Managing nighttime symptoms of dry eye

In this Dry Eye Awareness Month series of posts, I've been trying to avoid re-hashing well known or readily available information, focusing instead on the patient-friendly angles that just don't get covered. But in practical things like night protection, I find that the 'information spread' is so large that I don't want to make assumptions... what's old hat to many patients is completely unknown to many others who could benefit. So, for night dry eye, I'm going to start by framing it with some key principles.

Fundamentals of night management

• Eyelid care: For bleph/MGD sufferers, warm compresses and lid hygiene just before bed can help with better nights. 
• Environmental issues: Ceiling fans, heat and A/C are lethal. If they can't be avoided altogether due to factors like climate and partner preferences, then they have to be compensated for aggressively with other forms of physical protection. Finally, in low humidity climates, a humidifier may be necessary, but don't use one unless you're prepared to keep it clean.
• Lubrication: Do you have a good enough lubricant that is lasting long enough?
• Physical barrier protection is KEY! Most people with severe symptoms benefit from some type of mask, shield, goggle, patch, or other physical protection at night. This is especially critical if their lids don't fully seal during sleep, but it is definitely not only people with poor lid closure that benefit. 

Goop?

Circling back to an ancient debate about whether ointments are good or bad. Personally, I don't particularly care about the principle of the thing all that much anymore. Seems to me that what works, works, and what doesn't, doesn't. I mean, in theory, I think ointments (i.e. petrolatum and mineral oil in varying proportions, depending which brand of a product with "PM" in its name you choose) are acknowledged by many to be not the greatest idea, in that grease effectively prevents liquid, in this case tears, from reaching the surface it's slathered on, so the eyes don't get the nourishment they need and deserve. But in real life, it's all about what actually works for real people. I have known so many people for so long who always do best with ointment at night. On the other hand, there are those whose eyes do get worse over time when they use ointment nightly, but who may have simply assumed it was disease progression and never questioned whether something they're using might actually be irritating their eyes in some way.

So to me, the bottom line is:

1. Questioning is always good. 
2. Understand your choices, including the non-lubricant aspects of night dry eye care.

Physical barrier protection

At my DryEyeShop business, a great deal of our phone time is spent in what we call 'night consultations': troubleshooting how best to help someone protect their eyes at night. 

It's really quite a challenge at times to find tools that will accommodate all the different types of constraints that may be in play, and address them well enough for someone to be able to live with it every night. Consider the following variables:

• Sleep style (back, side, stomach)
• Material sensitivities (latex, silicone, plastics, foams)
• Tolerance for things touching the lids while sleeping
• Skin type and conditions (edema, easily impressible, sensitive)
• Size and fit issues (large hat size, large orbits, very small head, eyes close together, extremely long lashes, very prominent eyes, very deep set eyes)
• Eyelid conditions (damage, scarring, missing parts of lids)
• CPAP usage (full face, nasal pillow, strap configurations)
• Non-closing eyelids (abrasion risk depending on sleep style? Do we force the lids down or simply vault them and keep the eyes safely sealed in?)
• Major asymmetries in the facial bone structure
• Strap constraints (scars, tumors, any scalp irregularities that could pose issues)
• Medical constraints (can we seal completely or must it be vented?)
• General safety (ensuring patient can see to prevent falls during the night)
• Corneal safety (patient rubbing hands in eyes, or eyes on pillow during sleep? How to balance comfort with keeping something securely in place?)
• Costs (is there a home-made version? A lower-cost alternative? How often does it have to be replaced? Are there parts that have to be replaced periodically?)
• Maintenance (does it involve too many steps for someone with severe arthritis? Too delicate for someone with Parkinsons?) 
• Et cetera....

WOW. That's actually the first time I have done a rapid-fire stream-of-consciousness list on that topic, and it turned out even longer than I expected it to! It's not exhaustive, either — every single case is different. I could spend weeks writing up all different types of situations we've encountered and tried to find solutions for over the years. I can't address them all in the blog here, but I will tackle a few of the broader issues that come up frequently.

Incidentally, while I don't want to use the blog to push people to my shop, I do want to mention that consulting on these things is always free, and encompasses not just what we sell, but everything we know is available, so feel free to call to brainstorm solutions! We're at 877-693-7939.

What to do when your lids don't close

This is probably the single most common issue that comes up: People whose eyelids don't close need protection to ensure the corneal surface doesn't dry out. Situations range from relatively mild — where one naturally has a small opening between the lids during sleep (not normally a big problem until/unless you also have dry eye!) — to botched blepharoplasties where there might be a slightly wider opening — to wide openings due to facial palsies, damage to eyelid muscles, injuries and so on.

