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John C Hagan III, MD, FACS, FAAO  
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Kansas City, MO

Specialties: Ophthalmology

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2018 General Information on Dry Eyes-Now known as Ocular Surface Disorder

Mar 10, 2018 - 55 comments

Dry eyes are one of the most common conditions seen in the practice of ophthalmology. Collectively dry eyes probably cause more eye discomfort and irritation than any other condition.  The term “dry eyes” will never go way but it’s misleading.  Eye MD ophthalmologists now call this “ocular surface disorder” (OSD) and sometimes “tears dysfunction syndrome.”  There are two forms of the problem. In the first (called by Eye MDs ‘aqueous deficiency’) there are no tears or few tears; it is often associated with dry mouth and is the most severe form. In the second form, the eyes water constantly or often. It is called ‘lipid deficiency’ and is caused by eyelid oil gland (Meibomian Gland Disorder or MGD) problems.  In the first form the eye doesn’t make enough tears; in the second form the tears are of poor quality.  There are many tests for OSD, some of them quite expensive, but the diagnosis can usually be made by a careful symptom review and examination of the eye and eyelids. For persistent problems a complete medical eye examination by an Eye MD ophthalmologist is needed plus telling the Eye MD about your symptoms and how troublesome you find them. Self education on OSD is extremely important.

         If you are menopausal or post-menopausal be sure you and your gynecologist maintain optimal hormonal balance. (Many women with dry eyes have dry mouth and dry vaginal canal). If you have joint pain have that evaluated to be sure you don't have Sjorgren's syndrome or rheumatoid arthritis. You might review your medications with your ophthalmologist. Almost any cold, allergy or sinus medicine can cause or aggravate dry eye and mouth. Oil and debris along the eyelids (blepharitis) can aggravate dry eyes. Blepharitis can also cause eyelid infections such as styes, blocked oil glands (chalazion) or eyelash loss and red eyes and eyelids.  Eye lid cleaners and wipes are very useful. They are non-prescription. The easiest to find, and among the best, are Ocusoft products:   http://www.ocusoft.com/ For recalcitrant cases the new prescription Avenova Eye https://avenova.com/ has worked extremely well.

OSD treatment usually begins with use of preserved and/or unpreserved artificial tears during the day and gels or lubricating ointments at bedtime. Environmental modification is important.  Don't belittle eye drops. They are not ‘all the same”. You would never walk into a restaurant and say “Bring many any type of food, it’s all the same.”  There are over 100 different brands of artificial tears and they can't all be lumped together. Sometimes one will find the perfect drop. That means you put the drop in and your eye becomes comfortable in 5-10 minutes and remains comfortable for at least 3-4 hours. If it stings or burns, write down the name on a list you keep and give it a failing grade. If it helps but only for an hour continue your search for one that lasts 3-4 hours; give it an average grade.   YOU MUST KEEP A LIST OF DROPS YOU HAVE TRIED AND HOW THEY WORKED OR DID NOT WORK FOR YOU.

Because the OSD problem is so prevalent the pharmaceutical companies are coming out with new products all the time. Some of the newest are Systane preserved and unpreserved, Optive, Blink, Soothe, and Retaine. Eye drops for dryness are classified as unpreserved drops (individual vials that must be used within 24-48 hrs.), preserved drops, gels and ointments. The unpreserved drops are more expensive and usually only help the small percentage of people that are really allergic to preservatives. Gels and ointments are normally used at night since regular artificial tears won’t last all night.  Ointments are messy and many people dislike them.  Be sure to try Nature’s Tear’s Eyemist a spray for dry eyes that works for many people. It is available without a prescription.  http://www.naturestears.com/

Tears may need to be used as often as 4-6 times/day.  House brand or generic eye drops may work for the mild forms but moderate or severe OSD usually requires newer brand names.  Omega 3, taken by mouth, has been shown to be helpful. Sources include fish oil (which some people have trouble tolerating), creel oil and flaxseed oil.  Environmental modification means not sleeping under a fan, not blowing air into the face (example in work station, cars, planes) and humidifying home and work and sleep areas during dry winter months.

Some activities aggravate both types of dry eyes because they cause the eye to blink less frequently. These include reading, use of any video screen (computer, iPad, iPhone, video games), watching TV, going to movies.  Discomfort can be helped a great deal by looking away from the screen and focusing on a distant object and blinking forcefully 8-10 times. Do this every 15 minutes during these activities. Because of the increasing amount of time young people are spending on computers/phones/tablets/videogaming there is an epidemic of dry eyes in young people: https://www.nbcnews.com/nightly-news/video/studies-excess-screen-time-could-be-aging-kids-eyes-870691907947  (as an aside young people are also developing impaired hearing at a much younger age due to loud music via headphones/earbuds).

