Tried everything still suffer? Possible causes by Dr Mark Milner

[deep_dry_eye]

My eyes have been pretty good - only need 1-2 drops a day.
Not sure if restasis will help me - but wont hurt to ask.

Personally I think topical Azithromycin > Xiidra >> Restasis.

However, Azithromycin is usually not considered a long term drug. If you have access to Xiidra, I recommend that. I am personally on both Xiidra and Restasis at the same time. My latest meibography showed structural improvements after IPL + Xiidra + Restasis treatment.

[MGD1701]

Thanks for sharing and great that you have made many improvements.
You are lucky to get both Restasis and Xiidra.

Meibography
Which tool you use to show structural improvements? LipiScan or LipiView?

[deep_dry_eye]

Thanks for sharing and great that you have made many improvements.
You are lucky to get both Restasis and Xiidra.

Meibography
Which tool you use to show structural improvements? LipiScan or LipiView?

The exact tool doesnt matter, I've had LipiView and Keratograph 5m. TBH, they're all very expensive machines but prob really cheap to make, its just infrared camera.

[MGD1701]

Found this is interesting today, so it should be July 12. 2018 from Ocular Surface News

Lid Wiper Epitheliopathy – what is it and who is at risk? by Leslie E. O'Dell, OD, FAAO Director, Dry Eye Center of PA Lid Wiper Epitheliopathy (LWE) occurs when epithelial cells, cuboidal cells, and goblet cells of the upper and lower marginal conjunctiva (the portion of the lid responsible for spreading tears with blink) become damaged. The main theory is that mechanical stress is to blame. The repetitive motion of a blink over the surface of the eye or contact lens combined with an unstable tear film is thought to increase friction and put one at risk for developing LWE. Impression cytology has shown a reduction in the number of goblet cells in those with LWE.1 Vital dyes such as lissamine green, fluorescein, or rose bengal can be helpful in identifying LWE, as the damaged cells will take up stain and be easily visible with the slit lamp. The staining pattern should not be confused with the “normal” thin line of staining that identifies the line of Marx. The grading scale is a subjective measuring of both the height and width of the staining band; however, researchers have found that inter-observer variation is not uncommon, with most observers tending to over-estimate the height and under-estimating the width.2 Consider that many of us "practice" optometry. Throughout our career, beginning with our education, we are amassing knowledge and clinical experience. SOAP (subjective, objective, assessment, plan) is a part of every clinic day. We treat our patients, then follow them back over time. From this, we gain practical knowledge which can enhance our diagnostic and treatment efficacy. We get a good sense of what works and what does not, knowing that each patient may require tailored therapies. Studies have shown that our clinical expertise improves with patient experience, and we rely on it, without even realizing it, every day. In 2002, Donald Korb showed that LWE was present in 80% of symptomatic contact lens wearers (vs. 13% of asymptomatic patients)3. However, it isn’t only contact lens wearers we should be concerned about. In 2005, Dr. Korb also demonstrated that LWE was present in 67% of symptomatic dry eye study subjects vs only 12% of asymptomatic subjects.4His overall conclusion was that LWE seems to be a significant contributor to dry eye symptoms but is often overlooked. LWE should not be a concern only for our contact lens wearing patients, but all dry eye patients including those in high-risk categories. High-risk groups for LWE: Contact lens wearers Digital device users Incomplete blinkers Inadequate nocturnal lid seal Meibomian gland dysfunction/Evaporative DED Mucous Fishing Syndrome Cosmetics I recently led a multicenter study which demonstrated that both clinical signs and symptoms of dry eye disease correlated with a decrease in ocular comfort in patients who use cosmetics.5 We also found that lower lid staining is an important diagnostic test for cosmetic wearing patients and should be evaluated. Our understanding of LWE continues to grow as our diagnostics for dry eye disease expand. Additional research is needed to fully understand this condition and its implications on tear film stability and patient symptoms. More articles on LWE https://emailactivity1.ecn5.com/engi...ilID=324769695

[Hokucat]

MGD1701, this is a very informative article on LWE. Thanks for sharing it! I think something like this deserves to be posted in a new thread.

