Dr. Korb - compromised lid seal found in majority of symptomatic dry eye patients who did not respond to regular treatments

[Guest]

https://www.healio.com/ophthalmology...-dry-eye-cases

I think it's best if you just watch the video at the link above so you get the words directly from Dr. Korb.

But in case the link stops working for any reason, here is a quick summary:

Symptomatic group of 50 with symptoms of dry eye that were recalcitrant to treatment - 80% had some form of compromised lid seal

Asymptomatic group of 50 - only 20% had some form of compromised lid seal

Treatment:
1. Tape lids tightly shut - not ideal though (he did not elaborate on this)
2. Use ointment or other highly occlusive medium to prevent air from reaching the ocular surface
3. Wear moisture chambers when sleeping that will prevent evaporation of tears at night

Lid seal issues lead to inflammation which leads to inflammation and desiccating stress at night that you must resolve.

My takeaways: if you have dry eye that is not responding adequately to treatment, it's worth considering lid seal issues since there are high odds that you have a lid seal issue. To me, even if one can't get confirmation via the test method he describes, the methods of treating lid seal issues are accessible to any of us, low risk to try, so why not experiment and see if one benefits.

[Milo007]

SAAG

Thanks for sharing this information.

From my personal experience I can say that I didn't initially realize that I was sleeping with my eyes partially open until Dowork123 pointed out that for me. After I started taping my eyes I am a lot better than what I was before. But yet I feel the tapes don't provide a perfect seal and it's effectiveness is variable.

I am thinking of trying the eyeseals 4.0 over my taped eyelids to see if it makes my eyes feel more moist overnight.

Also I would like to mention that I believe the reason why so many people are developing MGD is because they are becoming partial blinkers or developing nocturnal lagophthalmos which I believe in turn is an indirect consequence of a disturbed sleep pattern (due to modern lifestyle and blue light exposure from screens). People who fail to achieve a good sleep cycle often sleep with their eyes and/or mouth partially open. This was pointed out by my doctor when I told him that I was sleeping with my eyes open.

[Guest]

Milo007 Yes, I've long suspected that I sometimes (or maybe always??) sleep with my eyelids not completely sealed shut. So when I saw his video again today, I thought it was worth experimenting further .... I already know if I don't use enough ointment, I wake up way more dry than normal. I use the ointment not only as lubrication when sleeping, but to act as a seal.

Anyhow, I ordered a pair of silicone sleeping goggles today that are similar to the Eye Seals Rebecca sells https://dryeyeshop.com/collections/o...s-4-0-charcoal

I'm curious if they will make any difference.

[Guest]

There is a post replying to Milo from "guest" about sleeping goggles ... the "guest" is me.... rather than retype the whole thing, I'll just wait until Rebecca sees it and makes it go live

[Guest]

Rather than retype the first one, I'll just wait until Rebecca see it and makes it go live hehe

[Milo007]

Milo007 Yes, I've long suspected that I sometimes (or maybe always??) sleep with my eyelids not completely sealed shut. So when I saw his video again today, I thought it was worth experimenting further .... I already know if I don't use enough ointment, I wake up way more dry than normal. I use the ointment not only as lubrication when sleeping, but to act as a seal.

Anyhow, I ordered a pair of silicone sleeping goggles today that are similar to the Eye Seals Rebecca sells https://dryeyeshop.com/collections/o...s-4-0-charcoal

I'm curious if they will make any difference.

I would advice you to tape your eyelids before you put on the sleeping goggles because often the goggles get misaligned when people turn around while sleeping. So that would be a double protection.

Regarding ointments they don't work alone pretty well you will have yo use them in combination with tapes or sleeping goggles. The problem with ointments is that they tend to drain away from the ocular surface towards the eyelids (when your body temperature decreases it's viscosity and it tends to flow under gravity along the corners of the eye and the edges of the lower eyelids). So after a few hours at night the thick coating of ointment becomes thin over the exposed areas of the eyeballs and they don't protect them adequately.