      Warm compresses are often helpful.  Hot washcloths may suffice but a much better way is with re-heatable, eye pads available at any drug store. They are relatively inexpensive and way more efficient that hot washcloths. Follow the directions carefully to prevent damage to the eye. Additional things that can help include a diet rich in fatty fish (e.g. salmon, sardines, etc.). Fish oil taken by mouth usually 2 to 4/day has been show to help some patients. Do not start with this many fish oil/day. Start one per day with a meal and every 2 weeks as another to the amount recommended on the bottle. Ask your physician before beginning fish oil.  In addition, there are non-prescription pills for dry eyes available at most major drug stores or by direct order from the companies. Thera-tears formula for dry eyes is probably the most widely used. You can use any search engine to pull up the websites of the companies that see these.

For people that exhaust all these first and second level treatments, whom are still moderately or severely symptomatic and/or who are using drops 4 or more times/day, they might consider Restasis or Xiidra.  These are not artificial tears but prescription eye drops that over a period of 4-6 months: 1. reduce inflammation on the surface of the eye and 2. promote the formation of more efficient, high quality tears.  It is important to realize the commitment one is making when considering these:  1. twice/day for the rest of your life (or until something better comes along) 2. waiting 4-6 months for them to start working 3. expense associated with them (although in the long run may be less expensive than purchasing brand name eye drops to use 4-6 times/day).    You can read about them on their websites:  https://www.restasis.com/  and https://www.xiidra.com/

This is sort of a personal testimonial. I do not receive any money from any drug company for anything.  My wife and I have moderately severe dry eyes. I have aqueous deficiency, classic ‘dry eyes” and my wife ‘lipid deficiency’.  When we did not respond to first and second level treatment we went on Restasis. After 3-4 months we saw some improvement and after 6 months were entirely comfortable with only occasional use of artificial tears. Both of us have been on Restasis over 5 years.  There is a way of using Restasis in non-preserved vials that can dramatically reduce the cost. This method does not work with the multi-drop Restasis bottle introduced the past year. We always ask for the non-preserved vials.  Xiidra is relatively new. They are advertising heavily now using Jennifer Aniston as spokesperson. It is not better than Restasis and in the testing phase in some areas was not as good as Restasis. The company is marketing that its full onset comes 4 months after starting drops whereas Restasis is 6 months. I have not used a great deal of Xiidra in my practice for several reasons:  1. when patients hear how well Restasis did for me and my wife they want to try it. 2. In the few cases I have tried it the patients did not like it and especially 3. when the Xiidra first refill discount cards and samples are exhausted the patients have found it way too expensive.  

New treatments also include pulsed laser to the surface of the eyelids https://www.reviewofophthalmology.com/article/intense-pulsed-light-for-treating-dry-eye  and heat/compression to the eyelids https://tearscience.com/lipiflow/   I do not have much experience with these but patients treated elsewhere have told me they are quite expensive and may or may not prove helpful.

      If you reach a point of exhausting all the above see an ophthalmologist that specializes in "Cornea and External Disease". This is their special area of expertise. A final new treatment that they can often do is “Autologist Platelete-rich plasma” therapy. This uses eyedrops made out of your blood products. (reference Ocular Surgery News: November 1, 2007 page 46 lead author Jorge Alio MD.

     While dry eyes-ocular surface disorder cannot be cured, it is a chronic problem, is can almost always be helped a great deal. The Eye MD can only do so much and much of the success of treatment is determined by the willingness of the patient to learn about the problem and systematically work towards relief of their symptoms.


Comments
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Avatar universal
by dustinalvillar, Mar 11, 2018
(posting for girlfriend)ive suffered dry eyes for i guess the past year. im 28 female with type 1 diabetes. have had corneal abrasion and cataracts for the past year and have been through 3 different specialists out here who just refer me to the next once they figure out that they cant figure out whats wrong with me... ive had patches put on my eyes with gel underneath, been thru many eyedrops, had plugs put in my eyelids, had amniotic membranes placed on my eyes, now they are at the point of wanting to stitch eyelids together (i think called Tarsorrhaphy) not 100 percent sure i have it written in car.. they say that the stiches may be permanant. and blood sugar is very well maintained, drink lots of water, count carbs, i dont know what to do or who to talk to. if it helps i have medicare part a b and d and i also have transportation to wherever someone thinks they can help me

Right off the bat that puts the person with this problem in the worse 99.2% of dry eyes. Having been through all of that its likely  that the advice you have been given is appropriate. You are working your way up the referral ladder and its likely that the Eye MD ophthalmologist that is treating you is a cornea/external disease specialist with the appropriate training. Also you have a chronic problem that is not going to be cured so you need to go to an ophthalmologist that you can easily get to many times per year. You also should have a retinal Eye MD ophthalmologist on your team to examine your 'better' eye for diabetic retinopathy.   another option would be if you have a medical school department of ophthalmology that is close enough to go to regularly would be to get a second opinion from the cornea/external disease eye MD there. This is a terribly severe problem that is atypical of 'average" case of dry eyes.

Avatar universal
by mahniah, Apr 04, 2018
With regard to MGD (meibomian gland disease), there's a new treatment developed by a doctor in Florida and it seems to work, at least it did for me.  Meibomian gland probing isn't covered yet by insurance and there aren't a lot of docs doing it yet, although younger docs are more likely to do it.  I had it done and it changed my life.  It's basically clearing out the glands by probing.  Check it out.

