Tried everything still suffer? Possible causes by Dr Mark Milner

[MGD1701]

Many said they have tried everything and still suffer.
But do you really have an ''accurate'' diagnose with reliable/objective testings
(trial & error can NOT stop the progression) such as

gland function/images (doctor expresses glands see if 'clear' oil comes out),
osmolarity, MMP-9 (for the inflammation level), lid layer thickness, blinking,
Tear Meniscus Height (for tear volume), dyes/stainings.
Did your doctors check inflammation (bacteria/demodex?, lid margins, lids (if sealed?), lift up upper lids??
Comestic, make-up, skin care products: pay attention to bad chemicals and effective/safe lid hygiene
More - my old post http://forum.dryeyezone.com/forum/ar...a-tea-tree-oil

Maybe this short video (actually for doctors, dated May 2017) explain WHY!
https://dryeyecoach.com/2017/04/28/d...y-eye-disease/

or
https://www.ophthalmologymanagement....o-conspirators

Prof./Dr Milner mentionos possible co-conspirators are (which often doctors miss them):

Conjunctivochalasis (CCH)
Superior Limbic Keratoconjunctivitis - SLK
Superficial Punctate Keratitis SPK
Allergic or Atopic Conjunctivitis
Chemical Toxicity (like hair spray, make-up)
Medicamentosa (toxic medication use)
Mucus Fishing Syndrome
Contact Lense Related Toxicity
Floppy Lid Sydrome
-----------------------------------------------
another one is even more informative/interesting (by the same dr) - as it includes treatment options!

https://dryeyecoach.com/2017/05/31/d...ded-algorithm/

[MGD1701]

found this informative article, published online 2017 January
from Current Opinion in Ophthalmology

Dysfunctional tear syndrome: dry eye disease and associated tear film disorders – new strategies for diagnosis and treatment

+ Goblet cell deficiency/mucin deficiency
Patients with goblet cell loss suffer from a subsequent reduction in mucin production. Attached mucin glycoproteins at the cell surface and soluble mucins interact with the aqueous component to affect the surface tension of the tear film and improve the spreading of tears across the ocular surface. Goblet cell loss and/or mucin deficiency affects the stability of the tear film. Although a rapid TBUT (<10 s) is frequently observed in patients with MGD, rapid TBUT is also observed in patients with goblet cell loss and/or mucin deficiency

The primary characteristics of patients with goblet cell loss are a recognizable deficiency in goblet cell density (observed directly via impression cytology or conjunctival biopsy or inferred through observation of conjunctival inflammation and scarring [42]) and subsequent deficiency of mucin production.

If available, in-vivo confocal microscopy can also be used to evaluate goblet cells and inflammation of the conjunctiva.

Goblet cell deficiency may result from or be associated with cicatricial conjunctivitis, such as Stevens–Johnson syndrome, toxic epidermal necrolysis, pemphigoid, thermal and chemical injuries, vitamin A deficiency, contact lens wear, and even epidemic keratoconjunctivitis (EKC). Additionally, patients with chronic chemical exposure or who habitually administer multiple ocular medications, such as glaucoma drops, may experience goblet cell loss

--------------------------------------
Exposure-related dysfunctional tear syndrome

Excessive drying of the ocular surface due to anatomic defects, improper functioning, or malposition of the eyelids may result in exposure-related DTS.

Failure of the eyelids to fully close or abnormal lid positioning exposes portions of the cornea to the external environment for an extended duration. Exposure of the ocular surface beyond the interblink interval can initiate or exacerbate dysfunction of the tear film.

Observation of the positioning of the lids during the external examination, in conjunction with a careful review of the patient's medical history and chief complaints, can assist in a differential diagnosis of exposure keratopathy. Patients with Bell palsy, Parkinson disease, or other neurologic disorders may exhibit an incomplete or partial blink. Additionally, rigid contact lens wearers may have a reduced blink reflex in an effort to avoid disrupting the lens position.

Characteristic staining patterns on the ocular surface are observed when dye is applied during a slit-lamp examination, thereby assisting in the diagnosis of exposure-related DTS due to conditions such as lagophthalmos. Lagophthalmos may be associated with complications resulting from blepharoplasty, scarring of the eyelid, thyroid eye disease, and other conditions.

-----------------------------
Dysfunctional tear syndrome co-conspirators

The term ‘DTS co-conspirators’ is proposed to refer to conditions affecting the tear film and ocular surface that may masquerade or exacerbate DTS. DTS co-conspirators include superior limbic keratoconjunctivitis (SLK), medicamentosa, Thygeson superficial punctate keratitis, mucus fishing syndrome, contact lens-related toxicity, chemical toxicity, allergic/atopic conjunctivitis, conjunctivochalasis, floppy lid syndrome, and corneal hyperalgesia.

Ocular allergy is a common DTS co-conspirator that often shares similar signs and symptoms with DED. Testing, such as in-office skin testing and tear film IgE analysis, may help identify this condition [52,53]. A thorough patient history review and examination are required to differentiate these DTS co-conspirators from one or more of the four main subtypes of DTS. Identification of the DTS co-conspirators is critical in the management of DTS because patients often present with persistent signs and symptoms despite general treatment for one or more of the subtypes of DTS. Undiagnosed and untreated DTS co-conspirators can cause exacerbation of DTS and/or misdiagnosis because of the underlying condition.