If you use ointments tapes won't work so you will have to use a thin plastic sheet below the sleeping goggles. The pressure of the goggles will provide the seal.

Best of luck with your new find!
Keep us updated with the results!

[hopeful_hiker]

SAAG Milo007 Do you know if there are any sideeffects to taping eyes? Thank you for sharing the info.

[Milo007]

SAAG Milo007 Do you know if there are any sideeffects to taping eyes? Thank you for sharing the info.

To be honest there are possibilities of side effects with eyelid taping :

1. If you tape your eyelids tightly over your eyes there's a high chance that your cornea will be deformed by the elevated external pressure overnight. You will develop secondary astigmatism with an irregularly distorted cornea that can only be fixed using scleral lenses or laser assisted surgeries.

2. Taping your eyelids will result in loosening of the outer layer of skin over the eyelids overtime and can make the skin of the eyelids wrinkly.

3. Taping your eyelids tightly can increase your IOP to significantly high values that risks damage of your optic nerve. The increased IOP stays for 8-10 hours a day so that's enough time for potential damage. My IOP were 14 & 15 on 25th December 2018 before I started taping my eyes tightly. They increased to 21 & 22 respectively on 7th January 2019 after taping eyes tightly for just 13 days. Now I tape my eyes in a way such that they don't feel pressing over my eyelids but are snug enough to restrict my eyelids opening up too much. Taping this way for a few days (after 7th January 2019) I again re-evaluated my IOP on 15th January 2019 which came down to 18 & 19 respectively.

4. Taping your eyes can translate to adhesive intolerance and skin irritation (contact allergic dermatitis) associated with the adhesive of the tapes.

5. Taping your eyes will rip off some of your eyelashes everyday however carefully you remove them and make them disoriented (like a bird nest which is highly unacceptable for a woman I guess).


I am still managing with taping my eyes but I am considering using a moisture chamber goggle such as as eyeseals 4.0 as a substitute. Even though moisture chamber goggles come with their own potential side effects as well!

There's not a single "absolutely safe" way of keeping your lids mechanically closed till date I believe. Quite unfortunate for us.

[Guest]

I've tried taping before and just hated it... the skin on my lids is sensitive, and removing tape every morning didn't feel good at all.

[Milo007]

2. It was tricky to get tape on without causing a feeling of pressure on my eyes.

Yes so true! I have to re-adjust the tapes several times before they feel light over my lids. But sometimes I would wake up with slightly red and irritated eyes probably because a snugly applied tape is not always adequate to keep the lids absolutely shut and they fail those nights when I have restless sleep (heavy smartphone use the previous evening or having bad dreams). So in a way I am trying to say my eyelids open up more when I have restless sleep and the tapes fail if they are not tightly applied over my eyelids.

3. My eyelids stick to my eyeballs when they're shut for a while... and often if my eyes are really tired when I'm going to sleep, they start to stick almost instantly. So this means I can put ointment in and try to sleep, but literally within MINUTES find myself having to reapply it ... this process often repeats 2 or 3 more times before I finally stop feeling like my eyeball is starting to stick to my eyelid. It's a very uncomfortable sensation when this occurs, so not possible to ignore when it's happening. If I were taping, I'd have to remove and reapply the tape 2-3 times many nights, due to this kind of issue.

If your eyelids are sticking to your eyeballs and you don't have aqueous deficiency then most certainly your nighttime protection measures are failing - be it tapes or goggles they are simply not arresting evaporation of your tears from your eyes. As I have already mentioned and you confirm the same from your experience ointments or gels are ineffective for the purpose. Now regarding the reason the tapes were failing - your eyes were opening up below the tapes unconsciously. Trust me no matter how hard you try taping your eyelids shut they will open up below the tapes if you try opening your eyes since the outer skin of the eyelids are loose and they don't restrict the movement of the tarsus beneath them which retracts to create an aperture.If you have disturbed sleep your eyes open up quite a few times unconsciously and they may even remain open like you are half asleep.

My eyelids used to stick to my eyeballs when I didn't tape my eyes last winter. They felt horrible and would feel like raw skin peeling off. The pain was sharp.