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by JohnHaganMD, Apr 04, 2018
The treatment developed by Dr. Steve Masket  MD of Tampa is not new. This is a reference dating to 2010  https://www.healio.com/ophthalmology/news/blogs/%7B05533875-6996-4b98-aae3-13315cc9c5e5%7D/john-a-hovanesian-md-facs/squeezing-and-probing-those-meibomian-glands--does-it-work     There are a lot of things that work for some people.  I have not found it particularly effective and most people find it very uncomfortable. Glad it helped you.  

Avatar universal
by MjCg, Jun 06, 2018
Hello, Dr. Hagan - I'm so glad to have come across your article about dry eyes.  Under care from my optometrist, I had actually begun using Restasis two months before my detached retina occurred.  Although my optometrist and my retinal specialist have both told me that Restasis did not cause my RD, psychologically I can't bring myself to start using it again (aaack!).  What do you think?  Is it even slightly possible that Restatis could cause a tear/detached retina?    

Not not even remotely possible. My wife and I both take restasis very successively for over 5 years for dry eye.  There is only one eye drop that has been associated with RD and its almost never used anymore (pilocarpine).  Restasis just reduces inflammation on the surface of the eye and helps the eye make a higher quality tear.  You could try Xiidra but it is outlandishly expensive.

Avatar universal
by Tiigerlily, Jul 09, 2018
Since about last 3-4 wks.I have been experiencing dry eyes from time to time. As of 5 days ago I began to notice a sort of smudged view from the lower right area of my left eye; it seems to come and go, although when I cover my right eye it seems to go away... What are your thoughts?


See your ophthalmologist about this complaint.

Avatar universal
by jnowak_1, Aug 19, 2018

Dr. I had stevens Johnson syndrome  and the mucus lining in my eyelid were' burned out' so I only have tears to lubricate my eyes. Others I have corresponded with who have also had sjs or TENS syndrome have found a stem cell procedure to cure and restore the eyes from dry eye syndrome and scarred cornea's . the procedure is being done in California if my memory serves me correctly and you can get more information about it by contacting the Stevens Johnson Foundation (Julies) and contacting Jean the Founder as her daughter had sjs as well. very nice helpful people. hope this helps someone. The boston foundation for sight also makes custom fitted scalera len's which takes 5 days there to develop and fit if that route isn't an option which in on a link in the prior webpage. people I correspond with there have had great success.
jeff

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by JohnHaganMD, Aug 19, 2018
Stem cell transplants for cornea disease are relatively simple and widely available across the United States.  There is also a new blood test for Sjorgren's Syndrome from Bausch & Lomb.   For Steven's Johnson Syndrome treatment should be available at tertiary ophthalmology centers across the United States. Thanks for the comments

Avatar universal
by judithmhol, Aug 23, 2018
So very very helpful. And as I sat and read in it’s entirety,  I kept thinking about the days gone by when my eyes looked rested and didn’t bother me all the time.  They sting, always watering or feeling dry.  And I look so tired all the time.  Can’t use eye make up anymore, and if I make the mistake of rubbing my eyes....well I pay for it.
Anyhow, thank you for taking the time to send this out.  Will get back on my Restasis

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by JohnHaganMD, Aug 23, 2018
If you use the Restasis vials and use one up completely before opening the next (my wife and I both do this for our restasis)  it reduces the cost by 5/6 since one vial lasts about 3 days and normally if used as directed would use 6. The multidrop bottle is much more expensive.  Xiidra is out of sight expensive.

Avatar universal
by Paulaedwards, Nov 18, 2018
Great general Information on Dry Eyes-Now was known as Ocular Surface Disorder. Thanks for sharing with us. Your this kind of information was very helpful for all those people who suffer dry eye disease. Keep sharing more & more

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by JohnHaganMD, Nov 19, 2018
There is a new double strength Restasis just released called "Cequa"  should be very effective for Restasis failures. Since it's new have no experience with it yet and not knowledge of the cost.

Avatar universal
by Jim_in_Italy, Jan 14, 2019
Dr Hagan, first, thank you so much for your incredibly helpful info posted on medhelp. I have learned so much. Just for info, in Europe, where I live,  there is a drug Ikervis by Santen which is also double strength 1mg/ml. But whereas Cequa is dosed twice daily, Ikervis is once daily. (Both are about same strength I believe.)  Also Ikervis is incredibly expensive. I have yet to go to pharmacy but I believe it could be $300 for 30 vials !!!! Thanks for your tip to use vials more than once.
New question: have you heard of LO2A by Wize, also for OSD. If so, could you comment on it?

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by JohnHaganMD, Jan 14, 2019
Thanks for the information. Because of the US  Food & Drug Administration and the rapacious US tort lawyers we have a huge 'drug lag' in the USA.  The new head of the FDA is Scott Gottlieb MD and he is working hard to try and help the problem.  I have no experience with LO2A, sorry.   Xiidra and Cequa are very expensive in US also

Avatar universal
by HamzaRanjha, Jan 15, 2019
Can you reverse irregular astigmatism from dry eyes?

