Thursday, July 20, 2017

Dry Eye - Practical Prevention Pointers (2 of 2)

Yesterday's tips were focused on recognizing dry eye symptoms for what they are (or might be), and getting ahead of them with some purely practical prevention pointers. Today, we're going to shift to prevention tips for navigating some medical stuff.

Don't hurt yourself through ignorance...

...about drops, drugs, devices and surgeries.

The fact is, a great many medical treatments, drugs (ocular and systemic), and surgeries involving the eyes and lids CAUSE dry eyes - sometimes mild, sometimes temporary, but also sometimes severe and sometimes chronic or permanent. Getting dry eye at all, in any form, is lousy. Getting a really nasty, persistent, life-altering form of dry eye and knowing it was preventable is truly the pits. 

There are far too many forms of medically-induced dry eye (also called 'iatrogenic' dry eye) for me to cover here, so I'm just going to hit on a FEW frequent offenders that should be emphasized. Iatrogenic dry eye is actually such a big topic that the international medical consensus project known as TFOS DEWS II, whose 10-year report is about to be published, had an entire subcommittee and massive chapter focus just on this!

OTC Drop Shopping Tips

Look for eye drops with these things on the label:
  • Preservative-Free. Almost anything preservative-free, by the way, will come in a box of 30 or more individual vials. Waste of plastic? Sure. On the other hand, preservatives (i.e. what makes it possible to put eyedrops in a bottle) are toxic to the cornea. So pick your poison.
  • Lubricant Eye Drop (or geldrop). 
  • Alternatively, homeopathic drops. For mild dry eye or ocular allergy symptoms, they can be helpful without posing the types of risks medicated drops may introduce.

Try to avoid purchasing any of the following eye drops for regular use:
  • Redness relievers (vasoconstrictors). These are doubly damaging to the cornea. First, they have a rebound redness factor when used repeatedly, and second, they are usually preserved with benzalkonium chloride, which is quite toxic to the cornea. If you must use redness relievers, do so infrequently — save them for special occasions. *BUYER BEWARE*: There are many 'combo' drops on the market these days, and they get terribly confusing because they also claim to be lubricants. Just don't buy things with a redness reliever ingredient.
  • Antihistamine (allergy) drops, except for brief use, or unless you're seeing an eye doctor, in which case they'll probably want to put you on a better, prescription allergy drop anyway. That's *if* you really do have ocular allergies — because maybe your eyes are itchy due to dryness, after all! But as I was saying, antihistamine drops are drying, and again, have toxic preservatives. That's true of both OTC and Rx allergy drops. If you've got to use one, use  the one that works the best.
  • Eyewashes and salines, except for your first aid kit. Look out for preservatives. Don't overuse anything like this - they may be wet, but they have no lubricating properties and they dilute your precious tear film, which you can't do too terribly often without paying for it.

Rx Drop Awareness Tips

TOP TIP: Avoid using anything preserved on a daily basis for longer than a month if possible. If you have to, talk to your doctor about the preservative side effects and if it's possible to get a preservative-free version.
  • Glaucoma drops, historically, are top offenders. They have to be taken daily, and daily exposure to the most toxic preservatives can be a big dry eye contributor. There are many preservative-free glaucoma drops now, and ones with milder preservatives. Make sure you have the preservative talk with your glaucoma doctor.
  • Steroid drops and antibiotic drops are two more commonly used classes of eyedrops that are usually preserved with the most toxic preservative (benzalkonium chloride). If you don't need to be on them long, you will probably not want to bother worrying about it, but if for any reason you need to stay on them longer than a conventional course lasts, talk to your doctor about preservative side effect concerns, including dryness.

Drug Awareness Facts

Oodles and gazoodles of drugs are, or at any rate may be, drying. So it gets tricky talking about them ("Fine, but now that I know that, what do I do?"). With drugs in general, there is no free lunch, and it's all about navigating the tradeoffs. But the aspect I would want to emphasize is that IF you know you are at dry eye risk for other reasons, AND the drug you need to take is on the dry eye-causing spectrum, it's worth a conversation with the prescribing doctor about your concerns, drug selection and alternatives, and dosage. For example, there are a ton of antidepressants on the market, and while not all of them may be appropriate for you, you can at least raise the dry eye side effect potential with your doctor and ask them for help to pin down those suitable for you that are less frequently associated with dry eye.

