Tear Film Health is Essential for People with Keratoconus

People afflicted with keratoconus (KC) are often obligated to wear contact lenses in order to obtain functional vision. Unfortunately, wearing contact lenses can have detrimental effects on the ocular surface and tear film layers over the course of decades, ultimately reducing lens tolerance. Therefore, any intervention prolonging the comfortable wear time of contact lenses should be aggressively pursued. The tear film covers the surface of the eye, provides lubrication and is the primary defense against foreign bodies and infection. Without a robust and healthy tear film, safe and comfortable contact lens wear is not possible. This article will describe the structure of the tear film and review simple remedies that can keep it healthy throughout life.

Tear Film Layers

The tear film is a complex, triple layered structure comprised of mucus, water and oil. The surface of the cornea and conjunctiva contain cells specialized to secrete a sticky mucoid substance. These so called goblet cells produce the mucin layer of the tears, which creates a “Velcro” type interface and allows the overlying watery component to stick to the ocular surface without washing away.

The bulk of the tear film is comprised of the watery, or “aqueous” layer which is secreted primarily by the lacrimal gland. This specialized structure is located near the eyebrow. This gland continuously releases small amounts of watery fluid that also contains enzymes and antibodies to help fight infection and wash away contaminants.

The lipid layer is the final, outermost layer of the tears. If the tear film is the first line of defense for the ocular surface, then the lipid layer is the first line of defense for the entire tear film and the ocular surface combined. Because of that role, it is extremely important and helps stabilize the tear film by preventing evaporation. This thin, lipid based layer is released by the meibomian glands, which are modified sebaceous glands that reside in the upper and lower lids. In each lid there are 20-30 glands. These glands open up onto the lid margin and through the action of a complete blink, release the lipid secretion to ocular surface which gets spread with the upward motion of the upper eyelid.

Each one of these layers contributes to the structure of the tear film, and a problem with any one of these structures (goblet cells, lacrimal gland or meibomian glands) will negatively impact the corresponding tear layer.

Tear Film
Image 1 -Layers of the tear film across the ocular surface & Meibomian glands of the eyelids. (Picture courtesy of TearScience™)

Tear Film Issues

Because the tear film is so thin, each individual component is necessary to maintain the integrity of the tears as a whole. When any layer of the tear film is deficient, the tear film becomes unstable and the ocular surface becomes irritated and can progress to developing classic symptoms of dry eye. This includes burning, stinging, redness, tearing, fatigue and contact lens intolerance.

Deficiencies in the mucin layer are uncommon, and are typically the result of chemical or thermal insult, or scarring. An aqueous deficiency, primarily from a lacrimal gland related etiology, is also relatively uncommon, and can arise from autoimmune and inflammatory causes such as Sjögren’s Syndrome. The most common reason for a poor tear film is linked with excessive evaporation of our tears due to a lack of sufficient lipid secretions from non-functioning or obstructed meibomian glands. It is understood that many factors contribute to why these glands stop performing optimally.

One factor has been linked to our habitual working environments. The compressive force exerted by the muscles of our eyelids that control blinking are essential for lipid secretion. However, the use of computers or wearing contact lenses has been shown to negatively impact our blinking habits, both by reducing the number of blinks and making blinks less complete. With an incomplete blink, the upper and lower lids do not make contact. The negative consequences of this are 1) the meibomian glands do not release their lipid contents, 2) the lower part of the eye is chronically exposed to the air, increasing evaporative stress and 3) dead skin cells accumulate on the lid margin which can clog the meibomian gland openings.

When increased evaporation of the tear film occurs chronically, the integrity of the entire ocular system becomes compromised over time and problems to the health of the eye become permanent attributes. This condition is known as Meibomian Gland Dysfunction or MGD and is linked with 86% of all dry eye sufferers.

Image 2 - Histology slide of a Meibomian gland with a terminal duct blockage
Image 2 – Histology slide of a Meibomian gland with a terminal duct blockage

Contact lenses have been shown in multiple studies to have a negative impact on the integrity of the tear film. To begin with, placement of a lens onto the eye divides the tears into two sections, referred to as the “post” (behind) and “pre” (in front) lens tear films.

The characteristics of the post lens tear film can differ depending on the type of lens that is worn. For example, soft lenses and scleral lenses have very little turnover of this post-lens tear film. This can cause issues related to the build up of toxic waste and bacterial elements that ultimately aggravate the corneal surface. Conversely, rigid gas permeable lenses are designed to have substantial tear turnover behind the contact lens with every blink.

The pre-lens tear film is also greatly affected by the type of lens material, as well as the interaction between the lid and the contact lens surfaces. Eye doctors know that without a healthy tear film, chances for contact lens intolerance increases. The rate of contact lens intolerance substantially increases as patients enter their fourth decade of life, primarily because of MGD caused by years of poor blinking habits.

Tear Film Care

Fortunately, simple interventions can prevent and/or limit the severity of MGD altogether or help to manage it once it occurs. Just like brushing and flossing one’s teeth can prevent gum disease, attention to complete blinking and lid margin hygiene can improve the tear film and prevent contact lens intolerance problems.

Because partial blinking is strongly linked with developing MGD, it is vitally important that the two lids touch when blinking. It is best to practice this several times throughout the day as well as when you are reading or using the computer.

Akin to flossing the teeth, it is also important to clean the lid margins with a Q-tip soaked in saline solution or a bit of mineral oil by gently brushing the Q-tip across the lid margin 10-20 times each night. It is easiest to get the lower lid.

