September is Healthy Aging Month

Today, people are living longer than ever before so it’s important to be proactive and take responsibility for your health as you age.

Like any other organ in your body, your eyes do not stay the same as you get older. Vision changes are normal with age but vision loss and blindness are not. Older adults are at higher risk for certain eye diseases and conditions, including age-related macular degeneration, cataract, diabetic retinopathy, glaucoma, dry eye, and low vision. To continue to enjoy healthy vision as you advance in years, it’s important to have a comprehensive dilated eye examination with an ophthalmologist or optometrist on a regular basis.

Here are some other tips to maintain healthy vision now and as you age:

Eat a healthy, balanced diet. Fruits and vegetables can help keep your eyes healthy. Visit our website for healthy eye recipes, click here Eye Cook.

Maintain a healthy weight. Being overweight increases your risk for diabetes. By exercising regularly, you can help keep your body healthy and prevent vision loss.

Don’t smoke. Smoking increases your risk for age-related macular degeneration, cataract, and other eye diseases and conditions that can damage the optic nerve.

Wear protective eyewear when outdoors. Protecting your eyes from the sun’s ultraviolet rays when you are outdoors is vital for your eye health. Wearing sunglasses that block 99 to 100 percent of both UV-A and UV-B radiation.

Know your family history. Talk to your family members about their eye health history. It’s important to know if anyone has been diagnosed with a disease or condition since many are hereditary, such as glaucoma, macular degeneration, and diabetes . This will help determine if you are at higher risk for developing an eye disease or condition.

Consider a multivitamin. Vitamins C, E and the mineral zinc have been shown to promote eye health. Vitamins with Lutein and Zeaxanthin have been known to help patients with moderate to severe age-related macular degeneration.

Give your eyes a rest. If you spend a lot of time at the computer or focusing at any one distance, you sometimes forget to blink, resulting in dryness and eye fatigue. Every 20 minutes, look away about 20 feet in front of you for 20 seconds. This can help reduce eyestrain. Consider using a lubricant eye drop during long periods of intense eye use and rest your eyes for 5 minutes.

You can’t stop time, but you can take care of your eyes so that they remain healthy as you age. Having a healthy vision can be possible at any age!

A Second Vision

For the last few years Kristin McDonald, a former actress and television spokeswoman, has been applying her make-up without the aid of her eyes due to retinitis pigmentosa, a condition that reduces a person’s peripheral vision until all that is left is a pinpoint of sight.

Today, she is in a first stage study that is offering her and others hope that the injection of stem cells might be the mechanism that could slow, and maybe even halt the effects of this horrible disease. Discovery Eye Foundation helped support many of the preliminary translational studies necessary to bring the clinical trial to the FDA and get this exciting, novel approach to the patients.

I am Tom Sullivan, Ambassador of Vision for the Discovery Eye Foundation, and I was rocked when my phone rang recently and I heard the sound of my friend Kristin crying.

“What’s the matter?” I asked with real concern.

Her tears were quickly replaced by laughter, joyous laughter.

“It might be working,” she said, “I mean, the cells just might be having an impact.”

“Meaning your feeling change in your vision?” I asked.

“Tom,” she went on, “you won’t believe it. This morning when I was getting dressed and putting on my make-up, I saw my mascara in the mirror. Listen, I am not trying to tell you I can see, but since the cells were injected, I can focus on a light and even begin to notice shadows.”

“And, now,” she laughed again, “maybe I can put my mascara on straight!”

Kristin has no illusions about how far the injection of cells will take her; but, she is encouraged, as are many of the other patients who are part of Dr. Henry Klassen’s clinical study helped by DEF’s early stage funding. Maybe the old phrase really does apply – you probably know the one I mean – “hope springs eternal in the human breast.” That goes for the researchers, the patients, and all of us who treasure the gift of sight.

To read more about Kristin McDonald, visit her website at secondvision.net

Tom Sullivan
DEF’s Ambassador of Vision
sullivanvision.com

Chlorine & Your Eyes

Summer time is officially here and everyone enjoys a dip in a nice, cool pool during the summer months. While swimming is a great form of exercise and a relaxing way to cool down, the water can be hard on your eyes.