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by JohnHaganMD, Jan 15, 2019
Irregular cornea astigmastims is due to surface dryness so use of artificial tears, gels, ointments or the superstrong meds: Restasis, Xiidra, Cequa  make the cornea regular.    True irregular astigmasims is due to structural corneal disease such as scarring or keratoconus.

Avatar universal
by Jim_in_Italy, Jan 17, 2019
Dr Hagan, ref my comment above, here is the web page for LO2A. It is sold in a few European countries under different brand names
https://www.wizepharma.com/lo2a-eye-drops
I would be interested in your opinion.  Much less expensive than Restasis Xiidra Cequa, but I wonder if it “does the same the same thing”.  

Also regarding how many drops you get in a vial of Restasis, I have seen on the internet that a “drop” is generally measured as .05mL.  Restasis vials contain .4mL, so should be good for 8 drops. But that is only 2 days worth @ 2 drops/eye/day.  Am I calculating correctly? the reason I ask is to calculate how much the Ikervis (available to me here) would cost monthly. Each vial contains .3mL so theoretically should be 6 drops and last 3 days @ 1 drop per eye per day. That means the $300 pharmacy cost for 30 vials would be closer to $100/month.  Still not cheap of course, but a lot better until I can get to the US and get help with Restasis via Medicare.

many thanks

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by JohnHaganMD, Jan 17, 2019
LO2A is a proprietary molecule with an action completely different than Restasis, Xiidra or Cequa.  The study was small. It is not available and I only know what I have read so I cannot make a comparison to the latter 3 that I have used on patients.   Also your calculations on how long something will last is only theoretical and not practical. You are comfortable with internet searches.   Search a paper by Charles M. Lederer, MD  I think Archives of Ophthalmology on drop size. It demonstrates the average drop is not 55 microleters.  Also other studies show that same medication, same purported volume from different manufacturers (latanoprost) have different size drops and different number of drops. My wife and I use restasis in vials for many years successfully. One vial lasts me 3 days (12 drops)

Avatar universal
by Jim_in_Italy, Jan 17, 2019
Many thanks, Dr Hagan, for fast response. I have always wondered is a liquid’s viscosity was one factor in drop size. (I have a swimming pool and do my own maintenance, so I am constantly testing with chemical drops. Hence my comment on viscosity)
Since the LO2A is available here, and OTC, and relatively inexpensive, I will try it and post if I have anything of interest to report

Again my thanks to you for your patience and diligence

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by JohnHaganMD, Jan 17, 2019
Yes viscosity would be a factor however the studies I was talking about are all solutions not gels.


Avatar universal
by Alfreda123, Feb 01, 2019
Hello! I've been diagnosed with Graves Disease. My numbers are off the charts. I'm experiencing severe dry eyes, bags under my eyes with swelling , pain and dark circles. I use the drops for moisture and it only helps a little. What else can I do?

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by JohnHaganMD, Feb 01, 2019
You need to be under the care of an ophthalmologist.  If you have ‘bug eyes’ from the Graves Disease you need to see an oculoplastic surgeon about orbital decompression. You also likely need to go on Restasis or Xiidra or Cequa.    My wife and I both use restasis with great success for many years for severe dry eyes (ocular surface disorder)  If you go on restasis get the non-preserved vials (not preservative free multidrop bottle) and ask your ophthalmologist about using up all the drops in the vial before opening another. DRASTICALLY REDUCES THE COST.

Avatar universal
by Jim_in_Italy, Mar 03, 2019
Dr Hagan, would you kindly comment on the use of azithromycin (either Azasite in US or Azyter in Europe preservative free) for control of both blepharitis and OSD, which are often related, I believe.  Also, what is the treatment for using this med for blepharitis? Drops in the eye or applying it to the eyelids/eyelashes using Q-tip? I haven’t found an answer on the internet, even when I have read scientific studies on azithromycin as an effective blepharitis treatment. Many thanks in advance

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by JohnHaganMD, Mar 03, 2019
The treatment for blepharitis (essentially dandruff of the eye lid) is regular use of a lid cleaner such as ocusoft, foam and wipes.   A new prescription cleaner works even better Avenova.  Used twice/day every day.  Warm compresses by a reheatable, microwave pad (not hot wash cloth).    There are different types of blepharitis. MGD = Meibomean Gland Disease that is severe is often helped by using Azasite for 4-6 weeks.  Not for long term us and less helpful for non-MGD blepharitis.   The oil and debris and scales need to be removed from lid margins with appropriate cleaner.;   This is link to info on Avenova    https://www.youtube.com/watch?v=LulkK_087sU

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by JohnHaganMD, Mar 03, 2019
This is a link to Bruder warm eye pads   https://www.bruder.com/moist-heat-eye-compress

Avatar universal
by Jim_in_Italy, Mar 04, 2019
Dr Hagan, thank you very much for your prompt and informed response. I will follow up on the links suggested.

Is Azasite applied as drops to the eye, or used topically on the eye lids where the dandruff is located? I am assuming,, after re-reading your response, that it is used on the eyelids.

