Tried everything still suffer? Possible causes by Dr Mark Milner

[mbperso]

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.

''clinical signs are important for diagnosis of DED. For example, lissamine green and fluorescein staining may reveal dry, devitalized, or dead cells and areas devoid of mucin on the cornea and conjunctiva''
By Jay S. Pepose, MD, PhD (June 2016), full text
http://eyetubeod.com/2016/06/the-val...evaluating-ded

Hi,
I never had lissamine green test or fluorescein staining or osmolarity tests. (I think because doctors never say what they are doing when they examine me !)

-What is the purpose of lissamine green and fluorescein staining ? What is the treatment if the test is positive ?
-What is the interest of osmolarity test once we have been diagnosed MGD ? I thought it was just to diagnosis a DED

-Demodex: my doctor said it is not possible to see at the slit lamp, he said the only way is to analyze a lash, so I don't know whether I have it or not.
Sometime I feel on the upper lid margin itching or slight burning (not in the eye)
I bought Steribleph that contains tree tea oil. Do you know it ?. I also have Heyedrate Lid Cleanser but I haven't yet tried them. One thing at a time.
Now I'm experiencing anti-allergic drops (Cromedil)

[MGD1701]

Heyedrate Lid Cleanser: Great you got it. How/Where did you get it? cost? Thanks!

fluoresein staining:
Doctors at 2 different (big) Uni. hospitals did that for me recently but one did NOT wait for a few minutes so I doubt if they could find useful info, according to my research.

Osmolarity + MMP-9/InflammaDry tests are pretty standard in USA. Doctors use Osmolarity values to monitor/adjust if their treatment plans work etc. If difference is more than 8 or 12, it means one has dry eye.

Demodex: sounds like demodex to me if these occur when wake up or midnight.
Demodex is hard to avoid/treat/detect, my strategy: tea tree oil product (soap-free) + pure HOCL spray.

Steribleph: never heard of it.

[mbperso]

..........

[mbperso]

Heyedrate Lid Cleanser: I've got it from a friend who went to NY. Delivered by amazon to his hotel. 43$ the big bottle.

lissamine green and fluoresein staining: do you know the purpose of this test and treatment ?

MMP-9: a doctor (professor) prescribed me Doxycycline in case of inflammation. So treatment has been given without confirmation of inflammation.
I noticed relief after 15 days, so I suppose I had it.

Osmolarity: we already know we have dry eye ! so it is not useful I think.

Demodex: itching occurred at any time in the day. No doctor are able to help me telling me whether I have it !
So I will try some products in case of.

Steriblef: exists in UK. Contains tea tree oil (Melaleuca Alternifolia Leaf Oil).
I prefer use product for specific eye usage, more simple and less dangerous.
https://www.cocooncenter.co.uk/densm...0ml/32770.html

BTW none of the doctors I saw, recommended lid hygiene, that's curious. And you ? Maybe in Europe it is normal

[MGD1701]

Hi mbperso

Lid hygiene
90% of my doctors did NOT recommend - which I find unbelieable since it is very important. But they all said I did not have inflammation - slit lamp examination only. None of doctors mentioned Omega 3 to me.

Densmore Steriblef Eyelids Foam with Melaleuca Alternifolia Leaf Oil - Thanks! Hope it helps.

[mbperso]

Hi MGD1701,

When I talk about HOCL spray to all my doctors, included "MGD specialist" they do not recommend it.
A professor even told me it is not good, because the eye needs bacteria's and HOCL will disrupt the flora.
BTW here doctors do not know these US products, and are not interested in what a patient could learn them. They just apply what they learnt and no more.
I noticed they often are in a hurry to finish the consultation because of my questions. They are embarrassed not to know the answers.
Is it the same for you ?
I finally found out THE MGD specialist of the country and will ask him all questions, but is takes 3 months to get an appointment.

[MGD1701]

(pure) HOCL spray:
bacteria around eyes are mostly staph - I am not an expert just did lots of studies/experiments - it is such fascinating topic. Well, I was just soso curious so I searched for alternatives since we dont have any - found 3 brands and only, NatraSan, made in UK, helped.

Avenova produces many educational videos at YouTube or visit their company (NovaBayPharma) website.
Many articles in American professional journals too. It seems now a trend, most doctors/professors recommend such spray, I have noticed it.

Well, dry eye is too new and too many new stuff.
Good luck with your new specialist - keep us informed. Thanks!

