A question for Dr Justin Bazan

[eva b]

Hi Dr Bazan, and first of all many thanks for offering our community your help and support.

Since no-one else has taken advantage yet, I will plunge in and be the first to ask you a question.

I've been told I have blepharitis, MGD and "slightly" dry eyes. I've been advised to do warm compresses and lid hygiene (which I perform religiously) and this does seem to help, and I use moisture chamber goggles over my glasses, especially outdoors. The only other suggestion from several eye docs has been to try to find a moisturising drop which I can tolerate.

To date I have tried every single type of preservative-free drop available in the UK - they are different to US ones, but basic ingredients are similar I guess: povidone, PVA, carmellose, hydroxyethylcellulose etc. There is not one which I can tolerate. They're OK for 2 or 3 days, then I get intense irritation, burning, stinging etc on my eyelids. Not so much on the eye surface itself, as on the lids (possibly conjunctiva as well).

I am resigned to the fact that I can't use moisturising drops, but what scares me is that last year I had a horrendous reaction to the drops used during a hospital eye exam - they were in a single dose unit, so preservative free I assume, and contained anaesthetic as well as fluorescein.

I've been told an allergy to fluorescein is not uncommon - my question is, what would you do if you had a patient with my intolerance and you had to see what was going on in their eye? are there any other dyes which would not cause this dire effect?

There will come a time, I suspect, when I need another exam, and what will I tell the doctor then?

[Justin]

Hi Dr Bazan, and first of all many thanks for offering our community your help and support. Since no-one else has taken advantage yet, I will plunge in and be the first to ask you a question.

Thanks for being the first! Your very welcome, I hope to be of some help.

I've been told I have blepharitis, MGD and "slightly" dry eyes. I've been advised to do warm compresses and lid hygiene (which I perform religiously) and this does seem to help, and I use moisture chamber goggles over my glasses, especially outdoors. The only other suggestion from several eye docs has been to try to find a moisturizing drop which I can tolerate.

Without seeing you as a patient, keep in mind all of this is just food for thought. None of this is to be taken as medical advice. I do hope that it helps open up your dialog with your doctor.

You do not just have "slightly" dry eyes. You have chronic dry eye disease stemming from your lid disease which is progressive in nature. I am really impressed by your diligence and I applaud your lid hygiene (cleansing, compress, massage) and can't stress enough how important they are. Keep it up!

Restoring the lid to a normal healthy state would be where my primary effort would be concentrated on. Doing so would allow you to minimize or eliminate the need for artificial tears, because your own tears would be able to do the job.

The lid hygiene is crucial but it alone is not cutting it. I encourage you to inquiry about additional treatments, most often topical or oral antibiotics and/or steroids that will supplement the lid hygiene. With your eyes seemingly allergic to everything, a few thoughts come to mind. Treatment for dry eye can work from the inside out, and with MGD, it most certainly can be a very effective way to treat. In your case, why put something in the eye that has the potential to cause an allergic/toxic response when you can treat the condition systemically. You might benefit from an oral treatment of a drug like doxy or neutraceuticals such as biotears, fortifeye, or tears again hydrate. Please ask your doc. You may also want to ask him about the simple day to day things that you can do to help decrease your need for a moisturizing drop, like maintaining proper hydration.

If a systemic route is not taken or in addition to it, ask your doc about Vigamox, a preservative free antibiotic, to be used to more efficiently treat your lid/lash condition. You may also ask your doc if an dermatologist/allergist can test you to officially find out what you are allergic too. Lastly you may ask your doc if a compounding pharmacist can provide you with preservative free steroids/and or antibiotics that may be usefully in treating your lid disease. I do feel at this point, finding a palliative artificial tear is not as important as to efficiently restoring a normal functioning tear film, which hinges on the optimal management of your lid conditions.

I am resigned to the fact that I can't use moisturizing drops, but what scares me is that last year I had a horrendous reaction to the drops used during a hospital eye exam - they were in a single dose unit, so preservative free I assume, and contained anesthetic as well as fluorescein.

That was a horrible experience that I'm sorry to hear you suffered through. It's ok now and it will be avoided. It was most likely fluress or a similar anesthetic/fluorescein combo that caused a type of toxic reaction on your eye. That is a very common occurrence. Without knowing exactly what you are allergic to, you will be locked into your routine of trial and error. You are correct in thinking that many of the drops share similar chemicals and components.

I've been told an allergy to fluorescein is not uncommon - my question is, what would you do if you had a patient with my intolerance and you had to see what was going on in their eye? are there any other dyes which would not cause this dire effect?

