Dr. Rolando Toyos spends time with the Dry Eye Centre Experts

This past week leading Dry Eye expert Dr. Rolando Toyos came to London from the States and spent some time with The Dry Eye Centre experts Caroline and Conan.  

Dr Toyos is THE Intense Pulsed Light Pioneer. He discovered the effect of IPL on dry eye in 2001 and has been working since then to perfect his technique. The Dry Eye Centre has had IPL for two years now and we were the first clinic in the UK to have IPL for dry eyes. 

Dr Toyos, Caroline and Conan spent time over dinner discussing the latest dry eye treatments and impact on clients. The following day, Dr Toyos gave a talk at the Royal Society of Medicine where three Dry Eye Centre patients were given treatments from Dr Toyos as part of the presentation demonstrating the machines and protocols used by the Dry Eye Centre. 

We are the first clinic in the UK to be performing IPL to the exact protocol of Dr Toyos. 

Book an initial assessment to see if you are suitable for IPL treatment at the Dry Eye Centre.

Tear Film Ocular Surface Society Conference 2016

In September the Tear Film and Ocular Surface Society (TFOS) will hold its annual conference in Montpellier, France. TFOS are responsible for writing the definition of dry eye that all eye care practitioners use. They also organise research groups into the causes of dry eye, treatment and relationship to contact lens wear. 

At the TFOS conference, the latest research on the causes and treatments of Dry Eye will be presented by some of the most emminent researchers in the world, including Dr Donald Korb who discovered the relationship between Meibomian Gland Dysfunction and dry eye. 

Caroline Burnett Hodd, director of The Dry Eye Centre, was lucky enough to spend time with Dr Korb at his practice in Boston MA where she observed his method for treating dry eye. 

The conference will also present the latest evidence for Intense Pulsed Light treatment for Meibomian Gland Dysfunction. Caroline Burnett Hodd will be attending the conference.

Treatments for Aqueous Deficiency Dry Eye

The tear film is made up of 3 layers: an oily layer, a watery layer (called the Aqueous Layer) and a mucin layer. Deficiencies in the watery, Aqueous Layer can be caused by a variety of different reasons: medicines, auto-immune syndromes or LASER surgery (See causes of Aqueous deficiencies).

Eye Drops can alleviate some symptoms of Dry Eye

Deficiencies in the watery layer can lead to symptoms such as burning, grittiness and reduction in quality of vision as the cornea becomes dessicated (dried out).

While not all types of dry eye are helped by frequent use of artificial tear drops, we have found that many of our clients with aqueous deficiencent Dry Eye find eye drops help alleviate symptoms. In this case, drops should be used at least hourly.

Punctal plugs clinically proven to reduce symptons 

For aqueous deficient dry eye, the use of punctal plugs is our most commonly recommended treatment at the Dry Eye Centre. Punctal plugs can be used to block the puncta where the tears drain away. Clinical studies have shown that punctal plugs reduce symptoms and also decrease inflammation in aqueous deficient dry eye (footnote 1). 

There are two puncta in each eye, one on the top lid and one on the bottom lid, both near to the nose (see picture above). Punctal plugs are inserted and block these holes and prevent the tears from draining away.

Prescription Medicines can increase aqueous production in Dry Eye

In cases where drops and punctal plugs do not help, we often prescribe a cyclosporine drop called Ikervis. Ikervis has been shown to increase the amount of aqueous production. Probably by inhibiting a particular part of the immune system and hence reducing inflammation.

Scleral Contact lenses can be used to retain moisture

In severe cases where the cornea has become desssicated from dryness we often use scleral contact lenses to protect the ocular surface from the dryness. Scleral lenses are fitted so that they have a gap between the lens and the eye – this gap is filled with saline providing lubrication and protection to the cornea.

In conclusion, there are many different ways and combinations to treat Dry Eye. At the Dry Eye Centre, we evaluate each patient and craft a treatment program that is unique to your needs.

Please contact us if you would like to book in for an assessment and evaluation.

1 -April 2016 Effects of Punctal Occlusion on Clinical Signs and Symptoms and on Tear Cytokine Levels in Patients with Dry Eye

Causes of Aqueous Deficiencies in Dry Eye

The aqueous is the watery layer of the tears. It is produced in the lacrimal glands.

Deficiencies in aqueous production can be caused by:

• Auto-immune disorders, such as Sjogrens
• Medicines for blood pressure, anti-depressants, hormone replacement therapy
• LASER surgery
• Medicines for Acne, such as Roaccutane

Deficiencies in the watery layer lead to symptoms such as burning, grittiness and reduction in quality of vision as the cornea becomes dessicated (dry).