So the first and most basic decision is this:

Do I attempt to force the lids to close?

It has been my experience that if there is any way you can avoid forcing the lids closed, you should — for the very simple reason that forcing the lids down will usually make it harder to sleep, especially in severe cases. There just aren't all that many ways to force the lids down that are comfortable enough to endure all night.

There are lots of exceptions, and one of the most prominent of the exceptions is people who also have recurrent corneal erosions, where immobilizing the eyelids can be very helpful by preventing the sudden eyelid movements that so often precipitate erosions. People with extremely severe aqueous deficient dry eye plus exposure from poor lid closure sometimes also find nothing will protect them adequately short of taping them down.

...Or do I use a sealed moisture chamber?

The idea here is to seal in the eye area to improve humidity around the eye, reduce evaporative tear loss and eliminate any air movement. This may be all that's needed, along with of course an appropriate lubricant.

This is often the most practical route and there are far more choices available, from patches to shields, goggles and masks, whether they have been designed for the purpose or they can be appropriated for the purpose. That's where so many of the issues on my list come into play in the selection and nearly inevitable trial-and-error processes.

CPAP?

Shield/goggle compatibility: One of my must-do-in-2017-if-at-all-possible projects is to come up with a definitive list of compatibility between all the most commonly used CPAP masks and the commonly used night protection products (Onyix/Quartz, Tranquileyes, EyeSeals, and others). I can often, but not always, tell by looking at pictures online what will fit with what but, depending on the exact strap configuration, in many cases it depends on where exactly the straps rest on someone's face.

Clear, opaque, inside, outside? There are so often more complications... is it possible given the strap configuration to put the dry eye shield on last, or must it go on first, and if the latter, is it available in a clear version, and if not, how on earth do you manage? Then there are partner complications: you really need something opaque because your partner keeps the light or TV on forever, but your shield will only fit underneath your mask, meaning if you get up in the night you have to completely disentangle yourself from everything. There is so much to all this! Including things like the...

Rare but notable possibility in stubborn cases: There are documented cases of CPAP-related dry eye problems occurring not from a leaky mask blowing onto the eye surface externally, but rather from a mask on a high setting forcing air up through the nasolacrimal duct onto the eye through the puncta.

Stomach sleeper?

Another of the fairly common problems, but hard to solve in a way that someone can get comfortable sleeping. I'm not going to get into lots of detail here (if you're interested, you might want to glance at the little article I wrote about it for the shop) but I'll just touch on the key principles in play:

Any solution used for stomach sleepers with dry eye needs to take account of the following:

• It must be capable of preventing anything from touching the lids or eyes — either stiff enough or vaulting the eyes high enough or both. 
• It must have a means of securing it in such a way that it can't easily be dislodged.
• It needs to be comfortable enough to, you know, sleep.

Recurrent corneal erosions?

RCE has been a big hobby horse of mine for years. An awful lot of people with RCE do not get diagnosed properly until it's gone on a long time. Often they have visited several doctors, sometimes even including multiple corneal specialists, before diagnosis. Even when they do get diagnosed, they don't always get treatment specific to the condition. Recurrent Corneal Erosions are a condition that can happen with, or without, dry eye. (What makes it yet more confusing is that erosions can occur when there is severe dry eye, but that's different from RCE as a disorder.)

If you experience episodes of sharp pains in the middle of the night or first thing in the morning in one or both eyes, accompanied by tearing and blurred vision, please talk to your doctor about it. It can't hurt to ask.

Managing daytime symptoms of dry eye

Today's focus

Today's post is aimed at people who are plagued a lot of the day by really substantial daytime symptoms: burning, grittiness, light sensitivity, and other forms of discomfort.

This post is not about medical treatments at all, though. The assumption is that you're working on addressing medical aspects as best you can. Instead, this is focused on practical measures you can take to manage symptoms in parallel with medical treatments.

What's your pattern?

Some people start out their days in pretty good shape, but their comfort and vision slowly degrade through the day. 

For others, symptoms are entirely driven by specific environments and activities; for example, their hard times are at the office, driving, or during computer use, or outdoors in cold weather.

Some people really don't have bad symptoms during the day and can get by with just drops — their real challenge is nights. (I'll be writing about that tomorrow.)

Repeat after me: moisture chambers.