I’ve always thought of my lids like windshield wipers, and in my case especially as a scleral lens wearer for several years now. When my eyes got severely dry about half year after initially wearing sclerals, blinking was like having windshield wipers going over dry glass. I guess that might have been slightly better than blinking over dry eyes with no tear film and further damaging the eye surface, but it makes sense the lid “wipers” can get damaged too.

Now that I’ve been better able to manage, including comfortably wearing sclerals again as a key part of my daily regimen, I don’t feel like my lids are like windshields going over dry glass. But it’s something else definitely worth monitoring and addressing if an issue is developing with my lid “wipers”, by using drops over the sclerals periodically, wearing sclerals less hours, etc. I think me doing regular blinking exercises may have helped. Anyways, I believe my scleral specialist may already check for LWE, but am going to ask about it next time I see her, if I can see the green staining on my lids (see images in article below), so I can monitor for this going forward. I may also email her about it before then, as I just saw her a few weeks ago.

http://www.contamac-globalinsight.co...ns-or-the-lid/

[hopeful_hiker]

Interesting! I am going to pressure the doctors to tell me more about the lid wiper staining. I have blinking pain and some goblet cell loss but the doctors did not seem concerned.

[MGD1701]

Hi hopeful_hiker

Great you plan to pressure doctors - I guess that is only way to we can achieve more.

[MGD1701]

Have added Goblet cell deficiency/mucin deficiency etc on #2
in case someone cares to read.

[Italyboy]

Personally I think topical Azithromycin > Xiidra >> Restasis.

However, Azithromycin is usually not considered a long term drug. If you have access to Xiidra, I recommend that. I am personally on both Xiidra and Restasis at the same time. My latest meibography showed structural improvements after IPL + Xiidra + Restasis treatment.

Why you think azithormycin ( azyter drops in Europe ) is better than xiidra and restasis ?

i read that it’s just an antibiotic and plus you should use it just for 3 days ( I don’t think is enough too see result by the way )

but it I don’t get the connection between azithromicycin and restasis / xiidra

[deep_dry_eye]

Why you think azithormycin ( azyter drops in Europe ) is better than xiidra and restasis ?

i read that it’s just an antibiotic and plus you should use it just for 3 days ( I don’t think is enough too see result by the way )

but it I don’t get the connection between azithromicycin and restasis / xiidra

This is just based off personal experience. azithormycin is really fast acting and flushing out all the thick oil out of my glands. I was on 2 seperate 2 week trials (i.e., 2 weeks QD of Azyter).

[MGD1701]

found this interesting/useful

Systemic Disease Rising to the Surface
Keep an eye out for findings that might implicate these conditions during your anterior segment examination.
Published May 15, 2018

A thorough anterior segment evaluation remains a necessary component of every ocular health exam, and sometimes it can uncover a systemic diagnosis. Cataracts, floppy eyelid syndrome (FES), uveitis, conjunctivitis and episcleritis are just a few presentations that may have an underlying systemic component. In an effort to reduce ocular and systemic morbidity, clinicians must understand the relationship between these ocular findings and any associated conditions so they can clearly communicate with other pertinent care providers.


OSA Affecting approximately 15% of the US population, obstructive sleep apnea (OSA) has become an increasingly common sleep-related breathing disorder.⁸ The collapse of the pharyngeal airway during the sleep cycle leads to decreased levels of blood oxygenation and increased levels of carbon dioxide. Consequently, frequent arousal from sleep is necessary to allow for normalized blood-gas exchange.^9,10 Risk factors for OSA include increasing age, male sex, obesity, craniofacial and upper airway abnormalities and smoking.^8,11,12

Floppy eyelid syndrome
is a common, yet often underdiagnosed, ocular condition with a well-known association with OSA. Of those diagnosed with FES, 85% have OSA, whereas between 4% and 16% of patients with OSA will present with FES.^13,14 Due to increased laxity and easily everted lids, patients with FES often present with complaints of foreign body sensation, burning, tearing and matting, which are commonly worse upon waking as a result of exposure, mechanical irritation or both (Figure 1).^15-18 Consequently, corneal and conjunctival complications are common and may include papillary conjunctivitis, superficial punctate keratitis, keratoconus, filamentary keratitis and infectious keratitis.^15,17-1