Thanks again

Avatar universal
by Jim_in_Italy, Mar 04, 2019
Dr Hagan, as you suggested, I checked out both the Avenova and Bruder web sites. Interestingly, Bruder offers a Hypochlorite acid spray double strength compared to Avenova, and claims that it doesnt require a prescription. Your timely advice led me to dryeyezone.com where I read numerous posts by patients and doctors. There is much discussion of Natrasan; another OcuSoft product :Hydrochlor; and Heyedrate, all  of which we available at a fraction of Avenova’s cost, without prescription

Have any of these products come to your attention?  What gets most attention is Natrasan. Do you have an opinion of any of these?

Many thanks

http://forum.dryeyezone.com/search?q=Natrasan&searchJSON=%7B%22keywords%22%3A%22Natrasan%22%7D


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by JohnHaganMD, Mar 04, 2019
As I understand it. The OTC products all carry the warning not to get in your eye and are not approved to apply to the eye while Avenova is.   On paper Avenova looks expensive but at least in Kansas City/Missouri & Kansas they have a mail order pharmacy they deal with an co-payment is never higher than $60 and for most people around $40 which compares favorably with what the OTC products cost. But I don’t have experience with Hydrochlopr and Heyedrate.  You could try them and see what you think

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by JohnHaganMD, Mar 04, 2019
As I understand it. The OTC products all carry the warning not to get in your eye and are not approved to apply to the eye while Avenova is.   On paper Avenova looks expensive but at least in Kansas City/Missouri & Kansas they have a mail order pharmacy they deal with an co-payment is never higher than $60 and for most people around $40 which compares favorably with what the OTC products cost. But I don’t have experience with Hydrochlopr and Heyedrate.  You could try them and see what you think

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by x_Aria_x, Apr 08, 2019
Thank you for writing that, very informative!  Do you think punctal plugs are helpful for dry eyes?  I don't have extremely dry eyes, but I had lower plugs inserted a few weeks ago.  If they're helping, I'm not feeling it.

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by PeriMenopauseSX, May 05, 2019
First & foremost, Thank You Dr Hagan MD. Your dedicated time and efforts in this subject matter have been clear and evident and most helpful.

Historical background: Female, 50+ yrs of age. Dx with Peri-menopause approx. 2 yrs ago. Quite a wild array of non-specific / specific sx during the last two years, but always deemed part of the peri-menopause journey by my Physician. Blood work always appears normal (CBC W/Differential). Hormones are in balance at this time, but elevated LDL #'s despite always maintaining a solid diet. Never a smoker in life, rarely consume alcohol, 80% keto-genic diet etc. A level 4 fitness instructor for 20 yrs as secondary occupation. Never took any HRT.

With all this stated, over the last 4 months, I've experienced significant dry eye complications. Though I've never had an abnormal eye exam in past, after having my annual eye exam to renew my contact lens prescription with my optometrist in Feb 2019, she confirmed I had meibomian gland dysfunction. Shortly after, I scheduled an exam with a known Opthalmologist who specializes in dry eye complications. After my consult with him, he confirmed MGD. He also has MGD, so he understands the discomfort. As such, he prescribed Retaine & Xiidra. Both of which have provided some relief. He also suggested I have the Lipi-Flow procedure in the future if these products were not conducive. Two weeks ago, I decided to schedule the Lipi-Flow procedure as it seemed a good path forward for my case. Surprisingly, and shockingly, out of the blue, my right eye began to experience a strange aura of blurred vision in the right side of upper/ lower eye. I immediately scheduled an appt. over the weekend with the optometrist and after dilation etc. she confirmed posterior vitreous detachment as the culprit. She saw a black dot which is isolated in the vitreous, but indicated she saw "no tail attached". This black dot followed any movement with the eye in which I see constantly. She also said the inflamed / hazed area on right side of eye that I also see daily is evident on the photo-map result. Over the past 48 hrs, this has worsened with two more straight black areas surrounding the isolated black dot. Very concerning.

Luckily, I see my Ophthalmologist this week. Though originally scheduled for the Lipi-Flow procedure, I'm very hopeful he will have insight as to a path forward for the new discovery of PVD. This is very stressful especially in my profession(s). Not to mention complications in vision as I take vision very seriously. No history of glaucoma or retinal problems in my family.

Regarding my inquiry to you Sir, I reviewed your blog posts regarding specific eye care. The Ocusoft and Natural Tears products are two that I ordered. Over the last year, would you care to share any newer products you find useful or beneficial in a case such as mine? Or any other insight?

Very much look forward to your reply when convenient during your busy schedule. Again, thank you for the time you carve for answering questions here on this sight. Very much appreciated and admired.

In kind,
PM.