Even now I am waking up with discomfort in the inner surface of my lower eyelids despite careful taping. That's why I feel something like eyeseals should be used as second line of defense to restrict dessication.

But honestly I am afraid of the potential side effects of eyeseals too. They create an environment around your eyes that's low in oxygen (no replenishment from the atmosphere) and high in stagnant moisture - both perfect conditions for bacteria to seek an advantage.

The long term complications?

Bacterial blepharitis and biofilm formation?

This scares me so much.


Well I have an advice for you. I think you could do an experiment with plastic sheets and medical tapes. Cut two round or oval pieces of plastic sheets of the size of your orbits. Attach tapes to the periphery of the plastic cuttings so that half of the tape strips are free to adhere to another surface. Now paste these cuttings to cover your orbits entirely creating a seal. Make sure there's no gap anywhere to let moisture out. If the seal is perfect you will notice the plastic sheet fogging inside within half an hour or less. Sleep with them on for a night. See if your eyeballs stick to your eyelids the next morning. If no your taping methods were failing previously. Next you could do the same thing with eyeseals 4.0 replacing the plastic sheet cuttings with the eyeseals. Put two drops of artificial tears (of your choice) in your eyes before you seal around your eyes. Ointments or gels won't be necessary if the seal is perfect.

The video demonstrates what I am trying to convey :

https://m.youtube.com/watch?v=YWQND6XSpac

[Guest]

Yeah, I'm aqueous deficient, have MG dysfunction (I'm pretty sure I have some truncated glands, for starters).

[Guest]

If anyone watches her video and finds it helpful, please click on the "thumbs up" button located below the video (on YouTube) to show your appreciation.

[Milo007]

What I do notice though is that if I can significantly decrease overall ocular inflammation, the eyelid sticking is much less. So trying to seal off my eyes at night better than I've been able to accomplish with ointment is on my list of things to try in an effort to improve things.

Cannot agree more. Infact when I am on steroids or I tape my eyes properly each night and there's no inflammation visible my meibomian glands start producing significantly more volume of lipids (I check them with my 15x mirror too). I believe dry eyes are a direct consequence of ocular inflammation - the causes of inflammation maybe different for different people.

Also note that evaporative stress due to a low LLT is a key contributer to inflammation so MCG is a must in the waking hours.

I'm also doing blinking exercises a LOT, in an attempt to strengthen the muscles used to cause a complete blink, and hopefully to retrain them so that they seal 100% at night eventually on their own... no idea if it's possible to accomplish this though. I figure at best, I increase the percentage of my blinks that are complete (studies show this is possible to accomplish with blinking exercises) AND maybe my overnight lid seal issues fix themselves thanks to the "training" of my blinking muscles. And worst case, the only thing that improves is that the percentage of complete blinks increases. Either way, I win.

Yes I believe working out your eyelid muscles and training them to accomplish a full closure will help address both incomplete or partial blinks and nocturnal lagophthalmos. Keep doing them!

re: eye seals and oxygen

My thinking is that since the eyelids don't breathe, the oxygen beneath the eye seal mask isn't going to go anywhere, but will just stay trapped under the nighttime goggles.

You forgot cutaneous respiration! Our skin do respire absorbing oxygen through cellular gaseous exchange. So overtime the little trapped reservoir of oxygen will be depleted creating an environment devoid of oxygen.

re: "Bacterial blepharitis and biofilm formation?"

Well, I'm also using Natrasan spray twice daily on my lids, which should help prevent that. I am also monitoring the openings of my MG glands with my 15x magnifying mirror... so I'll see early signs of anything going awry. Lastly, my plan is to wipe down the nighttime goggles with 70% rubbing alcohol every morning to clean them (I wouldn't want to do this at bedtime in case some lingering fumes would irritate my eyes... if I do it in the morning, all fumes will be long-gone by the time I have to wear the nighttime goggles again that evening.)

Those are the exact things I contemplated to counter the downsides of goggle use. It's great to know you are so careful about your measures.

