Dry eye after LASIK

[webeyeclinic]

Dry eyes after lasik is very common because with lasik you cut the corneal nerves that are very important to keep the eye hydrated and also keep the corneal cells function normally. Sometimes eye pain after lasik surgery can be due to blepharitis, under or over correction or sinusitis. It dont recommend to use restasis for long term as it has some potential and serious complications. Punctal plugs can be very helpful

[Justin]

http://www.eyeworld.org/article.php?sid=4381
OPHTHALMOLOGY NEWS Demodex treatment options
by Michelle Dalton EyeWorld Contributing Editor New treatment, old cause

Before Dr. Tseng and his colleagues tried the tea tree oil scrub, “there was no treatment that could kill the Demodex. You can clean the lashes and use the shampoo, but no agent could truly kill it. Tea tree oil does. That’s very major. If doctors can’t kill an organism, they don’t really know if the treatment is effective,” he said.
To diagnose the problem, Steven Safran, M.D., said initially the diagnosis requires examining the lashes with a microscope to know what to identify.
“[The mites] sit head down, tails up, with the tails aligned along the lash at the root,” Dr. Safran said. “Often there is columnar dandruff or cylindrical cuffing. If you rock the lash from side to side and pull, you’ll see the tails spread out along the base of the lash like little bristles. When you pull the lash, often the mites stay in the follicle, and you have to dip the lash back down into the follicle to get some of the mites onto the lash for evaluation.”
He said most patients are disbelieving at first, “until you show them the mites moving under the microscope. When they see that, they’re ready to listen.”
Dr. Safran stressed that epilating the lashes alone is not sufficient.
“With many of the first patients I examined, I missed the mites because I was just pulling lashes and looking, which was quite ineffective in many patients,” he said.

Ophthalmologists are just beginning to understand how the mite causes recurrent inflammation to eyelids

A species of Demodex on a patient’s eyelashes


Demodex furrowing into the eyelid of a patient


A patient with mild Demodex infestation on the lids
Source: Steven Safran, M.D.


Call it “The Case of the Mighty Mite.” For decades, refractory blepharitis has confounded ophthalmologists. Some patients respond to lid scrubs; some do not. Some present within days of a spouse’s presentation. Some present concurrently with pterygia. Blepharitis seems more pronounced in some than in others.
The cause of blepharitis may be as simple as the Demodex mite. A recent journal article noted a variety of pathologic features together with conjunctival inflammation can be found in patients with Demodex infestation of the eyelids.1 These same kinds of pathologies are commonly found in ocular rosacea, said Scheffer C.G. Tseng, M.D., director of the Ocular Surface Center and medical director, Ocular Surface Research & Education Foundation at TissueTech, Miami.
“When conventional treatments for rosacea fail, tea tree oil lid scrubs seem to eradicate the mites,” Dr. Tseng said. “In any type of ocular inflammation where the condition is refractory, doctors need to consider Demodex as a causative agent,” he said. “For instance, recurrent pterygia may be the result of an inflammatory disease, and it may be Demodex that hasn’t been well treated. That would explain the pterygia’s recurrence.”

Identifying symptoms of Demodex

Early morning itching and irritation is common with these mites because of their aversion to light, Dr. Safran said.
“They come out at night and mate, lay their eggs on the lashes, and then crawl back into the follicle in the morning, causing the patient to itch,” he said.
What makes the diagnosis of Demodex difficult is that some patients will have “a lot of Demodex, but no symptoms. I leave those people alone,” Dr. Safran said. “Other people have what appears to be an allergy to the mites causing severe itching and inflammation. These are the blepharitis patients that respond to Patanol (olapatadine, Alcon, Fort Worth, Texas), but it doesn’t cure them.”
In patients with facial rosacea, “the pathogenesis of skin lesions has been speculated to be caused by an increasing density of mites, which trigger inflammatory or specific immune reactions, mechanically block the hair follicle, or act as a vector to bring in bacteria,” Dr. Tseng said.