Finally, performing warm compresses daily can provide heat to the Meibomian glands to soften the hardened oil that can plug the meibomian gland ducts. Warm compresses need to be done continuously for at least 10 minutes with consistent heat in order to attain a temperature that is sufficient to melt the oil that clogs the glands. We recommend folding 5-6 small towels or facecloths into a rectangular shape and wrapped together into a circular bundle, similar to the appearance of a cinnamon roll. The towels should be damp and moist, placed in a microwaveable safe dish with a lid and heated for approximately 1 minute and 50 seconds. After removal, wait a minute or two and then proceed to use the outermost cloth and cover the rest. Replace the first cloth after two minutes and grab the next outer most towel from the bundle, continuing this until all towels are used. In this way, the temperature can be adequately maintained for the full 10 minutes. The high temperatures applied to the lid are transferred to the cornea and very often cause temporary deformation, a phenomenon characterized by transient visual blur immediately following compress application. Therefore, it is vitally important, especially for patients with keratoconus, that pressure never be exerted onto the globe of the eye with a compress or massage administered to the lids of closed eyes after a compress.

It is becoming apparent that MGD is developing in patients at earlier ages. Because of this, the condition has likely been present for decades by the time the patient becomes symptomatic. It may take significant time and effort to rehabilitate not only the glands themselves, but also to reduce the resulting inflammation of the ocular surface.

Meibography is the technique used to image Meibomian glands. In chronic cases of MGD, we see abnormal changes to gland structure, in the form of atrophy or loss of gland tissue and/or dilation of glands where obstructed material causes glands to become widened. In severe cases, the prognosis for recovery is guarded.

The visual clarity that contact lenses provide for patients with keratoconus is incredibly important. But the ability to comfortably wear contact lenses is reliant on our body’s ability to provide a sufficiently thick protective tear film. Taking a small amount of time daily to attend to the lipid producing Meibomian glands by proper blinking habits, exfoliation of the lid margin with a Q-tip and warm compresses will help to extend the number of hours, and ultimately the number of years, that contact lenses can be safely and comfortably worn.


tear filmAmy Nau, OD
Korb and Associates, Boston, MA
Contact lens fitting for keratoconus, other ocular surface disorders and dry eye

tear filmDavid Murakami, MPH, OD, FAAO
Tear Science, Inc.
Researcher, Dry Eye

Increased Awareness for Saving Vision

The following is a survey done by Essilor (a French company that produces ophthalmic lenses along with ophthalmic optical equipment) and a large marketing research firm in the UK, YouGov. While the focus in on people living in the UK, the results would probably be similar to the US population. Even with increased access to the Internet, many people are still not aware of the risks associated with eye disease and what they can do to help retain their vision. Increased awareness of informational resources are important for saving vision.
saving vision
There are a number of websites with easy to understand information about taking care of your vision that I have listed under Resources to Help Save Vision at the bottom of this article. And while there are eye diseases that are hereditary, you can slow the onset and progression by making good lifestyle choices about smoking, diet and exercise. Your eye care specialist is also an excellent source of information about what you can to do reduce your risk of vision loss, at any age.

Increased Awareness for Saving Vision

A YouGov poll conducted with Essilor reveals that most Britons are unaware of damage to their eyes by surrounding objects, activities, and devices. This widespread lack of awareness means fewer people seeking methods of prevention and avoidance, and for those that are aware of risks, most are not informed of existing preventative measures.

The poll has shown* that many British people remain uninformed about the various ways in which eyes are damaged by common daily factors, despite evidence that eye health is affected by blue light, UV rays (reflected from common surfaces), diet, obesity, and smoking.
Of the 2,096 people polled, the percentage of respondents aware of the link between known factors affecting and eye health were:

  • Poor diet – 59%
  • Obesity – 35%
  • Smoking tobacco – 36%
  • UV light, not just direct from the sun but reflected off shiny surfaces – 54%
  • Blue light from low energy lightbulbs and electronic screens – 29%

More than one in ten people were completely unaware that any of these factors could affect your eyesight at all.
saving vision
72% of respondents own or wear prescription glasses but only 28% knew that there were lenses available (for both prescription and non-prescription glasses) to protect against some of these factors; specifically, blue light from electronic devices and low energy light bulbs, and UV light from direct sunlight and reflective surfaces.

76% admitted they haven’t heard of E-SPF ratings – the grade given to lenses to show the level of protection they offer against UV.

Just 13% have lenses with protection from direct and reflected UV light, and only 2% have protection from blue light (from screens, devices, and low energy bulbs).

Poll results showed that younger people were most aware of the dangers of UV and blue light, yet least aware of how smoking tobacco and obesity can affect your eye health. Within economic sectors, middle to high income people are more aware of the effects of smoking & obesity on eyesight than those with low income –

  • 39% of people with middle to high income compared to 33% of people with low income are aware of the impact of smoking tobacco.
  • 38% of people with middle to high income compared to 31% of people with low income are aware of the impact of obesity.

Awareness of the impacts of smoking and obesity on eye health is significantly higher in Scotland (47% & 49% respectively) than anywhere else in the UK (35% & 33% in England and 40% & 38% in Wales).
Essilor’s Professional Relations Manager, Andy Hepworth, has commented: “The lack of awareness about these common risks to people’s eyes is concerning. Not only would many more glasses wearers be better protected, but also many people who do not wear glasses would likely take precautions too, if made aware of the dangers and the existence of non-prescription protective lenses.”

To see the full results of the poll, please visit the Essilor website.

For more information on the protection offered from blue light and UV through specialist lens coatings, for both prescriptions and non-prescription glasses, please see here for UV & Blue Light Protection options.