You seem to be not sure about your meibomian glands. Did you ever have a lipiview or a meibography done?

Just curious about the results...

[Guest]

Now that better data is available, I'd definitely consider it since it's available in my home city. However, I won't be back for months so it's not something I can do right now anyhow.

[Milo007]

It's just that the quality of my secretions can change week by week, day to day... the appearance of my gland openings can change not only day by day, but hour by hour in terms of what's coming out of them, if anything is collecting in a little dome over them or if clear oil is coming out, etc. I can say with certainty that compared to the way they looked when I started with Blephasteam, they look a ton better. I can say with certainty that since doing copious amounts of blinking exercises, they look even BETTER still. However, they are not secreting the quantity of oil I'd like to see (based on my past observations), which is one reason why I'm going to continue with the Blephasteam and blinking exercises indefinitely for now in the hopes of reviving them even more from the damage done by this months-long flare up. Another thing I hope to gain by continuing with these is to prevent/minimize deterioration of my MG's in future.

OMG!!! Finally I found someone who's monitoring her meibomian gland orifices like I do. I have also been monitoring my meibomian gland orifices for the past 6 months initially with naked eye (I have good near vision) and now with the help of a 15x mirror I bought recently from amazon (by essential skin solutions). Like you said the lipid secretions change not only day by day but also hour by hour for me. And I have noticed that whenever I see lipids coming out of my gland orifices upon application of light pressure I don't have symptoms and my TBUT is well over 10s and it's sometimes more than 1 or 1.5 minutes! Also trust me I can observe the interference pattern of the lipids spreading over my eye surface (that's how LIPIVIEW records LLT). I do it by adjusting the light source creating a semi dark ambience over the eyes with some light reflecting from below the eyes. Doing so I can see the lipids spreading over my tear film and when my lid margins are thickly coated with lipids I see the interference pattern more vivid in colors (like an oil film over water reflects kind of a rainbow colored interference pattern). When my lid margins are dry and matt the lipids either don't reflect colors or very dull shades of colors.

Also I see epithelial cappings over my meibomian gland orifices that look like a bubble of skin trapping the lipids at the mouth of the orifices (mostly in the lower eyelid margins). When I puncture them carefully one by one with a sterile needle (0.45x13mm) they pop and some explode with lipids that floods the lid margin surface with thick lipid coverage that's highly reflective. I feel almost immediate relief after the procedure and the feeling of something evaporating from my eye surface vanishes instantly. My TBUT goes up to more than a minute. So the formation of these cappings are part of the problem for me.

The other thing that I have noticed is that the volume of secretions is directly related to inflammation. The days when I wake up with fresh eyes that aren't reddish or seem irritated I see my meibomian glands pumping more lipids (some eject out copious amount while others decent amounts). The days when I accidentally spill soap or shampoo in my eyes I see very low volume of lipids coming out of my glands for the next few days. The same thing also happens when my eyes feel dry for long in a dessicating environment or when I tape my eyes loosely and wake up with reddish/irritated eyes. So inflammation directly determines the volume of lipid secretions. I think the glands get blocked internally due to inflammation the same way our noses gets blocked due to inflammation when we catch cold.

In my case I don't see cloudy or turbid lipid secretions but the cappings are a problem for me and they reform within 12 hours after being popped. When I pop the cappings I see clear lipids coming out of my glands (provided the glands are not affected by inflammation).

Also, until recent years Lipiflow wasn't available in my home country and was still so new that I didn't see enough data to convince me it was worth committing to 4-6 treatments to fix things, and ongoing maintenance treatments every 6-12 months after that.

Now that better data is available, I'd definitely consider it since it's available in my home city. However, I won't be back for months so it's not something I can do right now anyhow.

I think having a lipiview done is of use to you. They will provide you clear picture of the morphological features of your glands and also important parameters like LLT or PB. But I am not a big fan of lipiflow which is way too costly for a one time compress and miking of glands. It's better to stick with blephasteam and blink exercises regularly.