Reversing Dry Eye Syndrome
Practical Ways to Improve Your Comfort, Vision, and Appearance
By STEVEN L. MASKIN PAMELA THOMAS YALE UNIVERSITY PRESS
Copyright © 2007 Steven L. Maskin, M.D.
All right reserved. ISBN: 978-0-300-12285-5
Chapter One
What Is Dry Eye Syndrome, and Who Gets It? Myth Dry eye syndrome is not a serious disease.
Fact
If dry eye syndrome is not treated properly, it can lead to severe eye problems, including blindness.
Sandy, aged 48, says her eyes are so red, dry, and irritated that it has become difficult for her to drive, even if she is wearing dark sunglasses. She's been meaning to see her eye doctor, but has put it off. In the meantime she has been relying heavily on over-the-counter eyedrops bought at her local pharmacy. They don't help. In fact her eyes hurt when she puts the drops in, but the bottle said the contents were for dry and irritated eyes, and her eyes certainly fit that description. Maybe after a while, Sandy hopes, pain relief will kick in.
Carl, 42, has been treated with insulin since he was first diagnosed with Type I diabetes at the age of 16. Lately he has noticed a painful, gritty feeling in his eyes.For the last few months, he's been a little lax (well, okay, very lax) about keeping his glucose levels down, so he figures that if he just watches his diet more carefully, then the pain in his eyes will disappear as well.
Marie, 28, has been wearing contact lenses since she was 15 years old, but lately they just don't feel right. She takes them out, cleans and wets them, and puts them back in, over and over; but in just a few minutes, the pain bothers her so much that she has to remove her contacts yet again. Marie has been thinking that wearing contacts just isn't worth it. She is nearsighted and doesn't own a pair of conventional glasses (she thinks they would make her look ugly). Lately she has been wondering whether she should see that eye doctor she has heard about who performs LASIK (laser in situ keratomileusis) surgery.
Arthur, 84, suffers from Parkinson's disease. As a direct result of the disease, he doesn't blink with regularity, which would normally lubricate and cleanse his eyes. Crusting frequently builds up around his lashes and lids, and results in constant feelings of grittiness, discomfort, and pain. He has used over-the-counter eyedrops and rinses to try to alleviate the problem, but he is unable to administer the drops on his own and his wife has trouble helping him. Arthur also has trouble physically just getting around, but he attributes his problems solely to the Parkinson's disease and does not realize that dry eye, including a distinct loss of vision, is strongly exacerbating his other issues.
As an ophthalmologist who has treated thousands of patients, I know that millions of people-men and women, young people and old, some suffering from chronic illness and others who are otherwise perfectly healthy-urgently need treatment for dry eye syndrome. Some may not even know it! Sandy, Carl, Marie, and Arthur are typical of many patients I have had. (I will be discussing a number of my patients in this book, but I will not be using their actual names, although their symptoms and problems are real.)
Sandy is using over-the-counter drops that not only are not helping her, but ultimately are increasing her pain. For starters, she needs to stop using the commercial eyedrops. She needs to see an eye doctor as soon as possible to find out why her eyes are hurting so much and to obtain proper treatment. The problem may be that she is allergic to-or, at least sensitive to-the preservatives in the artificial tears.
Carl is correct that he should get his blood-sugar level as close to normal as possible. Diabetes can cause many eye complications, from dry eye syndrome to blindness, as well as other noneye problems such as heart attack and stroke. However, Carl shouldn't assume that improving his blood-sugar level will make his eye problems instantly vanish, nor should he assume that he can handle this problem on his own. He needs to consult with both an endocrinologist for his diabetes and an eye doctor to resolve his dry eye syndrome.
If Marie follows through on her plan to have LASIK surgery to improve her nearsightedness (that is, if she can even find an eye doctor who would be willing to operate on her severely dry eyes), she is at high risk of augmenting the problem she already faces. Maybe Marie can't wear contact lenses any more. Or perhaps she simply needs a different type of contact lens, one that allows for better hydration of her eyes. She also may require minor surgery (usually an in-office procedure) to increase her tear volume and comfort her eyes.
Arthur sees a neurologist regularly to keep his Parkinson's disease under control, yet continues to complain about stumbling and has trouble seeing properly. It hasn't occurred to him, his wife, or even his primary-care physician, that he could benefit by being actively treated for dry eye. All have simply assumed that his problems are Parkinson's related. He should consult with an eye specialist as soon as possible.
WHAT IS DRY EYE SYNDROME?