*All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 2,096 adults. Fieldwork was undertaken between 21st and 24th August 2015. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+).

Resources To Help Save Vision
All About Vision
Macular Degeneration Partnership
National Eye Institute (NEI)
Prevent Blindness


Susan DeRemerSusan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Laser Refractive Surgery: LASIK, LASEK, PRK and PTK

The introduction of the excimer laser to eye surgery in the early 1990’s represented a revolutionary innovation in the treatment of refractive errors: nearsightedness, farsightedness, and astigmatism. The development of this technology allows the safe and dependable correction of vision in many patients. For the most part, however, keratoconus (KC) patients are not candidates for such procedures for 2 reasons. First, the inherent biomechanical weakness of the keratoconic cornea could worsen if tissue is removed from the already thin cornea. Second, in addition to standard nearsightedness, farsightedness, and astigmatism, keratoconic vision is also impeded by higher order aberrations, which can be thought of as static in the eye’s optical system. However, recent advances may make variations of such procedures applicable to selected patients with KC.
Laser Refractive Surgery: LASIK, LASEK, PRK and PTK


Today, laser in situ keratomileusis (LASIK) is the most popular method of laser eye surgery. LASIK uses an excimer laser to correct nearsightedness, farsightedness, or astigmatism by removing a thin lenslet of tissue from the surface of the cornea (the clear, front “watch crystal” of the eye). This is analogous to removal of a “tissue contact lens”. In LASIK, which is now an “all-laser” technique, a pancake-like thin flap of the cornea is first prepared with a high speed femtosecond laser. The flap acts to preserve the surface epithelial cells (which are like tiles on a floor) to promote quick healing and recovery of vision. Next, the excimer laser is used to remove a small amount of tissue from the corneal surface beneath the flap. The excimer laser used in LASIK produces a beam of invisible ultraviolet light energy, which when applied via an eye tracking mechanism, results in meticulous removal of this “tissue contact lens”. After corneal reshaping, the LASIK procedure is finished when the corneal flap is repositioned. When the flap is replaced, it lies in the bed of excimer laser removed tissue, causing the surface to change shape with the effect of decreasing nearsightedness, farsightedness, or astigmatism.

Laser vision correction can also be performed without a LASIK flap. These procedures, which are also perfomed with the excimer laser, go by a number of names – PRK (photorefractive keratectomy), LASEK (laser epithelial keratomileusis), epi-LASIK, or ASA (Advanced Surface Ablation). Although LASEK and LASIK sound the same, unlike traditional LASIK, LASEK does not require the preparation of a corneal flap. This has two potential advantages. First, risks of making the corneal flap in LASIK are avoided. This may be important in some patients in whom there is an additional risk in making the flap, such as patients with corneal scars or irregularities. Second, since laser treatment is done on the surface, LASEK/PRK preserves more corneal tissue. In particular, patients who have thinner corneas may be more safely treated with a no flap technique rather than LASIK.

At the beginning of the LASEK / PRK eye surgery procedure, the surface cells of the cornea are loosened and removed. The laser treatment then is applied, just as in LASIK, removing the properly shaped “tissue contact lens” for the desired optical correction. At the end of the procedure, a contact lens bandage is applied. Topical drops are used for a few week afterwards to avoid infection and control wound healing.

Vision after LASEK/PRK takes a little while longer to completely improve and stabilize than after LASIK because the epithelium needs to grow and smooth. Substantial improvement usually is noticed the day after the procedure and fluctuates over the next 2 weeks. The contact lens is removed in 5 days in most patients. Driving vision in the days after the procedure can be variable and take up to 2 weeks in some patients.

For both LASIK and LASEK/PRK, there are two basic types of possible side effects. Because patients may respond and heal differently, it is possible that the entire refractive error may not be fully corrected. In this case, vision will be clearer without glasses, but may not be as good as desired. In these situations, patient often can undergo a re-treatment procedure to further improve their vision. In addition, optical side effects include halos around lights and glare, especially at night, and some patients may experience dry eye sensations. Other, more rare, complications include infection or scarring.
Recently, there has been much talk in the keratoconus community about combining corneal collagen crosslinking with topography-guided LASEK/PRK. Topography-guided PRK uses information gained from your corneal map to program the laser to help make your cornea more optically regular. The goal of topography-guided PRK, like Intacs, is to improve corneal contour in the KC patient to improve glasses corrected vision and contact lens tolerance. In general, you will still need contacts and glasses afterwards.

Typically, LASEK/PRK procedures for keratoconus are combined with corneal collagen crosslinking, which has the goal to strengthen the weak keratoconic cornea and decrease progression of corneal mishapening over time. It is important to note that such treatments are not FDA-approved and are not generally available in the U.S. However, a number of international surgeons have been exploring the potential role of combined LASEK/PRK with crosslinking to improve keratoconus outcomes. In our practice, we have also had the opportunity to use Intacs and other procedures to further improve corneal shape in patients who have undergone topography-guided treatments with crosslinking with encouraging results.

In addition to LASIK and LASEK/PRK, the excimer laser may provide a novel therapeutic modality in the treatment of a number of superficial corneal disorders. This treatment is known a phototherapeutic keratectomy or PTK. Whether PTK eye surgery is used alone or as an adjunctive strategy in traditional corneal surgical techniques, a number of disorders affecting the corneal surface may be successfully treated by taking advantage of the excimer laser’s ability to meticulously remove superficial corneal tissue. These include a variety of corneal degenerations and dystrophies, corneal irregularities, and superficial scars, such as surface nodules found at the apex of the keratoconic cone. While some of these conditions, heretofore, could be treated by mechanical superficial keratectomy techniques, PTK may minimize tissue removal and surgical trauma.