Here at the Dry Eye Centre, we diagnose aqueous deficiency using the Schirmer's test. In this test a small strip of paper is inserted under the bottom lid. The paper is left for 5 minutes and at the end of the test the length of the paper that has become wet from absorbing the tears is measured. A measurement less than 10mm is considered abnormally low. 

At the Dry Eye Centre, we try to understand the cause(s) of patient dry eye and aim to treat not only the symptoms of Dry Eye but also the cause of Dry Eye, where possible. We are happy to work with your GP or Consultant to develop a comprehensive medical approach that works for you. 

TearLab Osmolarity Test at the Dry Eye Centre

We are now pleased to have the Tear Lab Osmolarity test at the Dry Eye Centre. This is a useful tool in our diagnostic armoury.  The test measures the osmolarity of the tears. Osmolarity is a measurement of the number of solid particles in a solution. Increased osmolarity means an increased number of particles. When measuring tears this means that an increase osmolarity or hyperosmolarity means there is an increase in the saltiness of the tears compared to normal tears.

Hyperosmolarity is now included in the definition of dry eye. So an elevated level is 90% predictive that the patient has Dry Eye.

The Tear Lab test is easy to perfom and allows us to determine whether or not you have dry eye. In addition it also gives an indication of the severity. 

If you want this test included in your examination, please ask at your appointment.

Isotretinoin / Roaccutane use is a potential cause of Dry Eye

Isotretinoin is a drug used for the treatment of acne. It is a retinoid, meaning it derives from vitamin A and is found in small quantities naturally in the body. Isotretinoin binds to and activates nuclear retinoic acid receptors (RAR), thereby regulating cell proliferation and differentiation. This agent also exhibits immunomodulatory and anti-inflammatory responses and inhibits ornithine decarboxylase, thereby decreasing polyamine synthesis and keratinization. Isotretinoin noticeably reduces the production of sebum and shrinks the sebaceous glands. The exact mechanism of action is unknown, however it is known that it alters DNA transcription. It is a very successful drug in the treatment of acne.

Unfortunately the meibomian glands in the eyes are sebaceous glands and they are often affected by Isotretinoin. Many studies have shown that Isotretinoin causes dry eye symptoms as well as causing dry lips.

Patients taking Isotretinoin should use eye drops to keep their eyes lubricated and perhaps include an oily drop such as Eumistil. Contact lens wearers may want to reduce or cease wear whilst on Isotretinoin.

For most patients, these symptoms disappear after stopping the drug. However we have seen several cases where the symptoms have not improved. We have found both meibomian gland dysfunction and aqueous deficiency in these patients. If symptoms of dry eye do not disappear within 3 months after stopping the medicine we would recommend a dry eye assessment.

Good news for Dry Eye Sufferers: Ciclosporin eye drops

Ikervis has been launched in the UK. 
For several years now a medicine called Restasis has been available in the United States. Restasis is a drop containing ciclosporin. Ciclosporin acts by inhibiting the immune system. In the eye it helps to turn off immune cells that perpetuate the inflammation related to dry eye. These memory cell cause the condition to be chronic even when the signs of dry eye have been treated.

 In the UK we have not had a suitable alternative to Restasis and we were not able to prescribe it as it is not licenced here. However we now have a European alternative called Ikervis. Ikervis is also a ciclosporin drop. It is unpreserved and comes in unit doses and is used once everyday at bed time.

Unfortunately, it is not yet being prescribed on the NHS but as one of the few clinics in the UK that is licensed to prescribe medicine for eyes, we can give a private prescription at the Dry Eye Centre.

Book in for an assessment with our experts to see if Ikervis may be right for you.

Do I have Dry Eye? : Common Symptoms of Dry Eye

What are the most common symptoms of Dry Eye?

The most common symptoms of dry eye are:

  -Soreness
  -Burning
  -Gritty sensation
  -Redness
  -Visual disturbance (that often changes on blinking)

Dry eye has been shown to have a significant impact on quality of life and has also been linked to depression. We don't yet know what exactly causes dry eye, but we now know that there are two different forms of it. It can be mild to very severe and can sometimes fluctuate over time.

Take our questionnaire to find out if you have Dry Eye. 

Aqueous deficiencies: Why IPL is not a suitable treatment?