Wilson’s Disease
This is a rare autosomal recessive disorder—a result of defective excretion of copper by the biliary system—that can lead to copper accumulation in various organs, particularly in the liver and brain.^1-4 Excess copper can be toxic and can result in acute liver failure.⁴ Neurologic manifestations of Wilson’s disease (WD) include personality and cognitive changes and motor dysfunctions such as dystonias, tremors and ataxias.¹

More
https://www.reviewofoptometry.com/ar...to-the-surface

[MGD1701]

read this today from Dr Neda Shamie
a great video

''Patient with contact lens intolerance referred for LASIK.
The main problem though is floppy eyelid syndrome (FES)...an under-diagnosed entity characterized by chronic papillary conjunctivitis in upper palpebral conjunctiva that is poorly respondent to topical lubrication and steroids.

With the right diagnosis, the patient is now receiving treatment for the underlying problem.
I may still proceed with lasik if he wishes for independence from contact lenses but not until I have optimized his eye surface.''

https://www.instagram.com/p/BnkPX5ZA...d=60x5pzwymdj0

[MGD1701]

Found this interesting article on SLK,

Etiology of eye redness key in treating ocular disorder by Michelle Dalton, ELS Apr 23, 2018

''.....In a case example, Dr. Rapuano spoke of a patient who presented with “some blepharitis, some lid thickening,” but nothing that was overtly obvious.

“Lifting the lid, I was a little bit more suspicious,” Dr. Rapuano said, noting there was more redness and inflammation superiorly, and when he had the patient look down, there was evidence of lissamine green staining.

“I did not rub the lissamine green strip on the eye—this was a very, very localized staining of the superior conjunctiva in the patient’s right eye, and a pretty identical superior lissamine green staining in the left eye,” he said.

Flipping the eyelid showed a “velvety pattern under the upper lid,” leading Dr. Rapuano to a diagnosis of superior limbic keratoconjunctivitis (SLK), which can often present in conjunction with dry eye or blepharitis that usually affects middle-aged females (3-5:1 female to male ratio).

“This is a condition [that is missed] all the time,” he said. “And
you'’ll continue to miss it if you don’t lift the upper lid and have the patient look down.”

This disorder is easy to overlook, but not hard to diagnose— SLK is typically bilateral, chronic, but is relapsing.

“Symptoms can come and go, often for months or years; it is associated with thyroid disease in about 30% of patients, so once you have the ocular diagnosis, consider a work up to determine if the patient needs to be treated systemically for other issues,” he said, although treating the thyroid disease will not help the SLK.

Unknown etiology

The etiology of SLK is unknown, but is most likely related to a mechanical trauma involving the superior palpebral and lax bulbar conjunctiva that is continually rubbing.

Clinical signs will include hyperemia, a redundance and laxity of superior bulbar conjunctiva, a “lack of luster and positive staining of the superior bulbar conjunctiva—and this is true for lissamine green and rose bengal dyes,” he said.

“In bad SLK you can get filaments and erosions and sometimes a superior pannus,” Dr. Rapuano said.''

This article was adapted from Dr. Rapuano’s presentation during Cornea Subspecialty Day at the 2017 meeting of the American Academy of Ophthalmology

full text
http://www.ophthalmologytimes.com/dr...cular-disorder

[MGD1701]

Vit. D and B12 play a role in (neuropathic) pain

Just shared what I have learnt recently.
One Indian professor mentioned this in an international conference so should have some level of credit.
sorry, I did not keep the details but good to do blood tests to find out if you have sufficient of these Vit.
Also read from another expert from USA mentioning similiar things.

Most people do not have enough Vit. D (due to office work or sunblock) but have no signs/discomfort.
Dont just take supplements, do blood tests first. Overdose is risky.

[MGD1701]

Doctors can only detect following masqueraders, if they lift up the eyelids
(check underneath the eyelid - both eyes)
(like #57 Dr Shamie does or following photo) to examine if

anterior basement membrane dystrophy, AMBD
flooy eyelid syndrome
papillary/allergic conjunctivitis
Salzmann's nodular degeneration
Superior limbic keratoconjunctivitis, SLK
etc. present.

Only 1-2 doctors flipped my eyelids and said no scar tissue were found.


Giant papillae in vernal keratoconjunctivitis
copied from American Academy of Ophthalmology
http://eyewiki.aao.org/Atopic_Keratoconjunctivitis