Other diseases that affect the ocular surface and tear film, such as allergic conjunctivitis, frequently coexist in patients with DTS and contribute to the signs and symptoms. All identified DTS co-conspirators should be addressed as part of a patient's treatment regimen. Treatment of these other ocular conditions is outside the scope of this monograph and should be managed according to the clinician's preferred treatment options. The ‘Diagnostics and clinical assessments’ section presents further discussion and detailed information pertaining to the description and interpretation of the diagnostic tests that are used to obtain a differential diagnosis.

from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5345890/

Mark S. Milner,^a,b,∗Kenneth A. Beckman,^c,d,∗Jodi I. Luchs,^e,f,∗Quentin B. Allen,^gRichard M. Awdeh,^hJohn Berdahl,ⁱThomas S. Boland,^j,kCarlos Buznego,^hJoseph P. Gira,^lDamien F. Goldberg,^m,nDavid Goldman,^oRaj K. Goyal,^p,qMitchell A. Jackson,^r,sJames Katz,^tTerry Kim,^uParag A. Majmudar,^p,vRanjan P. Malhotra,^wMarguerite B. McDonald,^x,y,z,aaRajesh K. Rajpal,^bbTal Raviv,^ccSheri Rowen,^dd,eeNeda Shamie,^ff,ggJonathan D. Solomon,^hhKarl Stonecipher,ⁱⁱShachar Tauber,^jjWilliam Trattler,^hKeith A. Walter,^kkGeorge O. Waring, IV,^ll,mmRobert J. Weinstock,^nn,ooWilliam F. Wiley,^pp and Elizabeth Yeu^qq

[PhoenixEyes]

I'm surprised SPK (Superficial Punctate Keratitis) would be an easy miss. Most doctors do a fluorescein stain dye test to diagnose dry eye and the keratitis shows up on that as little green dots.

[MGD1701]

Well, most of my doctors (maybe 65-75%), did NOT do lissamine green and fluorescein staining even they did tear osmolarity tests, took glands images. These two tests are important for dry eye.

[MGD1701]

..........

[PhoenixEyes]

Well, most of my doctors (maybe 65-75%), did NOT do lissamine green and fluorescein staining
even they did tear osmolarity tests, took glands images. These two tests are important for dry eye.
Now I know if doctors do not do staining, I should look for another doctor so root causes can be identified.

Wow I see, didn't know so many don't bother with the dye test. I've been getting it done at nearly every appointment, though I do have punctate keratitis.

[PhoenixEyes]

One ophthalmologist I see will sometimes carefully clean my eyelid margin by inverting the eyelids and sweeping across with a Q-tip which I guess is similar to debridement, they have to put anesthetic in first as I am sensitive. In my case the glands are largely blocked due to scar tissue I think after TEN, so it's more just to remove the build-up of mucous that will scrape along the eye surface, I am aqeous deficient as well due to lacrimal gland scarring so I guess the mucous doesn't wash away as normal. I think it helps briefly but things soon gunk back up again. I'm too wary to do it myself and not sure if the BlephEx rotating tip will be safe for me with how thin the skin is now on my eyelids (even wearing a bandage contact lens for a day caused a open nick wound under eyelid). But I think for those with less complications it could be worth a try, some places seem to offer BlephEx quite cheaply.

[MGD1701]

You are indeed very lucky. Any idea how to detect if we have such issue? No doctors told I have such issue.

Just found this interesting video. I am 100% sure none of my doctors waited for a few minutes. And yous?

according to Dr. Scott Schachter,
it makes proundly difference if wait for a few minutes - which he learnt from another doctor - it is so great there are many doctors share their knowledge!!
''Nuances of Fluorescein Dye and Fluorescein Staining''
https://dryeyecoach.com/2017/01/06/d...ence-staining/

[PhoenixEyes]

You are indeed very lucky. Any idea how to detect if we have such issue? No doctors told I have such issue.

Just found this interesting video. I am 100% sure none of my doctors waited for a few minutes. And yous?

You can just ask them to invert the eyelids to check. If you Google Blephex plus the name of your country you should be able to see if any opticians offer it. They have a channel with demo videos etc.

https://www.youtube.com/channel/UCTv...cOkpCn53aRsYtQ

Yeah that is an interesting video. Sometimes when I have to have both anheastetic drops and the dye they wait a minute so that the anesthetic can settle, but not specifically for the dye to settle I think. Though with me the staining is evident immediately I think, and they do spend a couple minutes while looking at the eye to examine my eyelids, how my tear duct plugs are sitting etc. so I guess if there was a big change on the surface they might notice. But certainly something that should maybe be made common knowledge in future ophthalmology / optician training.

[MGD1701]

BlephEx:
My last dr said I did not need it as my lids were so clean and no demodx were found (examined with slit lamp) - who also did not use staining.

Dr list for BlephEx: I asked the agent to provide, just near my city - they refused due to data protection - a joke, right?

[PhoenixEyes]

Dr list for BlephEx: I asked the agent to provide, just near my city - they refused due to data protection - a joke, right?

Weird. They already publically list doctors who offer it. I Googled your country + Blephex and found one listed on their site, might not be close to you though and if doctor says you don't need it then may be a waste of money / time.

[PG]

You cannot see demodex with the naked eye ...

[MGD1701]

Happen to find these. Maybe someone are interested.

Debridement of a "capped" meibomian gland
https://www.youtube.com/watch?v=7u8-yhstxwg

July 2017

https://www.youtube.com/watch?time_c...&v=j57ffQ4Olao

[mbperso]

My last dr said I did not need it as my lids were so clean and no demodx were found (examined with slit lamp)

Hi,
I asked my doctor to check if I have Demodex and he said he cannot see on the slit lamp, I need to analyse a lash.
Is that true ?

[MGD1701]

Demodex
Great, dr did not find demodex.
Well, demodex is hard to avoid/detect, so I use tea tree oil & only 5% can kill them, but some say 50% or 20%.
Dr. Sandra Lora Cremers has this interesting video
Best way to wash your face and use diluted tea tree oil
https://www.youtube.com/watch?v=14kFLBqXDHk