So, for patients with keratoconus, it is important to know that, although LASIK type procedures are generally not indicated, research using these advanced technologies continues. A tailored therapeutic approach over time may combine a variety of procedures to optimize the corneal shape and ultimate visual outcome for the patient with keratoconus.


Peter Hersh, MD - Laser Refractive Surgery: LASIK, LASEK, PRK and PTKPeter S. Hersh, MD
Cornea and Laser Eye Institute – Hersh Vision Group
CLEI Center for Keratoconus

Treatments for Dry Eye Disease

This is the third and final installation of the comprehensive series we have presented on dry eye disease. Dr. Wade first discussed the symptoms you might experience if you have dry eye and the Dr. Garg explained the process of diagnosing they type of dry eye disease you might have. In this article Dr. Farid reviews treatment options based on your diagnosis of dry eye disease.treatments for dry eye

Treatments for Dry Eye Disease

As our understanding of dry eye disease expands, so do treatment options. We now know that dry eye disease is a multifactorial disease. There is no one cause so there is no one magic cure. Treatments aim to improve tear composition, reduce eye surface inflammation, and target eyelid margin disease. Here, we will review many treatment options, but the treatment combination or “cocktail” that is appropriate for you will depend on your specific type of dry eye disease. This is usually determined after some testing by your eye care provider.

Environmental, Dietary, and Medication Adjustments
Before going into specific dry eye treatments, there are modifiable causes and preventative methods to improve dry eyes. Simple changes in the environment, diet, and medications can be easy ways to improve symptoms.

Environmental Changes
As expected, a dry environment will worsen dry eyes. Humidifiers and moisture goggles have been shown to help alleviate these symptoms. Furthermore, situations that cause decreased blinking, such as prolonged use of computer screens, can worsen dry eyes. Patients should take frequent breaks from computer screens and reading, allowing their eyes to rest and resume normal blinking. When in windy, smoky, or dusty situations, sunglasses can act as a barrier to the eyes, reducing dry eye symptoms. Avoiding wind, fans, or any source of air blowing into the eyes may also help.

Dietary Changes
Drinking adequate water keeps patients hydrated and reduces exacerbations of dry eye symptoms. Omega-3 fatty acids, particularly eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), have been shown in many clinical studies to improve dry eyes. It is believed that these fatty acids help inhibit inflammatory mediators. Essential fatty acids cannot be synthesized and must be ingested through diet. Foods rich in omega-3 fatty acids include fish, other seafood, and flaxseed oil. Supplements are also available.

Adjusting Medications
Many medications are associated with dry eyes, and patients may benefit from adjusting doses or finding alternative treatments. You can work with your physician to weigh the costs and benefits about modifying your current medications if they are suspected to worsen dry eyes. Some of these medications include: hypertensive drugs, antihistamines, decongestants, antidepressants, acne medications, birth control, and hormone replacement therapy. Eye drops with preservatives, such as glaucoma medications, can also worsen dry eyes.

Lubricating Treatments
For patients with decreased tear production, supplementation of tears or reduction of tear drainage will improve symptoms.

Artificial tears, gels, and ointments
Artificial tears, gels, and ointments are readily available over the counter. Artificial tears are eye drops that are used throughout the day as needed, up to eight times for dry eyes. You must make sure to get “lubricating” drops. There are multiple available brands that are excellent and equivalent in providing artificial moisture. Avoid “redness relief” brands as they are focused on reducing appearance of the vessels in the eyes as opposed to actual dry eye relief. Gels and ointments are thicker and very effective but can blur vision. Non-commercial comparison testing between brands has not been done. Because the ingredients, preservatives, and consistency vary from brand to brand, it is recommended for patients to choose the best option that works well for them based on trial and error.

Preservatives are used in many eye drops to help them to last longer. Unfortunately, they can be irritating to the eyes, especially when used often (more than 4 drops/day) or with other drops containing preservatives (ie. glaucoma medications). Patients who frequently use eye drops are recommended to use preservative-free (PF) drops. Unfortunately, preservative-free drops are more expensive because they come in “single use” containers. You may be able to extend the life of each single use container by spreading out its contents over multiple uses throughout the day.

Lipid-containing lubricants, such as those with castor oil, attempt to mimic the oils found in the tears, reducing evaporative dry eyes, but more research is necessary to study their efficacy.

Punctal Plugs
Your ophthalmologist can place small plugs at a clinic visit into the punctum, a small hole at the upper and inner lids that drain tears from the eyes. One plug can be added initially, and if more tear retention is required, another plug can be added. There are absorbable and non-absorbable types. Absorbable types are made of collagen and last 1 week to 6 months. Once placed, they are not visible or removable. Non-absorbable plugs are usually silicone, and permanent. They are easily placed by your ophthalmologists and remain visible in follow-up exams. Some patients feel the plugs, and there may be mechanical rubbing, especially when the plug is not the proper size. Some patients may also experience excessive tearing with plugs. If problematic, patients can wait for the plugs to dissolve if absorbable or they can be removed with forceps if non-absorbable.

Autologous Serum
Serum is extracted from a patient’s blood and turned into an eye drop. The growth factors, vitamins, and antibodies present in serum are the same as those in natural tears. Evidence is showing significant promise in alleviating symptoms and signs of chronic dry eye disease. A good collaboration between a phlebotomy lab and compounding pharmacy is necessary to make the products. The products must be kept refrigerated or cold between uses. They can be frozen for long-term storage. Each blood draw provides a supply of drops that can last 3-6 months.