Do we use IPL for aqueous deficiencies? 
Intense Pulsed Light treatment is primarily for Meibomian gland dysfunction. Although it does reduce inflammation to the eye it is not an effective treatment for aqueous deficiency as the aqueous is produced in the lacrimal glands of the eye.

At the Dry Eye Centre we have many treatments for aqueous dry eye such as punctal plugs and ciclosporin medication. We will determine the type of dry eye you have at your initial assessment. If you have combined aqueous deficiency and Meibomian gland dysfunction then we may recommend IPL as part of your treatment.

8 Tips to Prevent Dry Eye when You're Gaming

8 things to do to prevent dry eye when you are gaming:

1. Make sure that your screen height is sensible, if it is too high your eyes will be more open than usual which promotes more tear evaporation.

2. Make sure that you are NOT sitting directly facing an air current. A blow heater, air conditioning or even a draft from a window will quickly dry eyes that aren't blinking much.

3. Set a timer so that you are reminded to blink. Bear in mind that we should be blinking 15 times per 3 mins at least. Set a timer on your phone or get some freeware to remind you to blink.

4. Use preservative-free artificial tears at regular intervals.

5. Invest in a humidifier for your gaming room.

6. You might want to try out moisture chamber glasses.

7. Use the natural breaks in the game to pause and blink for 20 seconds.

8. Take a break every 20 minutes and blink 20 times in 20 secs while looking into the distance. 

For some people the dry eye has gone too far and they need specialist treatment, like prescription eye drops or Intense Pulsed Light treatments. 

Gaming Eyes can often be minimised by following the steps above and by practicing good eye hygiene. If your eyes continue to bother you at the end of the day, however, they are telling you something so you may want to consider cutting back the hours you spend gaming and see a Dry Eye Specialist if the pain and irritation continues. 

An Eye for Gaming

Playing video games calls for extreme concentration. In order to succeed you need to stay constantly alert and vigilant...after all getting sniped whilst playing Call of Duty usually occurs within a 'blink of an eye'. As such, serious gamers (and other people who spend long periods of time concentrating on a screen or monitor) can often go minutes without blinking.  Whilst this is good for gaming, unfortunately, it’s not so good for your eyes. 

An average person blinks around once every 12 seconds. Some gamers can go minutes without blinking. This soon has an impact on your eyes. People often experience 'Gaming Eyes'  after prolonged screen use. They complain of sore, bloodshot, dry eyes, often with headaches and back and/or neck pain and occasional blurred or double vision. The medical term for this is Computer Vision Syndrome and at The Dry Eye Centre we are seeing an increasing number of patients suffering Dry Eye as a result of prolonged screen use. 

If you're experiencing any of the above symptoms after spending long periods of time at work or play staring at a digital monitor, we would recommend having an assessment done by a Dry Eye Specialist. Without treatment, mild symptoms can growing increasingly worse and there are usually simple treatment(s) available to treat both the cause and symptoms you experience. 

    

FAQ: IPL Treatments at the Dry Eye Centre

One of the most frequently asked questions we get is: Why can’t I have Intense Pulsed Light treatment without having an initial assessment?

At the Dry Eye Centre we always perform an initial assessment before carrying out any treatment. We do this is because it is essential to determine the cause of your dry eye so that we can give you the correct treatment. Intense Pulsed light treatment does not work for everyone. We have many other treatments which may be more effective depending on the type of dry eye.

Do you have a question for our Dry Eye Experts? If so, leave a question in the comment section and we will use it in an upcoming FAQ post. 

Dry Eye and Computer Screens

At the Dry Eye Centre we have been astounded by the number of working-age patients that we see. Until recently dry eye in this group was uncommon. In our modern world many of us spend most of our day in front of a computer screen or using tablets or mobile phones. When we perform this type of activity our blink rate drops significantly as does the quality of the blink (often it stops being complete). One explanation is that when we concentrate it is similar to when we used to hunt...and if you blink when you are hunting you lose the prey.

Many of our patients report that when they go on holiday their symptoms often improve, and studies have shown that increased computer use can lead to Dry Eye. Heavily concentrating on a computer, mobile phone or tv screen has been shown to significantly reduce your normal rate of blinking.

Blinking performs two very important functions. First, it replenishes the tear layer across the eye and secondly it squeezes the Meibomian glands that release the lipid layer of the tears that stops the tears from evaporating. Once we stop blinking properly, the Meibomian glands can start to become blocked by the oil that is not being released as it should. This leads to a vicious cycle which eventually gives the symptoms of dry eye.

Once the glands are blocked it is possible to use Intense Pulsed Light therapy to unblock them and then to institute blinking exercises to stop the problem occurring again. 