What Chlorine Does to Your Eyes –

Yes chlorine can make your eyes red! But the real dangers in pool water aren’t just a result of your eyes coming in contact with the chemical. The redness and discomfort that sometimes accompany swimming can be caused by bacteria that linger in the water. When submerged in chlorine-treated water, your eyes lose the tear film that protects against infection. Even though the purpose of chlorine in pools is to reduce the amount of harmful bugs, some contaminants are resistant to the chlorine that is used. This means the health of your eyes can be compromised with infections caused by bugs still lingering in the water.

This can result in these three common eye issues:

Pink eye or conjunctivitis – This is one of the most common eye infections swimmers can get, as it can be either viral or bacterial and spreads quickly and easily through the water.

Red, irritated eyes – This is a result of your eyes becoming dehydrated due to the chlorine and the removal of your tear film. Sometimes you may also experience blurriness and distorted vision, this is usually only temporary.

Acanthamoebic keratitis – This is a severe eye infection that is caused by amoeba in the water becoming trapped between the cornea and the contact lens. It can begin to live there, which can result in ulcers on your cornea and permanent damage to your vision.

Swimming with Contact Lenses

Wearing contact lenses in any type of water—including a pool, hot tub, ocean or lake—puts you at higher risk for a corneal infection. Bacteria and other microbes can grow on the lenses even after just one swim. Because contact lenses sit on your eyes for an extended period of time, your eyes are then continuously exposed to chemicals, bacteria, fungi or parasites after you swim. That can lead to a painful infection, corneal damage, and even loss of vision.

To avoid any kind of infection, remove contacts altogether when swimming or use swim goggles. You can get prescription swimming goggles to help keep your vision clear and eyes healthy in the pool. Talk with your eye care provider for more information about the different kinds of swim goggles available.

If you have any of these eye infection symptoms are increasing one hour or longer after swimming, see your eye doctor right away.

Redness
Pain
Tearing
Being very sensitive to light
Blurry vision
Sensation of having something in your eye
Discharge from your eye
Eye swelling

With all of these risks to your eyes from chlorine, swimming might seem a bit scarier than before. However, there is no need to panic! By taking a few safety measures, you can protect your eyes and still enjoy your time in the pool.

Wear Goggles – Wear a pair of swim goggles every time you swim. Goggles keep pool chemicals out of your eyes.

Wash Your Eyes – Immediately after swimming, splash your closed eyes with fresh tap water. This washes chlorine and other chemicals off your eyelids and eyelashes.

Use Eye Drops – Use over-the-counter lubricating eye drops before and after swimming to keep the tear film balanced and eyes comfortable.

or Use Gel Tears – If you have dry eye, thicker artificial tears called gel tears will help protect your tear film, use these drops before putting on your goggles.

Stay Hydrated – Don’t forget to drink plenty of water. Staying well hydrated is an important part of keeping your eyes moist and comfortable.

Don’t miss out on the fun this summer! By taking these easy steps whenever you decide to take a dive, you can have peace of mind that your eyes and your vision are protected.

April is Sports Eye Safety Month

Basketball, Baseball and Air/Paintball Guns Top the List of Leading Causes of Eye Injuries

More than 40 percent of eye injuries that occur every year are related to sports or recreational activities. A recent study found that about 30,000 people in the U.S. went to an emergency department with a sports-related eye injury, a substantially higher estimate than previously reported. Three sports accounted for almost half of all injuries: basketball, baseball and air/paintball guns.

Basketball was the leading cause of injury in males, followed by baseball/softball, and air/paintball guns. Baseball or softball was the leading cause among females, followed by cycling and soccer.

In support of Sports Eye Safety Month in April, we are offering athletes of all ages guidance on how to protect their eyes.

Sports-related injuries can range from corneal abrasions and bruises on the lids to more serious, vision-threatening internal injuries, such as a retinal detachment and internal bleeding. About one-third of sports related eye injuries happen to kids.