If you are reading this book, no doubt you at least suspect that you have chronically dry eyes, or very possibly you have been diagnosed with dry eye syndrome, indicating that your problem has reached a crucial point. My primary goals here are to help you reduce your eye pain and irritation; improve your vision; and possibly even eliminate the redness from your eyes, making you look better. To achieve these ends, I aim to supply you with all the information you'll need in order to deal with your dry eye problem. This includes guiding you toward working effectively with your eye doctor.
Dry eye syndrome, known medically as keratoconjunctivitis sicca, is an umbrella term for a condition of severely dry eyes caused by a lack of proper tear production and distribution. (Recently, some experts have recommended that the label "dry eye syndrome" be changed to "dysfunctional tear syndrome." The term "dry eye syndrome" connotes different things to both physicians and to patients, and "dysfunctional tear syndrome" is considered by some experts to be more consistent with the basic issue, which is the diminished quality and quantity of tears. The term "dry eye" suggests that dryness is present in all patients, which is not necessarily the case. Still, for the purposes of this book, I have chosen to call the disorder by its best-known label: dry eye syndrome.)
Basically, dry eye syndrome manifests in one of two ways: aqueous tear deficient dry eyes or evaporative dry eyes. Aqueous tear deficient dry eye develops because the lacrimal (tear) glands, located under the eyelids, do not produce enough tears to keep the surface of the eye sufficiently moist. Evaporative dry eye results from an abnormality in tear composition causing the tears to evaporate too quickly (all of this will be discussed in detail in Chapter 3).
If you have dry eye syndrome, you are well aware that it can be extremely painful. In addition, dry eye syndrome impedes vision by generating blurriness and visual distortion. Glasses don't help because the problem lies with the physical dryness. Contact lenses don't help; in fact, they may make the situation worse because contact lenses need the lubrication of tears to work effectively. Without sufficient tears, contacts often feel like they're painfully glued onto your eyes-as if you are wearing a salty potato chip instead of a contact lens.
Dry eye can severely affect virtually every aspect of your life, from the simplest everyday occurrence to the progress of your career. Experts have found that, with severe dry eye, the decrease in the quality of life is comparable to that among patients with severe angina or a disabling hip fracture. For example, many patients with dry eye syndrome must plan ahead carefully before embarking on the most simple everyday activities, from going to a movie or play, to enjoying dinner in a restaurant, even to riding in a car. They must be sure their eyes are sufficiently lubricated and that they avoid sitting near a heating duct, air-conditioning unit, fan, or any other place where the ambient air is agitated. Not surprisingly, severe dry eye sufferers should avoid smoke-filled rooms and socializing with smokers. They even need to think about the weather as it pertains to their eyes, since wind, rain, and dry or cold conditions affect chronically dry and irritated eyes.
Many patients with dry eye syndrome are dismayed by their deteriorating appearance, for their eyes can often be red and even teary. Often family members, friends, and colleagues begin to notice the sufferer's red, irritated eyes. While most people will be sympathetic, others (one's boss, for example) may mistakenly conclude that the person with the bloodshot eyes must have a serious drug or alcohol problem.
Most seriously, a moderate to severe case of dry eye syndrome can affect the quality of one's work and ultimately the progress of one's career. This is particularly true for anyone who spends several hours each day working on a computer terminal. In this day and age, that includes many, many workers-from lawyers, bankers, accountants, journalists, and writers, to office workers of virtually every stripe. Dry eye can make work that involves the eyes very painful, and, if the dry eye is not dealt with properly, work may become impossible.
WHAT ARE THE SYMPTOMS?
Everyone has itchy or irritated eyes once in a while, and you shouldn't panic if your eyes occasionally feel a little gritty and inflamed. Conversely, if you develop severe, constant eye pain, call your eye doctor immediately to rule out a neurologic cause such as stroke, a corneal ulcer, a glaucoma attack, or some other serious problem.
Cases of dry eye usually begin with mild symptoms, and the first line of defense for most sufferers is over-the-counter eyedrops or artificial tears. These will treat the symptoms, but don't necessarily alter the progress of the disease. If your eyes are annoyingly scratchy, irritated, and/or inflamed for more than a week or two, have an eye doctor check them.
Listed below are the key symptoms of dry eye syndrome. You may well have dry eye syndrome if you experience only one or two of them; in extreme cases, you may suffer from most or even all of them.
Eye pain, such as achy or sore eyes Redness of the eyes, inflammation Scratchy, grainy, gravelly feelings in the eyes Sense of a "foreign body" in the eyes Burning or stinging in the eyes Constant or frequent itching of the eyes Contact lens discomfort Nighttime dryness Difficulty opening your eyes in the morning because they feel glued shut Frequent blurred or fluctuating vision Heavy or tired eyes Excessively watery eyes Excessive mucus discharge from the eyes Sensitivity to light
Eye Pain
Eye pain is probably the most debilitating symptom of dry eye syndrome. Sometimes the pain is so excruciating that you can't open your eyes; you constantly squint for some relief. Eye pain develops because the cornea is extremely sensitive, and when it is not protected by tears, its nerves become exposed. Sometimes the pain is unremitting.