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by JohnHaganMD, May 05, 2019
First of all I am far more concerned about the area of blurred vision.  The most important things:   1. confirm this is a PVD and not something new.  If your original problem was a PVD the blur should move when you move your eye; same thing for the two new straight lines. If they do not move it suggests a primary retinal problem.  If possible I would suggest you see a retina Eye MD ASAP especially if you have or had any flashes of light like lightening or have any loss of peripheral vision or the blurred areas do no move when you move your eye or if you are moderate/high myopia or have a family hx of RD.   Retina Eye MD specialists are used to emergencies and will often see a symptomatic person same or next day. I would call your ophthalmologist TODAY, all Eye MDs have 24 hr emergency lines. Someone else might be on call but you can talk in real time. You also need to ask your Eye MD about your fitness activities while the retina symptoms are occurring.

Now for your MGD/Dry eyes. Your prognosis for continuing contact lens is very very low.  Dry eyes is 90% post menopausal female and often gets worse as people get older. Even in younger people it is among the top reasons people can't wear contact lens.  I have no personal experience with Lipi-Flow, we don't use it in our practice and only refer people who 'demand' it. Those doctors that have it use it a lot, I suspect in part because they have to pay for the instrument, treatments in our area are expensive. I have not seen anything in the medical literature about Lipi-flow causing PVD.  In MGD it is possible to manually express the MG and it is much less expensive.  I hope you have been told not to wear your contacts till your eyes are back to normal.  Your increase risk of cornea ulcer if you try and wear them now.

I hope you have read that Xiidra takes a minimum of 4 months to work. So write down when you started. I have not used much Xiidra.  1. It's way more expensive than Restasis once the coupons expire.  2. In testing it was not better and in some aspects not as good as restasis  3. the few patients that I have tried it on complained of sting, burn, redness.   I have mentioned that both my wife and I have been on restasis for over 5 years with excellent results.  I have aqueous deficiency (no tears), she has evaporative/lipid deficiency (poor quality tears/water all the time).    We use the preservative free droper-ettes and not the multi-dose large bottle of restasis and the cost is very low using up the dropper-ette.   If you have a very dry mouth your Eye MD might want to do the new quick test to rule out Sjorgren's Syndrome.

Back to your MGD.  If you are going to use Ocusoft use the Platinum. However there is a superior prescription eyelid cleaner called Avenova.  It is important to fill the RX at the company recommended pharmacy which dramatically reduces the co-pay to about 40-60 dollars and is not much more expensive or same price as buying over the counter cleaners like Ocusoft.  MGD is also treated with Azasite drops for 4-8 weeks sometimes and sometimes with oral tetracyclines.

Back to my original point.  Dry eyes (which Eye MD call ocular surface disorder) is not going to be cured only controlled. But I am concerned about the retina problem and would act on that first.  

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by PeriMenopauseSX, May 05, 2019
Dr. Hagen, again, thank you for your prompt and in detail response. Secondly, my profuse apologies if I was unclear in any way. This subject matter w/ sx is challenging to describe adequately and intelligently.

Allow me to address or better clarify my sx. The blurred area. Indeed, with movement of my right eye, the jelly-like (viscous) area that includes thee small shaped black lines and dot move with the eye. The blurred area to the right upper and lower seemed fixed on the photo map result. But when I move my eye especially to the left or up and down, a quick dark flash occurs in a half-moon shape. Uncertain if this would also be considered the blurred area in question. I’m hopeful I conveyed the above appropriately. Further, I do not have a family history on either side of RD. No eye diseases that I’m aware. Thank you in kind for letting me know that I should refrain from wearing my contacts until further understanding of my condition. I was not informed of this, but have not worn them for that reason.

Also, very glad you shared your insight regarding Restasis. This product was not discussed during my visits with the Ophthalmologist as an option. I’ve not yet been tested for Sjögren Syndrome but will indeed.

Today, I purchased the Ocusoft but not the platinum. I will do so tonight. My goal was to pop in and see my Ophthalmologist as soon as they opened their doors tomorrow. However, reading your responses involving my condition this may warrant an emergency call tonight to a Retina specialist as you suggested. If after reviewing my response, you feel that should still be the path forward... I will honor that steadfast advice ASAP.

Look forward to your response.

Very Truly
PM

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by JohnHaganMD, May 05, 2019
What is describe is a classic PVD.  The presence of flashes when you move your eye indicates you have vitreous traction (I believe what your optometrist said "no tail" mean he/she did not see traction on the retina".   PVD's are common  1 in 2 by age 50 and 3 in 4 people by age 70 whereas a RD is about one in 8000 to 12000.  Nevertheless the flashes need to be examined by an Eye MD with dilation and a test called scleral depression.   Note also since your eyes are obviously same age somewhere down the line you will have similar symptoms in other eye.   What is your glasses or contact lens prescription? If -2.50 or over increased risk of RD if over -6 major increase.  

You might check with your insurance/pharmacist and see what your co-payment is going to be when the company supplied discounts on the first several bottles goes way.  Restasis is not expensive if a person off label uses up a dropperette completely before opening the next. So instead of using two restasis dropperrette per day one lasts 3 days. My wife and I share one prescription.

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by PeriMenopauseSX, May 05, 2019
Understood on all fronts. I believe Restasis is the option for me. Will move forward with that path tomorrow morning ASAP ...!