Hydroxypropyl Cellulose Ophthalmic Inserts (Lacrisert)
An insert is available for people who find regular artificial tear use to be difficult. A physician can order the inserts through a pharmacy. The patient places the insert in the inferior fornix of the eye, the area between the lower lid and sclera of the eye. It slowly dissolves over 24 hours, giving constant lubrication.

Anti-inflammatory Treatments
Inflammation is now being recognized as a major underlying cause of chronic and worsening dry eye disease. Many patients who have been suffering from chronic dry eyes, particularly those with autoimmune diseases like Sjogren’s Syndrome, will do well on treatments that reduce the amount of inflammation in the tear film and ocular surface. Your physician can order these medications for you if needed.

Cyclosporine A (Restasis)
The FDA approved Restasis for dry eyes in 2002. This is an immunosuppressive and anti-inflammatory eye drop medication. Relief is not instant, and may take 6-8 weeks of sustained use for improvement in dry eye symptoms. Less than 20% of patients may experience a burning sensation with the drops, but the safety and tolerability profile is otherwise excellent.

Doxycycline and minocycline are used for inflammatory ocular surface and eyelid disease. The antibiotics have a dual effect: they act as anti-inflammatories and anti-microbials. As an anti-microbial, these medications can improve meibomian gland function. They can decrease lid bacterial flora, reducing a cause of meibomian lipid breakdown. A low-dose (doxycycline 20 mg BID) regimen for 1-2 months has been shown to be effective. Side effects are usual mild but include stomach upset, yeast infections, and photosensitivity.

Steroids act as anti-inflammatories. Because steroids are associated with complications in long-term use, they are mainly used in short pulses either at the initiation of treatment or as rescue during exacerbations. A short 4-6 week course is generally well tolerated as a “rescue treatment,” or an urgent treatment, to relieve intolerable symptoms quickly before resorting to other treatment options.

Meibomian Gland Treatments
Meibomian glands produce oils that are crucial in preventing our tears from evaporating too quickly. Treatments that target the glands can help patients with meibomian gland dysfunction or lid margin disease.

Warm compresses and lid scrubs
Warm compresses provide heat that warms the oils in the glands, unclogging the glands and improving oil flow. Warm washcloths, small rice bags heated in the microwave, or commercial hydrogel pads are all effective, and no studies have been done to compare the different methods. The heat. The compress should be placed over the eyes for 5-10 minute. Gentle circular or rolling massage of the eyelids can help express the oils from the glands.

Lid scrubs are useful particularly in cases of blepharitis, or mild inflammation of the lids, that cause them to become crusted. There are excellent over the counter commercial lid soap formulations that work well to clean the lid margins. Alternatively, baby shampoo and a washcloth gently applied to the lids can work as well.

Thermal pulsation (Lipiflow)
Lipiflow is an FDA approved in-office treatment for meibomian gland dysfunction and dry eyes. During the 12-minute procedure, a device is placed over the eye and eyelids that provides localized warmth and pressure on the lids (Figure 1).

treatments for dry eye
Image 1 – Lipiflow treatment

The procedure is 100% safe and very effective at clearing out the trapped oil glands and allowing smooth flow to be re-established. After approximately one month, the consistency of the oils in the tear flow will have improved remarkably with associated improvement in dry eye symptoms. With one procedure, the effects last between 12-24 months.

Intense Pulsed Light (IPL)
Originally approved for acne and rosacea dermatologic disease, IPL uses bursts of light to minimize blood vessel size. It can be used off-label for ocular rosacea and meibomian gland dysfunction, but results have not been reported.

There are many treatment options for dry eye disease. Generally, conservative over-the-counter treatments should be tried first. Commonly, environmental changes, dietary changes, artificial tears, and warm compresses will improve the majority of dry eye symptoms to tolerable levels. However, when these options are exhausted, there are many additional options for patients. Work closely with a trusted health professional to determine the optimal treatment combination as each patient is different.


treatments for dry eyeMarjan Farid, MD
Director of Cornea, Cataract, and Refractive Surgery
Vice-Chair of Ophthalmic Faculty
Director of the Cornea Fellowship Program
Associate Professor of Ophthalmology
Gavin Herbert Eye Institute, University of California, Irvine



treatments for dry eyePriscilla Q. Vu, MS
Medical Student
University of California, Irvine School of Medicine

Dry Eye Diagnosis

As covered earlier by Dr. Wade, the symptoms of dry eye disease (DED) can be variable. Simply put, dry eyes can be separated into two categories: aqueous tear deficient (ATD) or dysfunctional tear syndrome (DTS). More commonly there is a combination of the two that I like to refer to as ocular surface disease (OSD). Lucky for you, as clinicians, we have several tools that will allow us determine what type of DED you have.

Steps In A Dry Eye Diagnosis

First is a review of your symptomatology. This is crucial to determining if you 1) have DED, and 2) what type you have. This determination can drive our treatment plan that is individual to you. In addition, we utilize various questionnaires that can help us hone in on your OSD.