Tea tree oil treatment

Dr. Safran said Dr. Tseng’s identification of tea tree oil to treat the Demodex is novel, and he has slightly modified the formulation. While physicians can buy tea tree oil from most health food stores, Dr. Safran has also used an ointment Dr. Tseng is working on. If using the heath food store variety, he said to cut the oil to 50% in Macadamia nut oil.
“I apply it with cotton tip applicators after one drop of tetracaine, so there’s no shield required,” he said. “I am very aggressive with trying to get the oil into the lash roots and along the lashes to kill any eggs. I also aggressively treat the eyebrows. I don’t like the applicator dripping wet, but it should be moist enough so I can see the oil getting onto the skin when it’s touched. I treat the brow first, then the lid to get rid of the excess oil where it won’t irritate as much. I’ll do three applications a visit, about 10 minutes apart, and then finish with a tea tree ointment at 20%, which I have mixed for me at a compounding pharmacy. I do this for three visits, each one week apart.”
Dr. Safran warned other physicians not to use full strength tea tree oil. “I tried that on myself, and it was not a pleasant experience,” he said.
The patient must institute hygiene at home, he said, and that includes tea tree shampoo, scrubs and face wash.
Dr. Safran has patients follow this protocol:
• use tea tree shampoo for the hair and eye lashes every day
• use tea tree soap or face wash every day
• women should throw out makeup and not use any new makeup for a week
• clean sheets and/or buy new pillows
• ensure the spouse is checked
• have any pets that sleep on the bed checked
• for the first few weeks, patients should use tea tree ointment at night after the shampoo scrub at home
“If there’s a lot of inflammation, I like Tobradex (tobramycin 0.3% and dexamethasone 0.1% sterile ophthalmic suspension and ointment, Alcon) that’s replaced by bacitracin or erythromycin after one week,” Dr. Safran said.
Anecdotal stories from Dr. Safran’s patients indicate that upon presentation, on a scale of 1 to 10, most patients stated, “Red eyes are associated with not feeling well, lack of sleep, those sorts of things. When their eyes burn and are red, patients are very aware of it. After they have the tea tree oil treatment, patients’ scores go from a 9 to a 2, or an 8 to a 1.”

Surprising asides

“A surprising finding was that once we got rid of the mites, some patients’ vision improved,” Dr. Tseng said. “Originally we thought this was a coincidence. Because mites affect the oil glands, the tear film is not doing well. If the tear film is unstable, it will cause a blur when the eye opens quickly. Once the mites are gone, the tear film stabilizes, and the vision improves.”
He did note that not all patients’ vision will improve; the fact that some did was a pleasant surprise. “The tea tree oil is probably not the last word on killing [Demodex], but it’s better than anything else we have right now,” Dr. Safran said.
Editors’ note: Dr. Safran has no financial interests related to his comments. Dr. Tseng has filed a patent on the use of tea tree oil for ocular use.
CONTACT
Safran: 215-962-5177; safran12@comcast.net
Tseng: 305-274-1299; stseng@ocularsurface.com
References:
1. Kheirkhah A, Casas V, Li W, Raju VK, and Tseng SCG. Corneal manifestations of ocular Demodex infestation. Am J Ophthalmol. 2007;143:743-9.

[Justin]

You're welcome. It really is a pleasure helping out around here. TTO can be found all over the internet and locally at places like GNC, Vitamin Shop and other nutrition oriented stored. I do not make brand recomendations yet as I myself do not know much about how the various products differ. Dr. Tseng has me on his notify list and I hope to have his product in my office soon. With all your symptoms it really is hard to speculate, but your lids certainly need to be addressed and TTO is worth evaluating.

[BillyBoy]

Dr. Bazan, Your website is very informative by the way. You should write a book! Here is an article I found on Tea tree oil and the treatment of mites on eye lashes. Amazing info. Thanks for the tree oil advice!