Redness or Inflammation
Eye redness isn't always caused by dry eye syndrome; it can also result from infections, trauma, lack of sleep, alcohol abuse, or medications. However, many people with dry eye syndrome have at least some degree of eye redness and inflammation, and the redness can be extreme in some patients. Because dry eyes aren't getting lubricated sufficiently with tears, the lids in effect create a "mechanical trauma" with each blink, which results in inflammation of the surface of the eye. Researchers have been investigating this mechanical aspect of dry eye and the resulting inflammation, and have recently recommended new treatments based on their findings, including the first prescription medication specifically to address dry eye symptoms.
Scratchiness
Many dry eye sufferers experience a sense of scratchiness in their eyes, as if something is abrading the surface of their eyes.
Foreign Body Sensation
Another common symptom of dry eye is the constant sensation that a foreign body, such as an eyelash or a piece of dirt, is lodged in the eye. The feeling can be simply annoying or excruciatingly painful, but no matter how much you rub or rinse the eye, the sensation remains. Sometimes a piece of mucus has attached itself to the eye, or the cornea may be swollen. Often no actual foreign body exists; instead, the cornea has become more sensitized as a result of the dryness.
Burning or Stinging
If burning or stinging of the eyes is your problem, you may suffer from evaporative dry eye and require special therapies to obtain relief. At the same time, burning or stinging could mean that you have an allergy that needs to be identified and treated.
Constant or Frequent Itching
An aggravating sort of itching can be another symptom of dry eye syndrome, especially if you suffer from allergies. This symptom can be exacerbated by rubbing your eyes. The rubbing will not help the itchy feeling go away; besides, the mechanical trauma of rubbing may increase inflammation and thus aggravate your risk for more itching or for developing an eye infection as your fingers transport germs into the normally sterile environment of the eye. Dry eye also allows for increased concentration of allergens to collect on the surface of the eye, resulting in a feeling of itchiness.
Contact Lens Discomfort
Many people who have worn contact lenses for years develop dry eye, the obvious symptom being that wearing their contacts becomes extremely uncomfortable. This can be true not only with old-fashioned gas-permeable hard lenses, but with soft lenses as well. The symptoms may manifest as irritation or pain.
Nighttime Dryness
Many patients with dry eye syndrome have serious problems with nighttime dryness of their eyes. The cause may be a problem called nocturnal lagophthalmos, or incomplete eye closure during sleep.
Difficulty Opening Your Eyes in the Morning
Difficulty opening your eyes, or the sensation of pain when opening your eyes in the morning, can indicate an irritated eye from dryness or a type of corneal abrasion called an erosion. If the symptoms become severe, a more serious eye problem may be involved, such as a corneal ulcer or infection that needs to be treated immediately.
Blurred Vision
It's common for patients with dry eye syndrome to have blurred or fluctuating vision much of the time; the lack of tears and the smooth optical surface they provide make focusing difficult. Blurry vision is frequently diagnosed as something other than dry eye, and doctors often prescribe tests looking for a brain tumor or stroke. Numerous patients have come to see me after having had computerized tomography (CT) or magnetic resonance imaging (MRI) that revealed nothing abnormal to explain the blurry vision. In virtually all these cases, it has turned out that the problem was caused by dry eye syndrome.
Heavy or Tired Eyes
The feeling of heavy or tired eyes may result when the surface of the eye is not getting an adequate cleansing. Old, dirty tears containing allergens and irritants are not being properly removed from the ocular surface and replaced by healthy, fresh tears. As a result, the eyes may feel tired. It's like trying to wash windows with dirty dish water; the "window" never gets clean. Heavy eyes may also be caused by a situation called conjunctivochalasis, where the conjunctiva tissue is draped onto the lid margin.
Excessively Watery Eyes
Ironically, dry eye syndrome can stimulate an overproduction of very watery tears. Normally, when a piece of dirt or other foreign body lodges in a healthy eye, the eye will produce lots of watery tears to wash the foreign body away. With chronic dry eye, the cornea may become so irritated that the same signal is sent to the tear glands, which then produce an abundance of watery tears. The cycle may keep repeating itself until the dry eye is properly treated.
(Continues...)
Excerpted from Reversing Dry Eye Syndrome by STEVEN L. MASKIN PAMELA THOMAS Copyright © 2007 by Steven L. Maskin, M.D.. Excerpted by permission.
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