“Scleral depression”  as you mentioned will be discussed tomorrow at my visit. Regarding cost involving Restasis, in my humble opinion, I cannot put a price tag on my vision as it’s just that critical to me and my husband. We will put forth any cost necessary to save my vision.

Good Sir, if possible, and necessary, we would be more than willing to schedule an appt. with you for a consult / eval if you would be willing to examine my eye condition.

Words cannot adequately convey how appreciative we are for your time in this discussion. You’ve taken time out of your busy schedule to answer questions in which you are not obligated or compensated. This we truly recognize and appreciate.

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by JohnHaganMD, May 05, 2019
Scleral depression is a way of looking for breaks in the peripheral retina, the area that has the highest likelihood of tearing. Some Eye MDs use a 3 mirror lens.

I have been asked before if it's worth coming to my office for an exam, and while I'm flattered the answer is no, not unless you live close enough to provide ongoing care.  Your profile says you live in California and there is no reason to spend the time money only to be told in person what I'm telling you here.   I have always believed in 2nd opinions and use them extremely common (ophthalmology has over 8 subspecialties).  If a patient asks me for a second opinion, I'm never offended.  If your Eye MD is not comfortable with retina he/she could certainly refer you to a retina specialist. The odds are heavily in your favor that the PVD will NOT cause a tear or RD.   For the dry eye the branch of ophthalmology dealing with that is cornea/external disease.

I had a guy show up in my office from California. Found my name from this website.  He had a problem called negative dysphotopsia. That is what he was told by the Eye MDs in California.  I told him the same thing then referred him to a surgeon in Los Angeles that specializes in that problem.

So stay in your area that you can drive easily for ongoing care.   Best of luck.  

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by PeriMenopauseSX, May 05, 2019
With the above categories you’ve kindly provided, you command our respect and loyalty. For what it’s worth, we are in an industry that allows us free travel domestically and abroad. Hence, no cost to us for traveling to see you. Regardless, we respect your advice. To us, vision is priceless and a necessity due to our occupation as we are dependent on vision.

We are hopeful that our Ophthalmologist can shed as much assistance and insight as you have. Again, we would still be willing to schedule a visit if you are willing. It would be worth it to us considering the time you’ve spent answering questions and concerns. Not something we take lightly.

Thank you Sir,

PM

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by JohnHaganMD, May 05, 2019
See how things go.  

Avatar universal
by ladyinCanada, May 17, 2019
Dr. Hagan,  Great site and information you provide. I just happened upon it.  I am a 56 year old women who has been diagnosed finally with OSD  sudden vision loss (blurriness) and needing distant eye glasses for the first time as I never needed glasses for distance before. I was also have eye pain and facial pain. After seeing a few doctors for the last 4 months - a Neuro Opthamologist found corneal pitting in my left eye. I have been on Xiidra for two months and two weeks. There has been no improvement with and the Xiidra as noted by specialist - it also  burns and almost feels like it dries out my eyes more. My eyes are redder than they used to be while I am on it and I noticed more black floaters as well. Could the Xiidra make my eyes more red?  Would you suggest that I move right over to the Restasis?  One of my doctors gave me a prescription for Restasis if I wanted to try.  I just don't want to mess with my progress...  Just wondering if it would be more helpful. Your advice would be greatly appreciated.  Thank you.

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by JohnHaganMD, May 17, 2019
It is extremely important to not that the FDA literature on Xiidra requires telling patients that maximum effect is not until the person has been on it for FOUR months. Some people see improvement at 6-8 weeks .  I have to tell you I don't like Xiidra. In head to head testing it was not better than Restasis but it is outlandishly expensive after the available discounts wear off. In what few patients I have tried it many have complained of stinging and burning.

I do like Restasis.  Both my wife and and I have ocular surface disorder (OSD).  My eyes were bone dry (aqueous deficiency) and my wife's watered all the time (evaporative or lipid deficiency)  we both were miserable and using artificial tears 4-6 times/day.  We went on Restasis at different times. My wife has been on restasis for 7 years and me 5.  My wife some some improvement in 6 weeks I didn't see any improvement for 3 months.   Now neither of us use artificial tears.  To keep the cost reasonable it is important to get the individual preservative free dropperettes.   The directions say use once and throw away. Or use 2 per day.  We  use different vials (don't share) but if you use up everything a vial will last 3 days. that reduces the cost by 5/6   We keep vial in refrigerator and do not use after 3 days if anything still in it.   The company tries to make everyone use the multidrop bottle that only has about 30 day supply. It is much more expensive.

Many people have stinging and burning when starting restasis. I usually put them on steroid drops for a week before starting restasis and for 2 weeks after then stop the steroids.  Not many people have trouble with stinging and burning after 2 weeks. Because it takes so long for the medicine to work artificial tears and warm compresses must be continues.  I have all my patients write on their calendar when they started and the date 6 months for then. THAT IS A TRIAL.  In the medical literature there are also reports of severe dry eyes (Sjorgren's Syndrome) for instance of using restasis 3 times/day but that is off label use.  You would need to discuss this with the ophthalmologist that is going to manage you OSD as it is a lifetime disease that often worsens with time especially in women.  There are other important things like warm compresses, lid hygeine if Meibomian Gland Disease is present, environmental modification, and omega 3 supplements (NOTE: if you search the literature a recent study suggested omega 3 not good for dry eye. The study was extremely flawed because the placebo they used was olive oil which is not inert and also helps dry eyes.