OPHTHALMOLOGY NEWS
Demodex treatment options

by Michelle Dalton EyeWorld Contributing Editor

New treatment, old cause

Before Dr. Tseng and his colleagues tried the tea tree oil scrub, “there was no treatment that could kill the Demodex. You can clean the lashes and use the shampoo, but no agent could truly kill it. Tea tree oil does. That’s very major. If doctors can’t kill an organism, they don’t really know if the treatment is effective,” he said.
To diagnose the problem, Steven Safran, M.D., said initially the diagnosis requires examining the lashes with a microscope to know what to identify.
“[The mites] sit head down, tails up, with the tails aligned along the lash at the root,” Dr. Safran said. “Often there is columnar dandruff or cylindrical cuffing. If you rock the lash from side to side and pull, you’ll see the tails spread out along the base of the lash like little bristles. When you pull the lash, often the mites stay in the follicle, and you have to dip the lash back down into the follicle to get some of the mites onto the lash for evaluation.”
He said most patients are disbelieving at first, “until you show them the mites moving under the microscope. When they see that, they’re ready to listen.”
Dr. Safran stressed that epilating the lashes alone is not sufficient.
“With many of the first patients I examined, I missed the mites because I was just pulling lashes and looking, which was quite ineffective in many patients,” he said.



Ophthalmologists are just beginning to understand how the mite causes recurrent inflammation to eyelids


A species of Demodex on a patient’s eyelashes


Demodex furrowing into the eyelid of a patient


A patient with mild Demodex infestation on the lids
Source: Steven Safran, M.D.

Call it “The Case of the Mighty Mite.” For decades, refractory blepharitis has confounded ophthalmologists. Some patients respond to lid scrubs; some do not. Some present within days of a spouse’s presentation. Some present concurrently with pterygia. Blepharitis seems more pronounced in some than in others.
The cause of blepharitis may be as simple as the Demodex mite. A recent journal article noted a variety of pathologic features together with conjunctival inflammation can be found in patients with Demodex infestation of the eyelids.1 These same kinds of pathologies are commonly found in ocular rosacea, said Scheffer C.G. Tseng, M.D., director of the Ocular Surface Center and medical director, Ocular Surface Research & Education Foundation at TissueTech, Miami.
“When conventional treatments for rosacea fail, tea tree oil lid scrubs seem to eradicate the mites,” Dr. Tseng said. “In any type of ocular inflammation where the condition is refractory, doctors need to consider Demodex as a causative agent,” he said. “For instance, recurrent pterygia may be the result of an inflammatory disease, and it may be Demodex that hasn’t been well treated. That would explain the pterygia’s recurrence.”

Identifying symptoms of Demodex

Early morning itching and irritation is common with these mites because of their aversion to light, Dr. Safran said.
“They come out at night and mate, lay their eggs on the lashes, and then crawl back into the follicle in the morning, causing the patient to itch,” he said.
What makes the diagnosis of Demodex difficult is that some patients will have “a lot of Demodex, but no symptoms. I leave those people alone,” Dr. Safran said. “Other people have what appears to be an allergy to the mites causing severe itching and inflammation. These are the blepharitis patients that respond to Patanol (olapatadine, Alcon, Fort Worth, Texas), but it doesn’t cure them.”
In patients with facial rosacea, “the pathogenesis of skin lesions has been speculated to be caused by an increasing density of mites, which trigger inflammatory or specific immune reactions, mechanically block the hair follicle, or act as a vector to bring in bacteria,” Dr. Tseng said.