The good news is that simply wearing protective eyewear can prevent about 90 percent of eye injuries. Follow these tips to save your vision:

Wear the right eye protection: For basketball, racquet sports, soccer and field hockey, wear protection with shatterproof polycarbonate lenses.
Put your helmet on: For baseball, ice hockey and lacrosse, wear a helmet with a polycarbonate face mask or wire shield.
Know the standards: Choose eye protection that meets American Society of Testing and Materials (ASTM) standards. See the Academy’s protective eyewear webpage for more details.
Throw out old gear: Eye protection should be replaced when damaged or yellowed with age. Wear and tear may cause them to become weak and lose effectiveness.
Glasses won’t cut it: Regular prescription glasses may shatter when hit by flying objects. If you wear glasses, try sports goggles on top to protect your eyes and your frames.

Virtually all sports eye injuries could be prevented by wearing proper eye protection. That is why athletes are encouraged to protect their eyes when participating in competitive sports.

Anyone who experiences a sports eye injury should immediately visit an ophthalmologist, a physician specializing in medical and surgical eye care.

The Do’s and Don’ts of Proper Lens Care

If you’ve ever slept in your contact lenses, worn disposable lenses past the prescribed replacement schedule, rinsed your contact lenses with tap water or gone for a dip in the community pool without removing contacts from your eyes first, it’s time to rethink your habits.

lens Most problems associated with contact lenses cause minor irritation, but serious eye infections from poor lens hygiene can be extremely painful and may lead to permanent vision loss. About 80 to 90 percent of contact lens-related eye infections are bacterial. A type of infection you can get is called pseudomonas aeruginosa, a fast-growing bacterial infection that can lead to a hole in your cornea. Unfortunately, patients who get this infection have a high chance of permanent scarring and vision loss. Beyond bacteria, fungal infections are also potential threats to your vision.

Do:

Always wash and thoroughly dry your hands before handling contact lenses.
Carefully and regularly clean contact lenses as directed by your eye care specialist. If recommended, rub the contact lenses with your fingers and rinse them thoroughly before soaking the lenses overnight in multipurpose solution that completely covers each lens.
Store lenses in the proper lens storage case, and replace the case at least every three months. Clean the case after each use, and keep it open and dry between cleanings.
Use only fresh solution to clean and store contact lenses. Never reuse old solution—it loses its effectiveness. Change your contact lens solution according to the manufacturer’s recommendations, even if you don’t use your lenses daily.
Always follow the recommended contact lens replacement schedule prescribed by your eye care specialist.
Remove contact lenses before swimming or entering a hot tub.Avoid tap water to wash or store contact lenses or lens cases.
See your eye care professional for your regularly scheduled contact lens and eye examination.

Don’t:

Use cream soaps. They can leave a film on your hands that can transfer to the lenses.
Use saliva to rinse or lubricate your contact lenses
Use homemade saline solutions. Improper use of homemade saline solutions has been linked with a potentially blinding condition among soft lens wearers.
Put contact lenses in your mouth or moisten them with saliva, which is full of bacteria and a potential source of infection.
Use tap water to wash or store contact lenses or lens cases.
Use products not recommended by your eye care specialist to clean and disinfect your lenses.
Use saline solution and rewetting drops not designed for contact lenses.
Sleep in contact lenses. The contact lens and your eyelid act as a double barrier, potentially trapping bacteria on the lens directly on your eyes.

There Is Something In Your Eye – Now What?

It is never planned. You could be putting on makeup, gardening, or even just running errands on a windy day, but all of a sudden you have something in your eye and it hurts. What do you do?

Small Foreign Objects

First and foremost – DON’T RUB your eye!! This could scratch your cornea and make things much worse.

Wash your hands thoroughly with soap and water.

In a well-lighted area, look in a mirror to try and find the object in your eye.

If you wear contacts, remove them before trying to remove the object or flushing your eye.

Try blinking and letting your natural tearing flush out the object.