Second is the ocular examination. We use a microscope (slit-lamp) to carefully examine the surface of the eye. When we look at your tear film we are looking to see the amount and health of your tears, how well they are working, and what effect they are having on the ocular surface (conjunctiva and cornea). Not only do we look at your tears, but we pay special attention to your eyelids. In your eyelids, there are oil producing glands called Meibomian Glands. These glands are responsible for creating a key component to the tear film: lipid. Human tears are very complex, but simply put, tears have 3 main components – water, mucus, and oil. I like to describe tears like salad dressing. In order to have tasty salad dressing, there needs to be a balance of oil, vinegar, and spices. Human tears are very much similar. In order for your tears to work properly, There needs to be the proper balance of the aqueous component (water), lipid component (from the Meibomian glands), and mucus component (image 1).

dry eye diagnosis
Image 1 – A relatively healthy meibiomian gland examination

If there is an imbalance in your tears, this will reflect in their function, and ultimately cause signs and symptoms of ocular surface disease. To highlight the appearance and function of the tears on the ocular surface, clinicians often use special stains that can aid us in determining the amount and function of your tears. Two of the most common stains are fluorescein and lissamine green. Each of these stains has particular characteristics that help determine the severity and extent of your ocular surface disease. For example, if you have significant staining near the bottom part of your cornea, your eyes maybe slightly open when you sleep, and therefore you may benefit from using an ointment at nighttime. Alternatively, if your tears appear to break up very quickly on your ocular surface, there is likely an imbalance in the tear composition that may benefit from institution of warm compresses along with tear replacement in the form of artificial tears.

Third is the use of ancillary testing to help confirm our clinical diagnosis. We are fortunate to have access to several commercially available OSD diagnostics at the Gavin Herbert Eye Institute. A brief description of if you have these diagnostics follows.

    1) Schrimer Testing – This is a very simple and common method of determining whether a patient has hey aqueous tear deficiency. Essentially, the eye is numbed and a sterile piece of special paper is placed in the lower outer corner of the eye. After a specified amount of time, the amount of tears is recorded, and if under a threshold value (generally 10 millimeters at five minutes) there is a high suspicion of aqueous tear deficiency. Treatments for this subtype of OSD will be covered in the next blog.
    2) Tear osmolarity – The most available tear osmolarity system is from TearLab. With this test, we look at the integrity of the tears by determining the osmolarity – essentially the ultrastucture of the tears. If the tear osmolarity is high (hyperosmolar), we know that the tears are not functioning properly. With proper institution of treatment, the osmolarity can normalize indicating a healthier tear film. This test is very noninvasive, requiring only a tear sample of 50 nanoliters – less than the volume of a single tear!
    3) InflammaDry – Inflammation has long been accepted as a hallmark of dry eye disease/ocular surface disease. As such, many of our treatment modalities have focused on treating ocular surface inflammation (discussed in the next installment of this blog). Prior to having access to the InflammaDry test, we would have to assume that there was inflammation involved in an individual’s OSD. Now, however, we can test the ocular surface for inflammatory markers and have an answer within just a few minutes. This test not only allows us to custom tailor treatments to an individual, but also we are able to see if our treatments are working. Again, this test is minimally invasive requiring the small sample of tears for testing.
      4) LipiView II – This test allows us to Image of the structure and function of the meibomian glands in vivo. The images obtained allow for several things. First, we are able to determine the extent of meibomian gland dysfunction. Second we are able to determine the extent of meibomain gland drop out (image 2).
dry eye diagnosis
Image 2 – Significant dropout of meibomian glands
    And third we are able to educate our patients so they can see the importance of treatment of their MGD. Again, this information can help us custom tailor treatment options for the individual patient.

In conclusion, as you can see diagnosis of ocular surface disease can be quite intricate. We are fortunate to be in and age where there has been significant improvements in our tools to help us better diagnose our patients and use this information to individualize treatment options. Stay tuned for the next installment of this blog focusing on treatments for ocular surface disease.


Sam Garg, MDSumit “Sam“ Garg, MD
Medical Director and Vice Chair of Clinical Ophthalmology
Assistant Professor of Ophthalmology
Gavin Herbert Eye Institute – UC Irvine

Symptoms of Dry Eye Disease


If you could be a fly on the exam room wall of your local ophthalmologist, you would hear patient after patient report symptoms of dry eye disease.

Some patients come in already knowing they have dry eyes. However, the variability of symptoms that can occur from dry eye disease is so wide many patients don’t even use the word “dry.” We will cover some of these symptoms in this article.

symptoms of dry eye
Redness often associated with dry eye

Underlying Factors

Dry eye disease has many underlying factors including an inadequate production of tears, rapid evaporation of tears, poor eyelid function and an imbalance in the tear composition of water, oil, and mucus. Dry eye disease can be associated with systemic conditions such as Sjogrens disease, Sarcoid disease and sleep apnea among many others. It is more common in females especially after hormonal changes such as menopause.

Exacerbating Influences

Many medications can exacerbate dry eye disease. Over the counter antihistamines are one example.

Environmental factors may also worsen dry eye symptoms. These include dry climates, windy weather conditions, smoky environments and the dry air found in airplanes.

Modern life includes hours and hours of focusing our eyes on everything from cell phones to computer screens to television. Prolonged focusing reduces the blink rate resulting in more tear evaporation and worsening of dry eye symptoms. Increased evaporation can also occur with exposure to heating, air conditioning, fans and rolling down the car windows while driving.

Symptoms Fluctuate

It is very common for dry eye symptoms (especially blurred vision) to wax and wane throughout the day. Symptoms can even change from blink-to-blink. Dry eye disease which is predominately due to insufficient tears tends to worsen throughout the day with symptoms worse at night. Dry eye disease that is more associated with blepharitis can be worse in the morning. Blepharitis is associated with burning and itching of the eyes.

Visual Symptoms

The front surface of the eye is the most powerful focusing surface of the eye. Thus, a dry ocular surface will produce visual symptoms. These symptoms can include:

Blurred vision: A decrease or fluctuation in visual acuity. This is manifested in the inability to see fine detail. Objects at both near and far may appear out of focus.