Tea tree oil treatment

Dr. Safran said Dr. Tseng’s identification of tea tree oil to treat the Demodex is novel, and he has slightly modified the formulation. While physicians can buy tea tree oil from most health food stores, Dr. Safran has also used an ointment Dr. Tseng is working on. If using the heath food store variety, he said to cut the oil to 50% in Macadamia nut oil.
“I apply it with cotton tip applicators after one drop of tetracaine, so there’s no shield required,” he said. “I am very aggressive with trying to get the oil into the lash roots and along the lashes to kill any eggs. I also aggressively treat the eyebrows. I don’t like the applicator dripping wet, but it should be moist enough so I can see the oil getting onto the skin when it’s touched. I treat the brow first, then the lid to get rid of the excess oil where it won’t irritate as much. I’ll do three applications a visit, about 10 minutes apart, and then finish with a tea tree ointment at 20%, which I have mixed for me at a compounding pharmacy. I do this for three visits, each one week apart.”
Dr. Safran warned other physicians not to use full strength tea tree oil. “I tried that on myself, and it was not a pleasant experience,” he said.
The patient must institute hygiene at home, he said, and that includes tea tree shampoo, scrubs and face wash.
Dr. Safran has patients follow this protocol:
• use tea tree shampoo for the hair and eye lashes every day
• use tea tree soap or face wash every day
• women should throw out makeup and not use any new makeup for a week
• clean sheets and/or buy new pillows
• ensure the spouse is checked
• have any pets that sleep on the bed checked
• for the first few weeks, patients should use tea tree ointment at night after the shampoo scrub at home
“If there’s a lot of inflammation, I like Tobradex (tobramycin 0.3% and dexamethasone 0.1% sterile ophthalmic suspension and ointment, Alcon) that’s replaced by bacitracin or erythromycin after one week,” Dr. Safran said.
Anecdotal stories from Dr. Safran’s patients indicate that upon presentation, on a scale of 1 to 10, most patients stated, “Red eyes are associated with not feeling well, lack of sleep, those sorts of things. When their eyes burn and are red, patients are very aware of it. After they have the tea tree oil treatment, patients’ scores go from a 9 to a 2, or an 8 to a 1.”

Surprising asides

“A surprising finding was that once we got rid of the mites, some patients’ vision improved,” Dr. Tseng said. “Originally we thought this was a coincidence. Because mites affect the oil glands, the tear film is not doing well. If the tear film is unstable, it will cause a blur when the eye opens quickly. Once the mites are gone, the tear film stabilizes, and the vision improves.”
He did note that not all patients’ vision will improve; the fact that some did was a pleasant surprise. “The tea tree oil is probably not the last word on killing [Demodex], but it’s better than anything else we have right now,” Dr. Safran said.

Editors’ note: Dr. Safran has no financial interests related to his comments. Dr. Tseng has filed a patent on the use of tea tree oil for ocular use.

[BillyBoy]

Thanks!

Thanks Dr. You have been a big help to me with your knowledge and support. I have to say this dryness I've had over the past 18 months has been like torture. Thinking about it every day and having to deal with it. Now I am on 5 days in a row with no signs of pain or discomfort. Just like the pre-LASIK days. I will try the tea oil. Where can I find this product? With all my symptoms, do you feel the main concentration is the eye lids (MGD, Bleph) or could it be from the severing of nerve endings in the cornea?

[Justin]

Great news! I would continue to do what is working for a couple more months and then attempt to reduce the dose again. You will hear varying ideas about long term systemic doxy use, but it is generally accepted that people can be on it for years. Ask your doc about what tests that can be done to monitor its systemic effects.

Natural remedies that come to mind would be food that has an anti-inflammatory effect. Check out: http://tinyurl.com/6edkuy

You may also want to u a 50% tea tree oil scrub as an alternative to the shampoo scrub.

[BillyBoy]

Update..

OK, well I am finally having "normal" days with my eyes 5-6 days out of the week. I have found that the warm/hot compresses 2x/ day along with lid massaging then gentle lid wiping with baby shampoo has helped tremendously. I continue to use the Restasis 2x/ day and Doxy 50mg 2x/ day. I never miss my daily fish oil and Hydroeyes and Flaxseed supplements. I limit my computer time to 3-4 hours per day with breaks every 30 minutes or so. I'm still trying to figure out if the LASIK procedure caused a reduction in lacrimal gland tears or caused MGD or Blepharitis or a combination of all the above. I did try reducing the Doxy to 50 mg once a day for 3 weeks and my discomfort started up again. When I went back to 100 mg a day, within 5 days I have nice wet eyes and no discomfort. A question Dr. Bazan. Is it possible to ever get off the Doxy? Any other natural remedies? Is the 100 mg/ day dosage considered a high dosage? I've been on it for 8 months now.