If you think you are suffering from dry eye due to screen use, please come see us for an assessment. We can treat you before things become chronic and recommend therapies and exercises for you to do to keep your Dry Eye at bay.

Book an appointment with us or call us on 02076366080 today.

Photo: Shutterstock

Dry Eye Disease and LASER Surgery

For many people, LASER eye surgery changes their lives for the better. However, Dry eye is a common complication of LASER surgery. Often it is temporary but for some it persists and causes a chronic problem. When you have LASER surgery the corneal nerves are cut when the flap is cut either by the microtome or by the LASER. These nerves send signals to the lacrimal glands telling them to release the aqueous into the tears. Without this innervation the glands may not produce enough aqueous and the eye can become very dry.

Often the people who have chronic dry eye post LASER report symptoms of dry eye before the surgery. We would advise clients who may have mild Dry Eye prior to LASER surgery to consider the risks before having surgery and potentially damaging the glands further. At the Dry Eye Centre we see many patients who have had LASER surgery. In many cases like this, it is not possible to correct the cause of the Dry Eye so we regularly monitor and treat the symptoms. After an initial assessment, we devise a tailored treatment program based on your unique needs.

Photo: Shutterstock

Treatment Time: Who is IPL not suitable for?

Who is not suitable for Intense Pulsed Light (IPL) Treatment

Unfortunately people of Afro-Caribbean or South East Asian origin may not be suitable for IPL. This is because the higher density of melanin in their skin absorbs the Intense Pulsed Light which produces heat in the skin and can lead to a condition like sun burn or discolouration of the skin. We will tell you if you are a suitable candidate for IPL at your initial assessment.

What do all the tests we do mean? 
At the Dry Eye Centre we do a battery of tests to diagnose your dry eye, including: LipiView, Meibography, InflammaDry, Schirmers test, Meibomium gland evaluator, Slitlamp bio-microscopy. Interested in an initial assessment to identify what treatment would be right for your Dry Eye? Book an appointment with us today.

Photo: Shutterstock

Lipiflow versus Intense Pulsed Light (IPL) Treatments

Both Intense Pulsed Light and Lipiflow treatments have to be shown to treat Meibomian gland dysfunction but what is the difference?

Lipiflow works by inserting a scleral shell into the eye that sits behind the lids heating the glands and massaging them to push the blockage out of the glands. The treatment is performed once and is supposed to provide treatment for one year. Each treatment requires a new scleral shell and unfortunately the cost of these and the machine is very high. Most clinics charge around £1200 per treatment. Unfortunately if the treatment is not effective the first time then a second treatment is a very expensive option.

Intense Pulsed Light treatment fires a very intense light onto the skin below the eye. The frequency of the light is tuned to the Meibomian glands and has several effects. Firstly when the light is absorbed it generates heat which melts the meibum in the glands. It also closes off blood vessels close to the skin which decreases the inflammatory markers at the glands which contribute to Meibomian gland dysfunction. IPL treatment also decreases the bacterial load on the skin. Once the treatment has been performed the glands are then expressed manually – rather than mechanically as in Lipiflow. The benefit of this is that we can see exactly what comes out of the glands – whether it is solid or liquid and also to see which glands are working and which are not. The treatment is repeated several times over 3 months to give a maximal effect and each time the glands are manually expressed and examined as well. IPL treatment costs £200-£250 for each treatment.

While Lipiflow has been shown to help treat Dry Eye, at the Dry Eye Centre we believe that IPL combined with manual expression achieves better results for clients at significantly less cost. Therefore, we generally recommend IPL for clients suffering from Dry Eye over Lipiflow.

Interested in an initial assessment to see if IPL or other treatments would be right for you? Book an appointment with us today.

The different types of Dry Eye

In 2007, a groundbreaking study found that Dry Eye Disease should be classified into two different types: Aqueous tear deficiency (ATD) and evaporative dry eye (EDE).

Aqueous deficient dry eye is when there is a lack of production of the watery layer of the tears. This can be caused by an auto-immune disorder called Sjogrens, or by other causes for example as a consequence of LASER surgery. Treatments from aqueous deficient dry eye include punctal plugs and ciclosporin medication, which the Dry Eye Centre is one of the few clinics licensed to prescribe.

Evaporative dry eye is caused when the tears evaporate too quickly. This is due to factors such as a lack of the oily layer of the tears (meibum) or from incomplete blinking. Intense Pulsed Light treatment is aimed at treating evaporative dry eye.