[MGD1701]

Osmolarity test:
It helps doctors to detect ocular surface health/disease - Most doctors find them important, what I have read/heard.
Found this interesting short video by TearLab, 2015 Nov.
''This video illustrates the damage that hyperosmolarity can have on the ocular surface and thus visual acuity.
Osmolarity increases due to a decrease in aqueous production and/or the decrease in lipid production.
Left undiagnosed and untreated, hyperosmolar tears become increasingly toxic to the corneal epithelium.''

https://www.youtube.com/watch?v=H-BeU5ZX4Co

-----------------
also found this interesting (old) video
Fluorescein Anterior Segment Instilation Technique ---2012
''If you use a 1mm round light as a target to fill - you will see how osmolarity is changing the tear flow.
With age, health, medicines, reactive oxygen species and toxins = lacrimal watery tear production is reduced also meibum oily production is reduced. This leads to dry eye and increased osmolarity.''

Such staining helps doctors find MORE useful info to detect causes - for example,
floppy eyelid syndrome and windshield wiper epitheliopathy
but more efforts so most doctors are not keen, I suppose??

https://www.youtube.com/watch?v=0O_-Y6HWwrA

[MGD1701]

I found this interesting/informative info.

Conjunctivochalasis / CCH : Symptoms, Diagnosis and Management

• Date November 25, 2016

''CCh is one of the most common under diagnosed and misdiagnosed ocular surface disease. Non-specific symptoms along with intermittent findings of conjunctival oedema often lead to misdiagnosis. Due to fluctuation in findings of disease process, several clinical exams may be required to confirm the diagnosis. Diagnosis of CCh is mainly clinical.

Slit lamp biomicroscopy (by an eye specialist) shows prolapsed or folds of conjunctiva in temporal, nasal or central part of lower lid-margin. Presence of redundant conjunctiva over lower lid margin suggests CCh. Prolapsed conjunctiva causes a disruption of tear movement and outflow through inferior lacrimal punctum resulting in epiphora.''

full text (aimu = American International Medical University)
https://www.aimu.us/2016/11/25/conju...nd-management/

[MGD1701]

Maybe someone are interested in this

Dry Eye Masquerades Jan. 26, 2018 by Dr Sumitra S Khandelwal, MD,

In this interview from AAO 2017, Dr. Sumitra Khandelwal explains her approach to managing patients who present with surface-related complaints.

Because she practices at a tertiary care center, most of her patients have already been previously diagnosed with dry eye disease and are on commercially available medication.

Their symptoms, however, still linger, which is often a sign of an underlying disorder.
According to Dr. Khandelwal, the key to diagnosing these patients starts with:

topography to assess the quality of the tear film, followed by a thorough slit-lamp examination and OCT of the anterior segment.

In her experience, some conditions that are often missed include conjunctival chalasis, anterior basement membrane dystrophy and superior limbic keratoconjunctivitis.

https://www.aao.org/interview/dry-eye-masquerades

[MGD1701]

Just found this interesting article Published March 15, 2018

Growing Pains

By Andrew S. Gurwood, OD

History

A 55-year-old Caucasian male presented to our office urgently with a chief complaint of a foreign body sensation in his right eye for a duration of two hours.

The patient explained that, before calling the office, he tried cold compresses and artificial tears, but could not find relief. He denied toxic exposure, trauma of any kind and any allergies.

more https://www.reviewofoptometry.com/ar...form=hootsuite

[MGD1701]

hi
maybe someone are interested in this video/article

Dry Eye vs. Neuropathic Pain: Which is Which?

March 27, 2018 By Anat Galor MD 1-Minute Video

Dr. Anat Galor provides tips on teasing apart the symptoms of dry eye disease from those of neuropathic pain in this 1-Minute Video.

Patients who experience ocular burning, or sensitivity to light and wind, are apt to have sensitized nerves rather than an ocular surface tear film dysfunction. A disconnect between the patient's symptoms and signs on an ocular surface exam may further indicate neuropathic pain, Dr. Galor says.

Patients who experience pain lasting longer than 15 seconds after receiving paracain eye drops, or those with tell-tale comorbidities (e.g., migraine, fibromyalgia, low back pain, depression or a history of LASIK) are likely to have sensitized nerves rather than dry eye disease.

https://www.aao.org/1-minute-video/d...uropathic-pain

[MGD1701]

Dr. Neda Shamie, an expert in cornea, LASIK and cataract surgery mentioned:

any autoimmune disease can affect the lacrimal gland where the tear is produced or structures around the eye that eyes.Once Dr. Shamie diagnoses the patient with dry eyes, she also thinks it is important to ask for other symptoms, in addition to Sjogren such as

joint pain, dry mouth, heat/cold sensitivity, tremors or weight loss/weight gain
to help diagnose the true underlying condition.

in an interview by Dr Raymond Douglas, MD, May 10, 2018
https://www.youtube.com/watch?v=s4syIVqe_hQ

[MGD1701]

Just found this from Prof. Alice Epitropoulos at Twitter
Maybe someone are interested:

''People with rheumatoidarthritis and thyroid problems are likely to have symptoms of dryeye.