If the object is on the colored part of the eye or under the upper lid you can try to flush it out gently with clean cool or lukewarm water in one of three ways:
1. Completely fill an eyecup or small juice glass with water and put your open eye into the container to flush out the object. Do this standing over a sink as the water will overflow.
2. Use a clean eyedropper and fill with water. Be careful to not touch the tip of the eyedropper to the eye.
3. Turn your head so your eye is down and to the side, then hold your open eye under a faucet.
If the object is in the corner or on the white part of the eye you can try flushing the eye using one of the methods listed above or a using wet cotton swab or twisted piece of tissue to lightly touch the foreign object. Make sure to not apply pressure to the eye.

If it is under the lower lid you can use any of the methods above by gently pulling down on your lower lid to access the object, but be careful to not push the object further down.

A scratchy feeling of slight discomfort may continue for a short time after removing a small object. I discomfort continues after 24-48 hours, your eye becomes red or your vision becomes blurred, immediately seek medical attention.

Never use tweezers, toothpicks or other hard objects to remove an object as these could damage your eye.

Never try to remove a piece of metal, anything that has punctured your eye or an object that will not come out after flushing with water. Cover both eyes to help prevent eye movement and there is no pressure on the eyes. Have a friend drive you to eye doctor immediately.

Chemicals

Do not touch your eye, but IMMEDIATELY flush your eye with clean running water from a faucet.

Flush your eye for a minimum of 15 minutes holding your eye open and at an angle so the runoff water does not run into the other eye. If both eyes are affected or the chemicals are on other parts of the face or body, you need to do the flushing in a shower.

If you wear contact lenses, leave them in and start flushing immediately. If they do not fall out from the flushing process you can try to remove them. Then repeat the entire flushing process.

Seek medical attention immediately upon completing the flushing process, regardless of how your eyes feel.

Prevention

The best way to protect yourself from getting anything into your eyes is to protect them.

Never use chemicals without wearing goggles that completely surround and protect the eyes.

Wear specially designed goggles when swimming.

Wear goggles when participating in sports where you could get hit with any flying object like a ball or bat. Also in any sport where you could get an opponent’s elbow or hand in your eye.

Wear protective eyewear when using power tools or striking tools like hammers.

When you are cycling, in dusty areas or it is windy, also protect your eyes with sunglasses or other protective eyewear.

Susan DeRemer, CFRE
Discovery Eye Foundation

What Is Happening In the Gas-Permeable Contact Lens Industry

The Gas-Permeable Contact Lens

The mainstay of treatment for our patients with keratoconus are gas-permeable lenses. Corneal gas-permeable (GP) lenses have been the treatment of choice for over 40 years and fit approximately two-thirds the size of the cornea. Corneal GP lenses translate and pump tears and oxygen under the lens with each blink. Hybrid lenses have a GP center bonded to a soft skirt that cushions and centers the lens. Scleral lenses are very large diameter lenses that completely vault the cornea and land on the relatively insensitive scleral tissue. Whether they are corneal GP, hybrid, or scleral lenses, the commonality is that all of these strategies use the optics and rigidity of GP materials to provide the best vision and comfort for this challenging condition.

The way that the GP industry works is that GP button manufacturers (there are 6 in the US) sell the raw material, or button, to independent laboratories (there are 39 in the US) who then craft the button using industrial lathes into hundreds of lens designs using their own intellectual property. GP buttons are used to make corneal GPs, hybrid, and scleral lenses. Doctors who are skilled in fitting and evaluating the lens designs craft custom made GP lenses for their patients for whatever purpose benefits the patient.

Not many people know that the GP lens industry is on fire right now. The turmoil began when Valeant Pharmaceuticals purchased Boston Products. Boston Products manufactures the raw material of GP lenses, GP buttons, and held around 80% of the US market share.

The independent laboratories have a trade association called the Contact Lens Manufacturer’s Association (CLMA) who have an educational wing called the Gas-Permeable Lens Institute (GPLI). The GPLI is universally beloved by practitioners because its primary function is to educate doctors to become better doctors in a non-branded, good-of-the-industry format. No lens design is favored over any other. Education is free to all doctors and expertise in specialty lenses is stressed, so that patients are placed in skilled hands. Jan Svochak, president of the CLMA, says, “The CLMA represents a longstanding group of Independent Contact Lens Manufacturers working collaboratively where we have shared goals. These include educational resources through the GPLI that work closely with Eye Care Practitioners and Educational Institutions as well as a dedication to protecting and advancing utilization of custom manufactured contact lenses.”