Top dry eye offender drug categories (in random order):
  • Antihistamines
  • Nasal decongestants
  • Blood pressure medications (beta blockers, diuretics)
  • Antidepressants
  • Antipsychotics
  • Parkinsons drugs
  • Hormone therapy; oral contraceptives
  • Acne medications
  • Sleeping pills
  • Pain relievers

Device hangup: CPAP and APAP

At the Dry Eye Shop we talk constantly with people whose eyes are dried out by their CPAP masks — they call, often after referral by their doctor, to get advice on shields, masks, or patches they could use to protect their eyes. CPAP is in such common usage, and has been for so long, that it is absolutely staggering to me how many people still struggle for a long time with this before someone finally tells them there are solutions and even products made specifically to help with it.

It would be nice if everyone could get a CPAP mask that fit perfectly and didn't leak, but till then, physical protection for the eyes, even if only a strip of plastic wrap, is very important for many CPAP users.

Surgery hangup #1: LASIK, et cetera

July 20th, 2017 - today! - is my 16th 'laserversary'... a term many of us who experienced laser surgery complications in the old days coined for a memorable day that we don't exactly celebrate. As you might imagine, I'm not a terribly big fan. No regrets about my own experience, because it ended up determining a new course for my life that gives me a great deal of fulfillment every day, but because it came at a high cost to vision and comfort, I would never recommend it for someone else.

Among the many things on the scale stacked up against LASIK, the dry eye risk features prominently, and all the more so because no one who gets LASIK has any idea how bad post LASIK dry eye can be when it's bad. 

Top illusions to avoid suckering to:
  • That you can escape this risk by going to the best, most reputable surgeon in your area. (Naw. We all did that too.)
  • That technology has improved so much this doesn't happen anymore.
  • That dry eye treatments are so good it doesn't matter.
  • That if you already have dry eye, a little increase doesn't matter. (Actually, it might mean the difference between dry eye and DRY EYE.)
  • That the worst that could happen is you need eyedrops or Restasis or Xiidra or plugs.
  • That your surgeon will be will equipped to help you through any ensuing dryness. (LASIK surgeons and dry eye specialists just don't normally come under the same label.)

Surgery hangup #2: Elective eyelid surgeries (blepharoplasty)

There is a particularly painful version of dry eye that comes sometimes with blepharoplasty - specifically, when the lids come up too short.

Top tips for lowering risk:
  • Seek only an oculoplastic surgeon, NEVER a plastic surgeon, no matter how qualified! Oculoplastic surgeons are ophthalmologists who do surgery on the eyelids. General plastic surgeons don't have enough specialized knowledge of the tear system.
  • Get a complete, detailed dry eye workup with a specialist before a blepharoplasty, to see if you have any pre-existing dry eye or dry eye risk factors that could make you unusually vulnerable to dry eye side effects.


Shari said...

I can't put any kind of eye drop in my "moderately" DRY EYES, even the ones without preservatives, without ending up with long, stringy mucous threads that impede my vision and that constantly have to be removed with Q-tips, which ultimately ends up irritating my DRY EYES even more. I have tried every kind of eye drop imaginable, including ones that aren't even sold in the US. My dry eyes took a major, unexplained turn for the worse a few months ago, I think perhaps during allergy season. The only thing that offers even remote relief is eye drops of eye wash solution, which doesn't end up causing mucous, (sorry to be so gross) which according to your article above is not a good idea. I am at my wits's end, depressed, and can tell the doc really has no good solution to offer.

Judith Anderson said...

I think Rebecca's warning about not using saline as an eye drop makes sense for most folks, indeed, but there are exceptions. I had been using Refresh Plus non-preserved drops and was struggling with a few issues - red eyes and not being able to wear my sclerals for enough hours to get through the day happily. I stopped the Refresh Plus and carefully avoid anything with long-chain "thickeners", except for Hylo non-preserved gel, which is unfortunately not available in the US. I keep my Hylo use to overnight only, and use Addipak saline often through the day as an additional moistener. This works for me, but my primary problem is corneal disease with associated moderate dry eye, not severe dry eye. I can now wear my sclerals for 12 hours and my eyes look and feel much better.

Rebecca said...

Whoopsie I didn't even realize I was getting comments! You know, about the saline / eye wash - it's really interesting. I never knew how many people were using it that way till the Unisol 4 discontinuation when with my dryeyeshop hat on I started talking to so many people who were calling in for Purilens. Honestly, I use saline directly in my eyes myself and I get it.... My concern is for people who unknowingly overuse it without realizing they might make themselves worse.

SHARI... Those filaments can be so miserable! I'm really sorry! There are mucolytic drops though I think that you might be able to use to help break them up? I totally get that when you're that uncomfortable, you just have to do what works!

JUDITH, I hear you! Polymer drops just really feel like more crud in the eye a lot of times.