

Once again on the tear film break up time two things could affect the score. First if you had reflex tearing the quantity on the eye could have affected the results, a false negative so to speak. Second the tear break up times seen on the cornea typicaaly are easily read after the disease has progressed significantly. You are likely to be in early stages of disease and the cornea has not yet started showing the signs of tear film instability.

As for plugs, I would ask for collagen plugs or teh extended duration pliugs first. See how you react to that first. The collagens are really too short term notice any sizable difference but most people do notice eyes feeling better. I personally would opt for silicone plugs to start with, they are easily removeable if need be. If you can't tolerate them, I would still avoid Smart Plugs and ask Dr. about OASIS Form Fit plugs. They are intracanlicular but very different in there inserted presentation. The smart plugs leave a space for tear to stagnate, the Form Fits completely fill the vertical canaliculus. theSmart plug is an acrylic material that can be more dense or hard and suspect to forceful irritation. The Form Fit is a hydrogel material that is soft like human tissue, it is 90% water when hydrated.

I hope this helps.