There are other dyes. Lissamine green and rose bengal can be used to look for clinical signs of ocular surface damage. I personally would consider using lissamine green applied with sterile unpreserved saline and a red filter.

Kindest Regards, Dr. Bazan

[eva b]

Hi Dr Bazan, and many thanks for your very comprehensive reply - it is much appreciated. I only wish I lived over your side of the Atlantic!

I am totally with you on trying to restore eyelid health and tear film as an absolute priority, and have been taking quite a strong Omega 3 fish oil supplement as recommended by eye doc, and am about to start (a little reluctantly, but needs must) a course of oral doxycycline. I do drink loads of water and herbal teas, so my hydration is more than adequate. (I'm an aromatherapist by profession, so the holistic approach is second nature to me)

I've already tried preservative free steriods (predsol) with bad reaction, burning and stinging, and really can't even use the (pres. free) saline which I occasionally used to any more without getting a slight reaction for the next 24 hours. My eyes seem to have become super-sensitised.

The most mysterious thing about all this is that last spring they got much better. The whole saga had originally started with a suspected shingles infection in one eye which I didn't know I had until my vision blurred. So by the time I saw a specialist, there was no infection, only scarring. however, they tried to treat it with various medications, and the subsequent frequent eye exams ended up with dreadful burning irritation.

But it did get better, and by the autumn my eyes were under control, with just compresses, massage etc. It was only when the hot air heating came on in my work place that the symptoms worsened, culminating in that last disastrous eye exam which you know about.

your suggestion of seeing an allergist is very appropriate, I think, and I will seek one out. Also, thanks for the suggestion of lissamine green - I've made a note in case I need it (hopefully not in the near future!)

You've given me a lot to think about, and some very good questions to ask my doctors.

with regards and gratitude
Eva

[Justin]

Hi Dr Bazan, and many thanks for your very comprehensive reply - it is much appreciated. I only wish I lived over your side of the Atlantic!

Your welcome. A quick search of the resources in London led me to this site. http://www.mclosa.org.uk/ I would email the admin and get a list of potential "second opinon" docs. If they are a part of this group, I would assume the have more of an interest in helping patients with your types of needs.

I am totally with you on trying to restore eyelid health and tear film as an absolute priority, and have been taking quite a strong Omega 3 fish oil supplement as recommended by eye doc, and am about to start (a little reluctantly, but needs must) a course of oral doxycycline. I do drink loads of water and herbal teas, so my hydration is more than adequate. (I'm an aromatherapist by profession, so the holistic approach is second nature to me)

The 03 supplements really need to be more than just strong fish oil for the body to process and utilize it properly. Please consult with Dr. Lange on this issue. I think the doxy is a good move. The herbal tea.....well a red flag popped up. How much caffeine do you suspect it contains? Is there a chance that it is acting like a diuretic?

Also, just yesterday I had a patient who had hypersensitivity to strong fragrances, like a makeup counter, flowershop, print shop, etc... This is a longshot, but have your eyes felt better when you were on vacation or just away from your job? I know the potencty of the aromatherapy products and I did have the thought that they might be contributing to your sensitivity issues. What do you think?

The most mysterious thing about all this is that last spring they got much better. The whole saga had originally started with a suspected shingles infection in one eye which I didn't know I had until my vision blurred. So by the time I saw a specialist, there was no infection, only scarring. however, they tried to treat it with various medications, and the subsequent frequent eye exams ended up with dreadful burning irritation.

That is actually pretty typical. That type of corneal infection can make the cornea less sensitive initially. One must also be aware of recurrences. It is possible that the nerve damage done by the virus is affecting the level of sensitivity your eyes are now experiencing.

But it did get better, and by the autumn my eyes were under control, with just compresses, massage etc. It was only when the hot air heating came on in my work place that the symptoms worsened, culminating in that last disastrous eye exam which you know about.

So at the least, we learned a trigger. Dry Heat. The partial solution would be a humidifier at work.

When you get a chance, think about the questions I have asked. I'm curious to hear your thoughts.

[Rebecca Petris]

Also, just yesterday I had a patient who had hypersensitivity to strong fragrances

What a great point to pick up on - whether or not it's applicable to Eva, maybe it will strike a chord with others. I know one fellow with lasik dry eye whose eyes are agony when he gets near anyone wearing cologne/perfume. He has to wear swim goggles at work. Identifying specific triggers is such a key part of the process of getting things under control.