It Also, may cause problems with inflammation of the eyelids (blepharitis).''

Some doctors recommend also check both T3 & T4 for thyoid.

[MGD1701]

I think this fits here better. Treatment Options for MGD

Seems many doctors, even in USA, still do not know several (new) options/tests, I therefore decide to compile this, hopefully it can help you achieve more.

Below is based on my daily learning/experiments & experience, in the last 2 years (since one & the only dr told me, 'Sorry, I can not help you,') from various American opinion leaders. Remember: only right order, combination, timing can achieve (the best) results and save money.

Firstly & most importantly, need all necessary objective data to identify causes & to stop progression. Especially

Gland images/status & oil status
(why important? Some oil still can seep even only 10% glands left, according to Prof. Preeya Gupta - in fact she was surprised too).

+ Osmolarity & MMP-9 (level of inflammation) tests
Some drs such as Dr Toyos prefers Keratograph 5M. Interestingly, about 95% (or more?) of these doctors do not perform Schirmer any more (for dry eye) - they consider it does not provide useful info.

Keratograph 5M (kind of LipiView + MMP-9 (debris in the tear?) + osmolarity & more, including tear meniscus height (tmh) - ''The DEWS II recommendation is for the tear meniscus height to be measured. A lower meniscus would indicate a more severe version of aqueous deficiency.”'' tmh can also be measured with slit lamp.
--------------------------------

Treatment Options

BlephEx, Debridement, Probing
(for inflammation (demodex/bacteria), capped glands, scar tissue etc.)

Manual expression (by doctors-- this is the cheapest)

Mibo, IPL, *LipiFlow (only removes obstruction/blockage)
Some people complain LipiFlow does not help, but other issues are to blame (e.g. inflammation (demodex/bacteria), partial blinking, CCH/folds, medication, allergies, eyes are open when sleep etc).

''Dr Periman, IPL first (to stop the inflammation) and then Lipiflow to push out whatever wasn’t addressed through IPL'' shared by hopfer_hiker, which I found useful to know.

*TrueTear...*FDA approved, only available in USA at moment
increase ALL layers production - works particularly effective for chronic pain

Probing
Debridement - tear can spread evenly.

If Inflammation presents
1) first BlephEx then LipiFlow
Prof. Marguerite McDonald mentioned that many opinion leaders NOW employ such combination for a better result, kind of 1+1=2.
BlepEx + LipiFlow = IPL, my own interpretations.
-Most doctors do NOT put plugs on when inflammation level is high.

2) IPL - particularly effective for people with rosacea/demodex/inflammation issue
According to opinion leader, Professor Preeya Gupta (from USA)
most successful for patients with
*advanced MGD, (mild to serve) evaporative DED
*+/- Rosacea or Seborrheic Dermatitis
*Telangectasia lid margins
. a non-laser light source
.suitable for almost any patient
(Dr Toyos, 1st dr who applied IPL to treat dry eye, mentioned in one of his videos that there is NEW model which suits for (almost) all skin types, I recalled)

--------------------------------
However, better & still need to:

-Master warm compress (not easy - one American dr even says most people do it wrong. It took me 3 months to realize the tricks. A MGD expert, Dr Caroline Blackie and her team found that so-called Bundle Method, 45C (& re-heat), proved to be the most effective. Many drs recommend: Burder/microwave or Blephasteam/electronic (constant/wet heat of 42.5C) In short, the best indication, in my view:
should feel 1) oil flowing & 2) great aftwards.

-Add omega 3 (+ GLA works more effective, that is why most doctors recommend HydroEye.

-perform Lid hygiene
(with pure HOCL to control bacteria overgrow, like *Avenova, only availabe in USA,
or Heyedrate (from USA but ship to UK etc??)
but I have managed to find an alternative, NatraSan, on the 3rd attempt - so you could try your luck too.) + healthy diet etc. The beauty of it: no resistance like antibiotics.

*Restasis - Good to get Restasis or *Xiidra (works much faster) - they work in a different way.

I have discovered all these (compress, omega 3+ GLA, pure HOCL) by myself which help my eyes fit. If I had knew all these, I should be able to reach to this stage in about 2 months not 10.

Above are just some NEW/basic but important tools.