While research has shown that a majority people suffer from evaporative dry eye, research also shows that up to 1/3 of patients suffer from combined ATD and EDE(2)  and that there are commonalities of both types, with inflammation being the most obvious.

When doing an assessment, it is vital that the professional keep an open mind and deliver a treatment program tailored to an individual's specific needs.

We believe that it takes a lot of experience and expertise to properly assess and treat patients who suffer from Dry Eye. The Dry Eye Centre was one of the first Dry Eye Speciality practices to open in the UK and our clinicians Dr. Caroline Hodd and Conan Tam are recognised experts in the field, having attended and spoken at many Eye Conferences on the subject.

If you're interested in having your own assessment done with our experts, book an appointment with us today.


Photo Credit: (1) The Definition and Classification of Dry Eye Disease: Report of the Definition and Classification Subcommittee of the International Dry Eye Work Shop (2007, THE OCULAR SURFACE / APRIL 2007, VOL. 5, NO. 2
(2) Lemp MA, Crews LA, Bron AJ, et al. Distribution of Aqueous-Deficient and Evaporative Dry Eye in a Clinic-Based Patient Cohort: A Retrospective Study. Cornea. 2012 May;31(5):472-8.

Test Time: Slit-lamp examination

We use a microscope call a slit-lamp to examine the eye. We are looking to see first how dry the eye is – using the Tear Break Up Time but also looking to see if there are any signs of inflammation of the eye, redness, swelling and the presence of little bumps on the lids called papillae that indicate an immune response. We also examine the Meibomian glands to see if they are expressing normally or are blocked. The examination can also help us determine if the eye is closing at night while sleeping or if the lids are closing correctly when blinking.

What do all the tests we do mean? 
At the Dry Eye Centre we do a battery of tests to diagnose your dry eye, including: LipiView, Meibography, InflammaDry, Schirmers test, Meibomium gland evaluator, Slitlamp bio-microscopy. Interested in an initial assessment to identify what treatment would be right for your Dry Eye? Book an appointment with us today.

Photo: Shutterstock

Test Time: What is Schirmers Test?

What is Schirmers test?
Schirmers test is old fashioned but still the gold standard way to measure the production of the watery layer of the tears (aqueous) by the eye. In this test we apply an anaesthetic drop and place a strip of special paper into the gap between the lower lid and the eye. We then wait five minutes then measure the length of the paper that has become wet. A measurement of less than 10mm in five minutes indicates that the eye is producing too little of the watery layer. We call this aqueous dry eye.

What do all the tests we do mean? 
At the Dry Eye Centre we do a battery of tests to diagnose your dry eye, including: LipiView, Meibography, InflammaDry, Schirmers test, Meibomium gland evaluator, Slitlamp bio-microscopy. Interested in an initial assessment to identify what treatment would be right for your Dry Eye? Book an appointment with us today.

Test Time: What is Meibography?

The Meibomian glands produce the oily layer of the tears. The openings of the glands run along the upper and lower lids. The glands themselves run perpendicular to the lid margins up into the lid. When there is inflammation or blockage of the glands they can atrophy and die away. Once atrophied they can not produce as much meibum. Meibography allows us to image the glands to see if they have been damaged. It gives a good indication of the potential of recovery from Meibomian gland dysfunction.

What do all the tests we do mean? 
At the Dry Eye Centre we do a battery of tests to diagnose your dry eye, including: LipiView, Meibography, InflammaDry, Schirmers test, Meibomium gland evaluator, Slitlamp bio-microscopy. Interested in an initial assessment to identify what treatment would be right for your Dry Eye? Book an appointment with us today.

Test Time: Tear Break Up Time

Tear Break Up Time is not related to relationships ending

What is Tear Break Up Time?
Every time we blink the lid spreads the tears across the surface of the eye. The tear film then stays there to protect the eye. After a certain time the lipid layer breaks up and the tears start to evaporate leaving parts of the eye not covered by tears. In a normal eye this should take around 10 seconds. In dry eye the tears can break up within a second, leading to dry patches. To measure this we put a little bit of a dye called sodium fluorescein into the eye which stains the tears. Then we watch through a microscope to see how long the tears take to break up.

What do all the tests we do mean? 
At the Dry Eye Centre we do a battery of tests to diagnose your dry eye, including: LipiView, Meibography, InflammaDry, Schirmers test, Meibomium gland evaluator, Slitlamp bio-microscopy. Interested in an initial assessment to identify what treatment would be right for your Dry Eye? Book an appointment with us today.

Photo: Shutterstock