[stella]

Thank you Dr Bazan - your reply to Eva has helped me greatly 'cos i have many of the same issues

[Justin]

Thank you Dr Bazan - your reply to Eva has helped me greatly 'cos i have many of the same issues

Your welcome, its always a pleasure helping. I appreciate the thanks.

[eva b]

Hi Dr Bazan, and Thanks once again for your detailed response

On the herbal tea front, I only drink caffeine free - I make sure of that!

and yes, your point about strong fragrances is a very good one. Since I've had these eye problems I haven't been using aromatherapy oils (I had to stop working altogether) - you're quite right, strong smells tip me over the edge so no scented cleansers/air fresheners or candles are used in my home. And I use no scented cosmetics or creams...in fact nothing at all on my face for fear of it migrating into the eyes. I have pretty much eliminated all possible sources of irritation that I can, and always wear foam lined goggles when doing any housework.

Thanks for the link to the MCLOSA site - I will certainly get in touch with them and see who is around in the London area.

I am aware of the possible recurrence of the original infection - that was part of the reason for my constant exams last year...none has every been seen, I'm glad to say.
However, I still am fairly convinced that it was the multiple instillation of fluorescein et al that has caused my hypersensitivity, because it is in both eyes, not just the one that had the suspected shingles.

Also, it's the lids which seem most irritable and where I feel the burning, possibly also conjunctiva - which would suggest some sort of epithelial issue, would it not? The surfaces of the eyes seem to be less troublesome, apart from feeling dry of course. But it's not where the pain is.

I'm glad Stella found this discussion useful as well - I hope some other members do too, then I won't feel guilty about monopolising your time!

thanks again, and regards
Eva

[Justin]

Also, it's the lids which seem most irritable and where I feel the burning, possibly also conjunctiva - which would suggest some sort of epithelial issue, would it not? The surfaces of the eyes seem to be less troublesome, apart from feeling dry of course. But it's not where the pain is.

I'm glad Stella found this discussion useful as well - I hope some other members do too, then I won't feel guilty about monopolising your time!

thanks again, and regards
Eva

Don't worry about monopolizing my time...remember, many people are just like you and are interested in getting some answers. You are there voice.

Some days I can spend more time online than others. But I can admit to being an internet junkie and will probably post at least every couple of days. Computer Vision Syndrome here I come! Not to hijack the post but, I do have quite an interest in CVS as well. Many of you guys are on the computer as much as me, so if you need some answers let me know.

The underside of your eyelids can quite frequently show a papillary reaction to an irritant. The irritant, causes the typically smooth skin of the underside of your eye lid to become inflamed and bumpy, kinda like sandpaper. This can be a source of pain for some. Ask your doctors about toxic papillary reactions. There are medical ways to treat this, but I hear people find relief in cold packs.

[stella]

Dr Bazon - advise please

Dear Dr Bazan -Thank you I will try your ziplock method of simultaneous heat and lid massage At present i use steaming as i find moist heat more soothing than dry
Could you recommend an eyelid/margin cream i could use at night please? My lids are sooo dry I have tried lots of things and am allergic to nearly everything i put in, on, or around my eyes
I have blepharitis (MGD) with evaporative dry eyes - probably associated with seborrhoeic (sorry for spelling)dermatitis 'cos i have a real struggle with scalp dandruff and dry areas down the side of my nose and behind my ears which i have to constantly moisturize
I have tried (on lids & margins only) lacrilube ,vasaline , olive oil - all seem to migrate into my eyes causing burning/foreign body sensation/prickle & itch
I had a chalzion and my GP ordered chloramphenical ointment to the lids -- to my amazement it really helped and the cyst went away in a week and i was able to tolerate it I have been using it ever since but tried to stop and got a flare up so have started it again - just the tiniest smear at night after eyelid hygiene.I use claramist in the day - a liposamal spray to the lids containing vits A and E and can tolerate that but it is not greasy enough It helps the DE i think(in place of eye drops)
Can I use the chloramphenical ointment indefinately ? - In GB we have a limited choice eg Erythromycin eye ointment is unavailable.
I also went on a course of doxycillen last yearfor 4 months and it was the first thing that helped me I try to keep that in reserve now if things get really bad . It would seem that antibiotics work for me
Thank you for your help and advise
Stella

[Justin]