Thank you very much!

[BillyBoy]

Your Welcome. This is an excellant and important question. The short answer is Yes.

Bring this exact point up with your doc at your follow up. Restasis is not a magic bullet and for some individuals it can be ineffective and/or irritating. An eye that is irritated is not producing and maintaining optimal tear production and tear film. I'm sure a search of this forum might turn up several real world examples of this.

Thank you sir!

Bill

[Justin]

Dr. Bazan,
Could the Restasis actually have a negative effect in the short term and/or long term?Thanks!

Your Welcome. This is an excellant and important question. The short answer is Yes.

Bring this exact point up with your doc at your follow up. Restasis is not a magic bullet and for some individuals it can be ineffective and/or irritating. An eye that is irritated is not producing and maintaining optimal tear production and tear film. I'm sure a search of this forum might turn up several real world examples of this.

[BillyBoy]

Dr. Bazan,

One more question please. I have been noticing for weeks now that when I MISS a dose of Restasis, my eyes actually feel better that day or if I miss a night dose, I awake with wetter eyes. When I take the Restasis, it almost always dries my eyes out, almost like it's breaking up my tear film for several hours. My eyes then gradually get better as evening approaches. Most evenings now, my eyes feel completely normal. Could the Restasis actually have a negative effect in the short term and/or long term?

Thanks!

[BillyBoy]

OK Dr. Bazan. Thank you.

[Justin]

One more question. What are your thoughts on punctal plugs? I can already feel my eyes getting dryer since being on the beta blockers again. Do you feel the plugs may be worth a try? I was thinking of trying the smart plugs.

If there are no signs of infection or inflammation, plugs are an option you should look into. If you have good quality tears and you just want to increase the on-eye quantity, plugs can help accomplish that. Ask your doctor about temporary punctal occlusion. Keep us posted.

[BillyBoy]

One more question. What are your thoughts on punctal plugs? I can already feel my eyes getting dryer since being on the beta blockers again. Do you feel the plugs may be worth a try? I was thinking of trying the smart plugs.

[BillyBoy]

Thanks Dr. Bazan for your words of encouragement!

[Justin]

Thank you for the update!

Is it "normal" to take the doxy for over 6 months? Can it take this long to clear up the Bleph. or MGD with doxy?

I'm hearing some very good things! Your a great patient, and your hard work is paying off. It is a slow process. We are trying to make systemic changes, and those take time. Remember that the goal of the treatment is to get the bleph under control, but it will always be present....hopefully at a sub-symptomatic level. With that said, lapses in your routine can cause flareups. You are well within a normal time frame for the doxy treatment. I am glad to hear that you are tolerating it well, keep it up. Discuss with your doctor, how long your treatment is going to be. This is good info to be aware of.

Can day to day stress, lack of sleep (4-5 hours/night) cause or contribute to dry eyes.

You bet! For the normal eye, good sleep, 8 hours of sleep, gives our eyes a chance to revitalize.

I notice that when I travel even for a couple days (relaxation, rest) my eyes are hardly dry or sore! Of course my computer time is cut way down also. I have three cats. Can one become allergic all the sudden? Lots to think about. Geeez. I need to figure out why they are so much better when I'm away from home/office/ cats, etc!! Thank you again for your time and advice.

Keeping your computer time down to a minimum will surely help. Also, look into this: http://workrave.org/. It forces you to take rest breaks. I have been personally using it for a few days and find it beneficial.

You have a great mindset...I wish more of my patients harbored similar thoughts of being an allergen detective. An allergist would be your best bet to find out what your allergic to. Keep us posted, many of us here would like to hear about the role of allergies in your dry eyes.