Sensitivity to light: Sensitivity to light is termed photophobia. It occurs because a dry ocular surface has more irregularities than a health surface. These irregularities scatter light entering the eye. This scattered light can cause significant discomfort. The inability to tolerate light may lead to squinting and headaches.

Difficulty with nighttime driving: During low light conditions, such as at night, the pupil enlarges and allows more light into the eye. When the ocular surface is dry, the incoming light becomes unfocused and scattered. Many of these abnormalities are filtered out by the small size of the pupil during the day. However, at night, the larger pupil size allows more light abnormalities to pass through to the retina. This results in nighttime glare and halos. Glare is a decreased tolerance of bright lights. Halos present as circles or auras around a bright source of light. Glare and halos from the headlights of oncoming traffic are especially troublesome.

Physical Symptoms

The front surface of the eye is richly supplied with nerve endings. As such, a dry ocular surface can result in significant symptoms of discomfort. In addition to feeling dry, these symptoms include:

Foreign body sensation: Patients may feel as if there is something present in the eye.

Redness of the eye: Enlarged blood vessels on the ocular surface cause the eye to look red.

Ocular and periocular pain: Pain from dry eye can be mild or severe. Pain from dry eye can be felt on the ocular surface. Pain can also be felt in structures around the eye such as the eyelids or scalp.

Periocular irritation: Stinging, burning, or itching sensations of the ocular surface and eyelids.

symptoms of dry eye
Watery eyes can be a symptom of dry eye

Watery eyes: Patients typically raise an eyebrow or two when I explain how the tearing they are experiencing is from dryness. “How can my eyes be dry if they are watering all of the time?” Although this may seem counter-intuitive, when the ocular surface is very dry it will overproduce the watery component of the tears as a protective mechanism.

Eye fatigue: A tired sensation of the eyes and heaviness of the eyelids.

Decreased tolerance of sustained visual focusing: As noted earlier, any activity that requires prolonged visual attention will decrease the blink rate and increase tear evaporation.

Discomfort while wearing contact lenses: Individuals may experience pain and irritation in the eyes while inserting or wearing contact lenses.

Inability to cry: Tears associated with emotional discomfort or watching a sad movie may be decreased in some types of dry eye disease.

Stringy discharge from the eye: A dry ocular surface can result in the overproduction of a sticky, mucus discharge.


There are many symptoms of dry eye disease. Some symptoms affect vision and others affect ocular comfort. If symptoms persist, an evaluation by your eye care provider can help clarify the cause and offer information on treatment options.

It is important to remember the symptoms of dry eye disease can overlap with the symptoms of other ocular conditions. One example is cataracts which, like dry eye disease, can also cause blurred vision and nighttime glare. The next post in this series will review how dry eye disease (and its sub-types) are diagnosed.

As a final note, while the name “dry eye disease” may sound innocuous, the symptoms of dry eye disease can be very severe in many patients. If you suffer from dry eye disease, you are not alone. Today there are many treatment options which can be very helpful. Significant research is underway to continue improving our ability to treat dry eye disease.


Matthew Wade, MD - toric intraocular lensesMatthew Wade, MD
Assistant Professor of Ophthalmology
Gavin Herbert Eye Institute



Minal Reddy was also a contributor to the is article.

Which Eye Care Specialist Do You Need?

It’s time to get your eyes checked – do you go to an ophthalmologist, optometrist or optician? Your optometrist sees the beginnings of age-related macular degeneration, but is sending you to see and ophthalmologist, why?
eye care specialist
One of the most confusing things about taking care of your eyes can be differentiating between an ophthalmologist, optometrist and optician. Each eye care specialist has a very important part to play in the health of your eyes and here is a quick synopsis of what each does so you can choose the best one for your vision issues and treatment.

These specialists are fully trained medical doctors that have completed the eight years of training beyond a bachelor’s degree. Their training has included a full spectrum of eye care, from prescribing glasses and contact lenses and giving eye injections, to carrying out intricate eye surgeries. Many doctors may also be involved eye research to better understand vision, improve eye disease treatments or potentially find a cure. They are easily identified by the MD following their name.

These medical professionals have completed a four-year program at an accredited school of optometry. They have been trained to prescribe and fit glasses and contact lenses, as well as diagnose and treat various eye diseases. They provide treatments through topical therapeutic agents and oral drugs, and are licensed to perform certain types of laser surgery, such as Lasik. They are easily identified by the OD following their name.

These eye care professionals are not licensed to perform eye exams, medical tests or treat patients. Their purpose is to take the prescription from the ophthalmologist or optometrist and work with you to determine which glasses or contact lenses work best for you. If you suffer from an eye disease like keratoconus, these specialists can make the difference between a relatively normal life, or one that is dictated short periods of vision because of contact lens pain. These eye care professionals may hold and associate optician degree or have apprenticed fore required number of hours.

While each one of these eye specialists has their own area of expertise, they can form a team whose only concerns are your eye health and the ability to see as clearly as possible.


Susan DeRemerSusan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Toric Intraocular Lenses after Cataract Surgery

Toric Intraocular Lenses for Post-Transplant Astigmatism

Corneal transplants can be very successful at replacing diseased or damaged corneas. However, vision after a corneal transplant is often limited by high amounts of astigmatism. Treating this astigmatism is often difficult. Typically the amount of astigmatism is higher than can be corrected with glasses. Rigid contact lenses are often required. LASIK, PRK and astigmatic incisions in the cornea (astigmatic keratotomy) have all been tried with varying success.