Next Valeant dropped the hammer on the industry. Overnight and for no apparent reason, they sent a letter to all of the independent laboratories announcing that they were increasing the price on scleral lens-sized Boston buttons by an astounding 60% (and other buttons by multiples). Simultaneously, they announced that they were dropping out of the CLMA. This move stunned the CLMA member labs as it blocked them from supplying Paragon CRT lenses to doctors. Being the market leading GP button manufacturer, dropping out of the CLMA essentially defunded the GPLI and ensured the immanent collapse of the CLMA.

The price increase sent shock waves throughout the industry. There was a simultaneous but independent reaction from many of the key-opinion leading optometrists who fit GP lenses. The problem with any increase in price on the GP button level is that these price increases are passed down the line through the laboratories, the doctors and eventually, to the patients. Valeant saw a huge backlash from optometrists who essentially stopped prescribing their materials. They admitted making a mistake, and lowered the cost of the buttons, but interestingly, not to the original level. Instead, there was an average 16% increase in the cost of scleral lens buttons to the laboratories. Similarly, Valeant did not rejoin the CLMA. The cost increase has been reported to fund Valeant brand specific education.

The other members of the CLMA came together and saved the association and the GPLI. Additionally, a key competitor to Valeant, Contamac, rejoined the CLMA. Contamac is a button manufacturer who formerly held around 8% market share of GP buttons. At present, key sources within the industry believe that the market share has essentially flip-flopped, so that now, Contamac has rapidly gained market share of the GP button space as doctors have largely abandoned Boston materials in protest of these moves.

In a reactionary panic, Valeant has most recently written to the CLMA, asking to rejoin, but paradoxically with demands. The CLMA is currently reviewing whether to allow Valeant to rejoin and under what terms. Long term, it is beneficial for the industry for everyone to work together for the common good. It is unfortunate that a large company has come into the keratoconus treatment area and is raising prices without providing any real value, such as research and development into newer and better tools. Companies like Valeant ultimately need to realize that they are not in control of an industry. The patients and doctors are.

Dr. Sonsino is a partner in a high-end specialty contact lens and anterior segment practice in Nashville, Tennessee. For over 12 years, he was on the faculty at Vanderbilt University Medical Center’s Eye Institute. Dr. Sonsino is a Diplomate in the Cornea, Contact Lens, and Refractive Therapies Section of the American Academy of Optometry (AAO), chair-elect of the Cornea and Contact Lens Section of the American Optometric Association (AOA), a fellow of the Scleral Lens Education Society, board certified by the American Board of Optometry (ABO), and an advisory board member of the Gas Permeable Lens Institute (GPLI). He lectures internationally, publishes in peer-review and non-peer-reviewed publications, and operates the website: TheKeratoconusCenter.org. He consults for Alcon, Art Optical, Allergan, Johnson & Johnson, Optovue, Synergeyes, Visionary Optics, Visioneering, and formerly for Bausch & Lomb.

3/30/16

Jeffrey Sonsino, OD, FAAO
The Contact Lens Center at Optique Diplomate
Cornea, Contact Lens, and Refractive Therapies,

Having Trouble with Your Scleral Lenses?

Scleral lens have become very popular and while many enjoy the comfort and vision correction they provide, some find it difficult to apply (insert) and remove these large diameter RGP lenses. If you are one of the many who are having difficulty managing to get your scleral lenses in or out, there are a number of tools available to help.

The Scleral Lens Education Society website provides a wealth of information about the care and handling of these lenses as well as an excellent video. There are photos demonstrating various ways to hold the lens while applying it …some you may not have tried! If you have trouble with your schleral lenses, see below.

