A question for Dr Justin Bazan

[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.

[stella]

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

[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.

[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.

[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 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 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?