This month, doctors at the Gavin Herbert Eye Institute at the University of California, Irvine, published a paper describing the use of commercially available, FDA approved toric (astigmatism correcting) intraocular lenses (IOL) during cataract surgery in patients with previous corneal transplant surgery.

Good candidates for this procedure are those who have had all transplant sutures removed and had corneal astigmatism that was stable, and for the most part symmetric and regular. (Image 1A shows topography that is both regular and symmetric. Image 1B is regular but not symmetric and image 1C is irregular.)

toric intraocular lenses

The study showed improvement in uncorrected vision (post-treatment average 20/40) and vision corrected with glasses only (post-treatment average 20/25). The images below, 1D and 1F, illustrate how toric intraocular lenses are positioned along the axis of corneal astigmatism.

toric intraocular lenses

While any intraocular surgery after corneal transplant can decrease the life expectancy of the graft, no complications or graft failures were seen during the course of the study. Not all types of astigmatism can be treated with this procedure.

This study highlights an effective treatment for regular symmetric corneal astigmatism after corneal transplant in patients needing cataract surgery.


Matthew Wade, MD - toric intraocular lensesMatthew Wade, MD
Assistant Professor of Ophthalmology
Gavin Herbert Eye Institute
University of California, Irvine

Eye Issues For Every Age Recap

Vision is something we take for granted, but when we start to have trouble seeing it is easy to panic. This blog has covered a variety of eye issues for every age, from children through older adults. Here are a few articles from leading doctors and specialists that you may have missed and might be of interest.
Artistic eye 6
Bill Takeshita, OD, FAAO – Visual Aids and Techniques When Traveling

Michelle Moore, CHHC – The Best Nutrition for Older Adults

Arthur B. Epstein, OD, FAAO – Understanding and Treating Corneal Scratches and Abrasions

The National Eye Health Education Program (NEHEP) – Low Vision Awareness
Maintaining Healthy Vision

Sandra Young, OD – GMO and the Nutritional Content of Food

S. Barry Eiden, OD, FAAO – Selecting Your Best Vision Correction Options

Suber S. Huang, MD, MBA – It’s All About ME – What to Know About Macular Edema

Jun Lin, MD, PhD and James Tsai, MD, MBA – The Optic Nerve And Its Visual Link To The Brain

Ronald N. Gaster, MD FACS – Do You Have a Pterygium?

Anthony B. Nesburn, MD, FACS – Three Generations of Saving Vision

Chantal Boisvert, OD, MD – Vision and Special Needs Children

Judith Delgado – Driving and Age-Related Macular Degeneration

David L. Kading OD, FAAO and Charissa Young – Itchy Eyes? It Must Be Allergy Season

Lauren Hauptman – Traveling With Low Or No Vision  /  Must Love Dogs, Traveling with Guide Dogs  /  Coping With Retinitis Pigmentosa

Kate Steit – Living Well With Low Vision Online Courses

Bezalel Schendowich, OD – What Are Scleral Contact Lenses?

In addition here are few other topics you might find of interest, including some infographics and delicious recipes.

Pupils Respond to More Than Light

Watery, Red, Itchy Eyes

10 Tips for Healthy Eyes (infographic)

The Need For Medical Research Funding

Protective Eyewear for Home, Garden & Sports

7 Spring Fruits and Vegetables (with some great recipes)

6 Ways Women Can Stop Vision Loss

6 Signs of Eye Disease (infographic)

Do I Need Vision Insurance?

How to Help a Blind or Visually Impaired Person with Mobility

Your Comprehensive Eye Exam (infographic)

Famous People with Vision Loss – Part I

Famous People with Vision Loss – Part II

Development of Eyeglasses Timeline (infographic)

What eye topics do you want to learn about? Please let us know in the comments section below.


Susan DeRemerSusan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation

Vision Recap Of Previous Articles of Interest

Besides the comments that we get, one of the best parts of putting together this blog is the wonderful group of guests who share their expertise and personal stories. I want to thank all of the eye care professionals and friends that have contributed to make this blog a success.
Vision Recap
Here is a quick vision recap of some of the articles we had in the past that you may have missed.

Jullia A. Rosdahl, MD, PhDCoffee and Glaucoma and Taking Control of Glaucoma

David Liao, MD, PhDWhat Are A Macular Pucker and Macular Hole?

Kooshay MalekBeing A Blind Artist

Dan Roberts15 Things Doctors Might Like Us To Know

Jennifer VilleneuveLiving With KC Isn’t Easy

Daniel D. Esmaili, MDPosterior Vitreous Detachment

Donna ColeLiving With Dry Age-Related Macular Degeneration

Pouya N. Dayani, MDDiabetes And The Potential For Diabetic Retinopathy

Robin Heinz BratslavskyAdjustments Can Help With Depression

Judith DelgadoDrugs to Treat Dry AMD and Inflammation

Kate StreitHadley’s Online Education for the Blind and Visually Impaired

Catherine Warren, RNCan Keratoconus Progression Be Predicted?

Richard H. Roe, MD, MHSUveitis Explained

Sumit (Sam) Garg, MDCataract Surgery and Keratoconus

Howard J. Kaplan, MDSpotlight Text – A New Way to Read

Gerry TrickleImagination and KC

In addition to the topics above, here are few more articles that cover a variety of vision issues:

If you have any topics that you would like to read about, please let us know in the comments section below.


Susan DeRemerSusan DeRemer, CFRE
Vice President of Development
Discovery Eye Foundation