I've been beating this drum for more years than I can remember. The reason I'm such an inveterate fan is that moisture chambers help most people with severe symptoms and really can't cause any harm. There's a lot to like about that combination.

• What are moisture chambers? Glasses or sunglasses that have some kind of added or built-in shield (foam, silicone, etc.) closing the gap between the frame and their face.
• What's the benefit? (1) Proofing against wind, vents, fans, and moving air in general, which all break up the tear film more quickly; (2) allowing humidity to build up immediately around the eyes; (3) keeping out infiltrates, allergens, etc. The net effect tends to be greater overall comfort with less need for constant lubrication. That's why moisture chambers are a staple for dry eye veterans.
• Outdoor use: 7Eye AirShields and WileyX Climate Control are the main contenders. Both brands have many different framestyles available and both sport a removable vented foam eyecup. 7Eye shields tend to be deeper than WileyX. For reference, these brands are $100-200 - you can definitely find much cheaper alternatives with built-in foam, in the $20-50 range. There are additional high end brands like Rudy Project.
• Indoors: This is where it gets tricky, because all of the foam-lined moisture chambers like the sports optical types look like goggles if you put clear lenses in them. Ziena Eyewear is really the only brand on the market designed specifically for dry eye and with a view to being reasonably discreet. But you can also get custom moisture chambers made for some conventional glasses — they're just very expensive.
• Need Rx? High-end moisture chambers are all Rx-friendly (7Eye, WileyX, Rudy Project, Ziena), though there are limits to how high the prescriptions can go. Some frames take a special high-Rx adaptor.
• Over Rx? This is a great way to test the concept before laying out a huge wad of cash on prescription moisture chambers. We have some options at dryeyeshop.com but you can also find them readily on Amazon.
• Cost? How long is a piece of string? You can find cheap ones ($20, Walmart, Amazon etc). Non-prescription quality ones run $100 to $200. With prescription lenses, you're looking at more like $300-500, more probably for progressives combined with special coatings. 

Humidification?

People living in very dry climates almost certainly need humidifiers at home and work. Some people also use car humidifiers, especially those who drive for a profession, and office workers sometimes use personal humidifiers at their desk.

Are you over-dropping?

• Constant dropping: Doctors' opinions will vary, so ask yours. But some people who put in drops more often than every hour or two may find themselves less rather than more comfortable.
• Sensitivities: Pay attention to how you are feeling in relation to the time after drops go in. People can develop sensitivities to common polymers in artificial tears and sometimes it never occurs to them that the drops that feel good going in might actually be contributing to discomfort with constant use. Switch things up, get something with a totally different active ingredient if your drops are feeling less comfortable.
• Autologous serum: When all commercial artificial tears just seem to make you worse, look into autologous serum, even if only as a way to take a 'drug holiday' for a while from conventional drops.
• WHY are you dropping? Many dry eye patients use eyedrops not so much for lubrication as for sensation management. That is, it's not because they're dry, it's because they're uncomfortable or in pain. This is a very important distinction. Those who have severe aqueous deficient dry eye really do have to be very careful to keep lubricated, for the health of their cornea, but those whose primary issues are discomfort rather than dryness per se also have the option to use alternative approaches to comfort... like cold compresses and moisture chambers. 

Are you focusing too much on nights?

I come across people sometimes who are putting all of their effort into maxing out moisture overnight, but whose main problems are actually occurring during the day (at least based on what comes out in conversation). Improving moisture during the night is great and will set you up to start the day in better shape, but in terms of setting reasonable expectations, that approach won't necessarily stretch very far into the day. It's important to make sure you're addressing symptoms at the time they're happening.

Cold compresses, chilled drops

Cold compresses are great for corneal pain, and also for inflammation and redness. Incidentally, just because you are doing warm compresses to treat MGD does not mean you can't also use cold compresses for pain management. I remember first hearing about chilled drops back in the early days when Dr Latkany in New York was practically the only one really popularizing the idea of a dry eye specialist. Cold drops were one of his common tips that many people picked up on.

How about a mid-day re-boot?

For those whose symptoms progress steadily downhill throughout the day, a half-hour break to baby them somewhere along the way can be very helpful.

15-30 minutes of shut-eye with a cold wet compress — anything from a wet cloth over a gelpack to the luxurious Tranquileyes XL Advanced kits — can do the trick.

PROSE, Sclerals

People who cannot get comfortable or functional at all during the day, even with maxed-out medical treatment and moisture chamber glasses, are probably going to want to investigate PROSE/sclerals.