Troubleshooting tips and tricks:

If you are unable to maintain fluid in the bowl of the lens as you bring it towards your eye, make sure that your face is fully parallel to the floor. It may seem like you are nearly standing on your head when you’re in the correct position to apply the lens.
Lid control is essential; use one hand to hold lids completely out of the way, and don’t release the lids until the lens is actually fully in place and the plunger (or your finger tripod) has been removed.
If you are unable to successfully apply a solid lens with saline, you could practice applying the lens after filling the bowl of the lens with Celluvisc™ or another non-preserved viscous lubricant. These viscous lubricants will blur your vision compared to saline, however, so you may simply want to use them to practice lens application. Once you’ve mastered this step, switch to saline to give you better vision.
Try to keep both eyes open as you apply your lenses. This may also help you to position the lenses correctly.
If you are using a bulbed (DVM) plunger, and can see the opening in the center of the suction cup, look directly at the hole as you bring the lens into position. This will help you to position the lens correctly.

Many find the DVM plungers helpful. They are readily available at your doctor’s office and online. These are just a few of the places to find them: DMV Corp, Dry Eye Zone, and Amazon.

Another variation to the standard lens inserters is a ring-style lens applicator by EZI Scleral Lens. It was designed by a post-transplant patient who like so many, had trouble inserting his scleral lens without getting a bubble. Read Tim’s story.

If you have tried the above techniques and still have trouble applying scleral lenses there are a number of devices available that may help. Dalsey Adaptives has developed the See-Green device that can be used to help successfully apply scleral contact lenses. The See-Green system comes with a stand that holds a lighted plunger (Figure 2). Using this system, you don’t hold the lens, you lower your eye onto it, which leaves both hands free for improved lid control. The light at the center of the plunger is used as a target to help you position the lens centrally on the eye. Click here to see the detailed instruction sheet.

Scleral lenses offer good vision and comfort but can be challenging to manage. Discuss these options with your eye care professional to get his or her recommendation for your specific situation.

1/28/16

Cathy Warren, RN
Executive Director
National Keratoconus Foundation

Wearing Contact Lenses in Winter

This has been a cold winter so far, and since it is only January, it is bound to get colder. The extreme cold, combined with winds, snow, rain and other environmental factors, can really take a toll on your eyes. And while it may be snowing or raining, winter air is actually drier than any other season. This can be especially difficult if you wear contact lenses. Here is what you should know about wearing contact lenses in winter.

Wear sunglasses for protection from UV rays and wind. Your eyes can become sunburned which cause blurry vision and can make your eyes feel like they are burning (think of your sunburned skin feels) for 24 to 72 hours. It will also protect your eyes from snow, rain or anything else the wind can send your way.
Avoid direct sources of heat such as heating vents and fireplaces. Indoor heating can draw the moisture out of the air, so consider a humidifier to help maintain the correct amount of moisture in the air to help keep eyes moist. Cool-air humidifiers have less of a tendency toward mold and bacteria.
Speaking of hydration, we also tend to drink less water in the winter months, so make a concentrated effort to keep up your water intake.
If it is so dry, why are my eyes watering? This is a common question and the answer may be a bit counter-intuitive. Anything that irritates your eyes, including dryness, causes a tearing reflex. Your tear glands go into overdrive trying to replace the moisture to your cornea. To try and reduce the tearing, you can use eye drops or artificial tears specifically designed for use with contact lenses.
Your eyes are not the only thing that dries out in the winter, so does your skin. Try to put in your contacts before moisturizing your skin, especially your hands. So wash your hands, put in your lenses and then use your creams and lotions.
Change out your contact lenses regularly in cold weather according to the recommended schedule, be it daily, every two weeks or monthly. This will allow them to better conduct oxygen, reduce irritation and increase comfort.
Take a break from your contacts and wear your eyeglasses. Putting them on when you get home from work can make a big difference. Contact lenses dry your eyes out on their own, when you add cold weather it gets that much worse.
Get plenty of sleep, which also helps with the dryness and fatigue. This will help you start the day with your eye refreshed and ready for the many things you will put them through throughout the day ahead.

Do you have any other suggestions that have helped you cope when wearing contact lenses in winter?

1/15/16

Susan DeRemer, CFRE Vice President of Development Discovery Eye Foundation

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 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.

10/20/15

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

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

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