Dear Dr Bazan -Thank you I will try your ziplock method of simultaneous heat and lid massage At present i use steaming as i find moist heat more soothing than dry
Could you recommend an eyelid/margin cream i could use at night please? My lids are sooo dry I have tried lots of things and am allergic to nearly everything i put in, on, or around my eyes
I have blepharitis (MGD) with evaporative dry eyes - probably associated with seborrhoeic (sorry for spelling)dermatitis 'cos i have a real struggle with scalp dandruff and dry areas down the side of my nose and behind my ears which i have to constantly moisturize
I have tried (on lids & margins only) lacrilube ,vasaline , olive oil - all seem to migrate into my eyes causing burning/foreign body sensation/prickle & itch
I had a chalzion and my GP ordered chloramphenical ointment to the lids -- to my amazement it really helped and the cyst went away in a week and i was able to tolerate it I have been using it ever since but tried to stop and got a flare up so have started it again - just the tiniest smear at night after eyelid hygiene.I use claramist in the day - a liposamal spray to the lids containing vits A and E and can tolerate that but it is not greasy enough It helps the DE i think(in place of eye drops)
Can I use the chloramphenical ointment indefinately ? - In GB we have a limited choice eg Erythromycin eye ointment is unavailable.
I also went on a course of doxycillen last yearfor 4 months and it was the first thing that helped me I try to keep that in reserve now if things get really bad . It would seem that antibiotics work for me
Thank you for your help and advise
Stella

Your very welcome. The Bazan Baggy might not be the best thing for you. Bringing dry heat and massage to an eyelid that is dry and irritated will in all honesty probably make it feel and look worse. Proceed with caution.

http://www.cetaphil.com/Products/Default.aspx
Has a good reputation. Is that echoed in the DEZ community?

Have you been evaluated for Rosacea or another masquerading condition like eczema? If you have not seen a dermatologist, I encourage you to do so. http://www.rosacea.org/index.php
Ask your doctors about using diluted dandruff shampoo as an eyelid cleanser. This is a very controversial topic, so you may here a few different opinions. Have you tried a foaming lid cleanser? Also inquire about Metrogel.

I am kind of amazed you are not able to get such a common antibiotic ointment. Call around, and keep in mind the internet has online pharmacies. In the US, tobradex ointment is usually the short term treatment of choice for many eye care providers. The steroid component really aids in the resolution of the typical inflammation associated with the condition.

Chloramphenicol is taboo in the US. I have heard good things from colleagues overseas, but I have 0 experience with it. I am glad you are enjoying success with it.

If the doxy helped you, ask your doctor about nutraceuticals geared to help the long term regulation of meibomian gland function. The doxy was working more as an anti-inflammatory than an antibiotic, the same way a nutritional supplement would work. Dr. Lange would be a great doc to consult with. Remember treating the underlying cause of the MGD is crucial to your success.

Lastly, if others are using/used claramist, kindly PM me your experience. I have not gathered enough experience with it to make a call on when, how and who to use this with. Thanks in advance.

[Rebecca Petris]

Lastly, if others are using/used claramist, kindly PM me your experience. I have not gathered enough experience with it to make a call on when, how and who to use this with.

Clarymist has several UK fans on the site... a quick search should bring up a lot of their posts. Also you might want to touch base with Tony Barnes who's a member here and I think is a rep of some kind for them - he's been very good about answering questions about it. I do not believe it has an exact equivalent in the US though (I think the Tears Again counterpart is different).

[stella]

Thank you again Dr Bazen for your prompt and very helpful reply

[eva b]

thanks, Dr Bazan, for another good suggestion - I went out today and got a cool pack to try on my eyelids in between the warm compresses.

I was intrigued by your comment to Stella about not using heat on eyelids which are already inflamed and irritated...perhaps I need to make my compresses a little cooler, although they do bring a lot of relief and I can almost feel the thick meibomian fluid becoming more liquid as the warmth penetrates.

I look forward to reading a thread on CVS - I think all of us on here are internet junkies, searching and searching for answers and ideas on how to improve our condition!

We're certainly lucky that you spend a lot of time online, cos you've provided a number of very useful links for us already!

[NYer]

Dandruff Shampoos for eyelids

Dr. Bazan,
Your posts here are immensely helpful. Thank you for taking the interest to take the time and care in your answers that you do. I hope you don't get bored with us. We need people like you here!

I'm very interested in what you said about using diluted dandruff shampoo as an eyelid cleanser. [This is a very controversial topic, so you may here a few different opinions. Have you tried a foaming lid cleanser? Also inquire about Metrogel.]

That makes so much sense to me, especially after having eye doctors look at my lids under their super duper magnifiers and tell me that they can see dandruff in the lashes. But what concerns me is that all of the dandruff shampoos go out of their way to warn about not getting it into your eyes.

So how do we use it on our eyes without getting it into our eyes? And is there a dandruff "shampoo" made specifically for the eyes?

Thanks!