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by JohnHaganMD, May 17, 2019
Xiidra would not cause floaters.  A new superstrong restasis is coming on the market CEQUA. I have no experience with it. I suspect like Xiidra it will be outlandishly expensive.


Avatar universal
by ladyinCanada, May 17, 2019
Thank you for all that information. I am going to go fill this prescription for Restasis. The opthomologist did have me in the steroids too when I first started the Xiidra so hopefully that is covered off with me starting the Restasis this week. I am pleased to know about the floaters not being caused by the meds. I am seeing a rheumatologist next month to see about Sjorgrens- so far my blood tests for it are negative...  I did read that about the fish oil in an article and questioned my opthamologist. Good to hear the study was flawed. I do keep up with a high quality fish oil daily but it does bother my stomach slightly. The hot compress that I heat up daily and use three times a day hasn’t changed anything so far for me. I will work hard to keep up the regime regardless and hope for improvement. Again thank you.

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by JohnHaganMD, May 17, 2019
For severe dry eyes especially with dry mouth Sjorgren's Syndrome needs to be excluded.  For the omega 3 be sure your fish oil is "enteric" coated. That means it doesn't dissolve in the stomach where it can cause fishy taste and belching and high quality manufacturer.  Lot of bad fish oil on the market even some from China contaminated by mercury. This is a high quality omega 3 and the company I use:  https://www.cardiotabs.com/omega-3-ec.html#tab-tab-product-description     Also as I said before be sure your Restasis RX is for the vials not the multidrop bottle.     back to fish oil take one with your largest meal for a couple of weeks then add a second with another meal. For most people the dose is 2 or 3 per day.   Heat is best applied with a resuable device heated in microwave rather than hot water on wash cloth.  This is the best of the lot at a good price:  https://www.ebay.com/p/BRUDER-Moist-Heat-Eye-Compress-2day-Ship/3027055877?iid=323398429497    

Avatar universal
by ladyinCanada, May 17, 2019
Appreciate this information as well and have written it down to ensure I receive the vials from the pharmacist. I’ve been using a Bausch and Lomb Thera pearl mask but will look into the Bruder product. I use a humidifier as well at night. I wonder about the night goggles I’ve heard others use but i question eyes not breathing naturally while sleeping. It’s really disheartening that this isn’t curable.

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by JohnHaganMD, May 18, 2019
Chronic disease means it can't be cured. It doesn't mean it can't be helped.  My wife and I were miserable with OSD. Now on restasis we are totally assymptomatic. We aren't cured but we are controlled and have no symptoms. Hopefully a year from now that will be the case for you.

Avatar universal
by ladyinCanada, May 18, 2019
That is good news and glad to hear for you and your wife. Any thoughts on eye drops made from one’s own plasma?  

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by JohnHaganMD, May 18, 2019
You are jumping way, way ahead in the treatment algorithm.  That is generally reserved for people that have failed with drops, gels, ointments, head, lid hygiene,  environmental modification, omega 3, tear duct plugs (for evaporation DSO only), and failing 6 months on restasis or Xiidra.      It is expensive and only done in select centers.  Generally there is structural damage to the cornea.  In the last 15 years I've not referred anyone to a center for that treatment. One thing I failed to mention is there is a new nasal stimulate for dry eye. I have not used it. It is put up the nose and mildly shocks the nerve that produces tears. It will work best with aqueous deficiency.   I have heard the device sells for $600=800 USD  but don't know this for a fact. I mention it only because you will run across it in your research:  LINK    https://www.truetear.com/  

Avatar universal
by ladyinCanada, May 18, 2019
That makes sense to stay the course with the first line of treatment. it’s a painful process and it’s hard to not feel anxiety and patience during this time.  I have aqueous deficiency and will investigate the nose drops for future if needed.  Again appreciate your solid professional research and for your most helpful communication.  

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by JohnHaganMD, May 18, 2019
Not nose drops. It's an electrical probe that goes up the nose. Check out the link

Avatar universal
by Dilly92, Oct 14, 2019
I have meibomian gland dysfunction and aqueous deficiency and I regularly get air bubbles in my lower eyelid that are big enough that I can see them burst. I believe it is just poor quality tears since this occurs when my eyes are super dry and burning. Are these air bubbles anything to be concerned about?

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by JohnHaganMD, Oct 14, 2019
The bubbles are common in MGD. Ask your eye doctor about Avenova eyelid cleaner

Avatar universal
by Dilly92, Oct 15, 2019
Thank you. In terms of prescription eye drops for dry eye, is Restasis or Xiidra safer/better to try first if the cost is not a concern (insurance covers  100% of the cost of both)?

Avatar universal
by Dilly92, Oct 15, 2019
I forgot to mention that I am 26 years old so I'm curious if one of the above drops is better for me based on my age?

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